Selective Interventions 453There is compelling evidence to support CBT, targeting the
antecedents and consequences of recurrent headache, as ef-
fective. Speci“cally, Holden et al. (1999) concluded that the
use of relaxation/self-hypnosis is a well-established and ef“-
cacious treatment (see Tables 19.1 and 19.2). Studies typically
use imagery-based or progressive muscle relaxation and en-
courage children and adolescents to engage in relaxation at
the onset of headache symptoms. The focus of this research
has been on promoting the use of the intervention, through
practice at home, without the aid of a psychologist/coach.
Furthermore, implementation of treatment in nonclinic-based
sites (in schools) and in self-administered formats has been
successful. For instance, McGrath et al. (1992) developed an
intervention in which children and adolescents with migraine
headaches were trained in coping and in relaxation tech-
niques; one group self-administered the intervention and one
group received the training with an interventionist. Compared
to an education-only control group, both intervention groups
show improvement in headache pain.
In the case of recurrent headache, the literature suggests
that cognitive-behavioral interventions are more effective
than pharmacological interventions (Hermann, Kim, &
Blanchard, 1995). However, the combined effects of CBT
with pharmacotherapy have not been well studied (Holden,
Deichmann, & Levy, 1999). In practice, cognitive-behavioral
interventions are employed with children with recurrent
headache less often than they merit. It has been recommended
that the research reviewed here be disseminated widely;
physicians and parents need to be informed of the effective-
ness shown for CBT for pediatric pain (McGrath, 1999).
Treatment Adherence
Nonadherence to prescribed treatment for acute and chronic
conditions is estimated to be about 50% in pediatric popula-
tions (La Greca & Schuman, 1995). Nonadherence also oc-
curs in the context of life-threatening conditions and in spite
of potentially serious short- and long-term consequences in
terms of development of illness symptoms, hospitalizations
and missed school days, and permanent disability. The fac-
tors associated with treatment adherence are complex and
various but key individual, family, and contextual factors
that promote adherence are being elucidated. Christiaanse,
Lavigne, and Lerner (1989) contend that treatment adherence
may be viewed as one aspect of adjustment to chronic illness.
The association between factors related to adjustment and
those related to adherence (Christiaanse et al., 1989) has been
supported in the general pediatric literature. Child factors of
younger age (Korsch, Fine, & Negrete, 1978; La Greca,
1990), use of adaptive coping strategies (Jacobson et al.,
1990), and adequate adjustment (Christiaanse et al., 1989;
Korsch et al., 1978) have been related to greater treatment ad-
herence in various pediatric samples. Parent problem-solving
skills (Fehrenbach & Peterson, 1989) and family functioning
(Christiaanse et al., 1989) have also been positively related to
treatment adherence.
Illness severity has not been reported as a predictor of ad-
herence while disease chronicity and treatment complexity
have (La Greca & Schuman, 1995). IDDM requires a com-
plex and intensive treatment regimen (Johnson, 1998); there-
fore, it has drawn the attention of child health psychologists.
The goal of treatment for IDDM is to give insulin in a man-
ner that approaches normal pancreatic function (Johnson,
1998). This goal is accomplished through blood glucose
monitoring and insulin provision over the course of the day.
Dietary restrictions and exercise are used to stabilize blood
glucose levels. This regimen requires knowledge, the ability
to make judgments regarding insulin requirements, technical
skill in terms of injections, and commitment. Hypoglycemia
and hyperglycemia are possible short-term complications.
Long-term complications of IDDM, particularly if poorly
controlled, include blindness, heart disease, renal disease,
and amputations.
Building an alliance among patient, parents, and health
care providers plays a role in improving adherence behaviors
(Gavin, Wamboldt, Sorokin, Levy, & Wamboldt, 1999). The
termtreatment adherencehas replaced the older term,com-
pliance,becauseadherenceconnotes the active and willful
role of the patient and family in administering treatment and
making decisions regarding illness management„it pre-
sumes the need for a partnership. Gavin et al. (1999) exam-
ined the association of treatment alliance with adherence
ratings and asthma outcome measured one year after initial
assessment in a study of 30 adolescents with asthma and their
families. Childhood asthma is a major cause of school absen-
teeism and hospitalization. The treatment regimen for asthma
is composed of medication management and prevention
through manipulation of environmental triggers. Poverty and
barriers to health care complicate treatment adherence (Creer,
1998). In the Gavin et al. (1999) study, physician report
of treatment alliance was associated with measures of treat-
ment adherence and asthma outcome for these adolescents.
Treatment alliance was not associated with demographic
characteristics of the sample or adolescent psychological
functioning but was associated with parent self-esteem and
family functioning.
A number of models have been presented to explain non-
adherence and identify targets for intervention. The health
belief model has received attention in the literature with
mixed results. In this model, perceived susceptibility to