Introduction to the special issue on adherence in pediatric medical conditions.

Research with a wide range of chronic health conditions in children and adolescents has indicated that nonadherence to medical treatment is pervasive, estimated to be as high as 50% for some conditions (Drotar, 2000; Rapoff, 2010). Nonadherence can take many forms including not filling prescriptions to skipping or missing doses and can be intentional (e.g., deciding not to take a medication because of side effects) or unintentional (e.g., forgetting). Poorer adherence has been documented for regimens that are more time-consuming and complex, and rates of nonadherence in pediatric chronic illness populations, especially among adolescents, are even higher than those in adult populations (Rapoff, 2010). Potentially serious health consequences can result from nonadherence. For example, incomplete adherence to immunosuppressive drugs has been linked to heart, kidney, and liver transplant failures (Ettenger et al., 1991). Nonadherence can influence clinical decisions about care, resulting in increases or changes in medication when none are needed. Nonadherence has been estimated to result in billions of dollars of excess medical care annually (The Task Force for Compliance, 1994). Despite the clinical importance of nonadherence and the significance of its impact on health care delivery, assessment of adherence is not routinely or systematically done in clinical practice, and treatments for adherence problems in pediatric chronic diseases continue to be limited (Rapoff, 2010). Moreover, few studies have evaluated the impact of interventions designed to promote adherence to medical treatment in childhood chronic diseases using randomized controlled trials (Rapoff, 2010). Many of the provisions of Affordable Care Act (ACA; Public Law No: 111–148, March 23, 2010) seek to align the incentives to health care providers to deliver improved patient health outcomes and reduce costs through the creation of accountable care organizations (ACO) and Patient Centered Medical Home (Berwick, 2011; Rittenhouse, Shortell, & Fisher, 2009). As noted by Rozensky and Janicke (2012), the recognition that these aims can best be achieved through interprofessional care that integrates mental and physical health care is an opportunity for pediatric psychologists to capitalize on our multi-disciplinary roots and, for many, our every day practice (Roberts, Canter, & Odar, 2012). Addressing adherence is one primary example of where and how pediatric psychologists can bring improved outcomes and value to the health care system. In a recent meta-analytic review of the efficacy of adherence interventions for children with chronic diseases across 71 studies, Graves, Roberts, Rapoff, and Boyer (2010) reported medium effect sizes for adherence interventions and health outcomes pre to post-treatment and at follow-up, with larger improvements in health outcomes for studies that combined education and behavioral intervention. Although many of these studies did not have the rigor of being randomized control trials, the effect sizes are encouraging. The purpose of the Special Issue of the Journal of Pediatric Psychology on Adherence is to highlight innovative approaches to the treatment or assessment of adherence or to understanding factors associated with adherence that can inform the development of more effective interventions to improve adherence in children with chronic medical conditions. Ultimately, we are most interested in improving adherence with the goal of improving health outcomes and child functioning and well-being.