Kelly I. Kamimura-Nishimura, MD, MS Assistant Professor Department of Pediatrics Division of Developmental and Behavioral Pediatrics
William B. Brinkman, MD, MEd, MSc Professor Department of Pediatrics Division of General and Community Pediatrics
Tanya E. Froehlich, MD, MS Associate Professor Department of Pediatrics Division of Developmental and Behavioral Pediatrics
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Cincinnati Children’s Hospital Medical Center University of Cincinnati Cincinnati, Ohio
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Supported by the National Institute of Mental Health R01 MH105425 (T.F.), R01 MH105425-S1 (T.F.), and K23 MH083027 (W.B.).
Several studies have investigated the influence of health services factors on ADHD medication adherence. Specifically, limited transportation services and lack of mental health providers in the community have been linked to decreased ADHD medication adherence.47,65,66 Furthermore, limited insurance coverage and higher costs of ADHD medications, which lead to substantial out-of-pocket payments for families, have been associated with decreased likelihood of ADHD medication adherence.29,67
Clinician-related factors also can affect ADHD medication adherence. For example, a clinician’s lack knowledge of ADHD care can negatively impact ADHD medication adherence.68 Two studies have documented improved ADHD medication adherence when treatment is provided by specialists (eg, child psychiatrists) rather than by community primary care providers, possibly because specialists are more likely to provide close stimulant titration and monitoring (ie, ≥ 3 visits in the first 90 days) and use higher maximum doses.62,69 Furthermore, ADHD medication initiation and adherence are increased when patients have a strong working alliance with their clinician and trust the health care system,31,34,35 as well as when there is a match between the caregiver’s and clinician’s perception of the cause, course, and best treatment practices for a child’s ADHD.65
Strategies to improve medication adherence
A number of strategies to improve ADHD medication adherence can be derived from our knowledge of the factors that influence adherence.
Patient/familyeducation.Unanswered questions about ADHD diagnosis, etiology, and medication adverse effects can negatively impact the ADHD treatment process. Therefore, patient/family education regarding ADHD and its management is necessary to improve medication adherence, because it helps families attain the knowledge, confidence, and motivation to manage their child’s condition.
Clinicians have an important role in educating patients about70:
the medications they are taking
why they are taking them
what the medications look like
the time of medication administration
the potential adverse effects
what to do if adverse effects occur
what regular testing/monitoring is necessary.
Clinicians can provide appropriate psychoeducation by sharing written materials and trusted websites with families (see Related Resources).
Behavioral strategies.Behavioral interventions have been among the most effective strategies for improving medication adherence in other chronic conditions.71 Behavioral strategies are likely to be particularly important for families of children with ADHD and comorbid conditions such as ODD because these families experience considerable caregiver-child conflict.72 Moreover, parents of children with ADHD are at higher risk for having ADHD and depression themselves,73 both of which may interfere with a parent’s ability to obtain and administer medications consistently. Thus, for these families, using a combination of psychoeducation and behavioral strategies will be necessary to affect change in attitude and behavior. Behavioral strategies that can be used to improve medication adherence include:
Technology-based interventions can reduce the impact of environmental barriers to adherence. For example, pharmacy automatic prescription renewal systems can reduce the likelihood of families failing to obtain ADHD medication refills. Pill reminder boxes, smartphone alerts, and setting various alarms can effectively prompt caregivers/patients to administer medication. In particular, these methods can be crucial in families for which multiple members have ADHD and its attendant difficulties with organization and task completion.
Caregiver training may assist families in developing specific behavioral management skills that support adherence. This training can be as straightforward as instructing caregivers on the use of positive reinforcement when teaching their children to swallow pills. It may also encompass structured behavioral interventions aimed at training caregivers to utilize rewards and consequences in order to maximize medication adherence.74
