Sunday, July 13, 2014

Reducing Noncompliance in Cystic Fibrosis

It has been estimated that at least 30% of children with chronic diseases are noncompliant with their medication and other treatment requirements (Ou, Feldman, & Balkrishnan, 2010). Adherence in children and adolescents varies with age, and younger children are usually more adherent than adolescents, although Chelsey had a difficult time with her lifestyle changes after being diagnosed at age three. The purpose of this paper is to develop a behavioral intervention to improve Chelsey's compliance with her medical routines, and to describe a rewards system based on the behavioral intervention. Further, a justification for the use of the intervention will be explained.


Chelsey is a three-year-old girl with cystic fibrosis. She has developed a distinct sense of autonomy for a child her age. Chelsey was recently diagnosed with cystic fibrosis and does not like taking medications or participating in her twice daily vest treatments. The vest is large for her and she is uncomfortable with the vibrations. Although typically, younger children like Chelsey are more likely to adhere to treatments, she cries and becomes angry and defiant when it is time for her vest treatment. She takes her medicines with slightly less issue, although not without crying. Mealtimes are relatively calm, and her parents have utilized a behavioral intervention that has helped them provide Chelsey and her siblings with a calm mealtime experience that has been conducive to maintaining a sense of normalcy for the family while providing Chelsey with an adequate calorie intake.

                                                        Chelsey's Reward System
Chelsey's reward system is based on operant conditioning, which utilizes positive reinforcement. This conditioning pairs the desired behavior with a reward or positive event, thereby increasing the likelihood that the behavior will occur again (Luersen et al., 2012). It is also based on Chelsey's love of all things princess-like. Chelsey's parents developed and utilize a system of behavior modification that provides her with award points when she follows her meal plans, including snacks, takes her medications without crying, and wears her treatment vest for 30 minutes each morning and evening. When Chelsey successfully completes one component of her routine: eating, snacking, or vest routine, she is awarded a crown or a princess on her Princess Chart. During her evening vest treatment, if she has earned enough stickers that day, she can exchange them for playing with her new princess dress-up box of garments, accessories, and crowns, which her parents have created specifically for this intervention. Chelsey is only allowed to play with the special box of princess finery during evening vest treatment time.


Positive reinforcement interventions for children with chronic diseases, such as cystic fibrosis have been associated with treatment adherence, which has the potential to improve health outcomes (Graves, Roberts, Rapoff, & Boyer, 2010; Luersen, & Feldman, 2011; Luersen et al., 2012). Sticker charts have been utilized to increase medication adherence with positive reinforcement (Ou et al., 2010). Chelsey's chart is straightforward, simple, colorful (in her favorite color) and its theme is based on her favorite interest, which is princesses. The aesthetic aspects of the chart are designed to engage her at her young age. One of the common reasons for poor adherence in younger children is getting them to sit still during treatment (Ou et al., 2010). The rewards system is designed to help Chelsey look forward to her vest treatment and provide her with a distraction while doing it. Stark and colleagues (2005) found sticker charts an easy and effective means of establishing treatment adherence in pediatric populations while improving patient health outcomes.


Although adolescents may have unique challenges to treatment adherence, young children have their own distinct difficulties sitting still long enough for treatments, and understanding why they must do it. Chelsey 's behavioral sticker chart, with its simplicity and attainable special rewards, helped her maintain compliance while she received the instant gratification of stickers, which were exchanged for a special reward at the end of each day during her evening treatment. Stark and colleagues (2012) provided evidence that utilizing the behavioral principles of positive reinforcement has the potential to increase treatment adherence in young children. The simple sticker program is a quick and easy-to-implement routine that can provide the patient and family with durable beneficial results. 


Graves, M. M., Roberts, M. C., Rapoff, M., & Boyer, A. (2010). The Efficacy of Adherence Interventions for Chronically Ill Children: A Meta-Analytic Review. Journal of Pediatric Psychology, 35(4), 368-382. doi: 10.1093/jpepsy/jsp072

Luersen, K. K., & Feldman, S. R. (2011). Increasing Treatment Compliance with Sticker Charts. Skin And Aging, 19(11), 42.

Luersen, K., Davis, S. A., Kaplan, S. G., Abel, T. D., Winchester, W. W., & Feldman, S. R. (2012). Sticker Charts: A Method for Improving Adherence to Treatment of Chronic Diseases in Children. Pediatric Dermatology, 29(4), 403-408. doi:10.1111/j.1525-1470.2012.01741.x

Ou, H., Feldman, S. R., & Balkrishnan, R. (2010). Understanding and Improving Treatment Adherence in Pediatric Patients. Seminars In Cutaneous Medicine And Surgery, (2), 137. doi:10.1016/j.sder.2010.03.012

Stark, L. J., Opipari, L. C., Jelalian, E., Powers, S. W., Janicke, D. M., Mulvihill, M. M., & Hovell, M. F. (2005). Child Behavior and Parent Management Strategies at Mealtimes in Families With a School-Age Child With Cystic Fibrosis. Health Psychology, 24(3), 274-280. doi:10.1037/0278-6133.24.3.274

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