Problem of nonadherence in chronically ill adolescents: strategies for assessment and intervention

Peer support in adolescents and young adults with chronic or rare conditions in northern America and Europe: Targeted literature review

PROBLEM

Adolescents and young adults with chronic or rare conditions face unique risks to their physical, social and emotional development. Research suggests that peer support improves their quality of life and reduces social isolation. However, there is a paucity of current information considering multiple intervention formats.

ELIGIBILITY CRITERIA

A targeted literature review was conducted to identify peer support interventions and assess their feasibility, acceptability and efficacy for this population. Searches were conducted in MEDLINE, Embase and American Psychological Association PsycINFO for records reporting peer support interventions in young adults with chronic or rare conditions. Data were extracted from relevant publications and qualitatively evaluated.

SAMPLE

Thirty studies were included, which assessed the use of peer support for young adults (aged 13-30 years) with chronic or rare conditions in Europe or North America.

RESULTS

Peer support interventions had positive effects on social positivity, psychosocial development and medical outcomes, though significance was not always demonstrated.

CONCLUSIONS

Peer support can enhance care for young adults with chronic or rare conditions. Current literature suggests that once-weekly virtual interventions are the most feasible and acceptable for patients, leading to multifaceted improvements in their well-being.

IMPLICATIONS

This study is one of the first to discuss in-person, virtual and hybrid peer-based interventions for young adults with chronic and rare conditions. While all formats improved social, psychological and medical outcomes, virtual formats may be most accessible to participants. Interventions should be made available to this population, and guidelines for optimal implementation of peer support are needed.

Facilitators and barriers to adherence to medical recommendations among adolescents with cancer: A systematic review

We aimed to systematically review barriers/facilitators of adherence among adolescents with cancer (aged 10-24 years), following a comprehensive approach to adherence that goes beyond medication-taking. Empirical studies published in English exploring determinants of adherence to medical recommendations among adolescents with cancer were identified in MEDLINE, PsycInfo, and Web of Science, up to October 2021. Records and full-text articles were reviewed by two independent reviewers, and results were classified according to the World Health Organization's (WHO) multidimensional adherence model. Eighteen studies were included. Despite heterogeneity in the definition and measurement of adherence, literature supported barriers/facilitators at patient, treatment, condition, healthcare team/system, and social/economic levels. Specifically, patient-related factors (i.e., psychological functioning and beliefs about disease and treatment) and social-related factors (i.e., family functioning) were major determinants of adolescent adherence. Few studies were conducted, and inconsistent findings were displayed for other dimensions (i.e., healthcare team/system, treatment, and condition-related factors). Adherence is a complex and multidetermined phenomenon. More research is needed to provide critical insights for policymakers and healthcare professionals in planning practices and interventions that effectively address meaningful barriers/facilitators of adolescents' adherence.

Designing a brief and simple intervention to help young people with type 1 diabetes to live well: Protocol for developing a novel intervention with participation from young people

Young people living with type 1 diabetes (T1D) navigate daily complex diabetes related tasks as they take on increasing (and eventually full) responsibility for managing their condition, in addition to developing their lives as independent adults. Alongside the need for careful day-to-day diabetes management, the psychosocial burden and mental health impact and stigma are well recognised. Despite advances in psychological care, many young people with diabetes still experience a greater mental health burden than those without diabetes. This study aims to develop a brief and simple intervention for young people with T1D that will support their wellbeing day to day, as required, and grow their ability to live confidently with their condition that requires lifelong meticulous management. Insights gained in this participatory study will guide the development and focus of the intervention which may involve a toolkit containing self-guided resources or which could be a series of recommendations on how to design a healthcare service with a support network that is tailored to the needs of young people. This study will consist of qualitative research and collaboration with young people with T1D and their siblings, friends, and peers to co-create a testable intervention. In Part 1, research interviews will be conducted with young people (16-24 years old) with T1D and, where possible, their siblings/peers to understand the day-to-day challenges of type 1 and what a novel intervention should address. Thematic analysis of interviews will inform the generation of a prototype intervention to take into part two, focus group discussions. Focus groups with (i) young people with T1D and, separately (ii) carers (comprising parents, carers, teachers, specialist nurses). Collaborative principles will be used to review, redesign and evolve the intervention to meet user needs. A blend of narrative and thematic analysis will inform the findings and report. Insights from Parts 1 and 2 will shape a user-defined and formatively analysed brief and simple intervention and future study design ready for pilot testing. The aim of this part of the research is to maximise acceptability and usability of a testable intervention by the target population. To aim of the future intervention will be to demonstrate effectiveness in helping young adults to live well with T1D.

Factors related to the readiness of Brazilian chronic pediatric patients to transition to care in adult clinics

OBJECTIVE

Advances in medicine have increased the life expectancy of pediatric patients with chronic illnesses, and challenges with the guided transition of adolescents and young adults from pediatric clinics to adult clinics have grown. The aim of this study was to better understand readiness and factors related to this transition process in Brazil.

METHOD

In this cross-sectional study of 308 patients aged from 16 to 21 years under follow-up in pediatric specialties, the degree of readiness for transition was assessed using the Transition Readiness Assessment Questionnaire (TRAQ) and its domains. Associations with demographic data, clinical data, socio-economic level, medication adherence, family functionality, and parental satisfaction with health care were evaluated.

RESULTS

The median TRAQ score was 3.7 (3.2 - 4.2). Better readiness was associated with female patients, socio-economic class A-B, current active employment, higher level of education, not failing any school year, attending medical appointments alone, functional family, and a good knowledge of disease and medications. A low correlation was observed between TRAQ and age. TRAQ presented good internal consistency (alpha-Cronbach 0.86). In the multiple linear regression, TRAQ score showed a significant association with female gender, advanced age, socio-economic class A-B, better knowledge of disease and medications, and independence to attend appointments alone.

CONCLUSION

TRAQ instrument can guide healthcare professionals to identify specific areas of approach, in order to support adolescents with chronic disease to set goals for their own personal development and improve their readiness to enter into the adult healthcare system. In this study, some factors were related to better TRAQ scores.

La négligence en matière de soins médicaux : travailler auprès des enfants, des adolescents et des familles

Les soins de santé sont un droit fondamental pour tous les enfants. Lorsque les besoins de santé de l'enfant ne sont pas respectés, quelle qu'en soit la raison, les professionnels de la santé doivent réfléchir aux obstacles en cause et aux processus nécessaires pour trouver des solutions. Des obstacles sociaux, économiques ou autres peuvent empêcher les parents d'accéder aux soins pour leur enfant. Il arrive que les avis, les priorités ou les valeurs des professionnels de la santé de l'enfant divergent de ceux des parents, ce qui compromet les soins à l'enfant. Dans certains cas, l'abstention des personnes qui s'occupent de l'enfant à assurer les soins nécessaires peut être considérée comme de la négligence en matière de soins médicaux. Des habiletés et des connaissances particulières peuvent aider les professionnels de la santé à éviter de telles situations et à collaborer avec efficacité avec la famille lorsque ces situations se produisent. Le présent document de principes offre une approche que peuvent utiliser les professionnels de la santé pour promouvoir l'intérêt supérieur, le bien-être et la sécurité des enfants ou des adolescents vulnérables à la négligence en matière de soins médicaux.

Medical neglect: Working with children, youth, and families

All children have a basic right to health care. When a child's health care needs are not met, for any reason, health care providers (HCPs) must consider the barriers involved and the processes required to resolve the situation. Social, economic, or other barriers can prevent parents from accessing care for their child. Sometimes differing opinions, priorities, or values, between a child's HCPs and parents come to impede the child receiving needed medical care. In some cases, caregiver failure to ensure needed care may be considered medical neglect. Specific skills and knowledge can help HCPs to prevent such situations from arising, and to work effectively with the family if they do. This statement offers an approach that HCPs can use to promote the best interests, well-being, and safety of children or youth at risk for medical neglect.

Efficacy of Motivational Interviewing to Improve Utilization of Mental Health Services Among Youths With Chronic Medical Conditions: A Cluster Randomized Clinical Trial

IMPORTANCE

Despite the high prevalence of anxiety and depression in youths with chronic medical conditions (CMCs), physicians encounter substantial barriers in motivating these patients to access mental health care services.

OBJECTIVE

To determine the efficacy of motivational interviewing (MI) training for pediatricians in increasing youths' use of mental health care.

DESIGN, SETTING, AND PARTICIPANTS

The COACH-MI (Chronic Conditions in Adolescents: Implementation and Evaluation of Patient-Centered Collaborative Healthcare-Motivational Interviewing) study was a single-center cluster randomized clinical trial at the University Children's Hospital specialized outpatient clinics in Düsseldorf, Germany. Treating pediatricians were cluster randomized to a 2-day MI workshop or treatment as usual (TAU). Patient recruitment and MI conversations occurred between April 2018 and May 2020 with 6-month follow-up and 1-year rescreening. Participants were youths aged 12 to 20 years with CMCs and comorbid symptoms of anxiety and depression; they were advised by their MI-trained or untrained physicians to access psychological counseling services. Statistical analysis was performed from October 2020 to April 2021.

INTERVENTIONS

MI physicians were trained through a 2-day, certified MI training course; they recommended use of mental health care services during routine clinical appointments.

MAIN OUTCOMES AND MEASURES

The primary outcome of uptake of mental health care services within the 6-month follow-up was analyzed using a logistic mixed model, adjusted for the data's cluster structure. Uptake of mental health services was defined as making at least 1 appointment by the 6-month follow-up.

RESULTS

Among 164 youths with CMCs and conspicuous anxiety or depression screening, 97 (59%) were female, 94 (57%) had MI, and 70 (43%) had TAU; the mean (SD) age was 15.2 (1.9) years. Compared with patients receiving TAU, the difference in mental health care use at 6 months among patients whose physicians had undergone MI training was not statistically significant (odds ratio [OR], 1.96; 95% CI, 0.98-3.92; P = .06). The effect was moderated by the subjective burden of disease (F2,158 = 3.42; P = .04). Counseling with an MI-trained physician also led to lower anxiety symptom scores at 1-year rescreening (F1,130 = 4.11; P = .045). MI training was associated with longer conversations between patients and physicians (30.3 [16.7] minutes vs 16.8 [12.5] minutes; P < .001), and conversation length significantly influenced uptake rates across conditions (OR, 1.03; 95% CI, 1.01-1.06; P = .005).

CONCLUSIONS AND RELEVANCE

In this study, use of MI in specialized pediatric consultations did not increase the use of mental health care services among youths with CMCs but did lead to longer patient-physician conversations and lower anxiety scores at 1 year. Additional research is required to determine whether varying scope and duration of MI training for physicians could encourage youths with CMCs to seek counseling and thus improve integrated care models.

TRIAL REGISTRATION

German Trials Registry: DRKS00014043.

Age and sex determine conversion from immediate-release to extended-release tacrolimus in a multi-center cohort of Canadian pediatric renal transplant recipients

ER-Tac, taken once per day, is associated with improved adherence. This study examined the potential patient and clinical factors that influence clinicians to convert pediatric patients from immediate-release to ER-Tac. This prospective multi-center observational study followed Canadian pediatric kidney transplant recipients up to 5 years post-transplant. Cox Proportional Hazards Regression was used to examine the influence of factors on conversion to ER-Tac. Sixty-six participants were included in this analysis. For every additional year of age at the time of transplant, the likelihood of conversion was more than doubled (HR 2.54, CI 1.83, 3.54, P < 0.001). The impact of age reduced by three percent for every month after transplant (HR 0.97, CI 0.95, 0.98, P < 0.001). Girls were more likely to be converted than boys (HR 3.78, CI 1.35, 10.6, P 0.01). Adherence measures (MAM-MM and tacrolimus trough variability), individual barriers to adherence, renal function, HLA mismatch, and rejection were not significant predictors of conversion in the final regression model. ER-Tac was preferentially prescribed to older age and female patients. Female sex and adolescence are both associated with worse graft outcomes, but we found no link between individualized markers of adherence/graft risk and conversion. Clinicians appeared to be using demographic features to distinguish patients at perceived higher risk and converted accordingly, without a case-by-case evaluation of who is more susceptible to poor outcomes.

Effectiveness of self-management programmes for adolescents with a chronic illness: A systematic review

AIM

To assess what is known about the effectiveness of face-to-face self-management programmes designed specifically for adolescents (10-19 years) with a chronic illness.

DESIGN

A systematic review and synthesis without meta-analysis (SWiM).

DATA SOURCES

Six international web-based reference libraries were searched with a date range of 1946 to July 2020.

REVIEW METHOD

The PRISMA statement and SWiM guideline were used for reporting the methods and results. The PICO format was used to develop a focused clinical question and the eligibility criteria of our review. Quality assessment of the included studies was performed using the Cochrane Effective Practice Organisation of Care criteria.

RESULTS

Eight studies (four randomized controlled trials and four descriptive designs) met the inclusion criteria and were published between 2003 and 2017. Results of the review: Three studies demonstrated measures of illness control which showed initial improvements in adherence as a result of the interventions but failed to demonstrate sustained adherence over time. Booster sessions were identified as an effective strategy to improve adherence, but were often omitted.

CONCLUSIONS

There is a limited body of evidence on the effectiveness of self-management programmes specifically developed for adolescents with a chronic illness, an important but under researched area. Future research lies in the development of more rigorous studies that focus on quantitative outcome measures for evaluating the effectiveness of self-management programmes to guide the development of future programmes.

IMPACT

It is crucial for adolescents with a chronic illness to develop independence and the self-management skills required to effectively manage their chronic condition as they transition to adulthood. On current evidence, in planning future self-management interventions should include booster sessions. Nurses with additional training and experience have a key role in supporting adolescents with a chronic illness to develop self-management skills as they assume responsibility for their own healthcare.

Care of Pediatric Solid Organ Transplant Recipients: An Overview for Primary Care Providers

As the number of living pediatric solid organ transplant (SOT) recipients continues to grow, there is an increased likelihood that primary care providers (PCPs) will encounter pediatric SOT recipients in their practices. In addition, as end-stage organ failure is replaced with chronic medical conditions in transplant recipients, there is a need for a comprehensive approach to their management. PCPs can significantly enhance the care of immunosuppressed hosts by advising parents of safety considerations and avoiding adverse drug interactions. Together with subspecialty providers, PCPs are responsible for ensuring that appropriate vaccinations are given and can play an important role in the diagnosis of infections. Through early recognition of rejection and posttransplant complications, PCPs can minimize morbidity. Growth and development can be optimized through frequent assessments and timely referrals. Adherence to immunosuppressive regimens can be greatly improved through reinforcement at every encounter, particularly among adolescents. PCPs can also improve long-term outcomes by easing the transition of pediatric SOT recipients to adult providers. Although guidelines exist for the primary care management of adult SOT recipients, comprehensive guidance is lacking for pediatric providers. In this evidence-based overview, we outline the main issues affecting pediatric SOT recipients and provide guidance for PCPs regarding their management from the first encounter after the transplant to the main challenges that arise in childhood and adolescence. Overall, PCPs can and should use their expertise and serve as an additional layer of support in conjunction with the transplant center for families that are caring for a pediatric SOT recipient.

Development of the InCharge Health Mobile App to Improve Adherence to Hydroxyurea in Patients With Sickle Cell Disease: User-Centered Design Approach

Background

Sickle cell disease (SCD) is an inherited blood disorder causing acute complications and chronic progressive end organ damage. SCD is associated with significant morbidity, early mortality, impaired health-related quality of life, and increased acute health care utilization. Hydroxyurea is a US Food and Drug Administration–approved medication that reduces disease complications, acute health care utilization, and costs. However, adherence to hydroxyurea is suboptimal. Mobile health (mHealth) interventions have the potential to improve hydroxyurea adherence, but few examples exist that are specific to the SCD population.

Objective

This study aimed to design a mHealth intervention for individuals with SCD to improve adherence to hydroxyurea, using a user-centered design that was informed by specific barriers to hydroxyurea adherence and utilization in this population.

Methods

This study consisted of 4 phases. In phase 1, individuals with SCD and health care providers participated in an optimization digital workshop. In phase 2, patients completed surveys pertaining to their interest in mHealth use, barriers and facilitators to hydroxyurea use, and health literacy. Phases 3 and 4 involved semistructured interviews and focus groups, respectively, and used the Health Belief Model (HBM) as the framework to investigate drivers of poor hydroxyurea adherence and to inform the development of an app prototype. In addition, in phase 4, we have incorporated the patients’ feedback on the preliminary app prototype and its features.

Results

Barriers to hydroxyurea adherence were consistent with the literature and included forgetfulness and several specific thoughts and emotions associated with hydroxyurea use (eg, fear of side effects, depression, stigma, and hopelessness). In addition, more than half of the participants reported potentially low health literacy. Preferred patient app features included 7 key components, namely (1) medication reminders and tracker, (2) disease education, (3) communication, (4) personalization, (5) motivation, (6) support during pain episodes, and (7) social support. Utilizing a user-centered design approach, data obtained from patients and providers were translated into features within the app, mapping to components of the HBM and the specific drivers of hydroxyurea adherence and matching the literacy level of the population, resulting in the development of a novel mobile app called InCharge Health.

Conclusions

The InCharge Health app is an mHealth intervention developed with substantial input from users and by mapping the HBM as the framework that guided the choice for its components. InCharge Health is a customized product for the SCD population aimed at optimizing medication adherence, with the end goal of improving quality of life and health outcomes among patients with SCD. The efficacy and implementation of the InCharge Health app as an mHealth intervention to promote hydroxyurea adherence will be tested in a future stepped-wedge multicenter trial for adolescents and adults with SCD.

The "combined team" transition clinic model in endocrinology results in high adherence rates and patient satisfaction

Background A structured transition process for young adults with chronic medical conditions from pediatric to adult clinics is strongly promoted. However, the most appropriate transition model has not yet been determined. This study evaluated the effect of a "combined team" Endocrinology Transition Clinic model, including a joint meeting with the patient and pediatric and adult endocrinologists, regarding medical treatment, adherence to follow-up and patient satisfaction with the process. Methods Clinical and demographic data of patients admitted to the Endocrinology Transition Clinic were collected. The clinical impact of the transition meeting was evaluated based on treatment modifications and patient adherence to follow-up. Patient satisfaction was evaluated using a questionnaire. Results From September 2014 through November 2018, 107 patients attended the Endocrinology Transition Clinic, 85.0% were females, mean age 19.7 ± 2.2 years (range 16-29), 97.2% were unmarried. The most common endocrine disorders were obesity (41.1%), Hashimoto's thyroiditis (41.1%) and ovarian hyperandrogenism (38.3%). The Transition Clinic visit modified treatment and/or evaluation for 48 (44.8%) patients. Adherence to follow-up in the adult clinic was 82.9% and was not associated with gender (p = 0.366), ethnicity (p = 0.725), age at transition (p = 0.479) or obesity (p = 0.375). Overall satisfaction reported by 65/85 patients was high (86.8%), although higher among patients who were adherent to follow-up (89.4% vs. 65.6%, p = 0.006). Conclusions The "combined team" transition model in endocrinology requires relatively few resources and has considerable clinical impact, high adherence to follow-up and high patient satisfaction rate. Implementing this model at the interface of pediatric and adult endocrinology units, and possibly in other medical fields, is feasible and efficient.

"Drugs Don't Work in Patients Who Don't Take Them"

The more recent term "adherence" is now taking the place of the earlier notion of "compliance," as it emphasizes the physician-patient partnership. To date, however, it has not been clearly defined. There are many limitations to measuring adherence, and presently no standard methods have been established. Even in clinical trials throughout medicine, the reported rates for adherence range only between 43 % and 78 %. Particularly medication adherence is highly relevant to the treatment of mentally ill adolescents, as they make up a population especially vulnerable to nonadherence - and high rates thereof have been reported. Factors influencing adherence are poorly understood and researched, especially in adolescents with mental illness. Physicians can currently rely only on concepts from other populations and expert recommendations. Concepts for children or adults should not directly be transferred to adolescent patients. Results from the current "SEMA" study should contribute to guiding future research in the development of interventions to improve medication adherence, in particular for this juvenile population.

Multidisciplinary Consensus on the Nonadherence to Clinical Management of Inhaled Therapy in Spanish asthma patients

PURPOSE

Rates of nonadherence to asthma treatment in Spain are between 24% and 76%, which results in poor disease control and increased health care costs. The main objective of this multidisciplinary consensus was to investigate the opinions of health professionals and patients regarding adherence to inhaled therapy in Spain. The results will help to identify the causes of nonadherence and to establish strategies to detect and correct the problem.

METHODS

This research was conducted by using a modified Delphi method organized into 2 rounds and involving a panel of 64 physicians, 16 nurses, and 10 community pharmacists. In addition, 70 patients with asthma completed a simplified 1-round survey, based on the Delphi questionnaire. The items proposed to reach a consensus included topics such as impact and causes of nonadherence, as well as strategies to improve adherence to treatment.

FINDINGS

Expert panelists reached a consensus on ~80% of the items proposed. They agreed that the lack of control in asthma has an important economic impact. The causes of nonadherence with more agreement were the patients' beliefs about treatment and the complexity of the inhalation devices. Panelists agreed that the most important strategies to improve adherence were modification of patients' beliefs, training of professionals in the management of adherence, and personalization of interventions. Most patients only agreed with items that referred to strategies to improve adherence.

IMPLICATIONS

Although the problems, impact, causes, and interventions regarding nonadherence to asthma treatment are known, adequate monitoring of adherence to treatment is not performed. A multidisciplinary and personalized approach is necessary to control and improve adherence.

Text Messaging and Mobile Phone Apps as Interventions to Improve Adherence in Adolescents With Chronic Health Conditions: A Systematic Review

BACKGROUND

The number of adolescents with chronic health conditions (CHCs) continues to increase. Medication nonadherence is a global challenge among adolescents across chronic conditions and is associated with poor health outcomes. While there has been growing interest in the use of mHealth technology to improve medication adherence among adolescents with CHCs, particularly text messaging and mobile phone apps, there has been no prior systematic review of their efficacy.

OBJECTIVE

The purpose of this review was to systematically evaluate the most recent evidence for the efficacy of text messaging and mobile phone apps as interventions to promote medication adherence among adolescents with CHCs.

METHODS

PubMed, Embase, CENTRAL, PsycINFO, Web of Science, Google Scholar, and additional databases were searched from 1995 until November 2015. An additional hand search of related themes in the Journal of Medical Internet Research was also conducted. The Preferred Reporting Results of Systematic Reviews and Meta-Analyses guidelines were followed. Two reviewers independently screened titles/abstracts, assessed full-text articles, extracted data from included articles, and assessed their quality using Grades of Recommendation, Assessment, Development, and Evaluation criteria. Included studies were described in original research articles that targeted adherence in adolescents with CHCs (12-24 years-old).

RESULTS

Of the 1423 records examined, 15 met predefined criteria: text messaging (n=12) and mobile phone apps (n=3). Most studies were performed in the United States (11/15, 73%), were randomized-controlled trials (8/15, 53%), had a sample size <50 (11/15, 73%), and included adherence self-report and/or biomarkers (9/15, 60%). Only four studies were designed based on a theoretical framework. Approaches for text messaging and mobile phone app interventions varied across studies. Seven articles (7/15, 47%) reported significant improvement in adherence with moderate to large standardized mean differences. Most of the included studies were of low or moderate quality. Studies varied in sample size, methods of adherence assessment, and definition of adherence, which prohibited performing a meta-analysis.

CONCLUSIONS

The use of text messaging and mobile phone app interventions to improve medication adherence among adolescents with CHCs has shown promising feasibility and acceptability, and there is modest evidence to support the efficacy of these interventions. Further evaluation of short- and long-term efficacy and cost-effectiveness of these interventions is warranted given the early and evolving state of the science.

Barriers to hydroxyurea adherence and health-related quality of life in adolescents and young adults with sickle cell disease

OBJECTIVES

To identify barriers to hydroxyurea adherence (negative beliefs, access, and/or recall barriers), and their relationship to adherence rates and health-related quality of life (HRQOL) among adolescents and young adults (AYA) with sickle cell disease (SCD).

METHODS

A cross-sectional survey was administered to 34 AYAs (12-22 years old) in SCD clinics from January to December 2015. Study measures included Brief Medication Questionnaire, Modified Morisky Adherence Scale 8-items, visual analog scale, and Patient Reported Outcomes Measurement Information System.

RESULTS

Participants (59% male; 91% Black) had a median age of 13.5 years (IQR 12-18). Participants reported negative beliefs (32%), recall barriers (44%), and access barriers (32%). Participants with recall barriers reported worse pain (P=.02), fatigue (P=.05), and depression (P=.05). The number of adherence barriers inversely correlated with adherence level using ©MMAS-8 (r_s =-.38, P=.02) and VAS_dose (r_s =-.25, P=.14) as well as MCV (r_s =-.45, P=.01) and HbF% (r_s =-.36, P=.05), suggesting higher hydroxyurea adherence in patients with fewer barriers.

CONCLUSIONS

Patients with fewer barriers to hydroxyurea adherence were more likely to have higher adherence rates and better HRQOL scores. Routine assessment of hydroxyurea adherence and its related barriers could provide actionable information to improve adherence rates, HRQOL, and other clinical outcomes.

Common Factors in Pediatric Psychiatry: A Review of Essential and Adjunctive Mechanisms of Treatment Outcome

OBJECTIVE

The purpose of this article is to review the literature on hypothesized behavioral correlates of pharmacotherapy treatment response. A particular focus is placed on what have been referred to as "common factors" across mental health treatments, including medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes. These understudied factors may provide unique explanations for mechanisms of symptom change, patient risk as a result of protocol deviation, and attenuated treatment outcomes.

METHOD

A literature search was conducted to evaluate the relationship between treatment processes in pediatric psychiatry and medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes.

RESULTS

Substantial variability and room for improvement was identified for each common factor. Behavioral protocols have already been developed to address many aspects of common factors in pediatric psychiatric treatment, but are not yet a part of many practice parameters.

CONCLUSION

Interventions to improve common factors can be used immediately in tandem with psychopharmacological interventions to provide increased symptom relief and reduce patient risk. Furthermore, incorporating instruction in common factors interventions can positively affect training of future providers and enhance understanding of the mechanisms of effect of medications. An increased focus on common factors, with a particular emphasis on quantifying the magnitude and mechanisms of their effects on psychopharmacological interventions stand to benefit child patients, their families, treatment providers, training facilities, and pharmaceutical manufacturers.

Development and preliminary effectiveness of an innovative treatment for binge eating in racially diverse adolescent girls

INTRODUCTION

Binge and loss of control (LOC) eating are significant concerns among many adolescents and are associated with poor physical, social, and psychological functioning. Black girls appear to be particularly vulnerable to binge and LOC eating. Yet, empirically validated, culturally sensitive treatments for these disordered eating behaviors are not well established. This investigation examined satisfaction, feasibility, and preliminary outcomes of a binge eating intervention for ethnically diverse adolescent girls.

METHODS

Participants were 45 girls (age 13-17years; 44.4% white, 42.2% black) randomized into a dialectical behavior therapy (DBT)-based intervention (Linking Individuals Being Emotionally Real, LIBER8) or a weight management group (2BFit). Following each meeting, participants completed satisfaction measures, and therapists assessed intervention feasibility. Participants also completed assessments of eating behavior and related psychological constructs at baseline, immediately following the intervention, and at 3-month follow-up.

RESULTS

Descriptive statistics indicated that LIBER8 was feasible, and participants were highly satisfied with this intervention. Significant reductions in eating disorder cognitions, dietary restraint, and eating in response to negative affect were observed for participants in both groups, with no differences between LIBER8 and 2BFit.

DISCUSSION

The acceptability and feasibility of LIBER8 and associated reductions in emotional eating show promise in ameliorating binge eating and provide insight into multiple options for treating this challenging eating concern.

BREATHER (PENTA 16) short-cycle therapy (SCT) (5 days on/2 days off) in young people with chronic human immunodeficiency virus infection: an open, randomised, parallel-group Phase II/III trial

BACKGROUND

For human immunodeficiency virus (HIV)-infected adolescents facing lifelong antiretroviral therapy (ART), short-cycle therapy (SCT) with long-acting agents offers the potential for drug-free weekends, less toxicity, better adherence and cost savings.

OBJECTIVES

To determine whether or not efavirenz (EFV)-based ART in short cycles of 5 days on and 2 days off is as efficacious (in maintaining virological suppression) as continuous EFV-based ART (continuous therapy; CT). Secondary objectives included the occurrence of new clinical HIV events or death, changes in immunological status, emergence of HIV drug resistance, drug toxicity and changes in therapy.

DESIGN

Open, randomised, non-inferiority trial.

SETTING

Europe, Thailand, Uganda, Argentina and the USA.

PARTICIPANTS

Young people (aged 8-24 years) on EFV plus two nucleoside reverse transcriptase inhibitors and with a HIV-1 ribonucleic acid level [viral load (VL)] of < 50 copies/ml for > 12 months.

INTERVENTIONS

Young people were randomised to continue daily ART (CT) or change to SCT (5 days on, 2 days off ART).

MAIN OUTCOME MEASURES

Follow-up was for a minimum of 48 weeks (0, 4 and 12 weeks and then 12-weekly visits). The primary outcome was the difference between arms in the proportion with VL > 50 copies/ml (confirmed) by 48 weeks, estimated using the Kaplan-Meier method (12% non-inferiority margin) adjusted for region and age.

RESULTS

In total, 199 young people (11 countries) were randomised (n = 99 SCT group, n = 100 CT group) and followed for a median of 86 weeks. Overall, 53% were male; the median age was 14 years (21% ≥ 18 years); 13% were from the UK, 56% were black, 19% were Asian and 21% were Caucasian; and the median CD4% and CD4 count were 34% and 735 cells/mm(3), respectively. By week 48, only one participant (CT) was lost to follow-up. The SCT arm had a 27% decreased drug exposure as measured by the adherence questionnaire and a MEMSCap(™) Medication Event Monitoring System (MEMSCap Inc., Durham, NC, USA) substudy (median cap openings per week: SCT group, n = 5; CT group, n = 7). By 48 weeks, six participants in the SCT group and seven in the CT group had a confirmed VL > 50 copies/ml [difference -1.2%, 90% confidence interval (CI) -7.3% to 4.9%] and two in the SCT group and four in the CT group had a confirmed VL > 400 copies/ml (difference -2.1%, 90% CI -6.2% to 1.9%). All six participants in the SCT group with a VL > 50 copies/ml resumed daily ART, of whom five were resuppressed, three were on the same regimen and two with a switch; two others on SCT resumed daily ART for other reasons. Overall, three participants in the SCT group and nine in the CT group (p = 0.1) changed ART regimen, five because of toxicity, four for simplification reasons, two because of compliance issues and one because of VL failure. Seven young people (SCT group, n = 2; CT group, n = 5) had major non-nucleoside reverse transcriptase inhibitor mutations at VL failure, of whom two (n = 1 SCT group, n = 1 CT group) had the M184V mutation. Two young people had new Centers for Disease Control B events (SCT group, n = 1; CT group, n = 1). There were no significant differences between SCT and CT in grade 3/4 adverse events (13 vs. 14) or in serious adverse events (7 vs. 6); there were fewer ART-related adverse events in the SCT arm (2 vs. 14; p = 0.02). At week 48 there was no evidence that SCT led to increased inflammation using an extensive panel of markers. Young people expressed a strong preference for SCT in a qualitative substudy and in pre- and post-trial questionnaires. In total, 98% of the young people are taking part in a 2-year follow-up extension of the trial.

CONCLUSIONS

Non-inferiority of VL suppression in young people on EFV-based first-line ART with a VL of < 50 copies/ml was demonstrated for SCT compared with CT, with similar resistance, safety and inflammatory marker profiles. The SCT group had fewer ART-related adverse events. Further evaluation of the immunological and virological impact of SCT is ongoing. A limitation of the trial is that the results cannot be generalised to settings where VL monitoring is either not available or infrequent, nor to use of low-dose EFV. Two-year extended follow-up of the trial is ongoing to confirm the durability of the SCT strategy. Further trials of SCT in settings with infrequent VL monitoring and with other antiretroviral drugs such as tenofovir alafenamide, which has a long intracellular half-life, and/or dolutegravir, which has a higher barrier to resistance, are planned.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN97755073; EUDRACT 2009-012947-40; and CTA 27505/0005/001-0001.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (projects 08/53/25 and 11/136/108), the European Commission through EuroCoord (FP7/2007/2015), the Economic and Social Research Council, the PENTA Foundation, the Medical Research Council and INSERM SC10-US19, France, and will be published in full in Health Technology Assessment; Vol. 20, No. 49. See the NIHR Journals Library website for further project information.

Patterns and predictors of medication adherence to lipid-lowering therapy in children aged 8 to 20 years

BACKGROUND

The American Academy of Pediatrics recommends lipid-lowering therapy (LLT) for children at high risk of cardiovascular disease. However, the use of LLT in children is rare, and rates of nonadherence are unknown.

OBJECTIVE

To identify patterns of use and predictors of nonadherence to LLT in children aged 8 to 20 years and the subgroup with dyslipidemia.

METHODS

Commercially insured patients with a new dispensing for an LLT were included. Nonadherence was defined as a gap of >90 days between the last dispensing plus the medication days supply and the next dispensing or censoring. Descriptive statistics characterize the patterns of LLT adherence and class-specific drug switching. Kaplan-Meier curves and multivariable Cox proportional hazard models identified time to, and predictors of, nonadherence for the cohort and the dyslipidemia subgroup.

RESULTS

Of the 8710 patients meeting inclusion criteria, 87% were nonadherent. Statins were the most common index prescription, and patients with an index statin dispensing were more likely to have multiple comorbidities and other prescription drug use. In multivariable analyses, nonadherence was inversely associated with dyslipidemia (hazard ratio [HR] = 0.61, 95% confidence interval [CI] = 0.57-0.65), chronic kidney disease (HR = 0.69, 95% CI = 0.54-0.88), higher outpatient (HR = 0.87, 95% CI = 0.77-0.98), and inpatient (HR = 0.83, 95% CI = 0.70-0.97) use. When limited to patients with dyslipidemia, nonadherence was related to age (HR = 1.21, 95% CI = 1.07-1.38) and obesity (HR = 1.23, 95% CI = 1.02-1.49).

CONCLUSIONS

Despite recommendations to begin continuous treatment early for high-risk children, nonadherence to LLT is frequent in this population, with modestly higher adherence in children with dyslipidemia.

Illness perceptions determine psychological distress and quality of life in youngsters with epilepsy

The aim of this cross-sectional study was to explore the extent to which gender, epilepsy severity, and self-regulation concepts (illness perceptions, autonomous treatment regulation, perceived autonomy support by parents) predict psychological distress and quality of life (QoL) in young patients with epilepsy. Structured interviews were conducted in 100 patients (Mage=13.9, SD=2.21, 41% girls), and data were analyzed by means of multiple hierarchical regression analyses. Seizures of most patients (91%) were well controlled by antiepileptics, 3% of the patients had infrequent seizures, and seizures in 6% were pharmacoresistant. At a multivariate level, it appeared that youngsters with epilepsy who expect that their disease will last for a long time, who believe that they have less personal control over their illness, and who expect the illness to have a high emotional impact reported higher levels of distress. In addition, a better QoL was reported by youngsters who believed that treatment did not control their illness and who thought that their epilepsy would not affect them emotionally. Findings indicate the importance of illness perceptions, and it is suggested that they should be targeted in future interventions in youngsters with epilepsy.

Medication compliance protocol for pediatric patients with severe intellectual and behavioral disabilities

Pediatric nurses are well aware of patient medication refusal. For a variety of reasons, many pediatric patients are noncompliant with their medication regimen. Medication administration is even more difficult when the population has severe intellectual and behavioral disabilities. An inpatient unit composed of children with these diagnoses presented a unique challenge. To address this issue, the unit RNs devised a medication compliance protocol. Initial implementation resulted in a success rate of 83.3% for six patients, after 4 weeks. Despite the small sample size, the RNs experienced a positive outcome with medication administration through consistent application of a medication compliance protocol.

Usability testing of the Internet program: "Teens Taking Charge: Managing My Transplant Online"

Adolescents with SOT demonstrate high rates of medication non-adherence and higher rates of graft loss compared to all other age groups. Self-management interventions encompass information-based material designed to achieve disease-related learning and changes in the participant's knowledge and skill acquisition, while providing social support. These interventions have had some success in chronic disease populations by reducing symptoms and promoting self-efficacy and empowerment. Using findings from a needs assessment, an Internet-based self-management program, Teens Taking Charge: Managing My Transplant Online, for youth with SOT was developed. This program contains information on transplant, self-management and transition skills, and opportunities for peer support. The purpose of this study was to determine the usability and acceptability of the initial three modules (Medication and Vaccines; Diet after Transplant; and Living with a Transplant Organ) of the online program from the perspectives of youth with SOT. Participants were recruited from SOT clinics at a large pediatric tertiary care center in Canada. Three iterative cycles (seven patients per iteration) of usability testing took place to refine the Web site prototype. Study procedures involved participants finding items from a standardized list of features and talking aloud about issues they encountered, followed by a semi-structured interview to generate feedback about what they liked and disliked about the program. All 21 patients (mean age = 14.9 yr) found the Web site content to be trustworthy, they liked the picture content, and they found the videos of peer experiences to be particularly helpful. Participants had some difficulties finding information within submodules and suggested a more simplistic design with easier navigation. This web-based intervention is appealing to teenagers and may foster improved self-management with their SOT. Nine additional teen and two parent modules are being developed, and the completed Web site will undergo usability testing. In the future, a randomized control trial will determine the feasibility and effectiveness of this online self-management program on adherence, self-efficacy, and transition skills.

Liver disease in the adolescent

This article discusses common liver diseases in the adolescent. Briefly reviewed is the evaluation of the adolescent with new-onset liver enzyme elevation. Then the article discusses common liver diseases, such as nonalcoholic fatty liver disease, hepatitis, metabolic disease, biliary atresia, cystic fibrosis, and inherited disorders of cholestasis. Finally, a management approach to the adolescent with liver disease is outlined, noting the challenges that must be addressed to effectively care for not only liver disease in the adolescent but also the patient as a whole.

An examination of the Allocation of Treatment Responsibility scale in adolescents with epilepsy

The purpose of the current study was to examine the psychometric properties of the adapted Allocation of Treatment Responsibility (ATR) scale and the distribution of tasks related to oral medication and clinic and laboratory visits in a sample of adolescents with epilepsy. Adolescents with epilepsy (N = 50; ages 13-17 years) and their caregivers completed the adapted ATR and a measure of medication management. Internal consistency for the adapted ATR was strong (total and subscale range: 0.75-0.97). Validity was partially supported by significant correlations between adolescent age and ATR oral medication responsibility for both respondent measures. Allocation of Treatment Responsibility total scores were not associated with adherence to medications and clinic appointments. Initial findings are promising and have important implications for assessing the distribution of treatment responsibility among adolescents with epilepsy and their families.

The adolescent liver transplant patient

The rapid development of new diagnostic tests and improved therapy, especially the success of liver transplantation, has changed the outcome for children with liver disease, many of whom survive into adolescence without liver transplantation. The indications for transplantation in adolescence are similar to pediatric indications and reflect the medical advances made in this specialty that allow later transplantation. These young people need a different approach to management that involves consideration of their physical and psychological stage of development. A focused approach to their eventual transition to adult care is essential for long-term survival and quality of life.

Adherence to a vitamin D supplement intervention in urban schoolchildren

Vitamin D supplementation is an important strategy for preventing low levels of serum 25OHD and improving bone health and consequent associated health risks, especially in children at risk of deficiency. Although vitamin D supplements are recommended, there is limited research on the factors that influence adherence to taking them. In a cross-sectional sample of 256 child (aged 9 to 15 years) and parent pairs in the Boston, MA, area during January to March 2012, analysis of covariance was used to determine associations between health beliefs about vitamin D, parental vitamin D-containing supplement use, and the individual responsible for pill administration with supplement adherence measured by pill counts. Mean and median supplement pill count adherence over 3 months were 84% and 89%, respectively. Adherence was positively associated with parents' use of vitamin D-containing supplements (7% higher, P=0.008) and with combined child and parent responsibility for administration of the supplement compared with child only (9% higher, P=0.03). Parents' beliefs about vitamin D neither predicted their children's beliefs nor positively influenced children's adherence. Adherence was higher when parents took vitamin D-containing supplements and when parents and children shared responsibility for administering the supplement. Promoting child supplement use through parent involvement and role modeling may be a practical solution for registered dietitians who are aiming to improve vitamin D adherence in at-risk youth.

Self-reported adherence to medications in a pediatric renal clinic: psychological aspects

Background

Chronically ill children and adolescents comprise a vulnerable population that requires specific considerations in order to positively impact their treatment outcome. Pediatric renal patients can be non-compliant and also forgetful in taking their medications.

Objective

The objectives of the study were to (a) assess medication adherence and (b) to identify emotionality and variables that influence non-adherence by use of “The Child & Adolescent Adherence to Medication Questionnaire” (CAAMQ), which was constructed at Texas Tech University Health Sciences Center.

Methods

Pediatric renal patients from 10 to 21 years-of-age, taking three or more medications, for longer than a three-month period, were eligible to complete the CAAMQ.

Results

Thirty-four patients participated in the study. Many of the respondents had problems remembering to take their medications on weekends (P = 0.021). The majority of the patients stated that they were not bothered about having to take their medications (70.6%); and that taking pills did not interfere with their daily activities (85.3%). Open-ended questions in the CAAMQ identified patients’ feelings of sadness, distress, and the importance of strong family support systems. The study participants reported that they preferred to take their medications at school, in the nurses’ office or in a place where privacy was assured. The results indicated that Prednisone was the most disliked of all of the medications. Female patients were more reactive and secretive than males regarding peers knowing about their disease and medication schedules (P<0.017).

Conclusions

Non-adherence in pediatric patients is a complex and serious problem, which ultimately affects the patients’ health. Privacy and daily routine were found to impact the patients’ adherence to medications. Creative and individualized reminders for teenagers need to be developed and validated. Further studies that take into consideration developmental and motivational factors may help researchers identify modifiable psychosocial predictors that will lead to improved medication adherence.

An exploratory study of the factors associated with medication nonadherence among youth in adult mental health facilities in Ontario, Canada

Although the issue of medication nonadherence among children and youth appears to be high, there is a paucity of research examining associated factors related to medication nonadherence among youth with mental health difficulties. Using logistic regression, this exploratory study sought to examine specific factors associated with medication nonadherence among youth with mental health needs in Ontario, Canada. Data on 3681 youth between the ages of 12-18 years old were obtained from the Resident Assessment Instrument for Mental Health (RAI-MH). Medication nonadherence was observed among 24.6% of the study population. Multivariate results showed that youth who experienced side effects of psychotropic medication were more than 3 times more likely to have failed to adhere to their medication. Other significant factors contributing to medication nonadherence include age, having multiple psychiatric admissions, limited insight into mental health, and having a disturbed/dysfunctional relationship with immediate family members. Tobacco use, cannabis use, depressive symptoms, and positive symptoms were also associated with medication nonadherence. Our data highlights some of the factors associated with medication nonadherence among youth with mental health needs. Physicians, clinicians and mental health care providers need to consider these factors, particularly when planning for discharge.

Transition in endocrinology: the challenge of maintaining continuity

OBJECTIVE

Transition from child to adult status is a crucial stage in young people's lives. It is important that young people continue to receive appropriate endocrine care throughout and following transfer from paediatric to adult services. This study examined indicators of patient loss to follow-up at initial transfer from paediatric care to identify implications for transitional care practice and research.

METHODS

A retrospective analysis of patient data following transfer from paediatric services to a young person's transition clinic was conducted. Attendance data from 103 patients transferred to the Young Person's Clinic were analysed to determine the factors affecting nonattendance 1-year post-transfer.

RESULTS

We found that overall one quarter of patients did not attend the young person's clinic in the first year after transfer. Those with poor attendance prior to transfer were likely to be poor attenders post-transfer. Further, those without an appointment scheduled in the first 6 months of their final paediatric transfer appointment were less likely to attend in the first year.

CONCLUSIONS

Young people are at risk of losing contact during the transfer from paediatric to the young person's clinic. Measures that promote continuity of contact could reduce the risk of long-term disengagement with care. Further development and research is required to identify the best ways to help young people with endocrine conditions in the transition from child to adult status.

LIBER8 design and methods: an integrative intervention for loss of control eating among African American and White adolescent girls

Loss of control (LOC) eating affects a significant number of adolescents of all racial and ethnic backgrounds and is associated with numerous psychosocial problems, including depression, anxiety, low self-esteem, body dissatisfaction, and weight concerns. However, empirically validated, culturally sensitive treatments for adolescents with these disordered eating behaviors are not available. This pilot project involved designing a developmentally and culturally appropriate treatment for LOC eating for adolescent girls. We intend to conduct multiple focus groups with adolescent girls who engage in LOC eating, and their primary caregivers. Data from these groups will inform the subsequent creation of a manualized treatment protocol. We will then evaluate the efficacy of this intervention (LIBER8-Linking Individuals Being Emotionally Real) to reduce LOC eating. This intervention will integrate components of dialectical behavior therapy, such as mindfulness and distress tolerance skills training, and cognitive-behavioral therapy. We will also integrate text-messaging, a key adolescent communication strategy, as a means of self-monitoring. Participants meeting study criteria will be offered participation in this 12-week randomized controlled trial comparing LIBER8 to a weight management control condition (2BFit). We hypothesize that this intervention will serve to reduce LOC eating, as well as improve psychosocial functioning as evidenced by decreased depression, anxiety, eating disorder cognitions, emotional eating, impulsivity, and improved quality of life. The feasibility and acceptability of this intervention will be extensively evaluated with the explicit intent of informing a subsequent larger randomized controlled trial.

Predictors of positive airway pressure therapy adherence in children: a prospective study

STUDY OBJECTIVES

Children with obstructive sleep apnea are increasingly being treated with positive airway pressure (PAP), particularly if they have underlying medical conditions. Although PAP is an effective treatment, its use is challenging due to poor adherence. We hypothesized that demographic, psychosocial, and polysomnographic parameters would be related to PAP adherence. We therefore prospectively collected data potentially pertaining to PAP adherence, and correlated it with PAP use.

METHODS

Fifty-six patients and their parents completed a series of psychosocial questionnaires prior to PAP initiation. Objective adherence data were obtained after 1 and 3 months of PAP use.

RESULTS

The population was primarily obese; 23% had neurodevelopmental disabilities. PAP adherence varied widely, with PAP being worn 22 ± 8 nights in month-1, but mean use was only 3 ± 3 h/night. The greatest predictor of use was maternal education (p = 0.002 for nights used; p = 0.033 for mean h used/night). Adherence was lower in African American children vs other races (p = 0.021). In the typically developing subgroup, adherence correlated inversely with age. Adherence did not correlate with severity of apnea, pressure levels, or psychosocial parameters other than a correlation between family social support and nights of PAP use in month-3.

CONCLUSIONS

PAP adherence in children and adolescents is related primarily to family and demographic factors rather than severity of apnea or measures of psychosocial functioning. Further research is needed to determine the relative contributions of maternal education, socioeconomic status and cultural beliefs to PAP adherence in children, in order to develop better adherence programs.

Complementary and alternative medicine use and adherence with pediatric asthma treatment

BACKGROUND AND OBJECTIVE

Complementary and alternative medicine (CAM) use for pediatric asthma is increasing. The authors of previous studies linked CAM use with decreased adherence to conventional asthma medicines; however, these studies were limited by cross-sectional design. Our objective was to assess the effect of starting CAM on pediatric adherence with daily asthma medications.

METHODS

We used a retrospective cohort study design. Telephone surveys were administered to caregivers of patients with asthma annually from 2004 to 2007. Dependent variables were percent missed doses per week and a previously validated "Medication Adherence Scale score." Independent variables included demographic factors, caregiver perception of asthma control, and initiation of CAM for asthma. We used multivariate linear regression to assess the relationship between medication adherence and previous initiation of CAM.

RESULTS

From our longitudinal data set of 1322 patients, we focused on 187 children prescribed daily medications for all 3 years of our study. Patients had high rates of adherence. The mean percent missed asthma daily controller medication doses per week was 7.7% (SD = 14.2%). Medication Adherence Scale scores (range: 4-20, with lower scores reflecting higher adherence) had an overall mean of 7.5 (SD = 2.9). In multivariate analyses, controlling for demographic factors and asthma severity, initiation of CAM use was not associated with subsequent adherence (P > .05).

CONCLUSIONS

The data from this study suggest that CAM use is not necessarily "competitive" with conventional asthma therapies; families may incorporate different health belief systems simultaneously in their asthma management. As CAM use becomes more prevalent, it is important for physicians to ask about CAM use in a nonjudgmental fashion.

Effect of communication style and physician-family relationships on satisfaction with pediatric chronic disease care

Over 8% of children have a chronic disease and many are unable to adhere to treatment. Satisfaction with chronic disease care can impact adherence. We examine how visit satisfaction is associated with physician communication style and ongoing physician-family relationships. We collected surveys and visit videos for 75 children ages 9-16 years visiting for asthma, diabetes, or sickle cell disease management. Raters assessed physician communication style (friendliness, interest, responsiveness, and dominance) from visit videos. Quality of the ongoing relationship was measured with four survey items (parent-physician relationship, child-physician relationship, comfort asking questions, and trust in the physician), while a single item assessed satisfaction. Correlations and chi square were used to assess association of satisfaction with communication style or quality of the ongoing relationship. Satisfaction was positively associated with physician to parent (p < 0.05) friendliness. Satisfaction was also associated with the quality of the ongoing parent-physician (p < 0.001) and child-physician relationships (p < 0.05), comfort asking questions (p < 0.001), and trust (p < 0.01). This shows that both the communication style and the quality of the ongoing relationship contribute to pediatric chronic disease visit satisfaction.

Adherence to oral chemotherapy in childhood acute lymphoblastic leukemia: an evolutionary concept analysis

PURPOSE/OBJECTIVES

To clarify the concept of adherence to daily oral chemotherapy in children with acute lymphoblastic leukemia (ALL), to examine its implications for clinical practice, and to provide a foundation for further research and knowledge development.

DATA SOURCES

Published literature identified through the MEDLINE®, CINAHL®, PsycINFO, and ERIC databases.

DATA SYNTHESIS

Identified attributes of adherence to oral chemotherapy in childhood ALL included motivation, persistence, collaboration, mindfulness, cognitive capacity, flexibility, active participation, and identification of key participants in the process. Identified antecedents included a diagnosis of leukemia, the perceived value of adherence, and patient, family, and healthcare system-related factors. Identified consequences included the potential for maintaining optimal drug levels and improving disease outcome, as well as increased patient and caregiver esteem through active participation in the process. Adherence in the context of childhood ALL is defined as the active self-care behavior of taking (or having the responsibility for administering) daily oral chemotherapy, in collaboration with and according to the instructions of the healthcare provider over a defined, prolonged treatment period.

CONCLUSIONS

Adherence to oral chemotherapy in childhood ALL is a complex, multidimensional behavior that involves not only a willingness to follow the prescribed regimen over a prolonged period, but also the cognitive capacity and psychomotor skills to carry out the process.

IMPLICATIONS FOR NURSING

Nurses should recognize the importance of clear communication of medication instructions, reinforcement of adherence-related behaviors, and assistance with common issues such as pill-swallowing skills and reminder systems in caring for children with ALL.

Age span challenges: adherence in pediatric oncology

OBJECTIVES

To review published literature to determine what is known about adherence to oral antineoplastic agents in children with cancer, to identify adherence-related challenges, and to examine the implications of these challenges for clinical practice.

DATA SOURCES

Published literature identified through the MEDLINE, CINAHL, and PsycINFO databases.

CONCLUSION

Oral antineoplastic agents are frequently used in childhood cancer treatment; supportive care regimens for children with cancer also rely heavily on the administration of oral medications. Adherence in pediatric oncology is a complex process involving both parent and child, and requires knowledge and understanding of proper and safe home medication administration in the context of multiple developmental and behavioral concerns that may change over time.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in adherence by providing patient and family education and psychosocial support targeted to the child's diagnosis, developmental stage, and specifics of the child's treatment regimen.

Family strategies for achieving medication adherence in pediatric kidney transplantation

BACKGROUND

Although nonadherence is well documented and strategies for adherence have been shown to be critical to overcoming barriers and improving overall adherence rates, it is unknown how family strategy use is related to adherence in the pediatric renal transplant population.

OBJECTIVES

The aims of this study were to assess (a) the strategies used by adolescents with kidney transplants and their caregivers to adhere to the posttransplant oral medication regimen and (b) the relationship of these strategies to objective adherence rates.

METHODS

Semistructured interviews to assess self-management were administered to 17 adolescents (14-18 years) and 17 caregivers. Adherence to oral immunosuppressant medication, measured via electronic monitors, was determined also for a subset of 13 dyads.

RESULTS

Common strategies endorsed by families included the following: making it part of the routine (88.2%), verbal reminders by caregiver (82.4%), caregiver verifying medication was taken (76.5%), placing medication in a convenient location (76.5%), and using a pillbox (70.6%). A greater number of family-endorsed strategies were correlated with higher levels of adherence. Of those strategies spontaneously endorsed, only caregiver reminders to take medication and caregiver verification that medications were taken were related significantly to higher adherence rates.

DISCUSSION

The findings highlight the importance of identification and use of specific strategies to improve adherence rates of pediatric renal transplant recipients and emphasize the need for continued caregiver involvement in the promotion of adherence to the treatment regimen.

A grounded theory of the process of adherence to oral chemotherapy in Hispanic and caucasian children and adolescents with acute lymphoblastic leukemia

Children and adolescents with acute lymphoblastic leukemia (ALL) receive treatment that relies on daily self- or parent/caregiver-administered oral chemotherapy for approximately 2 years. Despite the fact that pediatric ALL is uniformly fatal without adequate treatment, nonadherence to oral chemotherapy has been observed in up to one third of patients. Little is known about the reasons for nonadherence in these patients. This study used Straussian grounded theory methodology to develop and validate a model to explain the process of adherence to oral chemotherapy in children and adolescents with ALL. Thirty-eight semistructured interviews (with 17 patients and 21 parents/caregivers) and 4 focused group discussions were conducted. Three stages were identified in the process of adherence: (a) Recognizing the Threat, (b) Taking Control, and (c) Managing for the Duration. Doing Our Part was identified as the core theme explaining the process of adherence and involves the parent (or patient) taking responsibility for assuring that medications are taken as prescribed. Understanding the association between taking oral chemotherapy and control/cure of leukemia (Making the Connection) appeared to mediate adherence behaviors.

Anxiety, depression, and life satisfaction in parents caring for children with cystic fibrosis

OBJECTIVE

To assess the prevalence of symptoms of anxiety and depression and the extent of life satisfaction in parents caring for children with cystic fibrosis (CF) in Germany.

METHODS

The study included 650 caregivers of 564 children with CF ages 0-17, who completed the Hospital Anxiety Depression Scale (HADS), the Center for Epidemiologic Studies Depression Scale (CES-D) and the Questions on Life Satisfaction (FLZ(M) ).

RESULTS

More than one-third (37.2%) of parents showed elevated levels of anxious symptoms, compared to 18.9% of a population sample (P≤0.001) and significantly more parents reported elevated levels of depressive symptoms compared to a community sample (28% vs. 21%, P=0.01). Higher levels of anxious and depressive symptoms were associated with lower life satisfaction (P<0.001).

CONCLUSIONS

High levels of anxious and depressive symptoms among parents of children with CF suggested that annual symptom screening is warranted. This will facilitate identification of those at risk and provide referrals and intervention for those who are in need of it.

Predictors of medication adherence in children receiving psychotropic medication

AIM

Medication adherence is poor in many young people with chronic illness. However, little research has examined medication adherence in clinic samples of young people receiving psychotropic medication, and whether factors such as disorder or drug type influence adherence. This study aimed to examine medication adherence in children and adolescents receiving psychotropic medication.

METHODS

Young people receiving psychotropic medication and their caregivers were recruited from pharmacy and mental health services within a large metropolitan hospital. A brief cross-sectional survey examined medication history, missed doses within the previous week and other clinical information. Multiple regression analysis examined whether child characteristics, drug type and regimen characteristics were associated with medication adherence.

RESULTS

Poor adherence was associated with lack of parental involvement in medication routines (P < 0.05), use of complementary medicines (P < 0.01) and difficulty remembering doses (P < 0.01). Developmental diagnoses (P < 0.05), use of antipsychotics (P < 0.05) and use of concomitant non-psychotropic medication (P < 0.05) were predictors of good adherence.

CONCLUSION

Encouraging parental involvement in medication routines may be a practical target for clinicians aiming to improve medication adherence in young people. Use of complementary medicines may indicate a group with a higher risk of poorer adherence.

Attrition in paediatric weight management: a review of the literature and new directions

Paediatric obesity continues to be one of the most important health issues facing children and families today, and there remains a need for effective treatment options. There are a few reports in the literature demonstrating high rates of attrition from paediatric weight management programmes, ranging from 27% to 73%. While some studies show that racial/ethnic minorities, the economically disadvantaged and those with higher levels of obesity are at risk, other studies do not. There is some consistency in reasons given by families for attrition from treatment, most often scheduling issues and programmes not meeting family needs or expectations. This review highlights identified contributors to attrition from paediatric weight management and provides a framework to study this problem, based on models of adherence to paediatric medical regimens.

Adherence to antibiotic prophylaxis in children with vesicoureteral reflux

Vesicoureteral reflux (VUR) affects approximately 1% of children and may predispose a child with a bladder infection to develop pyelonephritis and renal scarring. To prevent these potential sequelae, one accepted treatment option for VUR includes low-dose continuous antibiotic prophylaxis (CAP) to maintain urine sterility until the condition resolves. Despite the widespread use of CAP, little data exists regarding adherence to long-term antibiotic therapy. Not only will poor adherence to CAP potentially preclude the intended benefit, but also nonadherence with antibiotic regimens may carry untoward effects including unnecessary treatment changes for presumed antibiotic failure, emergence of resistant organisms, and compromised clinical trial outcomes. We present an overview of medication adherence in children with VUR, discuss possible consequences of nonadherence to antibiotic prophylaxis, and suggest ways to improve adherence. We raise awareness of issues related to nonadherence relevant to healthcare providers, investigators, and the community.

Reactions of pediatricians to refusals of medical treatment for minors

PURPOSE

Treatment refusals in pediatrics must balance parental decision-making authority and best interest. General pediatricians and subspecialists were surveyed to understand the factors that influence their responses to refusals including (1) prognosis, (2) concordance of parent-minor decision, and (3) minor autonomy.

METHODS

Of 1,120 eligible pediatricians, 421 (37.6%) randomly selected from the American Academy of Pediatrics Web-based Directory completed a survey about their reactions to refusals of treatment by parents, minors, or both in cancer scenarios with a 5-year expected overall survival of 80% or 15% for both an 11-year-old and a 16-year-old minor. Statistical analyses compared pediatrician willingness to respect a refusal and the relative importance of various factors to explain physician reasoning.

RESULTS

Pediatricians were less likely to respect refusals when prognosis was good. Pediatricians were most likely to respect a refusal when prognosis was poor and when parent and minor concurred in their decision (93%, n = 360/385 for the 16-year-old vs. 89%, n = 345/386 for the 11-year-old, p < .05). When parent-minor dyad disagreed, pediatricians were more likely to accept a refusal by a 16-year-old minor as compared with an 11-year-old (28%, n = 111/393 vs. 4%, n = 18/405 in good prognosis, p < .001; and 65%, n = 251/384 vs. 20%, n = 79/389 in poor prognosis, p < .05).

CONCLUSIONS

Pediatricians' decisions whether to respect treatment refusals for minor patients are multifactorial. When prognosis is good, best interest dominates. When prognosis is poor, parental authority is more important in younger minors, and minor autonomy is more important in older minors.

Management of multiple sclerosis in adolescents - current treatment options and related adherence issues

Multiple sclerosis (MS) is a progressive inflammatory demyelinating disorder of the central nervous system that is increasingly recognized in children and adolescents. This realization comes with additional concerns about existing therapeutic options and the impact of the disease on health-related outcomes of adolescents with MS. This five-part review provides an update on management strategies relevant to the pediatric MS population. The first section gives an overview on the epidemiology and natural history of early onset MS. The second section outlines currently available MS treatments, including medications during acute relapses and long-term immunomodulatory therapies. The third section highlights adherence issues pertaining to MS, including the challenges uniquely faced by adolescents. The fourth section provides a summary of research into quality of life and psychosocial consequences of pediatric onset MS. Attention is drawn to the grief experience of affected adolescents and the importance of peer relationships. Finally, the family resilience framework is presented as a conceptual model to facilitate optimal adaptation of adolescents with MS. Healthcare professionals can promote resilience and treatment adherence by ensuring that these individuals and their families are sufficiently informed about available MS treatments, providing instrumental support for managing potential medication side effects, and addressing age-appropriate developmental needs.