PSYCHOSOCIAL AND PSYCHODYNAMIC ISSUES AFFECTING NONCOMPLIANCE WITH PSYCHOSTIMULANT TREATMENT

Patient nonadherence to a wide variety of psychiatric and medical treatments is highly prevalent, with noncompliance rates in adults ranging from 13 to 93%. Empirical studies indicate that high rates of nonadherence, ranging between 20 and 68%, are also seen in psychostimulant treatments of children with attention-deficit hyperactivity disorder (ADHD). Noncompliance is a major source of failure in pharmacological treatments, and may have important implications in understanding clinical and research findings about the outcomes of psychostimulant treatment. Especially in children, nonadherence is the result of complex interactions between actual drug response, psychosocial variables, and individual and family psychodynamics. Psychodynamic factors can imbue a medication treatment with a negative emotional valence at any time during the course of treatment. Even a positive therapeutic response can lead to noncompliance when it interferes with the child's or family's psychological adaptations and coping mechanisms. Clinicians must be prepared to deal actively with psychosocial sources of noncompliance, such as parents' or child's difficulty in emotional acceptance of the diagnosis, fears of medication, and media misinformation about medication. On a practical basis, the clinician can take active steps to help the child and family cope with the diagnosis of ADHD, and to encourage their active participation in the treatment. Adherence should be periodically monitored in a sympathetic manner that encourages the child and family to verbalize rather than act on the underlying fears, concerns, and conflicts that lead clinically to nonadherence to prescribed regimens, discontinuation of medication use, inconsistent administration, or diminished therapeutic efficacy.