Pediatricians and other primary care providers also act as the “point person” for families, setting them up with needed resources and care that falls outside of the therapeutic triad. Where possible, collaborating with a social worker can make the difference for families who are having trouble getting insurance coverage or accessing other resources. For patients with more entrenched adherence difficulties, or nonadherence in the context of psychosocial or family factors, referral to a pediatric psychologist or behavioral health specialist may be necessary to have any chance of fostering behavioral change. We close this chapter with a brief discussion of the role psychologists can play in helping children and their families manage a chronic illness.

Psychologists with training in behavioral health play a critical role in the delivery of adherence promotion interventions in pediatric health care. Traditionally, pediatric patients have been referred to psychologists only when they presented with comorbid psychological concerns such as depression, or when adherence problems had become severe and entrenched, or when family functioning declined to the degree that the medical provider felt unable to do more than watch the disaster unfold. However, we will also argue that there is room for psychologists to take an expanded role in adherence promotion , specifically with regards to screening and assessment, and development of interventions at different levels of need.

Pediatric psychologists are especially well-suited to assess the specific barriers and facilitators of adherence that an individual and family are experiencing, and to provide tailored behavioral interventions (Guilfoyle et al. 2013; Moser et al. 2014). Examples of practical intervention approaches in the behavioral specialist’s “toolbox” include pill-swallowing training to address mechanical or psychological difficulties with medication administration (Hankinson and Slifer 2013), adherence-related goal-setting and problem-solving (Guilfoyle et al. 2013), using electronic monitoring technology as a therapy tool (Herzer et al. 2012), and individual and family-based therapies to address family teamwork and parenting practices to facilitate adherence (Wu and Hommel 2014). Psychologists are also best situated to be able to draw upon the effective multi-component interventions reported here (Wu and Hommel 2014).

The importance of psychologists and other behavioral health specialists to adherence promotion is increasingly being recognized. For example, the ADA’s current treatment guidelines for children and youth with type 1 diabetes (American Diabetes Association 2014) recommend incorporating psychological assessment and treatment into routine care and suggest “collaborative care interventions and use of a team approach” when working with mental health professionals.

Psychologists also have a pivotal role in the development and dissemination of universal and low-intensity interventions that can be implemented by others. Anderson et al.’s (1999) teamwork intervention is a model for this sort of work, as it was designed to be used by clinical staff (physicians, nurses, even paraprofessionals) with minimal behavioral training in the course of routine care. Some further examples are presented in the last chapter, when we describe a preliminary model for providing both prevention and intervention services focused on adherence at three different levels of assessed risk and need (cf. Kazak 2006).

In an ACO [accountable care organization] model, it may not be unreasonable to reward both parents and children with the disease for their work as partners with the medical team to achieve optimal outcomes.—Stark 2013

Managing a child’s chronic medical condition is a complex endeavor that requires the coordinated efforts of patients, parents, and healthcare providers. The need for developing healthcare partnerships is motivated by extensive research showing that it is dangerous for youth with chronic illness to “go it alone.” Even when youth and their families want to take on this risk, it should be kept in mind that from a public health perspective, the costs of adolescent independence to society as well as to the individual patient can be huge. Autonomy-support is necessary in many instances to gain adolescent cooperation and acceptance of receiving help, without threatening (and indeed fostering) age-appropriate development.

Communication is the key to building and maintaining these partnerships. Communication is necessary for assessing adherence, resolving conflict, and engaging families in decision-making. Declines in adherence are often the direct result of communication breakdowns (Wysocki 1997). Communication also fosters the development of a shared model of illness, without which patients, families, and providers may find themselves working at cross purposes, although without good communication they would never know it.

The healthcare partnership we have described here is based on the notion of the therapeutic triad of De Civita and Dobkin (2004), but importantly it allows for the inclusion of additional members of the partnership team. In particular, it is often necessary to include a psychologist with expertise in behavioral health to help manage clinical issues that have become too big for the triad to manage effectively.

It follows from the arguments above that the most successful interventions for adherence problems are likely be those with a focus on strengthening the relationships between the different healthcare partners. There is a growing evidence base in support of this hypothesis, but especially given the complexities involved in three-way interactions, this remains an important area for future research.