What Will Our Child Actually Do?Factors Affecting Compliance

K. Verdolini Abbott, Ph.D., CCC-SLP

September 2010

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Caveat: Terminology

• Some people don’t like the term “compliance” (hierarchical model)

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• Alternate terms– Adherence– Concordance (e.g.,

Bissell et al., 1997)

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Caveat: Measuring compliance

• Problematic

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Adult literatureFactors increasing compliance (cites in Titze & Verdolini, 2010)

• Findings– Perceived severity of

health problem– Short duration of

illness– High income– Unemployed– Urban setting– Transportation

• Implications for kids– Many not be sharply

aware of problem– Many referred with

chronic problem– (Insurance issues?)– Child with time– ???– Important

Adult literature, cont’d

• Findings– Remembering– Positive attitude about

disease– Confidence in treatment– Internal locus of control– Self-efficacy– Minimal side effects

• Implications for kids– Help them to remember – Pump them up about the

process – Give them confidence – You can do it! – You can do it! – Minimize side effects

Adult literature, cont’d

• Findings– Family/social support

– Information about disease and treatment (sometimes)

– Clinician/patient match in information

– Infrequent doses

– Simple program

– Written instructions

– Follow-up

• Implications for kids– Parent support critical

– Education about disease and treatment process may help

– Adapt level of information to child

– Minimize exercises

– Make it simple

– Write out instructions

– Follow-up therapy

Adult literature, cont’d

• Findings– Clinician/patient

interaction

• Implications for kids– How we interact

matters

Children proper

• Distilling key points– Motivation– Remembering– Instilling confidence– Adapting info level– Minimize cosmetic s.e.– Keep the load simple– Write out instructions– Parental support– Clinical presence

• (Next pages)

Motivation

• Most children referred by an adult (parent, physician)

• Motivation may not be inherent

• Child may only be dimly aware of the problem, although it is troublesome to him/her

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Motivation

• Important to “set the stage” for the child

• Need child “buy-in”

• Speak directly to the child (even if parent is involved)

AIV (check)

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AIV (check)

AIV (check)

Motivation

• Maintenance of “buy-in” may be enhanced by extrinsic rewards for doing the tasks

• Caution about extrinsic rewards for how the task is done (potential extinction; Skinner; see motor learning lecture)

AIV (check)

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AIV (check)

Motivation

• Specific moderately-difficult goals may be better than “do your best”

– e.g. Kyllo & Landers, 1995

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AIV (check)

Remembering

• Key for compliance is remembering an instruction in the first place

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Remembering

• Conscious remembering is facilitated by so-called associational or elaborative processing (information presented in broader context)– E.g. Craik & Lockhart, 1972

AIV (check) Creation of stories about

voice and voice care should help make therapy instructions memorable to the child

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Instilling confidence

• Self-efficacy also applicable to compliance in children – (e.g. Heitzler et al., 2010)

AIV (check)Deal/talk directly with

childGive child opportunity for

successMake exercises “do-

able”

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Adapting information level

• Obvious AIV (check) Single program But adapt tone, language,

and some specifics according to age

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Cosmetics

• Child literature– Negative cosmetic side

effects of cyclosporine (hirsutism, gum hyperplasia) with renal transplantation may affect compliance with treatment (Willetts & Trompeter, 2004)

– Lack of confidence with headgear in orthodontic treatment affected compliance (Sergl et al., 2000)

AIV (check) Pay attention to child’s

comments and concerns about “sounding different”

Keep the load simple

• Child literature– Complexity: Single doses

of antibiotics have better compliance with children than multiple doses

– Duration: Two-hr eye patch use gets higher compliance than 6-hr eye patch use

– Arguedas et al., 2004; Gottlob et al., 2004

AIV (check) Keep the home program

short, sweet (and fun!)

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Write out instructions

• Definitely.• Audio CDs too!

AIV(check)

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Parental support

• Child literature– Critical mothers had more

difficulty getting child (6-13 yr) to comply with asthma treatments, as compared to less critical moms

– Critical parents had adolescents with greater improvement in asthma severity, greater reduction in steroid dose, shorter hospital stays; however those adolescents had poorer compliance with meds

– Schobinger et al., 1993; Wamboldt et al., 1995

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Parental support

AIV (check) Encourage parental

support rather than criticism or nagging

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Parental support

• Child literature– Parents and behavioral home

programs

– Home activity programs (HAP) for kids with global developmental delay (N=41; OT, PT, SLP)

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– Compliance increased with

• Support by therapist

• Fewer secondary health problems

• Smaller family

• Older child receiving program (4.3 vs 3.8 yr)

• Marital stability (longer marriage)

• Father with university degree

• Positive feelings about the program

» Tetreault et al., 2003

Parental support

• HAPs, cont’d• Many parents with high

stress maintained the program

• Important: When prescribing HAPs, be aware of demands placed on (Moms)

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Parental support• HAPs, cont’d: Implications?

– Important suggestions to help compliance

• 1. Check to see if other HAPs are already in place; do not overburden family

• 2. Ask parents if they agree to HAP

• 3. Choose goals/activities with parents, for easier use in daily life

• 4. No more than two goals per therapist, 6 goals total

• 5. Take time to teach parents how to use the HAP

• 6. Schedule follow-ups (e.g. phone calls)

• 7. Revise HAP every 3-6 months http://www.atlanticstreet.org/images/momdtr2.gif

Frank behavior problems(no extra charge)

• Autism– Noncontingent positive

reinforcement decreased self-injury behavior

– I.e. escape from learning activities on fixed time schedule

– Vollmer et al., 1995

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Frank behavior problems

• Autism and possibly some other conditions, implications?– Consider noncontingent

reinforcement?

AIV (check)The whole therapy is a

game“Escape” not

particularly needed

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Clinician presence

• Importance of rapport, patient-clinician relationship, emphasized

– E.g. Johnson et el., 1998 (orthodontia)

AIV (check)

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