Efficacy of a Parent–Youth Teamwork Intervention to Promote Adherence in Pediatric Asthma

Asthma, a respiratory illness defined as recurrent episodes of wheezing or coughing, is the most common pediatric chronic illness, affecting >9% of children in the United States (CDC, 2012). Persistent asthma is treated with daily inhaled corticosteroids (ICS) to reduce airway inflammation and inhaled bronchodilators taken to relieve symptom exacerbations (Hogan & Wilson, 2003). Poorly managed asthma can negatively impact a child’s functioning (e.g., increased school absences, decreased participation in extracurricular activities) (Fiese & Wamboldt, 2000). Regimen non-adherence has been identified as one factor underlying ineffective asthma management. Objective measurement of adherence (e.g., electronic monitoring) is less prone to bias owing to the tendency of parents and children to overestimate adherence on self-report (e.g., Bender et al., 2007). Studies using electronic monitoring have found that on average, children with asthma take 46–57% of prescribed ICS doses (e.g., McQuaid, Kopel, Klein, & Fritz, 2003). Adolescents are identified as particularly at risk for low adherence (Fiese & Everhart, 2006; McQuaid et al., 2003). Psychosocial changes that occur in adolescence, such as drive for autonomy and social pressure from peers, have been linked to non-adherence to prescribed medical regimens (Bender, Milgrom, Rand, & Ackerson, 1998). Despite these adherence difficulties, adolescents are more likely to be given primary responsibility for asthma management (Munzenberger, Secord, & Thomas, 2010). Yet, significant discrepancies exist between parent and child reports on who is responsible for specific asthma tasks (e.g., Wade, Islam, Holden, Kruszon-Moran, & Mitchell, 1999). Walders, Drotar, and Kercsmar (2000) noted that these discrepancies may be due to a decrease in parental supervision without a concordant increase in adolescent responsibility. Decreased parental involvement in asthma care has been linked to poorer adherence (Fiese & Wamboldt, 2003) and high morbidity and mortality (Birkhead, Attaway, Strunk, Townsend, & Teutsch, 1989). Parent–child collaborative management of regimens has been suggested for and related to better adherence and improved health outcome (e.g., Ellis et al., 2007; Fiese & Everhart, 2006). Families described as using a “family partnership” approach to managing pediatric asthma had the highest electronically monitored adherence rates (Fiese & Wamboldt, 2003). Yet, parents’ attempts at increasing their involvement in asthma care may be perceived as intrusive by youth (Drotar & Bonner, 2009; Penza-Clyve, Mansell, & McQuaid, 2004). Indeed, Bender and Bender (2005) reviewed qualitative studies examining patient-identified barriers to asthma treatment adherence and found that children and their parents cited challenges in effectively dividing and communicating shared responsibility for asthma management in the family. Behavioral interventions have significantly improved adherence in families with pediatric asthma. Specifically, studies have involved parents in managing children’s asthma via behavioral strategies such as shaping and/or problem solving for barriers (Bartlett, Lukk, Butz, Lampros-Klein, & Rand, 2002; Burgess, Sly, & Devadason, 2010), applying contingency management (da Costa, Rapoff, Lemanek, & Goldstein, 1997; Kamps et al., 2008), and using interactive health care devices (Guendelman, Meade, Benson, Chen, & Samuels, 2002) or audiovisual reminders (Charles et al., 2007). With a particular focus on parent–child collaboration, Otsuki and colleagues (2009) had parents provide adherence feedback to their child (aged 2–12 years) and provide rewards for meeting asthma management and adherence goals. Families used electronic monitors to track goal attainment, whereas researchers obtained pharmacy refill data to index adherence. They found a significant increase in adherence during this 2-month, home-based intervention; however, this trend was not maintained over time. These studies suggest that behavioral strategies, particularly with an adherence feedback component, show promise in improving medication adherence in pediatric asthma. These studies, however, are limited by lack of control groups (Bartlett et al., 2002), reliance on self-reported adherence (Guendelman et al., 2002), home visits that require substantial resources (Bartlett et al., 2002; Guendelman et al., 2002; Kamps et al., 2008; Otsuki et al., 2009), lack of treatment integrity measures (Bartlett et al., 2002), and no follow-up phases (Bartlett et al., 2002; Burgess et al., 2010; Guendelman et al., 2002; Kamps et al., 2008). Moreover, the literature still lacks a concerted effort to address shared parent–adolescent collaboration for asthma management tasks (i.e., division of responsibility). The pediatric diabetes literature provides some helpful directions. One study implemented a teamwork intervention focused on teaching parents and adolescents how to share responsibility for diabetes tasks and address diabetes management conflicts. The adolescents involved in the intervention had significantly improved glycemic control when compared with a standard care group (Anderson, Brackett, Ho, & Laffel, 1999). Using the Anderson et al. (1999) study as a guide, the current project used a randomized controlled trial (RCT) design to examine the efficacy of an asthma adherence intervention designed to increase youth responsibility through parent–youth collaboration and systematic fading of parental supervision of medication use. The primary goal of this study was to determine whether this parent–youth teamwork intervention improved medication adherence and related outcomes among youth with asthma. Participants were randomly assigned to one of three groups: Teamwork Intervention (TI) (i.e., establishing shared responsibility for asthma management), Asthma Education (AE) (i.e., traditional AE), and Standard Care (SC) (i.e., assessment only). Two primary hypotheses were made. Compared with youth in the comparison groups, TI participants will have significantly better medication adherence and health outcomes. Two secondary hypotheses were made: (1) Families in the TI will not have significant levels of parent–adolescent conflict throughout the study, and these levels will be significantly lower than those in the comparison groups; (2) Families in the TI will report high satisfaction with treatment procedures and outcomes.