April 1, 2026
Kevin Chan, OD, MS, FAAO, IACMM
Photo Credit: Dreamstime Photos
When I developed lateral epicondylitis (a.k.a. ‘tennis elbow’) a few years ago, I admittedly wouldn’t have considered myself the ‘best’ patient whom my doctor would have liked to handle. I wasn’t complying to the recommendations of doing cold compresses, or using the brace as much as I should. Unsurprisingly, the lackluster habit of adhering to medical advice, despite full autonomy, has delayed recovery time and also made the prognosis more unpredictable for me.
The experience hasn’t become too relatable until I once sat on the other side of the slit lamp in the exam room.
A silent sigh of reckoning and puzzlement.
I had once prescribed this 7-year-old child with atropine medication as part of the myopia management plan. I thought I did every possible step to ensure that the child and his family followed the logistics and understood the importance of using the medication as prescribed. However, three months later, the medication bottle that his mother brought was barely used. As I tried to probe into the history and possible rationale of what might have discouraged him from using the medication, his mother shrugged her shoulders and said, “I just applied it for the first couple of days; I didn’t know that my son is supposed to use it for long.’”
Where is the Disconnect?
Apparently, the knowledge gap here wasn’t atropine treatment itself; rather, it was the cognitive disconnect and the discordant expectations I had from reality.
Conventionally, the age-long dogma or mindset that “Prescribing A, B, or C to yield Outcome X, Y, or Z” has been so ingrained in clinicians’ minds. Parents and the public are also used to the unilateral, or ‘top-down’ mode of medical care at large. In the context of pediatric myopia care, one of the most common and intuitive questions I encountered from parents is, ‘Which treatment is the BEST for my child?’ Sound familiar? While this question can be seemingly straightforward or repetitive for some, it can indeed be one of the most complex and mind-twisting questions that clinicians can fully and comfortably comprehend and answer. While science brings us data, the art of interpreting science is what really changes behavior and calls for action.
Arguably, gauging treatment success for children at risk of myopia progression is paramount. Nevertheless, we as clinicians often view treatment itself as the endpoint, or a destination, in pediatric myopia care. Young patients and their families are also subconsciously primed to think that seeking THE best intervention, regardless of treatment modalities, is the sole and final “checkpoint” to assert confidence and get “the best bang for the buck.” In a financial sense, it simply signifies that parents have the undeniable desire of “getting the highest ROI” for their children.
While I genuinely understand and echo this sentiment, an innate and subtle aspect of human psychology is largely missing here. That is – ADHERENCE. “Adherence” is often misunderstood, or used interchangeably with “compliance.” Nevertheless, they are distinctly different in their clinical relevance, and thus the outcomes.
Going Deeper into the Psychology of Compliance vs. Adherence
Compliance is defined as “passive obedience,” or understood as the extent to which patients follow a set of instructions from a clinician. It primarily asserts a “top-down” approach where patients or caretakers are expected to do what they are told, regardless of whether understanding is met or not.1
Adherence, on the other hand, describes an “active partnership” between patients and practitioners. It is no longer a set of cardinal rules or regulations for which patients are obligated to follow. Rather, adherence EMPOWERS shared ownership and responsibility before outcomes are taken into effect.1
In essence, compliance simply reinforces obedience, while adherence deliberately invites partnership and mutual understanding of both parties. Unfortunately, most practitioners have long been so accustomed to reinforcing compliance, without fostering adherence. This type of unilateral approach can lead to frustration, disappointment and futile clinical outcomes.
Despite technological advances and influence by AI or automation, which are meant to clear barriers and enhance adherence, the inherent issues of non-adherence to interventions, particularly among children, have ironically remained widespread and underreported. A study found that medication non-adherence rates had been as high as 50-75% in children and adolescents with chronic medical conditions. Despite the favorable level of self-reported adherence, nearly 75% of patients and caregivers reported at least one or more barriers to adherence.2 In addition, 17% of new prescriptions for children were never filled.3
Practicing Adherence for Coalition
The importance and clinical merits of adherence to medical interventions cannot be overstated. But what remains lurking isn’t the clinical efficacy of an intervention itself, but is instead due to a plethora of psychological and behavioral factors, such as misconceptions about myopia treatment (“once-and-for-all” mentality), fear and anxiety of chronic side effects or dependency, as well as inaccurate or unrealistic expectations of how quickly treatments should work.
For myopia management, outcomes are built not solely on intention, but on intentional adherence.
Surprisingly (yet not shockingly), many parents still assume that myopia is a “quick fix.” Simply giving parents a prescription for eye drops or repeating the steps of applying contact lenses does little to overcome preexisting mindsets or behaviors. Instead, we need to be more focused on disrupting existing habitual loops and introducing new lifestyle modifications. For instance, instead of asking parents to fill the prescription at the pharmacy and warning them about potential side effects (i.e. attempting compliance), I tend to pivot the conversation and reframe the approach to treatment advice with the child:
“Hey buddy, THANK YOU for doing what you have done so far.
I need your help and I TRUST you that you can help make it possible
for US, because neither the Doctor or the prescription can do it all.”
Cultivating Adherence
This cultivates adherence, not compliance. Moreover, the emphasis of “US” instead of “You” signifies a sense of partnership and collaboration beyond one’s own chore or responsibility, which can seem burdensome. Children and their parents would certainly appreciate it.
While adherence and timely management isn’t commonly measured or discussed, it can easily become a make-it-or-break-it deal for treatment success. We as clinicians should be cognizant that adherence is a sophisticated skill which we shouldn’t take for granted.
Indeed, enhancing success for the journey of pediatric myopia care is not about increasing patients’ compliance. Rather, it is about ALIGNING respective treatment with one’s behavior to achieve adherence. Stop preaching and start building alliances with your young patients. By aligning children’s mindsets and clearing obstacles against their habitual behavior, it can become a key remedy toward self-sufficiency and partnership to “flatten the curve.”
References
- Mir. HCA Healthcare Journal of Medicine (2023) 4:2 https://doi.org/10.36518/2689-0216.1513
- Kevin E Todd, Meghan E Mcgrady, Anne Blackmore, Carrie Hennessey, Lori Luchtman-Jones; Assessing Barriers to Medication Adherence in Pediatric and Adolescent and Young Adult (AYA) Patients on Anticoagulation. Blood 2020; 136 (Supplement 1): 9–10.
- Zeitouny S, Cheng L, Wong ST, Tadrous M, McGrail K, Law MR. Prevalence and predictors of primary nonadherence to medications prescribed in primary care. CMAJ. 2023 Aug 8;195(30):E1000-E1009.
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