Nonadherence in Children

Nonadherence with drug recommendations (see also Adherence to a Drug Regimen) may occur at any age because of

• Cost

• Painful or inconvenient administration

• The need for frequent doses, complex regimens, or both

But many unique factors contribute to nonadherence in children.

Children < 6 years old may have difficulty swallowing pills and are more likely to resist taking forms of drugs that taste bad.

Older children often resist drugs or regimens (eg, insulin, metered-dose inhalers) that require them to leave their classes or activities or that make them appear different from their peers.

Adolescents may express rebellion and assert independence from parents by not taking their drugs. They may also skip a dose of the drug without seeing any immediate adverse effects and then incorrectly reason they do not need the prescribed drug, thus becoming more and more nonadherent. Adolescents want to be like their friends and to belong to and fit into their peer group. They wear the same clothes, prefer the same sneakers, and eat the same foods to belong. Having a chronic condition marks them as different from their peer group and they are often nonadherent so they will not be seen as different from or by their friends.

Parents/caregivers may only partially remember or understand the rationale and instructions for taking a drug, and their work schedules may preclude their being available to give children their scheduled doses. Some try folk or herbal remedies initially. Some have limited income and are forced to spend their money on other priorities, such as food; others have beliefs and attitudes that prevent them from giving children drugs.

To help minimize nonadherence, a prescribing practitioner can do the following:

• Ascertain whether the patient and parent/caregiver agrees with the diagnosis, perceives it as serious, and believes the treatment will work.

• Correct misunderstandings and guide the patient and caregiver toward reliable sources of information.

• Identify motivating factors for adherence.

• Give written as well as oral instructions in a language the patient and caregiver can review and understand.

• Make early follow-up telephone calls to families to answer residual questions.

• Assess progress and remind the patient and caregiver of follow-up visits.

• Review drug bottles at follow-up office visits for pill counts.

• Educate the patient and caregiver about how to keep a daily symptom or drug diary.

Adolescents in particular need to feel in control of their illness and treatment and should be encouraged to communicate freely and to take as much responsibility as is possible for their own treatment.

Regimens should be simplified (eg, synchronizing multiple drugs and minimizing the number of daily doses while maintaining efficacy) and matched to the patient’s and caregivers’ schedules. Critical aspects of the treatment should be emphasized (eg, taking the full course of an antibiotic). If lifestyle changes (eg, in diet or exercise) are also needed, such changes should be introduced incrementally over several visits, and realistic goals should be set so as not to overwhelm the patient or caregiver. Success in achieving a goal should be reinforced with praise, and only then should the next goal be added.

For patients who require expensive long-term regimens, a list of pharmaceutical patient-assistance programs is available at NeedyMeds.