Section EditorMary Margaret Gottesman, PhD, RN, CPNPOhio State University College of NursingColumbus, Ohio Mary Margaret Gottesman, PhD, RN, CPNP Ohio State University College of Nursing Columbus, Ohio Adherence is universally recognized as a critical and contentious issue in the management of both acute and chronic illness in children (Becker et al 1979Becker M.H. Maiman L.A. Kirscht J.P. Haefner D.P. Drachman R.H. Taylor W. Patient perceptions and compliance: Recent studies of the health belief model. John Hopkins University Press, Baltimore1979Google Scholar, Horne and Weinman 1999Horne R. Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness.Journal of Psychosomatic Research. 1999; 47: 555-567Abstract Full Text Full Text PDF PubMed Scopus (1552) Google Scholar, Ignjatovic et al 2004Ignjatovic V. Barnes C. Newall F. Hamilton S. Burgess J. Monagle P. Point of care monitoring of oral anticoagulant therapy in children: Comparison of CoaguChek Plus and Thrombotest methods with venous international normalised ratio.Journal of Thrombosis and Haemostasis. 2004; 92: 734-737Google Scholar, Paterson et al 2002Paterson B. Thorne S. Russell C. Disease-specific influences on meaning and significance in self-care decision-making in chronic illness.The Canadian Journal of Nursing Research. 2002; 34: 61-74PubMed Google Scholar, Thorne 1993Thorne S. Health belief systems in perspective.Journal of Advanced Nursing. 1993; 18: 1931-1941Crossref PubMed Scopus (16) Google Scholar, Thorne et al 2002Thorne S. Paterson B. Acorn S. Canam C. Joachim G. Jillings C. Chronic illness experience: Insights from a metastudy.Qualitative Health Research. 2002; 12: 437-452Crossref PubMed Scopus (121) Google Scholar, Thorne et al 2003Thorne S. Paterson B. Russell C. The structure of everyday self-care decision making in chronic illness.Qualitative Health Research. 2003; 13: 1337-1352Crossref PubMed Scopus (131) Google Scholar). Among definitions of adherence, the common elements refer to the extent to which the patient acts consistently and in accordance with medical recommendations (Becker et al.; Brenner et al 2004Brenner B. Grabowski E.F. Hellgren M. Kenet G. Massicotte P. Manco-Johnson M. et al.Thrombophilia and pregnancy complications.Thrombosis & Haemostasis. 2004; 92: 678-681PubMed Google Scholar, Cassileth et al 1980Cassileth B.R. Zupkis R.V. Sutton-Smith K. March V. Informed consent—why are its goals imperfectly realized?.New England Journal of Medicine. 1980; 302: 896-900Crossref PubMed Scopus (442) Google Scholar, Makoul et al 1995Makoul G. Arntson P. Schofield T. Health promotion in primary care: Physician-patient communication and decision making about prescription medications.Social Science and Medicine. 1995; 41: 1241-1254Crossref PubMed Scopus (289) Google Scholar). Practitioners’ concerns are that nonadherence results in decreased safety and efficacy, clinical complications, reduced quality of life, and avoidable health care costs for both families and society (Sabaté 2003Sabaté E. Adherence to long-term therapies: Evidence for action. 2003Google Scholar). The World Health Organization (WHO) sponsored a review of the adherence literature (Sabaté), which identified five sets of factors that determine adherence: social and economic, health system/health teams, condition-related, therapy-related, and patient-related (Box 1). The WHO framework provides a comprehensive approach for understanding and addressing the many factors that determine adherence. The ability of patients to follow treatment plans in an optimal manner frequently is compromised by more than one factor. Solving the problems related to each of these factors is necessary if patients’ adherence to therapies is to be improved. There is no single intervention strategy or combination of strategies that has been shown to be effective across all patients, conditions, and settings (Sabaté; Thorne, Paterson, & Russell, 2003). Consequently, interventions that focus on adherence must be tailored to the particular illness-related demands experienced by the patient. To accomplish this goal, practitioners need to develop a means of accurately assessing not only adherence but also the factors that influence it. This article will focus on child-related factors, specifically the knowledge and beliefs that affect motivation, confidence, treatment expectations, and, ultimately, adherence. The use of thrombosis as a substantive example will be exemplified because there is a particular lack of educational material in this field. However, the principles used to develop such materials are generic and may be applied across pediatric subspecialties.Five dimensions of adherenceDimensions characteristics1Social and economic factors•Socioeconomic status•Literacy•Social inequalities (e.g., racial)2Health system/health care team factors promoting effective patient-provider relationships•Quality of health services•Access to reimbursement•Quality of medication distribution systems•Knowledge and training among health care providers•Service provider workload•Provision of incentives and feedback•Capacity of the system to educate families•Service provider knowledge of strategies to promote adherence3Condition-related demands faced by the patient•Severity of symptoms•Type of disability (physical, psychological, social, and vocational)•Rate of progression and severity of disease•Availability of effective treatments•Comorbidities4Therapy-related factors•Complexity of treatment•Duration of treatment•Previous treatment failures•Immediacy of benefits•Side effects of treatment5Patient-related factors•Knowledge and beliefs•Motivation•Confidence in personal ability•Expectations of treatment•Consequences of nonadherenceData from Sabaté 2003Sabaté E. Adherence to long-term therapies: Evidence for action. 2003Google Scholar. Dimensions characteristics 1Social and economic factors•Socioeconomic status•Literacy•Social inequalities (e.g., racial)2Health system/health care team factors promoting effective patient-provider relationships•Quality of health services•Access to reimbursement•Quality of medication distribution systems•Knowledge and training among health care providers•Service provider workload•Provision of incentives and feedback•Capacity of the system to educate families•Service provider knowledge of strategies to promote adherence3Condition-related demands faced by the patient•Severity of symptoms•Type of disability (physical, psychological, social, and vocational)•Rate of progression and severity of disease•Availability of effective treatments•Comorbidities4Therapy-related factors•Complexity of treatment•Duration of treatment•Previous treatment failures•Immediacy of benefits•Side effects of treatment5Patient-related factors•Knowledge and beliefs•Motivation•Confidence in personal ability•Expectations of treatment•Consequences of nonadherenceData from Sabaté 2003Sabaté E. Adherence to long-term therapies: Evidence for action. 2003Google Scholar. Developmentally appropriate educational materials are needed to help children (i.e., children through teenage years) with thrombophilia develop an accurate knowledge of their disease and its management and thereby improve clinical outcomes (Hart and Chesson 1998Hart C. Chesson R. Children as consumers.British Medical Journal. 1998; 316: 1600-1603Crossref PubMed Scopus (72) Google Scholar). When children have an insufficient understanding of thrombophilia and their prescribed anticoagulant therapy, they may fail to manage their condition in a way that minimizes their potentially life-threatening risk for bleeding and new clots (Moores & Vine, 1988; Wilson et al 2003Wilson J. Wells P. Kovacs M. Comparing the quality of oral anticoagulant management by anticoagulation clinics and by family physicians: A randomized controlled trial.Canadian Medical Association Journal. 2003; 169: 293-298Google Scholar). The educational materials must be specific to the target audience if they are to meet their learning needs. Traditionally, parents are the child’s primary caregiver and are the sole recipients of treatment-related teaching (Ferris et al 2001Ferris T.G. Dougherty D. Blumenthal D. Perrin J.M. A report card on quality improvement for children’s health care.Pediatrics. 2001; 107: 143-155Crossref PubMed Scopus (64) Google Scholar; Hart & Chesson; McPherson and Thorne 2000McPherson G. Thorne S. Children’s voices: Can we hear them?.Journal of Pediatric Nursing. 2000; 15: 22-29Abstract Full Text PDF PubMed Scopus (20) Google Scholar, Theunissen et al 2004Theunissen N.C. Tates K. Visser A. Educating and counseling children about physical health.Patient Education and Counseling. 2004; 55: 313-315Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar). When teaching is focused on the parents, learning is limited to the parents. In contrast, when the teaching targets the child, both the parents and child learn (Ferris et al.; Hart & Chesson; Limbo et al 2003Limbo R. Petersen W. Pridham K. Promoting safety of young children with guided participation processes.Journal of Pediatric Health Care. 2003; 17: 245-251Abstract Full Text Full Text PDF PubMed Google Scholar). When the child is involved in developmentally appropriate learning from the time of diagnosis, this establishes the foundation for the child’s active participation and eventual transition to independent decision-making (Haggerty and Roghmann 1972Haggerty R.J. Roghmann K.J. Noncompliance and self medication Two neglected aspects of pediatric pharmacology.Pediatric Clinics of North America. 1972; 19: 101-115PubMed Google Scholar, Paterson et al 2002Paterson B. Thorne S. Russell C. Disease-specific influences on meaning and significance in self-care decision-making in chronic illness.The Canadian Journal of Nursing Research. 2002; 34: 61-74PubMed Google Scholar, Rudolf et al 1993Rudolf M.C. Alario A.J. Youth B. Riggs S. Self-medication in childhood: Observations at a residential summer camp.Pediatrics. 1993; 91: 1182-1184PubMed Google Scholar). It must be acknowledged that children are already making active treatment decisions with or without sound knowledge (Rudolf et al.). A sample of 400 healthy children aged 9 to 16 years attending a summer camp were surveyed about medication usage. Thirty percent of these children decided what medications to take and when to take them without supervision on a regular basis, and they reported feeling confident in doing so (Rudolf et al.). A variety of child-focused education programs have been used in the subspecialties of childhood diabetes (Paterson and Thorne 2000Paterson B. Thorne S. Developmental evolution of expertise in diabetes self-management.Clinical Nursing Research. 2000; 9: 402-419Crossref PubMed Scopus (78) Google Scholar, Snoek and Visser 2003Snoek F. Visser A. Improving quality of life in diabetes: How effective is education?.Patient Education and Counseling. 2003; 51: 1-3Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar) and asthma (Brown et al 2004Brown R. Bratton S.L. Cabana M.D. Kaciroti N. Clark N.M. Physician asthma education program improves outcomes for children of low-income families.Chest. 2004; 126: 369-374Crossref PubMed Scopus (67) Google Scholar, Evans et al 2001Evans D. Clark N.M. Levison M.J. Levin B. Mellins R.B. Can children teach their parents about asthma?.Health Education & Behavior. 2001; 28: 500-511Crossref PubMed Scopus (52) Google Scholar, Guevara et al 2003Guevara J.P. Wolf F.M. Grum C.M. Clark N.M. Effects of educational interventions for self management of asthma in children and adolescents: Systematic review and meta-analysis.British Medical Journal. 2003; 326: 1308-1309Crossref PubMed Google Scholar, Hansson-Sherman and Lowhagen 2004Hansson-Sherman M. Lowhagen O. Drug compliance and identity: Reasons for non compliance Experiences of medication from persons with asthma/allergy.Patient Education and Counseling. 2004; 54: 3-9Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar) and support the assumption that child-focused education positively influences the child’s attitude toward his or her illness and improves disease-related outcomes (Brown et al.; Guevara et al.). The education materials described in this article were developed for children aged 7 to 19 years with, or at risk for, thrombophilia who received care through the Pediatric Thrombosis Program at the Stollery Children’s Hospital, Edmonton, Alberta, Canada. Children with thrombophilia have confirmed venous or arterial thrombosis or are at an increased risk for thrombosis. The incidence of pediatric thrombophilia has increased because of changing treatment patterns in tertiary care pediatrics (i.e., the increased use of central venous lines and cardio-surgical interventions (Male et al 2003Male C. Chait P. Andrew M. Hanna K. Julian J. Mitchell L. et al.Central venous line-related thrombosis in children: Association with central venous line location and insertion technique.Blood. 2003; 101: 4273-4278Crossref PubMed Scopus (196) Google Scholar, Monagle et al 2004Monagle P. Chan A. Massicotte P. Chalmers E. Michelson A. Antithrombotic therapy in children.Chest. 2004; 126: 645S-687SCrossref PubMed Scopus (381) Google Scholar). Suboptimal adherence to prescribed treatment regimes may result in serious sequelae (Male et al.; Monagle et al.). The sequelae of venous thromboembolism are life-threatening and can include organ failure, pulmonary embolism, embolic stroke, and sepsis. Thromboembolism also is associated with long-term complications such as loss of central venous access and post-thrombotic syndrome, which is characterized by pain, swelling, collateralization of vessels, and poor venous return (Kuhle et al 2003Kuhle S. Koloshuk B. Marzinotto V. Bauman M. Massicotte P. Andrew M. et al.A cross-sectional study evaluating post-thrombotic syndrome in children.Thrombosis Research. 2003; 111: 227-233Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar; Monagle et al.). The rate of recurrent thrombosis and associated mortality rate are reported to be 8.1% and 2.2%, respectively, in children with acute lymphoblastic leukemia and central venous line–related thrombosis. Post-thrombotic syndrome occurs in up to 14% of children diagnosed with venous thromboembolism (Kuhle et al.). A search of the literature that addressed the development and use of children’s health education materials was completed using MEDLINE, CINAHL, and ERIC databases (1996-2005). The MeSH headings and key words used to select articles included “reading,” “readability,” “pamphlets,” “teaching materials,” “consumer health information,” “patient information needs,” “child,” and “adolescence.” The search was restricted to English language articles that focused on children. Additional articles were identified from the bibliographies of included articles. We extracted information on the importance of child-focused education, as well as the requisite educational principles that would be used in the development of the teaching materials. Based on this review, the authors identified and incorporated eight key design features that facilitate child learning. These features and the underlying principles will be discussed in the context of the included thrombosis module, Protein C Deficiency (FIGURE 1, FIGURE 2, FIGURE 3, FIGURE 4). This module is one of 14 modules that have been developed describing prothrombotic conditions and therapy for children.FIGURE 2KIDCLOT© Low C Educational Handout page 2. This figure appears in color online at www.jpedhc.org. Figure provided courtesy of Mary Bauman.View Large Image Figure ViewerDownload Hi-res image Download (PPT)FIGURE 3KIDCLOT© Low C Educational Handout page 3. This figure appears in color online at www.jpedhc.org. Figure provided courtesy of Mary Bauman.View Large Image Figure ViewerDownload Hi-res image Download (PPT)FIGURE 4KIDCLOT© Low C Educational Handout page 4. This figure appears in color online at www.jpedhc.org. Figure provided courtesy of Mary Bauman.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The handouts contained a variety of graphic images and required software that would support the design requirements. A number of software packages were available for the development of the educational pamphlets. Microsoft Publisher (Version 2003) was selected because of its ease of use, affordability, design capacity, and availability of the software. The following sections will discuss eight principles that may be used to guide the development of child health materials. The intent of describing underlying principles is to enable readers to use them in other clinical contexts. Children’s ability to learn about illness is dependent on their level of social and cognitive development (Carandang et al 1979Carandang M.L. Folkins C.H. Hines P.A. Steward M.S. The role of cognitive level and sibling illness in children’s conceptualizations of illness.The American Journal of Orthopsychiatry. 1979; 49: 474-481Crossref PubMed Scopus (55) Google Scholar). Theories of developmental cognition provide insight into the child’s understanding of bodily functions and illness. Erikson’s theory of personality development suggests that children aged 7 to 10 years are intellectually curious and are motivated to perform successfully (Erikson 1959aErikson E. Growth and crises of the healthy personality.Psychological Issues. 1959; 1: 50-100Google Scholar, Erikson 1959bErikson E. Identity and the life cycle.Psychological Issues. 1959; 1: 1-171Google Scholar). At this age, children are capable of comprehending basic knowledge of their inner body and are curious about their bodies and how they work (Bibace and Walsh 1980Bibace R. Walsh M.E. Development of children’s concepts of illness.Pediatrics. 1980; 66: 912-917PubMed Google Scholar, Gallo et al 2005Gallo A.M. Angst D. Knafl K.A. Hadley E. Smith C. Parents sharing information with their children about genetic conditions.Journal of Pediatric Health Care. 2005; 19: 267-275Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, Glaun and Rosenthal 1987Glaun D. Rosenthal D. Development of children’s concepts about the interior of the body.Psychotherapy and Psychosomatics. 1987; 48: 63-67Crossref PubMed Scopus (11) Google Scholar, Piaget 1962Piaget J. The stages of the intellectual development of the child.Bulletin of the Menninger Clinic. 1962; 26: 120-128PubMed Google Scholar). Teaching interventions at this age will capitalize on their readiness to learn (Menacker et al 1999Menacker R. Aramburuzbala P. Minian N. Bush P. Bibace R. Children and medicines: What they want to know and how they want to learn.Journal of Social Administration Pharmacy. 1999; 16: 38-50Google Scholar). As children grow into adolescence, both their ability to learn and understand about bodily systems and their self-competency skills increase. Education aimed directly at the child or adolescent empowers them to manage their condition in a healthy manner. Prior to 7 years of age, children commonly have misconceptions and may believe that illness is caused by magic, contagion (Koopman et al 2004Koopman H.M. Baars R.M. Chaplin J. Zwinderman K.H. Illness through the eyes of the child: The development of children’s understanding of the causes of illness.Patient Education and Counseling. 2004; 55: 363-370Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar), or as a punishment for bad behavior (Perrin and Gerrity 1981Perrin E.C. Gerrity P.S. There’s a demon in your belly: Children’s understanding of illness.Pediatrics. 1981; 67: 841-849PubMed Google Scholar, Piaget 1951Piaget J. The child’s conception of physical causality. Routledge & Kegan Paul, London1951Google Scholar). Educational materials need to address these potential misconceptions to promote an accurate understanding of the pathology and rationale for treatment. It is important for the practitioner to listen to the child and their parents to determine what they want to know (Korsch 1984Korsch B.M. What do patients and parents want to know? What do they need to know?.Pediatrics. 1984; 74: 917-919PubMed Google Scholar, McPherson and Thorne 2000McPherson G. Thorne S. Children’s voices: Can we hear them?.Journal of Pediatric Nursing. 2000; 15: 22-29Abstract Full Text PDF PubMed Scopus (20) Google Scholar). To determine the clinical content for the educational materials, the authors discussed learning needs with children and families attending the pediatric thrombophilia clinic. Their four key questions were: “What is it?” “What does it mean for me?” “How did I get it?” and “What do I do about it?” Moreover, these four questions were used as major headings to organize the content in the different educational modules. Health care professionals using these materials must determine what questions the child and parent bring to the teaching session (Korsch 1984Korsch B.M. What do patients and parents want to know? What do they need to know?.Pediatrics. 1984; 74: 917-919PubMed Google Scholar; McPherson & Thorne) and use the materials as a means of generating questioning and inquiry. Patient learning priorities evolve over time and become more complex as they become more experienced in managing their condition. Well-designed learning materials provide a conceptual foundation from which increasingly sophisticated learning can occur. Color serves to awaken the learner because it attracts the interest and curiosity of readers, motivating them to read on. The use of color has two purposes: first, to stimulate inquiry, and second, to assist the learner to encode the information into memory (Day 1980Day M.C. Selective attention by children and adults to pictures specified by color.Journal of Experimental Child Psychology. 1980; 30: 277-289Crossref PubMed Scopus (10) Google Scholar, Heibeck 1985Heibeck T.H. Markman E.M. Word Learning in Children: An Examination of Fast Mapping.Child Development. 1987; 58: 1021-1034Crossref PubMed Google Scholar, Sassenrath 1979Sassenrath J.M. Functional color components used in reading instruction.Psychology in the Schools. 1979; 16: 132-136Crossref Scopus (1) Google Scholar). The use of color leads the learner through the written material by means of carefully designed changes of color (Hoffman 1985Hoffman A. Patterns of family extinction depend on definition and geological time scale.Nature. 1985; 315: 659-662Crossref Scopus (39) Google Scholar). Sudden changes in text color or style cue the reader’s attention and are a key strategy for telling the reader that subsequent information is important, or that it addresses a different topic (Basu et al 2006Basu A. Chan P. Desai B. Dy F. Malapit K. Odorisio D. et al.Design principles: Color and graphics. 2006Google Scholar). Color coding is used to represent themes both in text and in illustrations (Day; Heibeck; Monsivais and Reynolds 2003Monsivais D. Reynolds A. Developing and evaluating patient education materials.Journal of Continuing Education in Nursing. 2003; 34: 172-176PubMed Google Scholar, Moore 1977Moore K. How patient education can reduce the risks of anticoagulation.Nursing 77. 1977; 7: 24-29Crossref PubMed Scopus (7) Google Scholar; Peterson, 1976; Sassenrath). For example, in the thrombophilia model (Appendix A), different shades of yellow are used to identify the inhibitors of coagulation—Protein S, Protein C, and Antithrombin—in the text, and each of the illustrated inhibitors have yellow hats or are shades of yellow. In describing the coagulation cascade, a green font and the words “turned on” are used to denote activation of the coagulation cascade. Different shades of red are used to represent the clotting factors and all blood clots. Piaget argued that children organize information into “schemata” as they interact with their environment. When a child encounters new information, existing schemata are then reorganized and adapted, and new schemata are developed as necessary. In Piaget’s stage of concrete operations, children develop knowledge by taking a singular concrete experience and then generalizing it to a similar situation, or to an abstract concept (Egan 2001Egan, K. (2001). The Cognitive Tools of Children’s Imagination, keynote address presented at the European Early Childhood Education Research Association, Alkmaar, The Netherlands.Google Scholar, Piaget 1962Piaget J. The stages of the intellectual development of the child.Bulletin of the Menninger Clinic. 1962; 26: 120-128PubMed Google Scholar, Wilson 2000Wilson F.L. Research you can use Are patient information materials too difficult to read?.Home Healthcare Nurse. 2000; 18: 107-115Crossref PubMed Scopus (19) Google Scholar, Wilson 2000Wilson S.L.A. “A metaphor is pinning air to the wall”: A literature review of the child’s use of metaphor.Childhood Education. 2000; 77: 96-99Crossref Scopus (4) Google Scholar). Using a concrete experience to represent an abstract concept helps the child conceptualize the abstract thought in a meaningful way (Brenner et al 2004Brenner B. Grabowski E.F. Hellgren M. Kenet G. Massicotte P. Manco-Johnson M. et al.Thrombophilia and pregnancy complications.Thrombosis & Haemostasis. 2004; 92: 678-681PubMed Google Scholar, Theunissen and Tates 2004Theunissen N.C. Tates K. Models and theories in studies on educating and counseling children about physical health: A systematic review.Patient Education and Counseling. 2004; 55: 316-330Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). For example, children are familiar with the game of dominoes and how a series of dominoes fall in a cascading sequence: this concrete schema is used to represent the abstract concept of the coagulation cascade. Children have existing knowledge of flagmen who direct and slow road traffic to prevent injury during construction. This analogy is used to demonstrate the abstract concept of the inhibitors of coagulation. The flagmen wearing yellow hats denote Protein S, and their yellow “slow” signs represent Protein C. The remaining inhibitor of coagulation, Antithrombin (AT), is represented by the puppies wearing yellow work hats. Each of these three inhibitors slow the falling coagulation cascade represented by a red domino for each factor. For each new section of the teaching materials, these concrete representations are consistently applied so that a child can build on existing schemata. In Multiple Mode Learning, Gardner offers a theory of multiple intelligences that suggests that children learn best through a combination of visual, auditory and textual modes (Brualdi 1996Brualdi A.C. Multiple intelligences: Gardner’s theory. ERIC Clearinghouse on Assessment and Evaluation, Washington, DC1996Google Scholar, Gardner 1983Gardner H. Frames of mind. 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Moreover, information will be encoded and stored in two separate cognitive processing systems that can be accessed by the learner. Nonverbal symbols (illustrations) simplify difficult concepts and frequently are being used as a method for conveying information. Patients showed a preference for textual information combined with pictures (Bromley 2001Bromley H. A question of talk: Young children reading pictures.Reading. 2001; 35: 62-66Crossref Google Scholar, Kiefer 1984Kiefer B. Thinking, language and reading: Children’s responses to picture books. 1984Google Scholar). When presented in combination, comprehension (Hameen-Anttila et al 2004Hameen-Anttila K. Kemppainen K. Enlund H. Bush Patricia J. Marja A. Do pictograms improve children’s understanding of medicine leaflet information?.Patient Education Counsel. 2004; 55: 371-378Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar) and therapeutic adherence were maximized (Sojourner and Wogalter 1997Sojourner R. Wogalter M. The influence of pictorials on evaluations of prescription medication instructions.Drug Information Journal. 1997; 31: 963-972Google Scholar). Colored illustrations have a motivational effect that increases the likelihood that the reader will attend closely to the information provided in the text. Well-designed pictures that capture the concept and accompanying text will help the learner to organize the content into meaningful schemata that can be stored in long-term memory and then retrieved (Sojourner and Wogalter 1997Sojourner R. Wogalter M. The influence of pictorials on evaluations of prescription medication instructions.Drug Information Journal. 1997; 31: 963-972Google Scholar, Szabo and Hastings 2000Szabo A. Hastings N. Using IT in the undergraduate classroom: Should we replace the blackboard with PowerPoint?.Computers & Education. 2000; 35: 175-187Crossref Scopus (144) Google Scholar, Theunissen and Tates 2004Theunissen N.C. Tates K. Models and theories in studies on educating and counseling children about physical health: A systematic review.Patient Education and Counseling. 2004; 55: 316-330Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). In FIGURE 1, FIGURE 2, FIGURE 3, FIGURE 4, the coagulation cascade is illustrated by a series of dominoes and the concept of homeostasis is represented by a balanced teeter-totter, and these are explained in the corresponding text. The coagulation cascade, risk factors, mechanisms of inheritance, and safety issues are primary illustrations that are repeatedly used throughout the series of pamphlets. A third component of Gardiner’s multimode intelligences is auditory (Gardner 1993Gardner H. In multiple intelligences: The theory in practice. Basic Books Inc, New York1993Google Scholar, Gardner 2000Gardner H. In intelligence reframed: Multiple intelligences for the 21st Century. Basic Books Inc, New York2000Google Scholar). Educational materials must be integrated with verbal discussion to determine what the child and his or her parents understand what needs to be clarified and whether all key concepts have been covered. To be effective, the educational materials must be used as a springboard for active learning, rather than as a tool for self-learning. Repetition is used to reinforce key messages (Bush et al 1999Bush P.J. Ozias J.M. Walson P.D. Ward R.M. Ten guiding principles for teaching children and adolescents about medicines.Clinical Therapeutics. 1999; 21: 1280-1284Abstract Full Text PDF PubMed Scopus (49) Google Scholar, Kinzie 2005Kinzie M.B. Instructional design strategies for health behavior change.Patient Educational and Counseling. 2005; 56: 3-15Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar). One of the core concepts in thrombosis is the coagulation cascade. This is represented repetitively by the falling dominoes, regardless of whether defining “good clots,” “bad clots,” or clotting in the presence of specific deficiencies. Risk factors for pathologic clotting are displayed in the blue bubble. These risk factors include the presence of a central venous line, trauma, surgery, the casting of a limb, air travel greater than four hours in duration, or immobility and pregnancy. It is critical for children to understand individual risk factors because they are the focus of preventive management. To emphasize the concepts that are critical to children’s understanding of prevention, the cascade and the risk factors are emphasized through repeated and simultaneous use of both visual and textual modes. Learning starts with the discussion of basic concepts and then builds on those concepts in a logical sequence (Bergan 1979Bergan J.R. Effects of prerequisite-skill acquisition and child characteristics on hierarchical learning.Child Development. 1979; 50: 251-253Crossref Google Scholar, Catellani 1991Catellani P. Children’s recall of script-based event sequences: The effect of sequencing.Journal of Experimental Child Psychology. 1991; 52: 99-116Crossref Scopus (6) Google Scholar, Resnick 1970Resnick L.B. Transfer and sequence in learning double classification skills. 1970Google Scholar). In our example, the first “building block” is the notion of blood clots. To this we add the idea of “good and bad clots.” Next, clotting factors are introduced, and then combined to represent the coagulation cascade. This incremental learning principle was applied to the discussion of veins and basic anatomy, and to the role of key risk factors. These educational materials are written at a grade three reading level, which corresponds with the developmental age characterized by peak curiosity and readiness to learn about their bodies. While the materials are designed for children, it is recognized that their parents also will rely on them as ongoing references. The recommended literacy level for adult materials is grade five equivalency (Wilson 2000Wilson F.L. Research you can use Are patient information materials too difficult to read?.Home Healthcare Nurse. 2000; 18: 107-115Crossref PubMed Scopus (19) Google Scholar, Wilson 2000Wilson S.L.A. “A metaphor is pinning air to the wall”: A literature review of the child’s use of metaphor.Childhood Education. 2000; 77: 96-99Crossref Scopus (4) Google Scholar, Wilson and McLemore 1997Wilson F.L. McLemore R. Patient literacy levels: A consideration when designing patient education programs.Rehabilitation Nursing. 1997; 22: 311-317Crossref PubMed Scopus (34) Google Scholar, Wilson et al 2003Wilson J. Wells P. Kovacs M. Comparing the quality of oral anticoagulant management by anticoagulation clinics and by family physicians: A randomized controlled trial.Canadian Medical Association Journal. 2003; 169: 293-298Google Scholar) and grade three for school-aged children. In this complete series of thrombophilia handouts, the Flesch-Kincaid reading level ranged from grade 3.1 to 3.9. To ensure that the content of the education materials was evidence-based and reflected internationally accepted standards of practice in pediatric thrombosis, the 2004 guidelines for pediatric antithrombotic and thrombolytic therapy developed by the American College of Chest Physicians Consensus Committee (Monagle et al 2004Monagle P. Chan A. Massicotte P. Chalmers E. Michelson A. Antithrombotic therapy in children.Chest. 2004; 126: 645S-687SCrossref PubMed Scopus (381) Google Scholar) were used. The content specific to pathophysiology and clinical management was reviewed by an expert panel comprised of 40 hematologists (both adult and pediatric) specializing in thrombosis who attended the Thrombosis Interest Group of Canada Symposium, October 2004. The consensus of the expert panel was that the content was accurate, evidence-based, and should be made readily available to thrombosis practitioners and patients. Developing high-caliber materials that will meet the learning needs of children though their teenage years will enhance treatment adherence is much more complex than most health care professionals realize and requires that the educator be attentive to the principles described in this article. Educational materials need to be child-friendly and fun and must attend to what children want to know about their condition so that the child’s interest is captured and maintained. The information provided must be consistent with the child’s level of cognitive development. Key principles of teaching and learning such as color coding, concrete representation, multimode learning, repetition, and incremental learning are critical to engaging the learner.terview. Finally, verbal discussion to clarify the child’s questions and understanding of the concepts is essential.