Adherence and Behavioral Health Care

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How common is this in pediatric mental health patients? A: Non-adherence to treatment recommendations is a fairly common problem for all of the chronic pediatric disorders, in that up to 50% of children have been found to have partial or complete non-adherence to treatment "/><meta id="metaKeywords" name="keywords" content="Pediatric Annals,Pediatrics,Adolescent Medicine,Ask the Experts"/><meta id="Meta1" name="scID"/><meta id="scID" name="scID"/><meta name="PostedDate" content="2013-08-01"/> <meta name="specialties" content="Pediatrics,Adolescent Medicine"/> <meta name="specialty" content="Pediatrics"/> <meta name="specialty" content="Adolescent Medicine"/> <meta name="primary_specialty" content="Pediatrics"/> <meta name="departments" content="Ask the Experts"/> <meta name="department" content="Ask the Experts"/> <meta name="content_type" content="Journal Article"/> <meta name="pageid" content="{6E6D6DBF-F676-469A-A1F7-A35AA63E94C0}"/> <meta property="og:image" content="https://web.archive.org/web/20130827043558im_/http://213a1ca8842e5e699a80-05ce35571e92a3f7383a191aa5840bba.r66.cf1.rackcdn.com/healio_safe_image.png"/><meta name="pubabbv" content="PedAnn"/><meta name="authors" content="Robert J. 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<span>›</span> <a href="/web/20130827043558/http://www.healio.com/pediatrics/journals"> Journals</a> <span>›</span> <a href="/web/20130827043558/http://www.healio.com/pediatrics/journals/pedann"> Pediatric Annals</a> </p>    <div id="SeeAlso" class="related-links"><h3>See Also</h3><ul><li><a href="https://web.archive.org/web/20130827043558/http://www.healio.com/pediatrics/journals/pedann/%7B63ecc8c8-93e8-436e-837b-77f9ab0a91e1%7D/health-care-transition-for-emerging-adults-with-chronic-health-conditions-and-disabilities">Health Care Transition for Emerging Adults with Chronic ...</a></li><li><a href="https://web.archive.org/web/20130827043558/http://www.healio.com/pediatrics/journals/pedann/%7Be590b0f8-00d0-481b-9274-a1b9cfebd515%7D/psychiatric-polypharmacy-monitoring-in-foster-care">Psychiatric Polypharmacy Monitoring in Foster Care</a></li><li><a href="https://web.archive.org/web/20130827043558/http://www.healio.com/pediatrics/journals/pedann/%7B8bafe4a6-be77-42b2-b716-c88fca4f467d%7D/behavioral-and-developmental-screening-advice-from-abcd-states-experience">Behavioral and Developmental Screening Advice from ABCD ...</a></li></ul></div> <div class="journals-content"><div class="journal-tab-group"><ul class="journal-tabs"><li><a href="/web/20130827043558/http://www.healio.com/journals/pedann">Current Issue</a></li><li><a href="/web/20130827043558/http://www.healio.com/journals/pedann/m/past-issues">Past Issues</a></li></ul><div class="journal-panes"><div class="abstract-content"><p class="kicker-top">Ask the Experts </p><h2><a href="#">Adherence and Behavioral Health Care</a></h2><p class="authors">Robert J. Hilt, MD, FAAP</p><div class="journal-info"><ul class="full-text"><li class="header">Read Full Text Article</li><li class="html"><a class="active" title="View Html Version" alt="View Html Version" rel="nofollow" href="/web/20130827043558/http://www.healio.com/buy-journal-or-article?a={6E6D6DBF-F676-469A-A1F7-A35AA63E94C0}&amp;returnUrl=%2fpediatrics%2fjournals%2fPedAnn%2f%7b6E6D6DBF-F676-469A-A1F7-A35AA63E94C0%7d%2fAdherence-and-Behavioral-Health-Care&amp;jrnl=J0212">Html Icon</a></li><li class="pdf"><a id="pdf" href="/web/20130827043558/http://www.healio.com/buy-journal-or-article?a={6E6D6DBF-F676-469A-A1F7-A35AA63E94C0}&amp;returnUrl=%2fpediatrics%2fjournals%2fPedAnn%2f%7b6E6D6DBF-F676-469A-A1F7-A35AA63E94C0%7d%2fAdherence-and-Behavioral-Health-Care'%3Fpdf%3D1'&amp;jrnl=J0212" class="active" title="View Pdf Version" alt="View Pdf Version" rel="nofollow">Pdf Icon</a></li></ul><ul class="article-citation"><li>Pediatric Annals</li><li>August 2013 - Volume 42 · Issue 8: 306</li><li class="doi">DOI: 10.3928/00904481-20130723-03</li></ul></div><div class="copyrights" style="float:right;"><a onclick="RightsLinkPopUpV2();" href="#"><img alt="Rights and Permissions" title="Rights and Permissions" border="0" src="https://web.archive.org/web/20130827043558im_/http://213a1ca8842e5e699a80-05ce35571e92a3f7383a191aa5840bba.r66.cf1.rackcdn.com/request-permissions.gif"></img></a><script type="text/javascript" language="javascript">function RightsLinkPopUpV2() { var location="https://web.archive.org/web/20130827043558/https://s100.copyright.com/AppDispatchServlet?publisherName=slack&publication=0090-4481&contentID=10.3928/00904481-20130723-03&publicationDate=2013&copyright=Copyright%20%26copy%3B%202013%2C%20Slack%20Inc.&title=Adherence%20and%20Behavioral%20Health%20Care&volumeNum=42&issueNum=8&author=Robert%20J.%20Hilt%2C%20MD%2C%20FAAP%26orderBeanReset%3DTRUE"; window.open(location,'RightsLink','location=no,toolbar=no,directories=no,status=no,menubar=no,scrollbars=yes,resizable=yes,width=650,height=550'); } </script></div><div class="article-tab-group"><ul class="article-tabs"><li><a id="anchor-tab-article" href="/web/20130827043558/http://www.healio.com/buy-journal-or-article?a={6E6D6DBF-F676-469A-A1F7-A35AA63E94C0}&amp;returnUrl=%2fpediatrics%2fjournals%2fPedAnn%2f%7b6E6D6DBF-F676-469A-A1F7-A35AA63E94C0%7d%2fAdherence-and-Behavioral-Health-Care'%3Ffulltext%3D1'&amp;jrnl=J0212">Article</a></li><li class="last"><a id="anchor-tab-refs" href="/web/20130827043558/http://www.healio.com/buy-journal-or-article?a={6E6D6DBF-F676-469A-A1F7-A35AA63E94C0}&amp;returnUrl=%2fpediatrics%2fjournals%2fPedAnn%2f%7b6E6D6DBF-F676-469A-A1F7-A35AA63E94C0%7d%2fAdherence-and-Behavioral-Health-Care'%3Ffulltext%3D1'&amp;jrnl=J0212">References</a></li><li class="cite-link"><a href="#" onclick="showCitation();">Get Citation</a><script type="text/javascript">function showCitation() {var w = window.open('', '', 'width=400,height=400,resizeable,scrollbars');w.document.write('Hilt R. Adherence and Behavioral Health Care. <i>Pediatr Ann.</i> 2013; 42: 306. doi: 10.3928/00904481-20130723-03 <a href="https://web.archive.org/web/20130827043558/http://www.healio.com/pediatrics/journals/PedAnn/{6E6D6DBF-F676-469A-A1F7-A35AA63E94C0}/Adherence-and-Behavioral-Health-Care">[link]</a>');w.document.close(); }</script></li></ul></div><div id="articleBody"><div class="ftContainer"> <div class="ftArticle"> <div class="ftAuthorNotes"> <p> </p> </div> <div class="ftAnchorFigure"><a name="x00904481-20130723-03-fig1"></a><a target="_blank" href="/web/20130827043558/http://www.healio.com/~/media/Journals/PedAnn/2013/8_August/10_3928_00904481_20130723_03/fig1.jpg"></a></div> <p><strong>Q: I have a treatment-resistant mental health patient who is surprisingly inconsistent with taking his medications. How common is this in pediatric mental health patients?</strong></p> <p><strong>A:</strong> Non-adherence to treatment recommendations is a fairly common problem for all of the chronic pediatric disorders, in that up to 50% of children have been found to have partial or complete non-adherence to treatment recommendations. <sup><a href="#x00904481-20130723-03-bibr1">1</a></sup></p> <p>I believe this is both because there has been less research documenting poor treatment adherence with child psychiatric conditions, and also because we as providers believe that psychiatric medications are unlikely to be skipped in the setting of significant psychiatric difficulties.</p> <p>The difference between our treatment adherence assumptions and the reality of practice is well highlighted by the class of psychiatric medication typically reserved for only severe mental health problems — the antipsychotics. In a 2010 analysis, antipsychotics prescribed to Medicaid children in 16 states were found to have a very high rate of non-adherence in that 40% had a greater than 20-day gap in their expected pharmacy refill dates. <sup><a href="#x00904481-20130723-03-bibr2">2</a></sup></p> <p>Given the national attention to reported “over-use” or “inappropriate” dosing of these medications for children, it is important for prescribers to realize that they are often not being taken as prescribed. Therefore a perceived treatment failure with one of these medications that would typically trigger a desire to increase dosage or to initiate another medication may be far better addressed by looking into what impacts adherence with the current treatment plan.</p> <p>I believe mental health medications are particularly prone to poor treatment adherence for the following reasons: 1) children have limited self-motivation for taking mental health medications; 2) mental health medications create side effects starting with the first dose but desired benefits take much longer to appear (with the exception of stimulants); 3) child mental health medications generally have significant limits to their effectiveness; and 4) household organization and cohesiveness which is known to affect adherence can be more impaired with some of the psychiatric conditions experienced in childhood.</p> <div class="ftSection"> <h3>An Adherence Action Plan</h3> <p>The first step is to do what we can to keep things simple as prescribers. Families are far less successful with four-times-a-day regimens than once-a-day regimens, so we should keep medication plans as easy for families as possible. I also avoid recommending overly complicated titration plans in between office appointments; as a rule of thumb I don’t recommend more than one dose change in between visits. Writing down medication plans, particularly if using multiple medications or if a recommendation differs from what is written on a current pill bottle, can be useful.</p> <p>The next step is to specifically ask about any problems with remembering to take prescribed medications, such as at each office visit. This could start with a normalizing phrase, such as, “I know how difficult it is to take this every day… About how many times a week do you think doses are getting missed?” Investigating the actual refill histories in the medical record or by calling the pharmacy where these are getting filled may provide useful data when poor adherence is highly suspected but is being denied.</p> <p>Poor adherence can also be a reflection of the child experiencing unwanted side effects, which should be inquired about specifically. Any side effect significant enough to give someone pause before taking their next pill is important to consider trying to address by reducing doses, changing the timing of administration, switching medications, or making a planned stop of the medication.</p> <p>Finally, we need to work with families about the best ways for them to incorporate medication administration into their daily routines. Concrete strategies like using pill organizers or planning out a reward system for regular administration can help. Behavioral health specialists can be requested to assist when the above measures have failed.</p> <p>Overall, we are well served as care providers to keep treatment adherence in mind whenever we encounter an apparent treatment plan failure, particularly when treating child mental/behavioral health conditions.</p> </div> <div class="ftRefList"> <h3>References</h3> <ol><a name="x00904481-20130723-03-bibr1"></a> <li>Rapoff MA. <em>Adherence to Pediatric Medical Regimens</em> . New York: Kluwer Academic/Plenum Publishers, 1999. doi:10.1016/S0735-1097(02)01886-7 <a target="_blank" href="https://web.archive.org/web/20130827043558/http://dx.doi.org/10.1016/S0735-1097(02)01886-7">[CrossRef]</a></li> <a name="x00904481-20130723-03-bibr2"></a> <li>Medicaid Medical Directors Learning Network and Rutgers CERTs. <em>Antipsychotic Medication Use in Medicaid Children and Adolescents: Report and Resource Guide from a 16-State Study</em> , June2010. Available at <a target="_blank" href="https://web.archive.org/web/20130827043558/http://chsr.rutgers.edu/MMDLNAPKIDS.html">chsr.rutgers.edu/MMDLNAPKIDS.html</a> . Accessed July 10, 2013. doi:10.1016/0190-9622(92)70239-C <a target="_blank" href="https://web.archive.org/web/20130827043558/http://dx.doi.org/10.1016/0190-9622(92)70239-C">[CrossRef]</a></li> </ol> </div> </div> </div></div><div id="articleReferences" style="display: none;"><div class="ftRefList"> <h3>References</h3> <ol><a name="x00904481-20130723-03-bibr1"></a> <li>Rapoff MA. <em>Adherence to Pediatric Medical Regimens</em> . New York: Kluwer Academic/Plenum Publishers, 1999. doi:10.1016/S0735-1097(02)01886-7 <a target="_blank" href="https://web.archive.org/web/20130827043558/http://dx.doi.org/10.1016/S0735-1097(02)01886-7">[CrossRef]</a></li> <a name="x00904481-20130723-03-bibr2"></a> <li>Medicaid Medical Directors Learning Network and Rutgers CERTs. <em>Antipsychotic Medication Use in Medicaid Children and Adolescents: Report and Resource Guide from a 16-State Study</em> , June2010. Available at <a target="_blank" href="https://web.archive.org/web/20130827043558/http://chsr.rutgers.edu/MMDLNAPKIDS.html">chsr.rutgers.edu/MMDLNAPKIDS.html</a> . Accessed July 10, 2013. doi:10.1016/0190-9622(92)70239-C <a target="_blank" href="https://web.archive.org/web/20130827043558/http://dx.doi.org/10.1016/0190-9622(92)70239-C">[CrossRef]</a></li> </ol> </div></div><h5>Authors</h5><p><a target="_blank" href="https://web.archive.org/web/20130827043558/http://cm.healio.com/%7E/media/Journals/PedAnn/2013/4_April/10_3928_00904481_20130326_03/fig1.jpg"><img alt="" style="width: 200px; height: 268px;" class="ftThumbnail" src="https://web.archive.org/web/20130827043558im_/http://cm.healio.com/sitecore/shell/Controls/Rich%20Text%20Editor/%7E/media/Journals/PedAnn/2013/4_April/10_3928_00904481_20130326_03/fig1.jpg"/></a> </p> <p>Robert J. Hilt, MD, FAAP, is an Associate Professor of Psychiatry at the University of Washington and Seattle Children’s Hospital. He is the Program Director for the Partnership Access Line, a child mental health consultation service for primary care providers in Wyoming and Washington, and the director of the Medication Second Opinion services in those same states. He is also the cochair of the Committee on Collaboration with Medical Professions with the American Academy of Child and Adolescent Psychiatry. Dr. Hilt has received board certifications in general pediatrics, adult psychiatry, and child and adolescent psychiatry.</p> Address correspondence to: Robert J. 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Adherence and Behavioral Health Care | Pediatric Annals