Rewarding adherence may be the key to treatment success in children with atopic dermatitis.
The treatment of atopic dermatitis is a widespread problem for many dermatologists. Consistent application of topical medications is highly effective for treating eczema flares and preventing their recurrence, but this requires diligence and motivation by the patient and/or the parent, which often diminishes over time. While prescribing more potent topical preparations may be an option, more substantial results may be obtained by instead instituting a method to increase adherence to the existing medication regimen. The use of sticker charts, in which a sticker is awarded upon completion of a medication dose and placed on a weekly or monthly chart, can give a school-age child a sense of pride and accomplishment and encourage continued adherence. Behaviorally speaking, these sticker charts positively reinforce adherence to treatment regimens by pairing a reward with the desired behavior.
In examining the literature on behavioral interventions to improve treatment adherence, there are no studies specific to atopic dermatitis, but Lori J. Stark, PhD, has emerged as a leader in the field with multiple randomized controlled trials demonstrating the impact of sticker charts on clinical outcomes in other chronic pediatric diseases. As the director of Behavioral Medicine and Clinical Psychology at Cincinnati Children’s Hospital Medical Center and Professor of Pediatrics at the University of Cincinnati College of Medicine, her expertise lies in health psychology and improving parent and child adherence to medical regimens via behavioral interventions. While much of Stark’s work has focused on developing behavioral interventions for cystic fibrosis patients, she has employed these techniques across numerous pediatric diseases, demonstrating the applicability of sticker charts as a means to increase adherence to atopic dermatitis treatment regimens.
Proven Success of Positive Reinforcement
For example, a recent study by Stark1 examined the efficacy of sticker charts on increasing caloric intake in cystic fibrosis patients with pancreatic insufficiency. The intervention, which included 79 children age 4 to 12, consisted of five sessions using a stepwise approach to positive reinforcement, with each session targeting increased food intake at a specific meal or snack (with the expectation that previously met goals would be maintained). Parents were instructed to use weekly sticker charts to reward their child for meeting the calorie goal of a specific meal and rewards were given when completed sticker charts were presented at subsequent treatment sessions. The use of sticker charts significantly increased caloric intake, weight gain and BMI in comparison to controls.
Another study by Stark and colleagues2 demonstrated increased dietary calcium intake in children with inflammatory bowel disease who had been treated with sticker chart positive reinforcement therapy. Thirty-two children age 5 to 12 with inflammatory bowel disease were randomized to receive the sticker chart behavioral intervention with a stepwise approach to increase calcium intake at specific meals or snacks. As in other trials, children were rewarded daily by parents for meeting mealtime calcium goals and at weekly treatment sessions for completing a week of calcium goals. After treatment, adherence to goal calcium intake was 81% in the sticker chart group versus 19% of controls. This corresponded to a virtual doubling of average calcium intake (955 mg/day to 1939 mg/day) in those using sticker charts compared to a mere increase of 274 mg/calcium/day in the control group.
Stark and colleagues3 also examined the effects of the sticker chart behavioral intervention on calcium intake in 49 children age 4 to 10 with juvenile rheumatoid arthritis. Stickers were again provided as a reward for increasing calcium intake at a specific meal or snack in a weekly stepwise paradigm. This approach significantly increased daily adherence to target calcium intake (54%) compared to education-only controls (25%) after 6 months. Average dietary calcium intake was at or above target level at 6 and 12 months, a significant jump from baseline calcium consumption and a feat not achieved by the control group. Most importantly, increased adherence resulted in improved clinical outcomes. In those children utilizing sticker charts, total body bone mineral density increased by 12% at 6 months compared to baseline and 20% at 1 year, greater than the increase observed in the education-only control group (8% and 16% at 6 and 12 months, respectively).
These examples — just a few of the studies performed by Stark — illustrate the capacity of sticker charts to increase adherence in pediatric populations and to improve clinical outcomes. Her work provides evidence that the behavioral principles of positive reinforcement can be administered in clinical practice to treat medical disease. Developing a sticker chart routine with patients takes but a few minutes that may otherwise be spent adjusting medication regimens for failed treatment and could have lasting beneficial effects. School-age children with atopic dermatitis are a good target population for this intervention, as it allows them to feel autonomy while still relishing the recognition of their accomplishments. As demonstrated by the extensive work of Dr. Stark, a few stickers and some support can instill consistent treatment adherence in an impressionable population.
Ms. Luersen is with the Center for Dermatology Research and the Department of Dermatology at Wake Forest University School of Medicine in Winston-Salem, NC.
Dr. Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Disclosure: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, L.P. Dr. Feldman is or has been a consultant and/or speaker for Galderma Laboratories, Abbott, Leo, Centocor, Amgen, Astellas, GSK/Stiefel, Photomedex, Coria and Novartis.
Dr. Feldman has received grants from Galderma Laboratories, GSK/Stiefel, Astellas, Abbott Labs, Leo, Centocor, Amgen, Photomedex, Coria, Pharmaderm, Ortho Pharmaceuticals and Aventis Pharmaceuticals. He has received stock options from Photomedex and holds stock in www.DrScore.com.
Ms. Luersen has no conflicts of interest to disclose.
Rewarding adherence may be the key to treatment success in children with atopic dermatitis.
The treatment of atopic dermatitis is a widespread problem for many dermatologists. Consistent application of topical medications is highly effective for treating eczema flares and preventing their recurrence, but this requires diligence and motivation by the patient and/or the parent, which often diminishes over time. While prescribing more potent topical preparations may be an option, more substantial results may be obtained by instead instituting a method to increase adherence to the existing medication regimen. The use of sticker charts, in which a sticker is awarded upon completion of a medication dose and placed on a weekly or monthly chart, can give a school-age child a sense of pride and accomplishment and encourage continued adherence. Behaviorally speaking, these sticker charts positively reinforce adherence to treatment regimens by pairing a reward with the desired behavior.
In examining the literature on behavioral interventions to improve treatment adherence, there are no studies specific to atopic dermatitis, but Lori J. Stark, PhD, has emerged as a leader in the field with multiple randomized controlled trials demonstrating the impact of sticker charts on clinical outcomes in other chronic pediatric diseases. As the director of Behavioral Medicine and Clinical Psychology at Cincinnati Children’s Hospital Medical Center and Professor of Pediatrics at the University of Cincinnati College of Medicine, her expertise lies in health psychology and improving parent and child adherence to medical regimens via behavioral interventions. While much of Stark’s work has focused on developing behavioral interventions for cystic fibrosis patients, she has employed these techniques across numerous pediatric diseases, demonstrating the applicability of sticker charts as a means to increase adherence to atopic dermatitis treatment regimens.
Proven Success of Positive Reinforcement
For example, a recent study by Stark1 examined the efficacy of sticker charts on increasing caloric intake in cystic fibrosis patients with pancreatic insufficiency. The intervention, which included 79 children age 4 to 12, consisted of five sessions using a stepwise approach to positive reinforcement, with each session targeting increased food intake at a specific meal or snack (with the expectation that previously met goals would be maintained). Parents were instructed to use weekly sticker charts to reward their child for meeting the calorie goal of a specific meal and rewards were given when completed sticker charts were presented at subsequent treatment sessions. The use of sticker charts significantly increased caloric intake, weight gain and BMI in comparison to controls.
Another study by Stark and colleagues2 demonstrated increased dietary calcium intake in children with inflammatory bowel disease who had been treated with sticker chart positive reinforcement therapy. Thirty-two children age 5 to 12 with inflammatory bowel disease were randomized to receive the sticker chart behavioral intervention with a stepwise approach to increase calcium intake at specific meals or snacks. As in other trials, children were rewarded daily by parents for meeting mealtime calcium goals and at weekly treatment sessions for completing a week of calcium goals. After treatment, adherence to goal calcium intake was 81% in the sticker chart group versus 19% of controls. This corresponded to a virtual doubling of average calcium intake (955 mg/day to 1939 mg/day) in those using sticker charts compared to a mere increase of 274 mg/calcium/day in the control group.
Stark and colleagues3 also examined the effects of the sticker chart behavioral intervention on calcium intake in 49 children age 4 to 10 with juvenile rheumatoid arthritis. Stickers were again provided as a reward for increasing calcium intake at a specific meal or snack in a weekly stepwise paradigm. This approach significantly increased daily adherence to target calcium intake (54%) compared to education-only controls (25%) after 6 months. Average dietary calcium intake was at or above target level at 6 and 12 months, a significant jump from baseline calcium consumption and a feat not achieved by the control group. Most importantly, increased adherence resulted in improved clinical outcomes. In those children utilizing sticker charts, total body bone mineral density increased by 12% at 6 months compared to baseline and 20% at 1 year, greater than the increase observed in the education-only control group (8% and 16% at 6 and 12 months, respectively).
These examples — just a few of the studies performed by Stark — illustrate the capacity of sticker charts to increase adherence in pediatric populations and to improve clinical outcomes. Her work provides evidence that the behavioral principles of positive reinforcement can be administered in clinical practice to treat medical disease. Developing a sticker chart routine with patients takes but a few minutes that may otherwise be spent adjusting medication regimens for failed treatment and could have lasting beneficial effects. School-age children with atopic dermatitis are a good target population for this intervention, as it allows them to feel autonomy while still relishing the recognition of their accomplishments. As demonstrated by the extensive work of Dr. Stark, a few stickers and some support can instill consistent treatment adherence in an impressionable population.
Ms. Luersen is with the Center for Dermatology Research and the Department of Dermatology at Wake Forest University School of Medicine in Winston-Salem, NC.
Dr. Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Disclosure: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, L.P. Dr. Feldman is or has been a consultant and/or speaker for Galderma Laboratories, Abbott, Leo, Centocor, Amgen, Astellas, GSK/Stiefel, Photomedex, Coria and Novartis.
Dr. Feldman has received grants from Galderma Laboratories, GSK/Stiefel, Astellas, Abbott Labs, Leo, Centocor, Amgen, Photomedex, Coria, Pharmaderm, Ortho Pharmaceuticals and Aventis Pharmaceuticals. He has received stock options from Photomedex and holds stock in www.DrScore.com.
Ms. Luersen has no conflicts of interest to disclose.
Rewarding adherence may be the key to treatment success in children with atopic dermatitis.
The treatment of atopic dermatitis is a widespread problem for many dermatologists. Consistent application of topical medications is highly effective for treating eczema flares and preventing their recurrence, but this requires diligence and motivation by the patient and/or the parent, which often diminishes over time. While prescribing more potent topical preparations may be an option, more substantial results may be obtained by instead instituting a method to increase adherence to the existing medication regimen. The use of sticker charts, in which a sticker is awarded upon completion of a medication dose and placed on a weekly or monthly chart, can give a school-age child a sense of pride and accomplishment and encourage continued adherence. Behaviorally speaking, these sticker charts positively reinforce adherence to treatment regimens by pairing a reward with the desired behavior.
In examining the literature on behavioral interventions to improve treatment adherence, there are no studies specific to atopic dermatitis, but Lori J. Stark, PhD, has emerged as a leader in the field with multiple randomized controlled trials demonstrating the impact of sticker charts on clinical outcomes in other chronic pediatric diseases. As the director of Behavioral Medicine and Clinical Psychology at Cincinnati Children’s Hospital Medical Center and Professor of Pediatrics at the University of Cincinnati College of Medicine, her expertise lies in health psychology and improving parent and child adherence to medical regimens via behavioral interventions. While much of Stark’s work has focused on developing behavioral interventions for cystic fibrosis patients, she has employed these techniques across numerous pediatric diseases, demonstrating the applicability of sticker charts as a means to increase adherence to atopic dermatitis treatment regimens.
Proven Success of Positive Reinforcement
For example, a recent study by Stark1 examined the efficacy of sticker charts on increasing caloric intake in cystic fibrosis patients with pancreatic insufficiency. The intervention, which included 79 children age 4 to 12, consisted of five sessions using a stepwise approach to positive reinforcement, with each session targeting increased food intake at a specific meal or snack (with the expectation that previously met goals would be maintained). Parents were instructed to use weekly sticker charts to reward their child for meeting the calorie goal of a specific meal and rewards were given when completed sticker charts were presented at subsequent treatment sessions. The use of sticker charts significantly increased caloric intake, weight gain and BMI in comparison to controls.
Another study by Stark and colleagues2 demonstrated increased dietary calcium intake in children with inflammatory bowel disease who had been treated with sticker chart positive reinforcement therapy. Thirty-two children age 5 to 12 with inflammatory bowel disease were randomized to receive the sticker chart behavioral intervention with a stepwise approach to increase calcium intake at specific meals or snacks. As in other trials, children were rewarded daily by parents for meeting mealtime calcium goals and at weekly treatment sessions for completing a week of calcium goals. After treatment, adherence to goal calcium intake was 81% in the sticker chart group versus 19% of controls. This corresponded to a virtual doubling of average calcium intake (955 mg/day to 1939 mg/day) in those using sticker charts compared to a mere increase of 274 mg/calcium/day in the control group.
Stark and colleagues3 also examined the effects of the sticker chart behavioral intervention on calcium intake in 49 children age 4 to 10 with juvenile rheumatoid arthritis. Stickers were again provided as a reward for increasing calcium intake at a specific meal or snack in a weekly stepwise paradigm. This approach significantly increased daily adherence to target calcium intake (54%) compared to education-only controls (25%) after 6 months. Average dietary calcium intake was at or above target level at 6 and 12 months, a significant jump from baseline calcium consumption and a feat not achieved by the control group. Most importantly, increased adherence resulted in improved clinical outcomes. In those children utilizing sticker charts, total body bone mineral density increased by 12% at 6 months compared to baseline and 20% at 1 year, greater than the increase observed in the education-only control group (8% and 16% at 6 and 12 months, respectively).
These examples — just a few of the studies performed by Stark — illustrate the capacity of sticker charts to increase adherence in pediatric populations and to improve clinical outcomes. Her work provides evidence that the behavioral principles of positive reinforcement can be administered in clinical practice to treat medical disease. Developing a sticker chart routine with patients takes but a few minutes that may otherwise be spent adjusting medication regimens for failed treatment and could have lasting beneficial effects. School-age children with atopic dermatitis are a good target population for this intervention, as it allows them to feel autonomy while still relishing the recognition of their accomplishments. As demonstrated by the extensive work of Dr. Stark, a few stickers and some support can instill consistent treatment adherence in an impressionable population.
Ms. Luersen is with the Center for Dermatology Research and the Department of Dermatology at Wake Forest University School of Medicine in Winston-Salem, NC.
Dr. Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Disclosure: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, L.P. Dr. Feldman is or has been a consultant and/or speaker for Galderma Laboratories, Abbott, Leo, Centocor, Amgen, Astellas, GSK/Stiefel, Photomedex, Coria and Novartis.
Dr. Feldman has received grants from Galderma Laboratories, GSK/Stiefel, Astellas, Abbott Labs, Leo, Centocor, Amgen, Photomedex, Coria, Pharmaderm, Ortho Pharmaceuticals and Aventis Pharmaceuticals. He has received stock options from Photomedex and holds stock in www.DrScore.com.
Ms. Luersen has no conflicts of interest to disclose.
