Use of differential reinforcement to treat medical non-compliance in a paediatric patient with leukocyte adhesion deficiency.

Leukocyte Adhesion Deficiency (LAD) is a rare immuno-deficiency disorder which results in chronic infections, such as gingivitis, necrotic skin infections and gastrointestinal ulcers. This case describes an 18-year-old male who was non-compliant during an inpatient hospitalization with several aspects of his complex medical regimen, particularly his wound care, physical therapy and use of his crutches. The patient's dressing change protocol was task analysed in order to create a structured, predictable routine by having the subject complete small, discrete steps. A differential reinforcement programme was implemented to provide the patient with tangible reinforcement for general compliance with his treatment, including compliance with dressing changes and physical therapy. Over a 1-month period, the subject's overall compliance with his medical regimen achieved an average of approximately 87%. His compliance with physical therapy and dressing changes both improved to 87 and 80%, respectively, by the end of his hospitalization. During the last week of his hospitalization, the use of his crutches was task analysed and included in his reinforcement programme using a changing criterion design. His average use of his crutches also improved to 80%.