How to Improve Medication Adherence in Adults and Teens with ADHD
The research is clear: Adherence to ADHD medication, particularly in puberty and adulthood, is not optimal. Patients stop taking their medications regularly — or completely — for any number of reasons. Solutions to several important ones are outlined below.
Clinical studies reveal that up to 80 percent of all adults with attention deficit disorder (ADHD or ADD) fail to comply with their treatment plan within the first year. Non-adherence to ADHD medication is a pervasive and serious problem that impacts overall health outcomes, which is why Dr. Anthony Rostain has set out to study why patients don’t comply — and devise clinician-recommended solutions.
Rostain is a professor of psychiatry and pediatrics at the Perelman School of Medicine at the University of Pennsylvania, and attending and supervising psychiatrist at the Children’s Hospital of Pennsylvania and the University of Pennsylvania Health System. He has studied non-adherence specifically in adults with ADHD and recently published “Addressing the Challenges of Treatment Resistant ADHD in Adults” in Psychiatric Times. This is the second of five articles based on his responses to questions in a recent APSARD webinar hosted by Dr. Gregory Mattingly of Washington University School of Medicine about aspects of treating ADHD. This article is presented for general educational purposes, not medical advice.
Dr. Mattingly: Based on your clinical and scientific research and experience, how can clinicians improve adherence in ADHD patients who are frequently non-compliant?
Dr. Rostain: Treatment non-adherence is the rule not the exception. According to several reliable meta-analyses, only 20 to 40 percent of patients follow their medication regimen regularly, if at all, after 12 months of treatment. More than two-thirds of patients take their stimulants on only three out of five days — or even less. This is true for both adults and adolescents.
The principle reasons why patients don’t follow their medication regimens are as follows:
- Adverse side effects
- Ineffective symptom control
- Dosing inconvenience or ineffectiveness
- Medication stigma
- Executive function deficits
To address these very real impediments to consistent treatment, I recommend the following six-part plan.
Step One: Explain the Neurobiology of ADHD
When I see a new patient for an assessment of ADHD symptoms, I do not offer a prescription for an ADHD medication immediately after the diagnosis is made. Instead, I spend a session on psychoeducation — teaching the patient about the neurobiological underpinnings of ADHD, including how medication works to help it.
These psychoeducational sessions are important not only for teaching, but also for assessing the patient’s beliefs and whether his or her expectations are reasonable. It helps the patient better understand what symptom control and improvement medication can, realistically, achieve. It also teaches him or her how to recognize negative side effects, and how to make medication adjustments with his or her clinician.
At the same time, education helps to build a clinician-patient alliance and to create a collaborative framework where the clinician and patient are jointly deciding upon and adjusting a medication plan. In my experience, patients who feel part of a collaborative partnership are much more likely to adhere to treatment than are those who feel the medication plan was unilaterally dictated.
Step Two: Investigate the Barriers to Adherence
Do not assume that, because you offered clear explanations and advice, your patients truly understand how medications work and, thus, you have successfully overcome barriers to adherence. As clinicians, we must acknowledge how difficult it is take medications every day. And we must be proactive in asking our patients, “How many times did you skip a dose, and what impact did that have on the treatment response?”
If a patient who is taking a stimulant skips a dose, and notices no impact, then that may indicate the patient may not be taking the best medication or the right dose of medication. Every time a patient skips a dose, it is instructive because that information helps determine whether treatment is effective. Of course, that is true only if you know he or she has skipped a dose, so excellent communication is critical.
If your patient is experiencing side effects or has symptoms that are not responding well to medication, then it is incumbent upon you to find a better treatment. There is no virtue in urging your patient to adhere to treatment plan — including the chosen medication as well as its dosing and timing — if it is not benefitting the patient.
Step Three: Prescribe with the Systems of Care in Mind
In addition to improved communication and collaboration, clinicians need to be proactive and preventative when designing the system of care. We need to establish reminders to check in with patients, and ways of identifying patients’ difficulties refilling or affording prescriptions. If, for example, a once-a-day medication will be easier to a patient to remember and take consistently, or an alternative medication is more affordable, then we need to sculpt the treatment plan accordingly.
Step Four: Create a Partnership
As clinicians, we need to look holistically at helping our patients participate in the decision-making process — helping them find the best medication, and providing the data they need to feel comfortable with adjusting that medication. As you build trust, the rate of adherence goes up because your patients believe that you truly understand them. If they don’t believe that their clinician understands them and if for some reason they are mistrustful of the medicine itself, then we merely end up without successful treatment.
Step Five: Approach Medication Adherence from a Behavior Change and Developmental Perspective
When a patient comes in to see you, he or she is contemplating dealing with his or her ADHD symptoms for perhaps the first time. How do we, as clinicians, help him or her prepare for change and move into action?
Not only does education need to start early and be reintroduced at each developmental stage, but we must also allot upfront time in our practice for discussion with patients before treatment begins. As important as education about ADHD is, just as important is helping the individual patient consider his or her own reasons for treatment as well as any concerns that may keep him or her from adhering to the plan of action that we develop.
In the pediatric setting, a child comes in with his or her parents, who are often ready to start medication, saying, “Let’s get him going.” But if the child isn’t also ready, he or she will find ways to avoid medication, find problems with it, and approach treatment with a negative attitude. I often hear from patients later who say how much they appreciated the chance to discuss their feelings, “Hey, Dr. Rostain, even though my parents wanted me to take the medicine, you said you wanted to spend more time talking about it.”
Studies have found that as many as 90% of children report that their feelings about medication were never discussed with their physician. A 10-year old has feelings and ideas. However, when asked “Why do you take this medicine?” they may respond “Well, it’s to help me study,” or, “It’s to help me be good.” But rarely do they have the tools to determine whether the medication is working because no one has explained to them how medication works and what it can be expected to achieve. If ADHD is a lifelong disorder, clinicians need to address patient’s attitudes and expectations at each stage in order to build a framework of trust.
Many adolescents are not convinced that medication is good or helpful, and frequently skip doses deliberately as well as unintentionally. Many are experimenting with independence and want to find out what they can accomplish without medication. They may say things such as “I don’t like myself and my friends don’t like me as much on the medication.” If this happens, it’s critical for clinicians to think developmentally. What stage of life is this patient in? What is going on hormonally and developmentally? Are they facing a stigma against ADHD and/or medication?
In a case like this with a patient who is not going to adhere to the medication regimen, I often recommend that they stop medication for a time and see what happens. Treat the adolescent like an ally by saying, “Look, I know you don’t want to take this. Your parents and teachers think it is helping, but you’re not convinced. I’m here to help you make the best decision. Why not stop the medication for a while and see what happens?”
Then, if the adolescent continues to have symptoms, he or she may be more receptive to treatment saying, “OK, I made a good effort at stopping and it didn’t help.”
One important caveat as far as stopping medication: It is imperative that patients and their parents understand the high risk of car accidents among the unmedicated, especially those in the riskiest age group from ages 16 to 25. This is a public-health issue that must be taken very seriously. I tell the parents of my patients that driving is a privilege, not a right, and that I would not allow children diagnosed with ADHD to drive a car without medication.
Step Six: Offer Executive Function Supports and Scaffolding
Keep in mind that, for many teens and some adults, it’s not willful non-adherence that gets in the way of effective treatment. Executive function challenges and comorbid learning disabilities are common among adolescents with ADHD. This translates into poor self-regulation, poor working memory, and poor time management — all skills needed to consistently take medication. Patients such as these may need more external structure in their lives, and help with organization systems to stick with their treatment plan.
In the end, I would say the most changeable factor in improving medication adherence is clinician-patient communication. Although we cannot change our patients’ attitudes directly, we must discuss with them their beliefs and clarify what is reasonable to expect from both the positive and adverse effects of ADHD medications.
Anthony Rostain, M.D., M.A., is a member of ADDitude’s ADHD Specialist Panel.