Implementing a Home-Based Telehealth Group Adherence Intervention with Adolescent Transplant Recipients.

Introduction: To improve access to care and engage adolescent transplant recipients for adherence-promoting interventions, innovative solutions utilizing technology are needed. Materials and Methods: This study describes the implementation of a five-session group intervention targeting medication adherence in adolescent transplant recipients through home-based telemedicine. Results: Seven videoconferencing groups were conducted with a total of 33 participants living a median of 57 miles away from their transplant medical center. The median coefficient of variation (CV) of tacrolimus (immunosuppression medication) decreased from 32.2% to 23.5% from the pregroup to postgroup phase. Analyses indicated that the group was acceptable and engaging for participants, as highlighted by one participant reporting, "I liked how me and the group members came together… it felt like a little family." Overall satisfaction with the group and with the technology was endorsed by 86%. The group intervention was generally feasible; however, there were technological difficulties reported by participants and the facilitator, particularly given the diversity of the home-based connections and equipment. Other adaptations helped improve recruitment, attendance, and participation. Discussion: Implementing a telehealth group can pose unique challenges, especially with a group of adolescent participants. Although nonsignificant, we observed a decrease in the median CV of tacrolimus, indicating that medication adherence generally improved after group intervention. Our experience facilitating these groups provides insights into strategies to optimize feasibility and the participant experience. Distance of participants from the hospital is an important consideration and provides a strong rationale for the need for telemedicine-enabled approaches. We explore and discuss the challenges to implementing a home-based group, suggest practical strategies and developmentally sensitive adjustments when working with adolescents, and propose strategies to prepare clinicians for obstacles that may present when implementing a telehealth group with youth.

Adherence in pediatric kidney transplant recipients: solutions for the system.

Non-adherence remains a significant problem among pediatric (and adult) renal transplant recipients. Non-adherence among solid organ transplant recipients results in US$15-100 million annual costs. Estimates of non-adherence range from 30 to 70% among pediatric patients. Research demonstrates that a 10% decrement in adherence is associated with 8% higher hazard of graft failure and mortality. Focus has begun to shift from patient factors that impact adherence to the contributing healthcare and systems factors. The purpose of this review is to describe problems within the systems implicated in non-adherence and potential solutions that may be related to positive adherence outcomes. Systems issues include insurance and legal regulations, provider and care team barriers to optimal care, and difficulties with transitioning to adult care. Potential solutions include recognition of how systems can work together to improve patient outcomes through improvements in insurance programs, a multi-disciplinary care team approach, evidence-based medical management, pharmacy-based applications and interventions to simplify medication regimens, improved transition protocols, and telehealth/technology-based multi-component interventions. However, there remains a significant lack of reliability in the application of these potential solutions to systems issues that impact patient adherence. Future efforts should accordingly focus on these efforts, likely by leveraging quality improvement and related principles, and on the investigation of the efficacy of these interventions to improve adherence and graft outcomes.

Medication adherence among adolescent solid-organ transplant recipients: A survey of healthcare providers.

The aim of this study was to assess healthcare provider perspectives on barriers to medication adherence and to discover recommendations for interventions among providers of pediatric solid-organ transplant patients. An anonymous online survey was administered to a multidisciplinary pool of pediatric transplant providers from February 2015 to March 2016. It consisted of 15 questions regarding transplant providers' attitudes, clinical practice, and beliefs pertaining to medication adherence among teenage solid-organ transplant recipients. Data were analyzed using descriptive statistics. Responses to open-ended questions were coded and categorized into themes. One hundred ten surveys were completed by providers specializing in pediatric heart, kidney, liver, lung, and/or intestinal transplantation. Commonly cited reasons for poor adherence were forgetting/poor planning (94%), the desire to be normal (86%), lack of support (86%), and poor parental monitoring (79%). Suggestions to improve adherence included increasing peer and family support, providing education, and incorporating technology into adherence regimens. Barriers to adherence in transplant patients are recognized by providers and are both similar to and disparate from patient and family identified barriers published in the literature. Providers recognize the importance of education, social support, and technologically driven interventions on improving outcomes in the transplant population.

The EPOCH Measure of Adolescent Well-Being.

We introduce the EPOCH Measure of Adolescent Well-Being, which assesses 5 positive psychological characteristics (Engagement, Perseverance, Optimism, Connectedness, and Happiness) that might foster well-being, physical health, and other positive outcomes in adulthood. To create the measure, a pool of 60 items was compiled, and a series of 10 studies with 4,480 adolescents (age 10-18) from the United States and Australia were used to develop and test the measure, including the factor structure, internal and test-retest reliability, and convergent, discriminant, and predictive validity. The final 20-item measure demonstrated adequate psychometric properties, although additional studies are needed to further validate the measure, extend to other population groups, and examine the extent to which it predicts long-term outcomes. As a brief multidimensional measure, the EPOCH measure contributes to the empirical testing and application of well-being theory, and offers a valuable addition to batteries designed to assess adolescent positive psychological functioning. (PsycINFO Database Record

Agreement Among Categorical, Dimensional, and Impairment Criteria for ADHD and Common Comorbidities.

OBJECTIVE: To compare the results of categorically based versus dimensionally based scoring algorithms for a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV)-referenced teacher rating scale for assessing ADHD and commonly co-occurring conditions and to determine their relative agreement with ratings of symptom-induced impairment. METHOD: Teachers completed Child and Adolescent Symptom Inventory-4R (CASI-4R) ratings for 1,092 youth (ages 6-18 years) referred to a child and adolescent psychiatry outpatient service. Caseness was determined according to DSM-IV symptom count (categorical model) and T-score (dimensional model) criteria. RESULTS: Agreement between symptom count and T-score cutoffs was generally good (kappa ≥ 0.61) for ADHD-Inattentive, ADHD-Hyperactive-Impulsive, ADHD-Combined (except adolescent females), Oppositional Defiant Disorder, and Conduct Disorder, but this was not the case for anxiety and depressive disorders where only 15% of kappas were good. Agreement of impairment cutoff with T-score and symptom count cutoffs ranged from poor to good. CONCLUSION: In general, although in many cases CASI-4R categorical and dimensional scoring algorithms generated similar results, there was considerable variability across disorders, age groups, scoring method, and in some cases, gender. Moreover, symptom counts and T-scores are not a proxy for assessing impairment suggesting that each scoring strategy likely provides unique information for clinical decision-making.

A Developmental Psychopathology Perspective on ADHD and Comorbid Conditions: The Role of Emotion Regulation.

Research investigating attention-deficit/hyperactivity disorder (ADHD) and co-occurring disorders such as oppositional defiant disorder, conduct disorder, anxiety, and depression has surged in popularity; however, the developmental relations between ADHD and these comorbid conditions remain poorly understood. The current paper uses a developmental psychopathology perspective to examine conditions commonly comorbid with ADHD during late childhood through adolescence. First, we present evidence for ADHD and comorbid disorders. Next, we discuss emotion regulation and its associations with ADHD. The role of parenting behaviors in the development and maintenance of emotion regulation difficulties and comorbid disorders among children with ADHD is explored. An illustrative example of emotion regulation and parenting over the course of development is provided to demonstrate bidirectional relations among these constructs. We then present an integrated conceptual model of emotion regulation as a shared risk process that may lead to different comorbid conditions among children with ADHD. Implications and directions for future research are presented.