The Impact of COVID-19 on Pediatric Adherence and Self-Management

Jill M. Plevinsky, PHD; Melissa A. Young, PSYD; Julia K. Carmody, PHD; Lindsay K. Durkin, MS; Kaitlyn L. Gamwell, PHD; Kimberly L. Klages, PHD; Shweta Ghosh, PHD; Kevin A. Hommel, PHD


J Pediatr Psychol. 2020;45(9):977-982. 

In This Article

Monitoring and Promoting Adherence and Self-management During COVID-19

It is incumbent on providers to proactively identify and address challenges to adherence and self-management with communication at the forefront of this process. Patient–caregiver–provider communication is critical to identifying adherence and self-management concerns and enacting individual, family, community, and healthcare system-level interventions to identify and develop effective solutions to barriers. For example, prior to the pandemic, a multidisciplinary urban clinic serving youth with HIV developed a robust and effective adherence support program, which relied on frequent clinic appointments, strong patient–provider relationships, and directly observed therapy. In response to the pandemic, the clinic adapted this model and has been proactively contacting patients to assess medication needs, explain new clinic procedures, and provide relevant COVID-19 education to patients and families via frequent phone check-ins, directly observed therapy via telemedicine, and connecting patients with medication delivery services (Armbruster et al., 2020). While resource and time intensive, this approach may serve to mitigate risk factors and minimize consequences of nonadherence during this time.

For patients with chronic conditions, regular outpatient consultation and disease monitoring via telemedicine are critical to promoting continued adherence and self-management during the pandemic. While providers may have reservations about the effectiveness of telemedicine, pre-COVID-19 studies directly comparing traditional face-to-face versus telemedicine services have not found telemedicine to be inferior (Bahrani et al., 2017; Tates et al., 2017). Virtual communication platforms such as messaging embedded in the electronic medical record and HIPAA-compliant smartphone applications (e.g., Doximity) can also enable communication sharing in the absence of face-to-face visits. Many of these platforms also enable patients to share pictures, videos, and other helpful data so that providers can deliver targeted recommendations and support. Regardless of the platform, it is crucial for providers to recognize how various aspects of the pandemic may be contributing to poorer adherence and self-management as previously discussed. Providers should maintain a non-judgmental stance in order to yield more accurate information while avoiding evasive or defensive reactions (Rapoff, 2010). Many families are having to make compromises regarding how time and resources are spent, and it is critical that providers take the time to understand each family's circumstances in order to align and set the stage for collaborative problem-solving.

Increased assessment and monitoring are also recommended, as a variety of strategies exist to assess adherence, including assays, observation, electronic monitors, pill counts, provider estimates, and patient/caregiver report (McGrady et al., 2018). While access to bioassays may be restricted in the COVID-19 pandemic, others can be modified and implemented in the absence of face-to-face visits. Video observation (i.e., either live or recorded and shared electronically) can offer insight into how well a treatment regimen is performed (e.g., exercises for physical therapy, inhaler use, chest wall oscillation, etc.). Moreover, home observations can reveal contemporaneous variables related to treatment adherence that may be amenable to intervention (Mash & Terdal, 1988). Patient and parent reports including global reports, structured interviews and questionnaires, and daily diaries can be easily adapted to telemedicine with patients or parents recording specific adherence behaviors over time (Plevinsky et al., 2020). This format can be particularly useful for identifying problem areas and problem-solving with families around their daily routine in order to maximize adherence. Daily monitoring can improve adherence (Greaves et al., 2011) and facilitate caregiver monitoring and implementation of behavioral strategies to promote adherence (e.g., token economy).

Adherence apps are one form of intervention freely available to youth and families with access to a smart phone or tablet. These apps can provide scheduled reminders, allow users to track adherence behaviors over time, and allow users to share these reports with their providers (Carmody et al., 2019). App-based medication adherence interventions have been associated with short-term improvements in adherence (Badawy et al., 2017), therefore these solutions can serve to supplement behavioral health interventions via telemedicine, or bridge patients until more intensive adherence interventions (e.g., accessing a psychologist) are available.