Cillian is 2 and a half years old, as I write this. His ten favourite things are cheerios, playgrounds, Mammy, monkey, Emma, diggers, nee-naws, treats, splashing water and dancing on the stones. The order of preference is largely a function of current hunger, fatigue and physical proximity. Although Cillian’s taxonomy of ten favourite things is a dynamic and wide-ranging list that is subject to hourly revisions, it has never once included ‘taking medicine’.
Like approximately one in 5 children under the age of six, Cillian lives with a mild version of a skin condition called eczema. This can be effectively managed with a twice daily one-minute application of emollient. This solution sounds simple, however Cillian’s adherence to this treatment has often involved elaborate and tetchy negotiation with stand-offs that would make recent industrial disputes look like love-ins. Peppa Pig stickers, Fireman Sam stories and even pre-treatment dance-offs have all been required at various times to make the daily adherence happen.
Cillian’s grandmother Margaret is more than 60 and less than 70. That is as precise as we have been permitted to be with that number. She too lives with a relatively common and related ailment, namely asthma. Each year she has an exacerbation of her symptoms and promptly proceeds to see the omniscient respiratory consultant who unfailingly asks if she has been using her preventer inhaler. Each year she gives a version of “not as much as perhaps I should”. Following a diplomatic and subtle reflection between the doctor and patient on the meaning of the word “preventer”, Margaret leaves the consultant’s office with a renewed commitment to both inhalers. Each year her symptoms abate following this “expert” and increasingly expensive specialist input.
As a Health Psychologist these experiences have forced me to reconsider the role of developmental processes in the science and practice of treatment adherence. As a General Practitioner Cillian’s mother, wants to know in simple terms what is to be done for this adherence problem and others that she sees in childhood, adolescence and adulthood. During this first two decades of life, in particular, we know that the capacity to self-manage health is in a constant state of transition from parental to self-control. Therefore the motivation and capacity to take medicine as prescribed are largely absent in infancy and childhood and the opportunity to take medicine is frequently a parent or carer initiated event.
Self-regulation is the central idea in many prominent psychological theories that inform behaviour change interventions. Broadly it refers to the extent to which humans can regulate inner states and responses such as thoughts, actions, emotions and attention. Psychological science demonstrates that the capacity for self-regulation develops throughout life as the central nervous system and autonomy develops, but particularly during childhood, adolescence and early adulthood. Recently, I have been struck by how often we neglect this critical aspect of psychological theory and evidence when we think about changing health relevant behaviour.
For example, the excellent work on developing behaviour change technique taxonomies by Michie and colleagues has had little to say thus far about how behaviour change techniques (BCTs) are linked to developmental processes. As some BCTs require more self-regulatory capacity it follows that some will be less effective earlier in the lifespan. For example, at 2 and half Cillian will not have the full cognitive capacity to reflect on the various pros and cons of using emollient in the way that might be encouraged in a complex decisional balance sheet BCT. While this is an extreme and perhaps facetious example there are several more subtle ways in which developmental psychology can inform whether a given BCT is likely to work at a specific stage of development.
For example, message framing is a popular approach used to influence health behaviour that has used with success in many contexts. This involves framing a choice in terms of losses or gains. Many studies have shown that people tend to avoid risk when messages are framed positively but seek risk when messages are framed negatively. For example people will be more likely to choose a treatment when potential lives saved due to the treatment are described than when potential lives lost are presented. The evidence shows that the human cognitive biases that message frames take advantage of appear to develop over the lifespan. Therefore message framing might be effective for promoting adherence for Margaret but this approach is less likely to make a difference to Cillian’s adherence to treatment.
Perhaps one of the most critical periods where developmental processes come into play for treatment adherence is during adolescence. The work of neuroscientist Sarah-Jayne Blakemore and others have shown that the adolescent brain continues to develop in important ways right through adolescence and into one’s 20 and 30’s. This can help explain the great difficulties that are often seen by health care professionals in the capacity to self-regulate treatment adherence in young people with chronic illnesses. Potentially relevant differences at this point of development include the increased tendency to take risk, heighted self-consciousness and weaker impulse control. These developmental changes can make it difficult for good relationships with adult carers and healthcare professionals to be maintained. Good communication and a mutually respectful relationship are often needed to manage chronic health problems that require on-going treatment adherence. During adolescence both the adolescent patient and the health care professional might struggle to adapt to these developmental changes.
Designing developmentally appropriate BCTs is a critical future step that myself and other investigators can pursue as we attempt to refine which BCTs work, under what conditions and in particular, during what stage of lifespan development. This work will involve developing a taxonomy of behaviour change techniques that is informed by developmental science and perspectives on self-regulation across the lifespan. This will help ensure that the full benefits of existing effective medical treatments can be realised.
Ultimately we need to figure out what psychosocial support provides the motivation, capacity and opportunities to follow medical treatments throughout life. In other words we need to answer the question, how do humans develop the will, skills and drills for pills across the lifespan?
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