Providers may find the following “tips” and suggestions useful in helping them as- sess for nonadherence in their pediatric patients. Asking questions can have benefi- cial effects on the provider-patient relationship, but it should be noted that it cannot take the place of standardized assessment in cases where it is indicated. An effective approach might be to routinely ask some subset of these questions, to be followed up with a validated measure if some concern comes to light.
1. Prior to meeting the patient, look for biomarkers (e.g., high HbA1c) without alternate explanation
a. But do not assume that the patient is nonadherent even if it seems obvious b. Do not confront the patient, or use scare tactics
2. Take a minute to develop rapport—you cannot learn anything if the family dis- trusts you
3. Meet with the child—give him or her the choice of meeting with you alone or with the parent present. Even children as young as 5 can benefit from some direct interaction with the provider.
4. Ask the child:
a. What are the most difficult parts of living with/taking care of ___?
b. How would ___ have to change for you to feel/do better?
c. What steps could you take to improve the problem?
d. What changes are you willing to make?
e. How can we (therapist, parent) help you take these steps/make these changes?
5. With older children, ask about:
a. Family support and conflict—e.g.,
i. Do you feel that you get enough support from your family around ___?
ii. Do you and your parents ever fight over managing ___?
b. Burnout—“Do you ever feel tired or just burned out over managing ___?
(See Peyrot and Rubin 2007; Schwartz, Axelrad et al. 2011; Wysocki 1997.)
159 References
Summary and Conclusions
In this chapter we have reviewed the evidence supporting the value of screening for nonadherence and contributory psychosocial risk factors. However, screening is not without its costs. It can be resource intensive, and challenging for clinicians practic- ing outside of major medical centers to implement. However, validated screening tools such as the PAT and the RI-PGC, which were designed for easy use in routine practice, may help extend the reach and feasibility of screening.
Nonetheless, moving forward into the new era of healthcare, it will be critically important to demonstrate that risk screening can indeed prevent costly complica- tions, and show its cost effectiveness. For example, it has been shown that risk screening at diabetes diagnosis can predict subsequent emergency room visits over the next 9 months (Schwartz, Cline et al. 2011). Specifically, children from single- parent households who also had behavior problems were much more likely to end up back in the ER for a diabetes-related concern. As there are well-established and very effective interventions for child behavior problems (Axelrad et al. 2009; Child and Adolescent Mental Health Division Evidence Based Services Committee 2007;
Eyberg et al. 2008), preventive interventions focused on these high-risk children have the potential to substantially reduce the incidence of expensive ER visits.
At the same time, we also need interventions developed for children who are at-risk but do not have (as of yet) clinically significant concerns, as well as more universal interventions focused on preventing the emergence of risk factors such as normative family conflict. Interventions aimed at these lower acuity patients, if implemented widely enough, could have broad effects on the health of the popula- tion of children with chronic disease. In the next chapter, we present a model for implementing a tiered, multi-modal intervention framework for providing interven- tion services at all levels of risk—Universal, Targeted, and Clinical—as delineated in Kazak’s (2006) PPPHM.
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