Overcoming the challenge
The question we all have asked is: how do we overcome the challenge of poor adherence in children? Most of the interventions that have demonstrated success in children with chronic illnesses use behavioral interventions or a combination of behavioral and other interventions.
The most frequently used intervention is the token reinforcement system. This intervention motivates adherence by providing tokens for taking medications successfully. The tokens can be used to earn privileges, gain access to certain activities or obtain other rewards.2
Additional tips clinicians may find useful for improving medication adherence in children and adolescents include the following:
- Attitude regarding a medication’s benefit does affect children’s willingness to take it
- Providing education to develop patients’ trust in the benefit and effectiveness of a drug regimen will assist in their understanding the necessity of taking the medication
- Using the simplest regimen that has been proven effective is key to better adherence
- Fewer pills taken fewer times each day will improve adherence in children and adults alike
The palatability of drugs can also affect adherence. Masking the taste of medication by mixing liquid medicines in juice or other beverage will make them easier to take. Another tip is to crush tablets and add them to foods like ice cream or pudding. The medication will taste better, and the child will not have to swallow a large pill. Check with your pharmacist before crushing any medicines.2
Children who are old enough should be encouraged to participate in the medication process. Let them take their medications under the supervision of a parent, and provide education to ensure safety. As youngsters get older, instruct the parent to allow them a more active role in taking their medications each day.
Getting additional family members, schools, and other social supports involved is a valuable strategy for maximizing the ability of school-age children to adhere to medication regimens.
Research on interventions to improve communication, health behavior, and adherence in pediatric settings is sparse. Parents and families need education to understand what they are being asked to do. In addition, they should be given the opportunity to provide feedback on their experience with a regimen. Sources of resistance need to be identified, and beliefs in the efficacy and benefits of treatment should be enhanced.5
Once a medication regimen has been established, ensuring that patients follow it is crucial. There are many ways to measure adherence, although some approaches are too costly and time-intensive. Direct methods include observed medication administration, measurement of the drug or its metabolite in blood, or assays for a biological marker in the urine.
Although direct approaches are more accurate at assessing adherence, they are expensive and burdensome to the clinician, and they may be susceptible to distortion by the patient.6 Indirect methods, which are the most cost-effective and feasible, include the use of patient questionnaires and self-reports, pill counts, rates of prescription refills, assessment of clinical response, use of electronic medication monitors, measurement of physiologic markers and patient diaries.2
Measurement of medication adherence in children largely relies on responses to questions (or questionnaires) by parents, caregivers, and sometimes teachers. The use of electronic monitoring is expensive and does not provide a useful solution in most clinical settings. In addition, electronic monitoring generally does not reveal whether or not the patient consumed the medicine, only that the container was opened. This is especially true when children have graduated to taking their own medication.3
The importance of persistence
In conclusion, administering medication to children and adolescents is difficult and challenging. Be patient, and know that at times adherence is going to seem impossible. As the clinician, your role is to focus on education, simplification of medication regimens, and some old-fashioned common sense. With time, issues involving medication adherence will become much easier for you and your patients.
Paul Zimbeck, NP, is a nurse practitioner specializing in cardiology at the Marshfield Clinic in Marshfield, Wisc.
- Gardiner P, Dvorkin L. “Promoting medication adherence in children.” Am Fam Physician. 2006;74:793-798.
- Lask B. “Motivating children and adolescents to improve adherence.” J Pediatr. 2003;143:430-433.
- Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-497.
- Frush KS, Luo X, Hutchinson P, Higgins JN. “Evaluation of a method to reduce over-the-counter medication dosing error.” Arch Pediatr Adolesc Med. 2004;158:620-624.
- Nevins TE. “Non-compliance and its management in teenagers.” Pediatr Transplant. 2002:6:475-479.
- Eisen SA, Miller DK, Woodward RS, et al. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med. 1990;150:1881-1884.
All electronic documents accessed January 12, 2012.