Teenagers often have a sense of invulnerability, may have less of a future orientation than adults and for a variety of reasons fail to connect consequences with specific behaviors. Their lives are usually very busy and as they strive for independence from authority figures, they may not follow the advice of medical professionals. Teens seek to control their own lives and non-compliance with a medication may offer a way for a teen to control his or her destiny.
Compliance refers to the extent to which patients—adolescents in this context—are obedient and follow instructions. This may refer to taking medications, changing lifestyles including risky behaviors, following diets, adherence to preventive health practices and returning for follow up appointments.
An adolescent, who willingly ingests drugs of abuse, may not take a prescribed medication. A teen may be wary of the side effects from the prescribed medication, and taking the prescribed medication may validate the teen’s condition. For example, if a teen is prescribed a medication for mental health issues, i.e. the teen thinks he or she is “crazy” then taking the medication validates the “craziness” in the teen’s mind. Not taking the medication suggests to the teen that he or she is not “crazy.”
A teen’s view of his or her illness may also influence compliance. For example, a number of Latino cultures classify illnesses and medications along a hot versus cold continuum. An upper respiratory infection or “cold” is felt to be a cold disease in some Latino cultures. Therefore a “hot” medication such as aspirin might be taken for someone who believes in the hot/cold theory. Western medicine would recommend, however, plenty of cold juices, rather than aspirin for a teen with a respiratory cold.
Adolescents may also choose to be noncompliant rather than appear different from their peers. Body image, sexuality and self-esteem are themes that may influence the level of compliance. For example, some medications for acne may cause the skin to turn red and dry. Medication for some seizure disorders may cause swelling of the teen’s gums. And steroids may cause weight gain.
Compliance with follow up appointments has been studied in regard to Hepatitis B immunization. Hepatitis B is a sexually transmitted illness that can be prevented by a series of three immunizations. Since Hepatitis B may only be a theoretical threat to teens, and three office visits are necessary to complete the series, many teens have failed to follow through with the entire series for reasons that also include the cost and inconvenience of office visits.
Studies have shown that compliance is increased when the vaccine is administered at school or in late afternoon or evening sessions. Even greater compliance has occurred when two double doses of the vaccine are given compared to the traditional three single doses. While education about the importance of Hepatitis B vaccination is important, the six-month period over which the vaccine is administered is too long a look into the future for most adolescents. In this case enlistment of the parents may help the teen to comply with the vaccine regiment. Studies have also shown that the vaccine may be administered at annual checkups with good levels of immunity after the third vaccination.
Adolescent girls who are prescribed oral contraceptives have difficulties with compliance in taking the medication on a regular basis. One would think that the motivation to take the pill, that is avoiding pregnancy, would be a strong factor in motivating the teen to take it properly. In fact, studies have shown that twenty percent of the 3.5 million unintended pregnancies in the United States are due to inconsistent use of oral contraceptives. In teens, predictors of poor compliance with oral contraceptives include a history of multiple sex partners, low degree of concern about pregnancy and a low evaluation of personal health. Good compliance has been linked to the patient’s satisfaction with her clinician, reading the information distributed with the oral contraceptives, the absence of annoying side effects and establishing a set daily routine to take the medication. Satisfaction with the clinician and absence of upsetting side effects may be themes that will help any teen to be more compliant with medication regimens. Pharmaceutical companies have developed a contraceptive patch, injectable contraceptive and a vaginal contraceptive ring to enhance compliance.
A teen well educated about HIV will not necessarily comply with safer sex practices. Of value in changing behaviors are the practices of the teen’s peers. The peer group’s attitudes and practices may have more power in shaping teen behavior than a parent or physician.
There are some ways to increase compliance in adolescents. A medication regimen that is simple and does not interfere with a teen’s lifestyle is very important. For example, some acne creams are used at bedtime and washed off in the morning. This regimen is very acceptable to most teens.
All medications have side effects. If they are discussed up front with the teen with written information, non-compliance may be avoided. For example, certain antibiotics cause diarrhea. If the teen is warned about this, then he or she may take preventive measures rather than discontinuing the medication if diarrhea occurs.
Teens should be enlisted in the treatment of their problem. For example, the clinician and teen should work together to find appropriate and convenient times for follow up visits at the office. A teen and his or her clinician can decide together on what, if any, confidential information may be released to parents. A teen’s perception of the confidentiality of the medical relationship has a bearing on compliance. But if a teen is not allowed to participate in the management of his or her illness or schedule the follow up appointments, there is a greater likelihood of non-compliance.
Non-compliance can be problematic for teens with chronic illness who are heading off to college. For example, a teen with cystic fibrosis often is required to take antibiotics on a regular basis, have once or twice daily treatments for chest mucus and schedule periodic medical visits. Non-compliance may be accentuated by the close living arrangements of college dormitories, peer pressure along with busy schedules, irregular sleep habits and the newly found independence from parental authority. During the year prior to college, counseling and planning for the new environment are necessary to help minimize non compliance as well as minimize the chance of the teen’s physical deterioration.
To encourage compliance with medications, pharmaceutical companies devise methods of drug delivery that encourage compliance. For example, in 2006, a patch for the treatment of attention deficit disorder was under review by the Food and Drug Administration. Placing a patch on a daily basis, rather than taking pills several times daily was felt to improve compliance. This needs to be proven.
Related topics:
Body image, chronic illness, confidentiality, counseling, cross-cultural issues, future orientation, growth and development, independence and rebellion, peer pressure, risk-taking, safer sex, self-esteem, sexuality
