Treatment nonadherence occurs most commonly during adolescence (; Drotar 2007; Iannotti et al. 2006; La Greca 1990; McAllister et al. 2006; Wray et al. 2006). The treatment demands of chronic physical illness can interfere with the adolescent's normative needs for separation from his or her parents. Adolescents may act out conflicts with their parents through overt or covert refusal to adhere to treatment. In addition, parental guilt related to their child's physical condition may lead parents to compensate for these feelings by failing to set limits on their child's behavior; this can indirectly encourage nonadherence. Additional developmental issues

Table 13-1. Biopsychosocial model for risk factors associated with nonadherence Biopsychosocial correlates Risk factors

Biological Factors related to the illness

Lengthy illness duration Illnesses with few symptoms Illnesses associated with cognitive decline Factors related to the treatment Complexity of the treatment regimen Unpleasant medication side effects Treatments with high financial costs Medications that are hard to swallow or have a bad taste Psychological/psychiatric Low level of perceived efficacy of treatment


Behavioral difficulty history Internal locus of control

Psychiatric disorders, such as posttraumatic stress disorder, depression, psychotic spectrum disorders, substance use disorders

Social Immediate environment of the patient

Lack of parental supervision

History of child abuse

Parental conflict

Parental psychopathology

Low socioeconomic status

Lack of family cohesion

Poor pattern of family communication

Characteristics of the care delivery environment

Lack of appointment reminders

Scheduling difficulties

Barriers to getting treatment (e.g., lack of insurance coverage) Characteristics of the provider Time spent with provider Provider perceived as supportive Characteristics of the health care system Fragmented vs. cohesive Universal vs. private

Reimbursement model that hinders coordinated care contribute to adherence difficulties in this age group. Adolescents are prone to misjudging the consequences of nonadherence due to cognitive difficulties in assessing personal risk, lack of experience with the consequences of risk, ignorance, and denial

(Brooks-Gunn 1993). The adolescent's desire for acceptance and conformity with his or her peers often conflicts with treatment adherence (Brooks-Gunn 1993). Chronic physical illness can carry a stigma, and the pressures for conformity may result in resistance to medication treatment recommendations, particularly involving those medications that have cosmetic side effects (Friedman and Litt 1987). The transition of responsibility for following medical recommendations from the parent to the adolescent is an important current focus of research (Annunziato et al. 2008).

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