Dialectical Behavioral Therapy (DBT) shows early evidence as an effective tool in improving medical regimen adherence in adolescents with chronic kidney disease (CKD), enabling them to accept their illness, have a better quality of life and gain eligibility for organ transplantation. This study, by investigators at The Children's Hospital at Montefiore (CHAM), was published today in the journal Clinical Practice in Pediatric Psychology.
DBT teaches patients skills to cope with stress, control emotions and improve relationships with others. It has proven effective in adult and adolescent patients with a range of psychiatric conditions and behavioral problems, so the investigators adapted the therapy to study whether it would be effective with a teen medical population, who are also traditionally difficult-to-reach, manage and treat.
Six teenagers with end-stage renal disease, who were in need of a kidney transplant, completed a nine-session DBT program. Participants' self-reported several measures pre- and post-intervention, with feelings of depression among participants decreasing 77.5 percent. Additionally, physicians reported improvements in adherence at the end of the intervention and 100 percent of participants transitioned to active status on the transplant list. Two patients have received a kidney transplant, while the others continue to wait for their transplants and have maintained all behavioral gains post-treatment.
"Adolescents with chronic kidney disease often engage in non-adherent behaviors such as skipping their medications, missing medical appointments and not following diet restrictions, resulting in poorer health outcomes," said lead author Becky Hashim, Ph.D., attending clinical psychologist, Behavioral Consultation Team, CHAM, and assistant professor, departments of Psychiatry and Behavioral Sciences and of Pediatrics, Albert Einstein College of Medicine of Yeshiva University. "The ultimate goal of this intervention was to help improve adherence so the patients could be eligible for transplantation, thereby improving the quality of their lives."
Approximately 14 million pediatric patients in the U.S. have end-stage renal disease, the most life-threatening stage of CKD when treatment with dialysis or transplant is required to survive. This condition is associated with cardiovascular diseases and bone disorders, and increases the risk of emotional and behavioral disorders such as depression, anxiety and social issues, which are often linked to non-adherence.
Patients in this study, prior to the intervention, expressed negative thoughts and emotions related to their illness, difficulty accepting their conditions and reported feeling "different" from their peers. They were all listed as inactive or unsuitable on the United Network for Organ Sharing list and previous attempts to improve adherence with different interventions had proven unsuccessful.
The DBT intervention taught participants several skills including "radical acceptance" of his or her illness -- letting go of fighting reality and seeing and accepting things as they are. Participants also were taught how to become more aware of their emotions and behaviors. They learned how to understand their behavior, identify adaptive solutions and develop techniques for averting these problems altogether.
Each participant was asked to keep a DBT diary card where they recorded non-adherent behaviors, urges and emotions, and documented medications taken each day, intensity of urges to not take medication and subsequent actions on those urges. Also recorded were intensity of urges to not attend medical appointments and subsequent actions on those urges, intensity of emotions (happy, mad, scared, sad) and comments regarding specific events during the week.
"Despite the clear prevalence of non-adherence in the chronically ill pediatric population and the high risks of morbidity and mortality, we have previously been unable to identify interventions that target both the behavioral and psychological components of these patients," said Dr. Hashim. "Our research demonstrates that DBT shows promise in targeting difficult-to-treat patients suffering from a chronic medical illness and struggling to adhere to their medical regimen. Adherence is so critical because it often proves that a patient is a good candidate for transplantation and it also can help prevent other conditions."
Dr. Hashim is currently in the process of adapting this protocol for other chronic illnesses at CHAM, with the hypothesis that the program may be an effective method of improving adherence across chronic diseases in pediatrics.
- Hashim, Becky L.; Vadnais, Majorie; Miller, Alec L. Improving Adherence in Adolescent Chronic Kidney Disease: A Dialectical Behavior Therapy (DBT) Feasibility Trial. Clinical Practice in Pediatric Psychology, September 2, 2013
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