Multimodal Psychological Interventions to Promote Treatment Adherence

Editors: Ahna L. H. Pai, Ph.D.; Meghan E. McGrady, Ph.D.

Date: July, 2019

Empirical review statusStrong Recommendation.

Summary of sample characteristics across studies:



Age range Mean age 0-29 years (CITE all after 2015 search)
Sex Mean percentage of males across studies 51.7-56% (cite all after 2015 search)

The percentage of minority group participants range from 0-100% (Graves et al., 2010).  Across studies, the average percentage of Caucasian participants is 82% (Graves et al., 2010). Currently, there is no data to indicate that race is a moderating factor in interventions. (correct and CITE after 2015 search)

Therapist type The training background of adhernece promotion interventions has varied widely.  They include: Physicians (Guendelman et al., 2002); Nurse (Goldbeck & Babka, 2001; Rapoff et al., 2002): Psychologists (Wysocki et al, 2007; Hommel et al., 2012); Social Work (Ellis et al., 2012); Dietician (Powers et al., 2003); Personal trainer/coach (Nansel et al., 2012; Stinson et al., 2010); Web-based (Naar-King et al., 2013);  Research Assistants/coordinators Respiratory therapists (Cite)
Presenting problem The diseases for which adherence promotion interventions have been provided to include: Arthritis (Rapoff et al., 2002), Asthma (Otsuki et al., 2009),  Cancer (Kato et al., 2008) Cystic Fibrosis (Powers et al., 2005); Depression (Clarke et al., 2005); Diabetes (Ellis et al., 2012; Wysocki et al., 2007); Epilepsy (Shope et al 1980); hemophilia (CITE); HIV/AIDS (Letourneau,  et al., 2012); Hypercholesterolemia (Lauer et al., 2000);  Inflammatory Bowel Disease (Hommel et al., 2012); obesity (Ebbeling et al., 2003); phenylketonuria (cite); Sickle Cell Disease (Berkovitch et al., 1998); Transplant (CITE); tuberculosis (Hovell et al., 2003); See if any of the new studies examined others.
Socioeconomic status Adherence promotion intervention studies use a wide range of measures of socioeconomic status that are difficult to compare across studies.  Therefore, the role of socioeconomic status on the effectiveness of the interventions is limited.  See if any of the new studies examined this.
Language Interventions reported have only been delivered in English (Kahana et al., 2008, Pai et al., 2014) except for the following which were also delivered in XXX (see if new search shows any studies where the intervention was delivered in more than one language).



Brief summary of treatment:

  • Basic premise: Adherence promotion interventions are designed to improve self-management behaviors thereby increasing adherence to treatment regimens prescribed to youth with a chronic disease or condition (e.g., oral medication adherence, blood glucose monitoring).  The Pediatric Self-Management Model (Modi et al., 2011) conceptualizes chronic medical condition self-management behaviors as occurring within patient, family, community, and healthcare systems domains. By targeting modifiable behavioral, cognitive, emotional, and social processes across each of these domains, psychological interventions have the potential to promote self-management and, as a result, improve adherence to treatment regimens.
  • Essence of therapy: The vast majority of adherence promotion interventions are comprised of multiple treatment components due to the complexity of adherence behaviors both in terms of what the treatment regimen requires and the numerous factors that can influence adherence behaviors. Common adherence-promotion intervention components include: 1) disease-specific education; 2) psychoeducation about adherence; 3) the teaching of cognitive and/or behavioral skills (i.e., self-monitoring of adherence behavior, problem-solving); 4) strategies targeting beliefs (i.e., self-efficacy) or emotions (i.e., depressive symptoms); 5) strategies targeting environmental context or resources (i.e., access to medication); and/or 6) strategies targeting social support.
  • Length: Variable.


Treatment resources:

Treatment Manual Available For Purchase

Self-Help Books



Clinical Trials (listed alphabetically by disease group):


  1. Rapoff, M. A., Belmont, J., Lindsley, C., Olson, N., Morris, J., & Padur, J. (2002). Prevention of nonadherence to nonsteroidal anti-inflammatory medications for newly diagnosed patients with juvenile rheumatoid arthritis. Health Psychology, 21, 620–623. PubMed
  2. Stark, L. J., Davis, A. M., Janicke, D. M., Mackner, L. M., Hommel, K. A., Bean, J. A., . . . Kalkwarf, H. J. (2006). A randomized clinical trial of dietary calcium to improve bone accretion in children with juvenile rheumatoid arthritis. Journal of Pediatrics, 148, 501-507. PubMed
  3. Stark, L. J.,  Janicke, D. M.,  McGrath, A. M.,  Mackner, L. M.,  Hommel, K. A., & Lovell, D. (2005). Prevention of osteoporosis: A randomized clinical trial to increase calcium intake in children with juvenile rheumatoid arthritis. Journal of Pediatric Psychology, 30, 377-386. PubMed
  4. Stinson, J. N., McGrath, P. J., Hodnett, E. D., Feldman, B. M., Duffy, C. M., Huber, A. M. . . . White, M. E. (2010). An internet-based self-management program with telephone support for adolescents with arthritis: A pilot randomized controlled trial. Journal of Rheumatology, 37, 1944–1952. doi:10.3899/jrheum.091327. PubMed.


  1. Baum, D., & Creer, T. L. (1986). Medication compliance in children with asthma. Journal of Asthma, 23, 49–59. PubMed
  2. Bonner, S., Zimmerman, B. J., Evans, D., Irigoyen, M., Resnick, D., & Mellins, R. B. (2002). An individualized intervention to improve asthma management among urban Latino and African-American families. The Journal of Asthma, 39,167–179.
  3. Burgess, S. W., Sly, P. D., & Devadason, S. G. (2010). Providing feedback on adherence increases use of preventive medication by asthmatic children. Journal of Asthma, 47, 198–201. doi:10.3109/02770900903483840. PubMed
  4. Burkhart, P. V., Dunbar-Jacob, J. M., Fireman, P., & Rohay, J. (2002). Children's adherence to recommended asthma self-management. Pediatric Nursing, 28 409-414.  PubMed
  5. Burkhart, P. V., Rayens, M. K., Oakley, M. G., Abshire, D. A., & Zhang, M. (2007). Testing an intervention to promote children's adherence to asthma self-management. Journal of Nursing Scholarship, 39, 133–140. doi:10.1111/j.1547-5069.2007.00158.x. PubMed
  6. Butz, A. M., Tsoukleris, M. G., Donithan, M., Hsu, V. D., Zuckerman, I., Mudd, K. E., . . . Bollinger, M. E. (2006). Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma. Archives of Pediatric and Adolescent Medicine, 160, 622-628. doi: 10.1001/archpedi.160.6.622  PubMed
  7. Christakis, D. A., Garrison, M. M., Lozano, P., Meischke, H., Zhou, C., & Zimmerman, F. J. (2012). Improving parental adherence with asthma treatment guidelines: A randomized controlled trial of an interactive website. Academic Pediatrics, 12, 302–311. doi:10.1016/j.acap.2012.03.006. PubMed
  8. Clark, N. M., Brown, R., Joseph, C. L., Anderson, E. W., Liu, M., & Valerio, M. A. (2004). Effects of a comprehensive school-based asthma program on symptoms, parent management, grades, and absenteeism. Chest, 125, 1674-1679. PubMed
  9. Dahl, J., Gustafsson, D., & Melin, L. (1990). Effects of a behavioral treatment program on children with asthma. Journal of Asthma, 27, 41-46. PubMed
  10. Ducharme, F. M., Zemek, R. L., Chalut, D., McGillivray, D., Noya, F. J., Resendes, S., . . . Zhang X. (2011). Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control. American Journal Respiratory and Critical Care Medicine, 183, 195–203. doi: 10.1164/rccm.201001-0115OC. PubMed
  11. Duncan, C. L., Hogan, M. B., Tien, K. J., Graves, M. M., Chorney, J. M., Zettler, M. D., . . . Portnoy J. (2013). Efficacy of a parent–youth teamwork intervention to promote adherence in pediatric asthma. Journal of Pediatric Psychology, 38, 617–628. doi: 10.1093/jpepsy/jss123. PubMed
  12. Farber, H. J., & Oliveria, L. (2004). Trial of an asthma education program in an inner-city pediatric emergency department. Pediatric Asthma, Allergy, & Immunology, 17, 107–115. doi: 10.1089/0883187041269913
  13. Guendelman, S., Meade, K., Benson, M., Chen, Y. Q., & Samuels S. (2002). Improving asthma outcomes and self-management behaviors of inner-city children. Archives of Pediatrics and Adolescent Medicine, 156, 114-120. doi: 10.1001/archpedi.156.2.114 PubMed
  14. Gustafsson, P. A., Kjellman, M., & Cederblad, M. (1986). Family therapy in the treatment of severe childhood asthma. Journal of Psychosomatic Research, 30, 369-374. PubMed
  15. Hederos, C. A., Janson, S., & Hedlin, G. (2009). Six-year follow-up of an intervention to improve the management of preschool children with asthma. Acta Paediatrics, 98, 1939–1944. doi:10.1111/j.1651-2227.2009.01477.x. PubMed
  16. Holzheimer, L., Mohay, H., & Masters, I. B. (1998). Educating young children about asthma: comparing the effectiveness of a developmentally appropriate asthma education video tape and picture book. Child Care, Health and Development, 24, 85–99. doi: 10.1046/j.1365-2214.1998.00055.x PubMed
  17. Homer, C., Susskind, O., Alpert, H. R., Owusu, M., Schneider, L., Rappaport, L. A., & Rubin, D. H. (2000). An evaluation of an innovative multimedia educational software program for asthma management: Report of a randomized, controlled trial, Pediatrics, 106, 210-215. PubMed
  18. Hughes, D. M., McLeod, M., Garner, B., & Goldbloom, R. B. (1991). Controlled trial of a home and ambulatory program for asthmatic children. Pediatrics, 87, 54–61. PubMed
  19. Joseph, K. E., Adams, C. D., Cottrell, L., Hogan, M. B., & Wilson, N. W. (2003). Providing dust mite-proof covers improves adherence to dust mite control measures in children with mite allergy and asthma. Annals of Allergy, Asthma, and Immunology, 90, 550-553. PubMed
  20. Joseph, C. L., Peterson, E., Havstad, S., Johnson, C. C., Hoerauf, S., Stringer, S. . . . Strecher, V. (2007). Asthma in Adolescents Research Team A web-based, tailored asthma management program for urban African-American high school students. American Journal of Respiratory and Critical Care Medicine, 175, 888–895. doi:10.1164/rccm.200608-1244OC. PubMed
  21. Krieger, J., Takaro, T. K., Song, L., Beaudet, N., & Edwards, K. (2009). A randomized controlled trial of asthma self-management support comparing clinic-based nurses and in-home community health workers: The Seattle king county healthy homes II project. Archives of Pediatrics and Adolescent Medicine, 163, 141–149. doi:10.1001/archpediatrics.2008.532. PubMed.
  22. LeBaron, S., Zeltzer, L. K., Ratner, P., & Kniker, W. T. (1985). A controlled study of education for improving compliance with cromolyn sodium (Intal): the importance of physician-patient communication. Annals of Allergy, 55, 811-818. PubMed
  23. Lewis, C. E., Rachelefsky, G., Lewis, M. A., de la Sota, A., & Kaplan, M. (1984). A randomized trial of A.C.T. (asthma care training) for kids. Pediatrics, 74, 478-486. PubMed
  24. Otsuki, M., Eakin, M. N., Rand, C. S., Butz, A. M., Hsu, V. D., Zuckerman, I. H., & Riekert, K. A. (2009). Adherence feedback to improve asthma outcomes among inner-city children: A randomized trial. Pediatrics, 124, 1513–1521. doi:10.1542/peds.2008-2961. PubMed
  25. Perez, M. G., Feldman, L., & Caballero, F. (1999). Effects of a self-management educational program for the control of childhood asthma. Patient Education & Counseling, 36, 47-55. PubMed
  26. Rubin, D. H., Leventhal, J. M., Sadock, R. T., Letovsky, E., Schottland, P., Clemente, I., & McCarthy, P. (1986). Educational intervention by computer in childhood asthma: A randomized clinical trial testing the use of a new teaching intervention in childhood asthma. Pediatrics, 77, 1-10. PubMed.
  27. Salisbury, C., Francis, C., Rogers, C., Parry, K., Thomas, H., Chadwick, S., & Turton, P. (2002). A randomised controlled trial of clinics in secondary schools for adolescents with asthma. British Journal of General Practice, 52, 988–996.  PubMed
  28. Smith, N. A., Seale, J. P., Ley, P., Shaw, J., & Bracs, P. U. (1986). Effects of intervention on medication compliance in children with asthma. Medical Journal of Australia, 144, 119-122. PubMed
  29. van Es, S. M., Nagelkerke, A. F., Colland, V. T., Scholten, R. J., & Bouter, L. M. (2001). An intervention programme using the ASE-model aimed at enhancing adherence in adolescents with asthma. Patient Education and Counseling, 44, 193–203. PubMed
  30. Volvovitz, B., Duenas-Meza, E., Chmielewska-Szewczyk, D. A., Kosa, L., Astafieva, N. G., Villaran, C., . . . Leff, J. A. (2000). Comparison of oral montelukast and inhaled cromolyn with respect to preference, satisfaction, and adherence: a multicenter, randomized, open-label, crossover study in children with mild to moderate persistent asthma. Current Therapeutic Research, 61, 490-506.
  31. Wilson, S. A., Latini, D., Starr, N. J., Fish, L., Loes, L. M.,  Page, A., & Kubic, P. (1996). Education of parents of infants and very young children with asthma: A developmental evaluation of the Wee Wheezers Program. Journal of Asthma, 33, 239-254. PubMed
  32. Zivkovic, Z., Radic, S., Cerovic, S., & Vukasinovic, Z. Asthma school program in children and their parents. (2008). World Journal of Pediatrics, 4, 267–273. doi:10.1007/s12519-008-0049-z. PubMed


  1. Kato, P. M., Cole, S. W., Bradlyn, A. S., & Pollock, B. H. (2008). A video game improves behavioral outcomes in adolescents and young adults with cancer: A randomized trial. Pediatrics, 122, e305–e317. doi:10.1542/peds.2007-3134. PubMed

Chronic Illness:

  1. Scholten, L., Willemen, A. M., Last, B. F., Maurice-Stam, H., Van Dijk, E. M., Ensink, E. . . . Grootenhuis M A. (2013). Efficacy of psychosocial group intervention for children with chronic illness and their parents. Pediatrics, 131, e1196–e1203. doi:10.1542/peds.2012-2222. PubMed

Cystic Fibrosis:

  1. Downs, J. A.,  Roberts, C. M., Blackmore, A. M., Le Souef, P. N., & Jenkins, S. C. (2006). Benefits of an education programme on the self-management of aerosol and airway clearance treatments for children with cystic fibrosis. Chronic Respiratory Disease, 3, 19-27. PubMed
  2. Powers, S. W., Jones, J. S., Ferguson, K. S., Piazza-Waggoner. C, Daines, C., & Acton, J. D. (2005). Randomized clinical trial of behavioral and nutrition treatment to improve energy intake and growth in toddlers and preschoolers with cystic fibrosis. Pediatrics, 116, 1442-1450. PubMed
  3. Stark, L. J., Opipari, L. C., Spieth, L. E., Jelalian, E., Quittner, A. L., Higgins, L.,. . . Duggan, C. (2003). Contribution of behavior therapy to dietary treatment in cystic fibrosis: A randomized controlled study with 2-year follow-up. Behavior Therapy, 34, 237-258.
  4. Depression:
  5. Clarke, G., Debar, L., Lynch, F., Powell, J., Gale, J., O’Connor, E.,. . . Hertert, S. (2005). A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 888–898. PubMed


  1. Anderson, B. J., Wolf, F. M., Burkhart, M. T., Cornell, R. G., & Bacon, G. E. (1989). Effects of peer-group intervention on metabolic control of adolescents with IDDM: Randomized outpatient study. Diabetes Care, 12, 179-183. PubMed
  2. Anderson, B. J., Brackett, J., Ho, J., & Laffel, L. M. (1999). An office-based intervention to maintain parent-adolescent teamwork in diabetes management. Diabetes Care, 22, 713-721. PubMed
  3. Brown, S. J., Lieberman, D. A., Gemeny, B. A., Fan, Y. C., Wilson, D. M., & Pasta, D. J. (1997). Educational video game for juvenile diabetes: Results of a controlled trial. Medical Informatics, 22, 77-89. PubMed
  4. Boardway, R. H., Delamater, A. M., Tomakowsky, J., & Gutai, J. P. (1993). Stress management training for adolescents with diabetes. Journal of Pediatric Psychology, 18, 29–45. PubMed
  5. Daley, B. J. (1992). Sponsorship for adolescents with diabetes. Health & Social Work, 17, 173–182. PubMed
  6. Ellis, D. A., Frey, M. A., Naar-King, S., Templin, T., Cunningham, P., & Cakan, N. (2005). Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control: A randomized controlled trial. Diabetes Care, 28, 1604-1610. PubMed
  7. Ellis, D. A., Naar-King, S., Chen, X., Moltz, K., Cunningham, P. B.,& Idalski-Carcone, A. (2012). Multisystemic therapy compared to telephone support for youth with poorly controlled diabetes: Findings from a randomized controlled trial. Annals of Behavioral Medicine, 44, 207–215. doi:10.1007/s12160-012-9378-1. PubMed
  8. Ellis, D. A., Templin, T., Naar-King, S., Frey, M. A., Cunningham, P. B., Podolski, C. L., & Cakan, N. (2007). Multisystemic therapy for adolescents with poorly controlled type I diabetes: Stability of treatment effects in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 75, 168–174. doi:10.1037/0022-006x.75.1.168. PubMed
  9. Franklin, V. L., Waller, A., Pagliari, C., & Greene, S. A. (2006). A randomized controlled trial of sweet talk, a text-messaging system to support young people with diabetes. Diabetes Medicine, 23,1332–1338. doi: 10.1111/j.1464-5491.2006.01989.x. PubMed
  10. Howe, C. J., Jawad, A. F., Tuttle, A. K., Moser, J. T., Preis, C., Buzby, M., & Murphy, K. M. (2005). Education and telephone case management for children with type 1 diabetes: a randomized controlled trial. Journal of Pediatric Nursing, 20, 83-95. PubMed
  11. Kumar, V. S., Wentzell, K. J., Mikkelsen, T., Pentland A., & Laffel, L. M. (2004). The DAILY (Daily Automated Intensive Log for Youth) trial: a wireless, portable system to improve adherence and glycemic control in youth with diabetes. Diabetes Technology & Therapeutics, 6, 445-453. doi: 10.1089/1520915041705893 PubMed
  12. Lawson, M. L., Cohen, N., Richardson C., Orrbine, E., & Pham, B. (2005). A randomized trial of regular standardized telephone contact by a diabetes nurse educator in adolescents with poor diabetes control. Pediatric Diabetes, 6, 32–40. PubMed.
  13. Mulvaney, S. A., Rothman, R. L., Wallston, K. A., Lybarger, C., & Dietrich, M. S. (2010). An internet-based program to improve self-management in adolescents with type 1 diabetes. Diabetes Care, 33, 602–604. doi:10.2337/dc09-1881. PubMed
  14. Nansel, T. R., Iannotti, R. J., & Liu, A. (2012). Clinic-integrated behavioral intervention for families of youth with type 1 diabetes: Randomized clinical trial. Pediatrics, 129, e866–e873. doi:10.1542/peds.2011-2858. PubMed
  15. Nansel, T. R., Iannotti, R. J., Simons-Morton, B. G., Cox, C., Plotnick, L. P., Clark, L. M., & Zeitzoff, L. (2007) Diabetes Personal Trainer Outcomes: Short-term and 1-year outcomes of a diabetes personal trainer intervention among youth with type 1 diabetes. Diabetes Care, 30, 2471–2477. doi:10.2337/dc06-2621. PubMed.
  16. Wysocki, T., Greco, P., Harris, M.A., Bubb, J., & White, N. H. (2001). Behavior therapy for families of adolescents with diabetes: Maintenance of treatment effects. Diabetes Care, 24, 441–446. PubMed
  17. Wysocki, T., Green, L., & Huxtable, K. (1989). Blood glucose monitoring by diabetic adolescents: Compliance and metabolic control. Health Psychology, 8, 267–284. PubMed
  18. Wysocki, T., Harris, M. A., Buckloh, L. M., Mertlich, D., Lochrie, A. S., Mauras, N., & White, N. H. (2007). Randomized trial of behavioral family systems therapy for diabetes: Maintenance of effects on diabetes outcomes in adolescents. Diabetes Care, 30, 555–560. PubMed
  19. Wysocki, T., Harris, M. A., Buckloh, L. M., Mertlich, D., Lochrie, A. S., Taylor, A., . . . White, N. H. (2006). Effects of behavioral family systems therapy for diabetes on adolescents’ family relationships, treatment adherence, and metabolic control. Journal of Pediatric Psychology, 31, 928-938. PubMed
  20. Wysocki, T., Harris, M. A., Greco, P., Bubb, J., Danda, C. E., . . . White, N. H. (2000). Randomized, controlled trial of behavior therapy for families of adolescents with insulin-dependent diabetes mellitus. Journal of Pediatric Psychology, 25, 23-33. PubMed

Etc.... (to be further updated after updated review)


Systematic Reviews, and Meta-Analyses

  1. Dean, A. J., Walters, J., & Hall, A. (2010). A systematic review of interventions to enhance medication adherence in children and adolescents with chronic illness. Archives of Diseases in Childhood, 95, 717-723. doi: 10.1136/adc.2009.175125 PubMed
  2. 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, 368-382. doi: 10.1093/jpepsy/jsp072 PubMed
  3. Kahana, S., Drotar, D., & Frazier, T. (2008). Meta-analysis of psychological interventions to promote adherence to treatment in pediatric chronic health conditions. Journal of Pediatric Psychology, 33, 590-611. doi: 10.1093/jpepsy/jsm128 PubMed
  4. McGrady, M. E., Ryan, J. L., Gutierrez-Colina, A. M., Fredericks, E. M., Towner, E. K., & Pai, A. L. H. (2015). The impact of effective pediatric adherence promotion interventions: Systematic review and meta-analysis. Child: Care, Health and Development, 41(6), 789–802.
  5. Pai, A. L. H. & Drotar, D. (2010).  Treatment Adherence Impact: The systematic assessment and quantification of the impact of treatment adherence on pediatric medical and psychological outcomes. Journal of Pediatric Psychology, 35, 383-393.
  6. Pai, A. L., & McGrady, M. (2014). Systematic review and meta-analysis of psychological interventions to promote treatment adherence in children, adolescents, and young adults with chronic illness. Journal of Pediatric Psychology, 39, 918-931. doi: 10.1093/jpepsy/jsu038 PubMed
  7. Salema, N. E., Elliott, R. A., & Glazebrook, C. (2011). A systematic review of adherence-enhancing interventions in adolescents taking long-term medicines. Journal of Adolescent Health, 49, 455-466. doi: 10.1016/j.jadohealth.2011.02.010 PubMed
  8. Wu, Y. P., & Pai, A. L. H. (2014). Health care provider-delivered adherence promotion interventions: A meta-analysis. Pediatrics, 133(6), e1698-e1707.