Motivational interviewing in pediatric practice

Motivational interviewing in pediatric practice

Motivational Interviewing in Pediatric Practice Holly A. Sindelar, PhD, Ana M. Abrantes, PhD, Chantelle Hart, PhD, William Lewander, MD, and Anthony S...

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Motivational Interviewing in Pediatric Practice Holly A. Sindelar, PhD, Ana M. Abrantes, PhD, Chantelle Hart, PhD, William Lewander, MD, and Anthony Spirito, PhD

otivational Interviewing (MI), which historically has been used with problem drinkers, has increasingly been adapted successfully for use in primary care settings. Recent investigations have shown that MI is an effective strategy for decreasing adolescent substance use, decreasing health-risk behaviors, and increasing adherence to treatment regimens. Given the increased interest in using MI in pediatric health settings and the relative effectiveness of such approaches, a review of MI studies with particular attention to its application to pediatric practice seems warranted. In this article, we will present the theory and background of MI and review the literature regarding the use of MI with adolescents and, specifically, its application by physicians in pediatric settings. We conclude with a review of basic techniques in applying MI and provide two case examples to demonstrate examples of MI’s practical application.

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History and Background of MI Origins of MI Motivational Interviewing originated as an alternative approach to intervening with adult problem drinkers who were either not interested in abstaining from alcohol, not severely dependent on alcohol, or for whom traditional treatment approaches were otherwise unnecessary or undesirable. Since the theory of MI was first published in 1983, randomized controlled trials have been conducted to test the effectiveness of MI and adaptations of Motivational Interviewing

From the Center for Alcohol and Addiction Studies, Brown University Medical School, Brown University, Providence, RI. Curr Probl Pediatr Adolesc Health Care 2004;34:322-339 1538-5442/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cppeds.2004.06.003

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(AMI) in reducing alcohol and drug abuse and substance-related problems.1 Meta-analyses have been published assessing the efficacy of MI, AMI, and other brief interventions. These approaches appear to be as effective as other active treatment approaches and are superior to no treatment and placebo/wait-list controls in reducing alcohol and drug-use problems among adults, with effect sizes in the medium or moderate range.2-5 MI also has been adapted for use in addressing a myriad of other health-risk behaviors in adults, such as diet and exercise, psychiatric treatment adherence, HIV risk behavior, and eating disorders, with the strongest effects to date in the area of diet and exercise.3,6 Thus, although MI has its roots in the field of substance abuse treatment, its theory and techniques are widely applicable to many problems as well as many settings in which behavior change is promoted. Its brevity relative to other treatment approaches makes it especially viable in settings with time-limited patient contact, such as in general medical care.

Development of MI The concept of motivation, within traditional alcohol and drug treatment, was generally understood to be intrinsic to the individual seeking help. Treatment failure, in turn, when it occurred, was blamed on the patient’s denial, resistance to treatment, or failure to make use of the treatment program. When treatment was successful, on the other hand, credit was most often given to the quality of the treatment program. One psychologist, William Miller, began to question these traditional conceptualizations in his own work with substance-abusing patients. He began to observe that the level of denial and resistance patients demonstrated was directly related to the way in which their counselor was interacting with them. Specifically, he found that the more confrontational and argumentative a therapist was, the more the patient would resist and deny the need for behavior change.7 Miller thus began

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to conceptualize motivation as malleable and affected by the interpersonal process, and he began developing an alternative approach to intervening with patients in substance abuse treatment that was potentially more widely productive and less prone to moral judgment: Motivational Interviewing. Miller subsequently developed the Drinker’s Check-Up and began to test his theory.8 The Drinker’s Check-Up consisted of a one-session assessment, followed by a consultation session which focused on presenting feedback using a nonconfrontational style that incorporated the following elements: supporting the patient’s self-efficacy; creating a discrepancy between current behavior and future goals; giving advice to cut down or quit drinking; and providing community resources and/or a discussion of methods of change. In one study of community residents who responded to an advertisement to receive a “check-up” of their drinking, the Drinker’s Check-Up resulted in reductions in drinking among these non-treatmentseeking patients.8 Six weeks after the initial feedback session, alcohol consumption was reduced by 27% and peak blood alcohol concentration (BAC) was reduced by 29%. These gains were maintained at the 18-month follow-up assessment. To further test the tenets of MI, Miller formally tested the therapeutic style of MI (ie, patient-centered) versus a more directive, confrontational therapeutic style.7 In this trial, therapists were trained to give identical, personalized feedback to nontreatment seeking adults from the community in either a confrontational, persuasive style or a supportive, empathic style. Results showed that the more therapists confronted patients (ie, challenging, disagreeing, disputing, incredulity, emphasizing negative patient characteristics, or sarcasm), the more resistance the patient demonstrated (ie, interrupting, arguing, off-task responses, or negative responses). In turn, the more resistance patients demonstrated during the feedback session, the more drinking they did during the year following the intervention.7 This demonstrated the importance of clinicians using an empathic and supportive style, especially in a brief consultation setting. Since these initial studies, MI continues to be tested in various settings to address a range of health-risk behaviors. Currently, MI is believed to represent a brief and effective method for addressing behavior change compared with more comprehensive intervention approaches.3 Moreover, its underlying principles

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are consistent with other theories of behavior change, such as the Stages of Change Model.9

Stages of Change At the same time that Miller was formulating his alternative approach to behavior change in the area of substance abuse, Prochaska and DiClemente were developing a theory-based model to explain the process of how behavior change occurs, since named the Transtheoretical Model.9 This model postulates that with regard to readiness to change a behavior, motivation is a “state” (ie, a transient, mutable condition), rather than a “trait” inherent to the individual, and that it can fluctuate and be influenced. In this way, a person facing a decision to change her/his behavior passes through a series of stages in the course of changing that behavior. In this model, change is viewed as a progression from an initial state, labeled precontemplation, in which the person is not yet considering change, to a period termed contemplation, during which the person evaluates the reasons for and against change, to a state of preparation, where plans for change are formulated. Once this stage is reached, the person takes action to make the identified change in behavior; if the behavior change is successful, the person then moves into a state of maintenance, in which s/he works to sustain long-term change.10 These stages appear to be relevant to the process of behavior change, regardless of whether that change is selfdirected or occurs with the assistance of a therapist, intervention, or treatment program.10 The Transtheoretical Model of behavior change is consistent and complementary to the theory underlying MI in the notion that not all individuals have the same needs and, thus, do not all need the same kind of help. For example, if someone is not ready to change, discussions about ways to take action will be counterproductive.11 When MI is used to intervene with health-risk behaviors, it is often useful and informative to identify and incorporate into the session a patient’s current “readiness to change” stage. For example, if a patient is in the precontemplation stage for changing her/his use of alcohol, quickly progressing to a discussion of behavioral and action-oriented change goals is likely to elicit resistance from the patient and result in a potentially unproductive session. Rather, a session in which the discussion constitutes full consideration of the benefits and drawbacks of change and of not changing is likely to be more productive in moving the

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person along in the change process. Given its focus on the dynamic nature of motivation throughout the entire process of changing behavior and its emphasis on discussing change based on its importance for the individual, MI is well-suited to assisting patients at all stages of “readiness to change.”

Research Evidence for the Use of MI with Adolescents With an increasing number of MI treatment outcome studies being conducted, several investigators have convincingly argued for MI as a useful treatment modality for adolescent populations. Adolescence is a developmental stage that is marked by significant biological, cognitive, and social changes.12 During the teen years, adolescents transition from childhood to young adulthood. An adolescent’s pursuit of autonomy and a sense of his/her own identity often characterizes this period. As a result, adolescents often challenge authority, in both minor (eg, arguing with parents) and potentially major ways (eg, engaging in regular substance use). As Baer and Peterson state, ambivalence is common among adolescents and, for this reason, clinical styles that are respectful, acknowledge choices and ambivalence, and do not increase resistance are well-suited for adolescent populations.13 MI also supports the notion of “personal change goals,” which is consistent with adolescents’ pursuit of autonomy. MI is usually most appropriate for individuals who have not yet reached the severe end of the spectrum of a specific health-risk behavior. In general, adolescents, because of their relative youth, have not experienced the extent of physical and psychosocial consequences of a problematic behavior that many adults have experienced. In addition, MI interventions are oriented toward reductions in problematic behaviors (eg, harm reduction approaches), which may be more realistic and attainable goals for youth than long-term cessation/abstinence or avoidance of a behavior. Last, adequate care for children and adolescents’ behavioral and mental health needs is often unavailable.14 MI interventions are versatile enough to be viable in a variety of different settings, such as primary care settings, thus maximizing the likelihood an adolescent’s needs will be addressed.

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MI for Adolescent Substance Use Behaviors The majority of studies examining the efficacy of MI with adolescents have addressed problematic substance use behaviors,3 in both health-care and nonhealth-care settings. First, a review of those studies conducted in health-care settings will be presented, followed by those in non-health-care settings. MI for Adolescent Substance Use in Health-Care Settings. One of the earliest studies to examine the efficacy of MI for youth15 consisted of a brief smoking intervention for adolescents in a hospital setting. In this study, 40 adolescent smokers who were being treated in an urban hospital’s emergency department (ED), outpatient clinic, or inpatient unit were randomized to either receive a 30-minute MI or a 5-minute brief advice condition (BA). The motivational intervention consisted of a nonconfrontational, empathic therapeutic style that helped develop teen self-efficacy and a discrepancy between an adolescent’s current behavior and her/his goals. In addition, individualized feedback was provided for each participant allowing for a tailored, personalized approach. While selfreported smoking status did not statistically differ between MI and BA groups at the 3-month follow-up as measured by biochemical saliva cotinine testing, a small-to-medium effect of MI was found on the percentage of teens who were abstinent at follow-up. This study also demonstrated that brief interventions with adolescents in a health-care setting were feasible as demonstrated by high rates of recruitment, retention, and quit attempts during the study. Alcohol use among adolescents has also been the focus of MI intervention in health-care settings. Monti and colleagues conducted a study that evaluated the use of a MI intervention to reduce alcohol-related use and consequences among older adolescents being treated in an urban hospital ED.16 The MI intervention was based on the principles of MI and provided personalized feedback and aid in establishing goals. Ninety-four older adolescents (ages 18 and 19) who were being treated in the ED for an alcohol-related event were randomly assigned to either the 35- to 40-minute MI intervention or the 5-minute “standardcare” intervention (ie, receiving a handout on avoiding drinking and driving and a substance treatment referral list). At the 6-month follow-up assessment, participants who were randomized to the MI condition were more likely to show decreased drinking and driving,

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traffic violations, and alcohol-related problems than those in the standard-care condition. In a more recent study of MI for teen alcohol problems, Spirito and colleagues conducted a brief MI intervention to reduce alcohol-related consequences and use among younger adolescents treated in an urban hospital ED following an alcohol-related event.17 One hundred and fifty-two adolescent patients (ages 13 to 17) with a positive blood alcohol level were recruited in the ED and randomly assigned to receive either MI or standard care. The MI intervention consisted of 35- to 45-minute sessions that were focused on developing a discrepancy between the teen’s current drinking behavior and current and longterm goals and to support the teen’s sense of selfefficacy about making positive changes. Both conditions resulted in reduced quantity of drinking during the 12 months of follow-up, while alcohol-related negative consequences were relatively low and stayed low at follow-up in both groups. However, adolescents who screened positive for problematic alcohol use at the baseline assessment in the ED reported significantly more improvement on two of three alcohol use outcomes (average number of drinking days per month and frequency of high-volume drinking) if they received MI compared with standard care. Other substance use among youth in health-care settings has also been the target of motivational interventions. The Cannabis Youth Treatment Study compared five interventions [Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), Family Support Network, Adolescent Community Reinforcement Approach, and Multidimensional Family Therapy] on the effectiveness of treatment for cannabis abuse or dependence among adolescents.18 A total of 600 adolescents were recruited from community facilities (eg, school systems and criminal justice programs) and from health-care settings. However, in the design of the study, investigators combined two individual sessions of Motivational Enhancement Therapy with three group sessions of Cognitive Behavioral Therapy. Preliminary (6-month) outcomes suggest that the combination results in similar outcomes to the other more lengthy and intensive treatments. Adding more sessions did not result in improved outcomes. Therefore, a MET/CBT combination appears to be a cost-effective approach to treating cannabis use disorders among adolescents in health-care settings. Last, Oliansky and colleagues examined the effectiveness of brief interventions in reducing substance use among at-risk primary-care adolescent patients in

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a community-based pediatric clinic.19 Thirty-three adolescent participants in the study were randomly assigned to either the intervention or a treatment-asusual control group. The intervention included brief education provided by a registered nurse and consisted of pamphlets, MI, and a contract of personal goals. Participants were reassessed at 1- and 3-month followups to determine the extent of their alcohol and other drug use. When compared with the control group, participants in the intervention group displayed significantly greater reductions in substance use at the follow-up time points. MI for Adolescent Substance Use in Non-HealthCare Settings. There are several studies examining the efficacy of MI interventions with adolescents for substance use that have been conducted outside of health-care settings. Two of these studies were conducted with clinical adolescent populations: Aubrey studied outpatient substance abusers20 and Brown studied psychiatric inpatients.21 In Aubrey’s study, 77 youths (aged 14 to 20 years) attending an adolescent substance use treatment program were randomly assigned to either receive or not receive personalized assessment feedback in an empathic, nonjudgmental manner.20 At the 3-month follow-up, those participants who had received the intervention were more likely to show decreases in substance involvement in addition to greater treatment retention compared with the control group. In the Brown and colleagues study of an MI intervention for smoking adolescents in an inpatient psychiatric facility, 191 adolescent smokers were randomly assigned to receive either two 45minute individual MI sessions or 5 to 10 minutes of informational brief advice.21 While smoking outcomes did not differ between the MI and brief advice conditions across the 12 months of follow-up, MI was more effective at increasing self-efficacy regarding ability to quit smoking. The remaining studies of MI for substance use behaviors among adolescents outside health-care settings consist of a study conducted in junior high schools,22 in the British school system,23 and in an internet virtual world chat room.24 Werch and colleagues examined the efficacy of a brief alcohol misuse preventive intervention for 178 junior high school students attending sports physical examinations.22 At 6-month follow-up, fewer students intended to drink alcohol or had used alcohol in the intervention group compared with controls. McCambridge and Strang examined the efficacy of a single-

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session motivational interview in reducing drug consumption among students.23 Two hundred young people (ages 16 to 20) enrolled in the British school system who had been identified as users of illegal drugs were randomly assigned to either an hour-long individual MI session or to an education-as-usual control condition. At the 3-month follow-up, participants who had received MI displayed significant reductions in cigarette, alcohol, and marijuana use, especially among those with the heaviest use at baseline. Similarly, MI was associated with significant reductions in smoking among 26 adolescents who participated in an internet intervention.24 This intervention consisted of cessation counselors utilizing MI techniques with groups of adolescent smokers in a real-time chat room for one hour, once a week, over the course of 2 months. However, this study is limited by the lack of a control group. In summary, one randomized study with adolescent smokers in an ED showed a small effect15 and one in a psychiatric hospital showed no effect.21 A third study with adolescents using the internet reduced smoking in an open trial.24 Of three randomized studies of alcohol use, one in an ED showed a reduction in alcohol-related negative consequences,16 another in an ED found reductions in drinking but only for adolescents who presented with prior significant alcohol misuse,17 and one in schools found a reduction in intention to use and in alcohol use.22 Four randomized MI studies have been conducted with drug use as the outcome. All four studies, one in a pediatric clinic,19 two in substance abuse treatment facilities,18,20 and one in the schools,23 resulted in reduced use. Overall, it appears that when adolescents have significant alcohol or other drug use problems, MI may result in reductions in use. MI in pediatric health-care settings seems to be as effective as MI used in other settings.

MI for Other Problematic Health Behaviors In addition to the above reviewed studies on MI for substance use behaviors among adolescents, several studies have examined MI for other problematic health behaviors. Most of these studies were conducted in health-care settings and the problematic health behaviors that were the focus of the MI included diabetes, dietary adherence, contraceptive use, and HIV/AIDS prevention. What follows is a review of these studies. In Channon and colleagues’ study of MI for adolescents with diabetes, 22 patients aged 14 to 18 years

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participated in MI sessions during a 6-month intervention period.25 The focus of the MI sessions consisted of awareness building (pros and cons), alternatives, problem solving, making choices, goal setting, and avoidance of therapeutic confrontation. After 6 months, patients who had received MI, compared with a nonrandomized comparison group, showed significantly improved glycemic control. In another study of adolescents with diabetes, Knight and colleagues administered an MI-based group intervention in six weekly one-hour sessions to 20 youth with poorly controlled diabetes.26 The intervention included externalizing conversations (ie, allowing separation between the problem and the person by personifying the problem and relating to it as an entity “external” to the person) as part of the group intervention. Participation in the MI-based group was compared with a “usual care” control group (n ⫽ 14). At the 6-month followup, adolescents who had received the group MI, compared with controls, were more likely to display positive shifts in their perception of diabetes, such as increased feelings of control and acceptance.26 Improvements in dietary adherence have also been demonstrated with an MI conducted with adolescents in health-care settings. As part of the Dietary Intervention Study in Children (DISC), Berg-Smith and colleagues introduced an individual, brief MI at the developmental transition into adolescence with 127 adolescents who had cholesterol levels in the 80th to 98th percentile for age and gender when they were children (ages 8 to 10).27 The goal of the brief MI was to improve or renew dietary adherence first addressed in the early phases of the study through a family-based group intervention. The brief intervention consisted of a 5- to 30-minute session that included principles from the stages of change model, MI, brief negotiation, and behavioral self-management. Follow-ups conducted in the first 3 months showed decreases in the caloric intake from fat and in dietary cholesterol in addition to increased readiness to change scores.27 However, they did not include a control group in this study and therefore are limited in the inferences that can be made about whether these results were related to the intervention. Behavior change counseling, derived from MI, is a patient-centered, directive therapy used to address risky behaviors.28 It has been used to increase motivation for behavior change among adolescents admitted to the hospital ED for various injuries. Johnston and colleagues randomly assigned 631 injured partic-

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ipants to receive either behavior change counseling or routine ED care.28 The intervention group underwent a brief session with a social worker focused on changing injury-related risk behaviors (eg, seatbelt use, bicycle helmet use, driving after drinking, carrying a weapon). At the 3- and 6-month follow-ups, behavior change counseling was associated with greater likelihood of positive behavior change in seatbelt and bicycle helmet use. Crowley and colleagues conducted an intervention study to encourage contraceptive use among adolescents at high risk for early childbearing.29 At a community adolescent health clinic, they provided a brief motivational and narrative-based intervention to 40 females who were seeking reproductive health services. The intervention consisted of a 30-minute session based on the FRAMES (ie, feedback, responsibility, advice, menu of options, and self-efficacy) concept of MI with the additional narrative therapy component. Narrative therapy is similar to MI in the attention paid to individual factors and the broader social context in which health-risk decisions are made. Narrative therapy can be summarized using the acronym CARE: Curious stance (ie, the clinician maintains an open stance with the patient); Alternative stories (ie, strengthen problem-focused descriptions of the patient by identifying strengths, knowledge, or resources); Reframe the problem (ie, collaborate with the patient to identify alternative conceptualizations of the problem); Expert knowledge (ie, draw on the patient’s expert knowledge of their own situation); and Envisioning a preferred future (ie, shift toward a focus on the patient’s future goals).29 At follow-up, they found that more than a third of adolescents initiated a hormonal method of contraception. However, interpretation of the results is limited because this study also did not incorporate a control group nor did it have a standard follow-up period.29 Last, MI has also been conducted with adolescents as a means of preventing HIV/AIDS risk behaviors. The study was not conducted in a primary health-care setting but in a substance abuse inpatient treatment program. Deas and colleagues randomly assigned 60 substance abusing adolescents either to a control group or to receive a 15-minute brief educational motivation intervention.30 While risky sexual behaviors decreased in the 6 months after treatment, there were no statistically significant differences between the intervention and control groups in this sample. The authors of the study note that a longer follow-up period may be

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necessary to obtain a treatment effect for the motivational intervention. In sum, four randomized and two open trials have been conducted with adolescent health behaviors: two with diabetes, one with dietary adherence, one with contraceptive use, one with HIV, and one with healthrisk behaviors. Of the randomized studies, the two with adolescents with diabetes and one with healthrisk behaviors had modest positive effects. Thus, the application of MI to pediatric patients is in only its very beginning stages, and conclusions regarding its efficacy will await the results of future studies.

MI with Parents and Families In addition to MI interventions targeted at children and adolescents, a few investigations focused on reducing children’s health-risk behaviors through parent-focused interventions. For example, Dishion and Kavanagh developed a brief motivational intervention called the Family Check-Up (FCU) to be conducted with parents of at-risk youth.31 The FCU is a threesession intervention composed of the following: (1) an initial intake interview to begin to identify strengths and challenges and engage the family; (2) a comprehensive, multi-agent, multi-method assessment; and (3) a family feedback session that uses an MI style to encourage maintenance of current positive parenting practices and changes in parenting problems.31 The goal of the intervention is to reduce problem behaviors among youth and to increase parental motivation toward constructive parenting. In a preliminary study to test the effectiveness of this intervention, 40 families were randomly assigned to FCU or to a wait-list control.32 The families that had participated in the intervention reported significantly fewer behavioral problems among adolescents as well as improved parental perceptions of family management skills than the wait-list controls. In a more recent study, Dishion et al. used the FCU to target parental monitoring practices in families with high-risk youth.33 Seventy-one families were recruited from middle schools and randomly assigned to either the FCU or a control group. By the 3-year follow-up (first year of high school for adolescents), while control group families reduced their monitoring practices, intervention families maintained parental monitoring of youth.33 In addition, their findings point to the prevention effect of the FCU on substance use as mediated by parental monitoring. Thus, conducting MI with parents may indirectly influence behavioral

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changes among adolescent offspring by improving parenting practices. Studies of the Family Check-Up have been limited thus far to the developing of the intervention and thus conclusions regarding its efficacy must be tempered. Nonetheless, the intervention appears promising and further research on this approach is clearly indicated. Finally, Emmons and colleagues assessed the effectiveness of a 30- to 45-minute MI intervention provided in-home by a health educator regarding reducing household passive smoke and quitting smoking (if the caregiver was interested in doing so) in 291 parents/ caregivers of children under age three.34 Four follow-up telephone calls were also conducted to evaluate progress toward goals, potential barriers, and setting additional goals. Results at 6-month follow-up showed that in the TV room and kitchen, nicotine concentration levels significantly dropped in the MI group, but did not change over time for the educationonly control group. There were no differences between groups regarding smoking cessation.

Limitations of Previous Research Based on the review of MI studies conducted with adolescent populations, there is preliminary evidence to suggest the clinical utility of MI approaches for youth in both health-care and non-health-care settings with varied problem behaviors. Even in cases where the MI intervention did not influence the target behavior of the study, it was related to secondary benefits such as number of smoking quit attempts,15 reductions in related problems,16 or increased self-efficacy.21 Given the often brief nature of the interventions, MI approaches may be highly cost-effective for the treatment of adolescent health problem behaviors. Despite these promising results, several limitations to these previous studies merit discussion. An important limitation lies in the fact that each of the interventions described in the studies were AMI. They are considered AMIs because they either incorporated a feedback component or were conducted in conjunction with nonmotivational approaches.3 While each study reported utilizing MI techniques in administering the treatment, the intervention differed substantially from one study to another. For example, the intensity of the interventions varied anywhere from one 15-minute session to seven hour-long sessions. While some studies attempted to study only the effects of a brief MI, others combined MI with cognitivebehavioral therapy,18 narrative therapy,29 and exter-

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nalizing conversations.26 Further, few studies had developed standardized interventions through the use of manuals and integrity checks to measure implementation of treatment.3 Another important limitation is the relatively short follow-up periods across most studies. As a result, it is not clear whether studies that did not find an effect of MI might have detected an effect had the follow-up periods been longer. In addition, the short follow-up periods do not allow for the determination of MI’s sustained efficacy—to what extent it produces lasting changes in youth behavior. Because these AMIs were each uniquely implemented, it is difficult to make comparisons across studies on the efficacy of MI for adolescents.

MI Studies in Progress Given the relatively few published controlled studies examining MI among adolescents, in addition to the limitations described above, well-designed future studies are necessary to advance our understanding of MI’s efficacy for youth health problem behaviors. Several studies currently funded by the National Institutes of Health will test the effect of MI interventions among adolescent populations. Two current studies involve conducting MI interventions to reduce substance involvement among homeless youth:35,36 Slesnick is recruiting participants from runaway shelters and randomly assigning them to Community Reinforcement Approach, Ecologically Based Family Therapy, or MI,35 and Baer is recruiting from local agencies and comparing Motivational Enhancement treatment to Treatment-as-Usual.36 Roffman is pilot testing the Teen Marijuana Checklist, a three-session, individualized brief intervention for adolescent marijuana users, with students in high school.37 High school students are also the focus of Weinstein’s study of MI to reduce dental avoidance among rural adolescents.38 Spirito and colleagues have adapted Dishion and Kavanagh’s FCU to specifically address adolescent alcohol misuse.31,39 Families of adolescents (ages 13 to 17) who are treated in an urban hospital ED for an alcohol-related event are being randomized to receive either an individual MI with the teen only or the individual MI plus the FCU (experimental condition). The goal of the experimental intervention is to increase parental motivation to make improvements in parenting practices, such as monitoring and parent– child communication, with the goal of reducing alco-

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hol misuse and other problem behaviors in their teenage children in the year following their ED visit. In another study, Gold is utilizing a computer-aided counseling approach to deliver a motivational intervention in a health clinic.40 The focus of the intervention is to alter the sexual and contraceptive behaviors of adolescent females to reduce teen pregnancy and sexually transmitted diseases. Last, Stein is conducting a study in the juvenile justice system examining the effects of an MI to increase treatment engagement and decrease substance use after discharge among incarcerated teens.41 Adolescents are randomized to receive either standard care plus the MI or standard care plus relaxation training. Preliminary results suggest that, at the 3-month follow-up assessment, teens receiving MI evidenced better treatment engagement and reduced alcohol consumption.42

MI and the Pediatric Health-Care Provider While published studies have been either conducted within a medical setting or focused on improving health behaviors, none of the interventions were delivered by pediatric health providers. However, there has been increasing interest in teaching medical providers how to use MI strategies with their patients to promote behavior change. Although MI is an effective method for promoting behavior change, there are a number of reasons adaptations to the approach need to be made to ensure that pediatricians and pediatric health-care providers can effectively implement such strategies within clinical encounters.11 For example, MI typically lasts for multiple sessions and requires training in the development of specific skills to promote change.11 However, pediatricians often only have one 10- to 15-minute encounter with patients to cover a myriad of health concerns in a given clinical encounter, and many pediatricians do not have the time or resources to devote to becoming trained in MI.43 Thus an approach that is both user-friendly and flexible in terms of the time-limited nature of ambulatory medicine is needed.

The Health Behavior Change Model As discussed previously, Rollnick and colleagues have developed a model for adapting MI to health-care settings so that medical providers can effectively promote behavior change in their patients within the

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constraints of a busy clinical practice.11 Their approach combines MI with patient-centered approaches to care in an attempt to develop a style of practice that focuses on working collaboratively with the patient to promote health behavior changes. Central to Rollnick and colleagues’ strategies for promoting behavior change is the importance of attending to the patient’s priorities regarding which, if any, behaviors she or he would like to change and respecting the patient’s autonomy in deciding their readiness for change.11 Two key concepts that Rollnick outlines in his practitioner guide as being fundamental to a patientcentered approach in a brief, consultative encounter are importance and confidence. Specifically, when consulting with a patient regarding behavior change, her/his state of readiness to change can be gauged by asking her/him why s/he places her/himself at that particular point on the continuum of change behavior (eg, precontemplation versus preparation). In their work in this area, Rollnick and coworkers describe two themes as repeatedly emerging: how important the change in behavior is to the patient, and how confident s/he feels in her/his ability to make said change.11 Importance is determined by such considerations as: “How will I benefit?,” “What will change?,” “Will it make a difference?,” and “Do I really want to?” For example, the readiness of an adolescent patient with diabetes to monitor her/his blood sugar may be partly determined by the relative importance of having to be excused from class in school to go to the health office to monitor or being asked questions by peers about her/his diabetes. In using a direct, persuasive consultation style, the physician is less likely to be aware of these factors that play a key role in the patient’s feelings about changing her/his health behavior. However, by asking key questions regarding the importance of change for the individual patient, the physician can help the patient more objectively weigh the risks and benefits of change with the hope of moving the patient closer to health promotion. Similarly, a patient may be very motivated to make a change in behavior but experience little confidence in her/his ability to be successful. For example, an adolescent cigarette smoker may have some concern about the potential negative impact of her/his smoking on her/his health, but may have experienced multiple failed quit attempts in the context of peer interactions or feel that s/he will be unable to cope with stress or other negative emotions without smoking. The patient will, as a result, feel little confidence with regard to the

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following: “Will this time be any different than before?,” “Can I quit for good?,” or “How will I cope with urges to smoke?” By exploring with the patient these questions of “Why should I change?” (ie, personal values and perceptions of the importance of change) and “How will I change?” (ie, self-efficacy), the readiness of a patient to make necessary changes in behavior can be more thoroughly understood. Such efforts are effective for clarifying the ambivalence a patient is likely to feel about changing her/his behavior, or when a lack of change is demonstrated despite seemingly clear evidence that change is warranted.

Strategies for Integrating the Health Behavior Model in Primary Care Although Rollnick and colleagues recommend a number of strategies for medical providers to use in promoting change in their patients, they state that the first step in motivating patients to change is developing rapport with the patient.11 This is where a patientcentered approach to care may be particularly important. Patient-centered care involves the use of active listening skills in which the provider attends to the patient’s fundamental beliefs regarding health and illness, including readiness for change, and confidence in making this change.11 Patient-centered care also involves the establishment of a working alliance between patient and provider in which the patient’s statements are clarified and summarized and reflective listening is utilized.44 Once rapport has been established, two strategies in particular may be most appropriate for busy pediatricians who only have 10 to 15 minutes to meet with their patients and families: (1) agenda setting, and (2) using scaling questions. Setting an agenda can be accomplished through the use of various strategies depending on the number and nature of health behaviors that are targeted for change. However, central to this strategy is asking open-ended questions to determine what the patient feels is important to discuss while also conveying to the patient the provider’s own agenda. For example, a provider may state the following in an attempt to set the agenda: “What would you like to discuss today? We could discuss X, Y, or Z [medical condition], but I would like to know what is important for you to discuss.” The remainder of the discussion should then be limited to those topics for which the patient expressed interest or concern. Scaling questions can be used once the agenda has been set to assess the patient’s confidence in making a

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behavior change, determining why the patient has this particular confidence level, and trying to elicit what would improve the patient’s confidence in making a change.11 For example, after a physician asks a patient how confident s/he is that s/he can be successful in changing a particular behavior (eg, asking on a scale from 0 to 10 their confidence in dieting), the physician can follow up with the following questions: “Why do you feel like you’re a 4 in terms of your confidence level? What would make your confidence level higher? Why isn’t it lower than 4?” Thus a busy pediatrician can incorporate MI strategies into practice by both involving the patient more in determining what to discuss during the visit and assessing the patient’s confidence for changing healthrelated behaviors.

Motivational Enhancement Therapy Similar to the Health Behavior Change model, Lask also described a model of adapting MI to health-care settings to promote adherence in children with chronic illness conditions.45 Consistent with Rollnick and colleagues, Lask proposed that medical providers develop a therapeutic alliance with children and their parents to work collaboratively and empathetically toward motivating children to improve adherence to their medical regimens.11,45 Based on Prochaska and DiClemente’s Transtheoretical Model, the following techniques are employed to motivate the child patient: (1) open-ended questions; (2) reflective listening; (3) double-sided reflections (ie, recognizing the patient’s report of both pros and cons); (4) eliciting the advantages and disadvantages of poor adherence; (5) draining (ie, exploring every detail regarding the advantages of nonadherence); (6) affirmation (ie, empathic acceptance of the patient’s views); and (7) summarizing (ie, checking to ensure that the patient is understood). Depending on how motivated a child is to increase adherence, the focus of MET varies. For example, if a patient is in the precontemplation or contemplation stage in terms of her/his willingness to change, the focus tends to be on assessing with the child the perceived advantages of nonadherence. In the preparation stage, there is increased focus on the balance between advantages and disadvantages of nonadherence. Finally, during the action and maintenance stages, the advantages of adherence are the focus of conversation. Although Lask described MET as an effective approach to motivating child patients to

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increase adherence, no empirical support was provided regarding its efficacy.45

Research Support for the Use of MI-Based Strategies by Pediatricians To our knowledge, no controlled studies have assessed the application of MI-based strategies by pediatricians, such as those recommended by Rollnick and colleagues.11 However, a number of studies have found that patient-centered consultation is effective in promoting positive outcomes of care. For example, patient-centered communication skills have been associated with increasing parent satisfaction with care,46,47 improving adherence to treatment recommendations,48,49 and increasing disclosure of psychosocial concerns.50,51 Given the importance of a patient-centered model of care in MI, results of these investigations are reviewed below. Parent Satisfaction with Care. A number of correlational studies within pediatric settings have found that family-centered approaches to care, including increased use of a collaborative style (ie, letting the family know that you want to work together toward improving health) and increased use of interpersonal sensitivity (eg, understanding the family’s needs), are associated with increased parent satisfaction with care.46,47,52 Specifically, studies have found that pediatricians’ use of encouragement and empathy53 and positive effect and friendliness49 are associated with increased parental satisfaction with care. Moreover, increased discussion of mothers’ feelings and concerns, as well as conveying to parents an understanding of their concerns, are important correlates of parental satisfaction.54,55 Conversely, less adequate provider communication, such as not listening to parents’ ideas regarding the management of their child’s illness, is associated with decreased satisfaction with care.56 Disclosure of Psychosocial Concerns. In addition to its impact on satisfaction, two studies have assessed the relationship between patient-centered communication and the disclosure of psychosocial concerns. Wissow and colleagues found that pediatricians’ direct questioning, expressions of support, and displays of interest and attention when listening were associated with parental disclosure of psychosocial issues.51 Furthermore, Hickson and colleagues found that parental perception of physician interest in psychosocial issues was one of the most important predictors of parental disclosure of a psychosocial concern.50

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Adherence to Treatment Recommendations. Although none of the above studies directly assessed the association between patient-centered communication and the promotion of behavior change, two older studies directly assessed the impact of patient-centered communication on promoting adherence to treatment recommendations. Korsch and colleagues assessed the relationship between parent-provider communication and adherence to treatment recommendations within pediatric settings.48,49 Findings indicated that maternal perceptions of their child’s pediatrician as unfriendly or as not understanding their concerns regarding their child’s illness decreased adherence to their pediatrician’s instructions.48 Furthermore, whether maternal expectations had been met during the pediatric visit (ie, whether the pediatrician assessed what the mother wanted to discuss and then addressed her priorities) was also a strong predictor of mothers’ adherence to treatment recommendations.48

Pediatric Interventions Designed to Enhance Patient-Centered Communication In addition to correlational studies that have shown that patient-centered communication is associated with positive outcomes of care, a few pediatric interventions have assessed whether increasing pediatricians’ skills in using a patient-centered approach to care can also improve patient outcomes. Results from these studies appear promising and are reviewed below. Lewis and colleagues conducted a videotaped intervention that attempted to increase children’s involvement in the medical visit.57 Three versions of a videotape were recorded: one tailored to the child, one to the parent, and one to the physician. Videotapes for physicians focused on research evidence on the importance of working collaboratively with their child patients (ie, it leads to improved health outcomes) and on developmental changes in children’s understanding of health information. Videotapes also provided clinical examples of how best to work collaboratively with patients.57 Immediately after the visit, children in the intervention group were more likely to remember recommendations regarding medications and were more satisfied with the visit than were children in the control group. However, although children in the intervention group did have better recall of medication recommendations, they did not have better recall for overall recommendations than did children in a control group.57

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Clark and colleagues assessed the effectiveness of an interactive seminar designed to promote physicians’ development of a collaborative style with their patients with asthma and their families.58,59 Parents of children whose pediatrician participated in the education perceived their child’s pediatrician as being more reassuring and encouraging, and as relieving their specific concerns regarding asthma more than parents whose pediatrician was in the control group. Furthermore, parents of children whose physician participated in the education were more likely to ask about daily asthma management. Although there were no significant group differences in the number of ED visits (except for frequent users) and the number of office visits, children who received care from physicians in the intervention group had fewer hospitalizations than did children of control group physicians.59 van Dulmen and Holl assessed the effectiveness of a 5-day communication training workshop in improving the use of patient-centered interviewing skills and the provision of support and understanding to patients and families.60 After the intervention, pediatricians were more likely to express agreement, provide information, and ask psychosocial questions than before the intervention. However, trained pediatricians expressed fewer concerns, reassurances, disagreements, orientations, and were less likely to ask parents for their understanding and give medical advice after the intervention. Compared with a control group, trained pediatricians asked more psychosocial questions and made eye contact with patients and parents more often. Although no investigations have assessed the effectiveness of pediatrician-delivered MI, there is considerable evidence that using a more interactive style with patients (in which the pediatrician is supportive and empathic and involves the patient in treatment decision-making) is effective in increasing satisfaction and enhancing adherence to treatment recommendations.

MI in the Medical Setting MI is particularly well suited for use in a medical setting given its relative brevity and the specific skills and techniques that have proven effective in promoting behavior change. When compared with psychotherapy, which commonly involves a series of 50minute sessions, MI offers a briefer alternative approach for intervening with patients; MI and AMI treatment protocols can be as brief as 20 minutes. By

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contrast, in the context of a medical setting where multiple health-related topics need to be addressed in a very brief encounter, MI and AMI can appear cumbersome and impractical. Yet, when one considers the amount of contact a physician can have with an individual patient over time, use of an expanded consultation style in the short-term is likely to result in positive change and fewer problematic and/or frustrating consultation sessions over the long-term. Rollnick, who is the co-author of Miller’s two books on MI,61,62 has focused his research on the development of effective styles of such brief physician consultation for the promotion of behavior change within a variety of medical settings. In a practical guide written with medical practitioners in mind, Rollnick cites case examples demonstrating the frustration many physicians and patients feel in pursuit of behavior change and of the way in which altering one’s approach to a slightly more extensive and patient-centered consultation style can reap benefits in long-term case management.11 Pediatricians managing children with chronic medical problems encounter the same sorts of situations, as described in the following case example adapted from Rollnick and coworkers:11 A 15-year-old teen has been diagnosed with insulindependent diabetes since the age of 11 years and has tried to live his life “despite” his disease, to the point of ignoring the need to properly monitor his blood glucose levels. This has led to several episodes of ketoacidosis. He has little energy and is getting no exercise. He has been advised, many times, to monitor his glucose levels, look after his diet, get more exercise, and so on, but he has made little effort to look after himself. Then one day, a doctor and nurse decided to take a different approach. No more attention would be paid to health behavior change in the consultation; they were going to find out what was important to him and how he felt about the disease. The rapport between them and the patient improved over a number of months. It emerged that he was embarrassed by being singled out in school for leaving class to monitor his glucose and did not know how to explain his condition to friends and peers. The doctor and nurse thoroughly discussed these issues with him, and based on his requests for assistance, helped him identify ways to care for his health and be more open with friends about his diabetes. His monitoring of blood glucose improved.

While the above-referenced case is oversimplified, the point is clear that a shift in practice from strictly providing advice and admonition in an expert role to doing so within a patient-centered consultation style can be extremely effective in addressing behavior change topics that are often problematic.

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Basic Techniques and Principles of MI Broad Principles in Conducting MI In refining the method more practically, Miller and Rollnick delineate the following four broad principles to guide the conduct of MI.61 First, express empathy. One should listen actively and seek to understand the patient’s point of view without judging, criticizing, blaming, or approving of behavior. Ambivalence is seen as normal, and reluctance to change is expected. The patient is not viewed as incapable of change; rather, s/he is understood as “stuck” in the current behavior pattern. For example, in relaying the seriousness of a patient’s health risks and lack of behavior change to date, a statement such as, “You just don’t seem to grasp the seriousness of your situation,” could be modified to relay the same message in a more empathic style: “You and I have talked about the risks you face, and I understand how difficult it can be to make such a major lifestyle change.” Second, efforts are focused toward developing discrepancy. The pros and cons of changing behavior and, conversely, of continuing in the current pattern should be elicited from the patient. In this way, the practitioner can begin to amplify, in the patient’s mind, a discrepancy between current behavior and future goals. This will serve to increase consideration of and motivation for change. For example, the following statement could be made to summarize a discussion with an adolescent regarding her/his glucose monitoring: “So you don’t want your diabetes to run your life, but you’re also worried about what could happen to your health if you don’t take care of yourself.” Third, the practitioner should become skilled in rolling with resistance. At the most basic level, the patient is always respected and engaged as a problemsolver in the session, assuming that s/he knows her/ himself better than anyone else. Resistance to change is understood as natural, but it can be reframed to increase motivation for change. For example, a patient statement such as, “I’ve tried to quit before and it hasn’t worked” can be restated in the positive: “So, you’re a step ahead of most people because you have experience with this and know what does and doesn’t work for you.” Or in some cases, resistance should be taken as a cue to change direction or focus, at least for the time being, because the clinician has “jumped ahead” in the discussion to a topic or stage that the patient is not ready for.

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Finally, one should make every attempt to support self-efficacy in the patient. The patient’s autonomy and responsibility for choosing and carrying out personal behavior change should be emphasized. Statements such as, “I can’t make this decision for you. It’s up to you to decide whether to make these changes” can be very effective in instilling a sense of personal responsibility for change. In addition, reflecting observations of relevant positive patient characteristics (eg, “The more I get to know you, the more I see how determined you are”), or asking the patient to identify such attributes (eg, “What about you makes you feel that you can succeed with what we’ve discussed?”) is an important element in boosting the patient’s confidence to enact the goals s/he has identified. Self-efficacy is a key element in readiness to change, and it is predictive of outcome.63,64 If a patient feels no confidence or control over the change process, success is unlikely. Common Elements Across MI Investigations (adapted from Miller and Sovereign).65 The ingredients found in common across most published trials of MI and its adaptations can be characterized by the acronym FRAMES. First, many interventions incorporate personalized feedback of the individual’s behavior. This can take the form of systematic assessment or laboratory results. In contrast to general educational discussions (which tend to exert little influence on behavior), providing information about an individual’s risk relative to a normative group has been shown to effect change in behavior.66 A second common element in brief interventions is an emphasis on personal responsibility for change. This promotes the patient’s sense of autonomy, as well as internal attributions of responsibility, rather than relying on external agents. Such an approach also tends to instill a greater sense of collaboration between clinician and patient, reducing the traditional notion of the clinician as the expert, with the patient having no part in the development of the change plan. Advice to change is a third common element of effective brief interventions. This is to say that MI approaches are not entirely passive or undirected. Clinicians remain active in advising the patient of the degree or severity of their health-risk behavior. Recommendations can also be made for how to proceed in altering behavior, along with eliciting from the patient her/his thoughts and ideas for pursuing behavior change. It is also important to keep in mind that when recommendations are made, a menu of options is to be provided, rather than providing a single approach or solution. In this way,

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the patient is free to choose a strategy that is most suitable to their current situation. Another important and consistent theme in MI is the expression of empathy toward the patient and their situation. This is reflected in the use of a patient-centered, understanding, and reflective style of interaction with the patient. Use of an empathic therapeutic style with patients has shown a strong relationship to improvement following alcohol treatment.67 Finally, MI promotes self-efficacy throughout interaction with the patient, in which a belief is instilled in the patient that she or he has the ability to succeed in changing the behavior. Ideally, these sentiments should be drawn out of the patient via open-ended questioning and reflection of self-motivating statements made by the patient. The “Spirit” of MI. Consistent elements of style within MI can be separated from the variable techniques that are employed within a consultation session. Miller has used the musical analogy that this “spirit” of MI represents the “music,” while the techniques are the “words.” Thus, regardless of the tools that are used, the following tenets should always be kept in mind and be present, stylistically:68 1. Motivation to change is elicited from the patient and not externally imposed. Focus should be on helping the patient identify and mobilize her/his own intrinsic values and goals to stimulate behavior change. 2. It is the patient’s task, not the physician’s, to articulate and resolve her/his ambivalence. Focus should be on facilitating the patient’s expression of both sides of her/his ambivalence (ie, reasons for and against change) and guide the patient toward an acceptable resolution that triggers a desire for change. 3. Direct persuasion is not an effective method for resolving ambivalence. Avoid the temptation to be “helpful” by persuading the patient of the urgency of her/his situation. These tactics often increase patient resistance and can reduce the probability for change. 4. The intervention style is generally a quiet and eliciting one. MI can appear slow and passive if unfamiliar, but more aggressive styles can easily push a patient into committing to changes s/he is not ready for. 5. The physician is directive in helping the patient to examine and resolve ambivalence. Ambivalence is viewed as the primary obstacle to change and its

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resolution is pursued within a patient-centered and respectful atmosphere. 6. Readiness to change is not a patient trait, but a fluctuating product of interpersonal interaction. Resistance and “denial” are feedback that the physician is making false assumptions regarding motivation or readiness to change. It is a cue to modify your own approach to the patient. 7. The physician–patient relationship is more like a partnership than an expert–recipient relationship. Respect for patient autonomy and freedom of choice regarding her/his own behavior is paramount. Interaction Techniques (adapted from the MI web site: www.motivationalinterview.org). The following specific skills can be employed, in the “spirit” described above, to enhance a patient’s readiness to change a particular behavior. Open-ended questions are inquiries that a person cannot answer with a “yes” or “no” or “three times in the last week” response. While close-ended questions also have their place, open-ended questions are very valuable in establishing rapport and gaining an understanding of a patient’s perspective. This may seem simple, but it is easy to slip into the use of close-ended questions if one is not careful, especially in the context of information-gathering during a brief encounter. For example, instead of asking “How have you been feeling?,” phrasing the question as, “Tell me what’s been happening with _____ since we last met” is likely to generate much more useful information. Affirmations are statements of recognition about patient strengths. Affirming statements can be very helpful in building rapport with a patient, especially one who has experienced little success in behavior change or has little support in such efforts. For example, simply acknowledging that a patient or child’s family has kept a scheduled appointment as a sign of commitment to her/his health can be powerful. Similarly, patient statements of apparent change attempt failures can be restated as “lessons learned” that can be drawn on in future planning. Affirmations must be genuine and sincere, however, or rapport can be damaged. One of the most essential and, for some, difficult techniques to grasp in MI is reflective listening. This essentially involves listening carefully to your patients. At times, a brief restatement of what the patient said will both show that you are actively listening to

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her/him and provide the patient a chance to hear her/his thoughts repeated. These reflections are also specifically directed toward moving the patient toward change. Thus, it is important to reflect patient’s “change talk” and not reflect comments that are off-topic or not directed toward change. It is important also to reflect the affect associated with a patient’s statements. If you are correct in identifying the affect you are sensing, this can have a powerful impact (eg, “You are worried about your health, but you haven’t been able to lose the weight you want to; you must be very frustrated.”). If you are wrong in the affect you identify, the patient will correct you, but you will nonetheless have a better understanding of the patient’s perspective. Another important technique in behavior change consultations is the use of summaries. Summaries are essentially an expanded form of reflective listening in which you reflect back to the patient what s/he has been discussing with you. Summaries can serve many very useful purposes in a session. They can express your interest in your patient, call attention to the most salient points of the discussion, and shift attention or the direction of the discussion. Summaries should thus include elements of both content of the discussion and the affect patients present. Summaries should provide the patient an opportunity to correct or add information that was missed and should generally be concluded with an open-ended question to continue the next phase of the session. For more details on specific methods and techniques of MI, see Miller and Rollnick, 200261 or Rollnick, Mason, and Butler, 1999,11 or visit the MI web site at www. motivationalinterview.org.

Conclusion Although the development of MI techniques stemmed primarily from the treatment of addictions and the desire to improve the efficacy of these treatments, its relative efficacy in promoting behavior change has led to its application across a range of health behaviors. These include adherence to difficult treatment regimens associated with chronic health conditions and the promotion of proper diet and exercise regimens. Of particular importance to the field of pediatrics are the promising results that have been noted for promoting adolescent health, particu-

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larly in terms of smoking and alcohol use as well as diet and exercise. It should be noted that most of these studies were conducted by research staff rather than health-care providers. Nonetheless, the applicability of MI to pediatric practice is promising and consistent with the patient-centered communication approach which has been presented in the pediatric literature. Research studies within pediatric ambulatory practice need to be conducted with particular attention paid to how pediatricians and health-care professionals can promote behavioral change with children and adolescents. It remains to be seen if pediatric health-care providers will be able to utilize MI in the context of busy clinical practices and whether MI will be effective when delivered under these real-life conditions.

APPENDIX Individual Case Example 1: Adolescent with Alcohol Involvement A 16-year-old adolescent male presents for a physical examination for his new high school. The teen is in good general health but has a very high-fat diet with few fruits or vegetables. His mother, a single mother, reports that he is demonstrating significant behavior problems, very poor performance in school, and a problematic peer group. The family also lives in an impoverished area, has recently moved for the third time in a year, and has limited resources. When interviewed privately about substance use, the teen reports smoking 10 cigarettes a day and drinking 8 to 10 standard alcoholic drinks two to three times per week. The teen indicates that he is currently in counseling, but indicates that it is a “waste of time” and that his counselor is “a jerk.” The teen has reported substance use at prior visits but has not responded to advice to stop smoking and drinking; in fact, his alcohol use has increased over time. Rather than repeat advice to quit smoking and drinking, the physician decides to take a more client-centered approach. She begins by thanking the teen for speaking openly with her about his

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use. She then asks the teen to tell her about his day-to-day life. The teen reports multiple significant life stressors, including an unsafe neighborhood, limited resources, a strong dislike for school, and few sources of support, aside from his mother. The physician reflects the teen’s frustrations and commends the teen for staying in school and for maintaining such a positive relationship with his mother. The physician then asks the teen what he enjoys about smoking and drinking. The teen indicates that smoking and drinking are a means of release and “escape” from the stressors of his daily life. The physician then asks the teen what he dislikes about smoking and drinking. The teen denies any “downside” to his smoking but reports experiencing several recent consequences of drinking, such as hangovers, absences from school, and arguments with his mother. Rather than repeat facts regarding the negative effects of smoking, the physician recognizes the teen’s willingness to discuss his drinking further and reflects the issues he raises as well as his emotions. She summarizes the discussion by pointing out that, while the teen drinks to relieve stress and “escape,” his drinking appears to now be adding to his life stress and negatively impacting his relationship with his mother, who is his primary source of support. The teen acknowledges that his drinking is beginning to hurt his relationship with his mother but sees little alternative. The physician then asks the teen about other activities he enjoys as well as how he relieved stress before he began drinking alcohol and smoking. The teen reports having enjoyed playing basketball with other teens in his old neighborhood and that he has seen a group of teens, one whom he knows from his old school, playing basketball near his house. The physician supports the teen for identifying an alternative activity and engages him in a problem-solving discussion around joining in on the neighborhood basketball game. The physician also reflects the teen’s strong bond with his mother, and the teen reports that he and his mother have always been there for each other, and he hates to upset her. The physician reflects his concern and supports the teen’s self-efficacy to reach

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out to his mother for support in reducing his drinking. A follow-up visit is scheduled in two months. At the follow-up visit, the teen’s mother indicates that she and her son are talking more and that his behavior is improving. In a private interview, the teen reports that he only drank alcohol once since the last appointment and is playing basketball with teens from the neighborhood approximately once a week. He also reports that his ability to play basketball has been affected by his cigarette smoking and that he is working to reduce his smoking as well. The teen appears proud of his accomplishments and indicates that his relationship with his mother has improved.

Individual Case Example 2: Infant Who Is Being Fed too Much A mother of a 6-month-old girl presents with her daughter for her 6-month check-up. The baby’s mother is complaining that she is spitting up constantly and is worried that she is not getting enough nutrients. On observation, the baby looks like a healthy, chubby baby girl and review of her growth chart indicates that she has excessive weight for her height. The physician determines that the baby is eating too much and that, to grow properly, her mother should cut the baby’s food in half. The mother is insistent that the baby wants and needs the amount of formula she is giving her. She states that her mother and other family members keep insisting that the baby be fed more formula and that she start to supplement her feedings with “table foods.” Realizing that she needs to work collaboratively with this mother for the health of her patient, the pediatrician first empathizes with the mother regarding the difficulties of managing a baby who is spitting up. The pediatrician further reinforces the mother’s belief that babies should not spit up as much or as frequently as her baby is and that this does indicate that something is not right. The pediatrician praises the mother for figuring this out on her own. The pediatrician then provides education to the mother regarding the “typical” amount of formula that 6-month-olds should be consuming and compares that with what the

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mother reported the child is drinking. The pediatrician also provides education regarding the size of the infant’s stomach, how much food/ formula she can handle at a given time, and her belief that the spitting up could be reduced if the baby was fed less frequently. Despite this education, the mother is still somewhat hesitant to feed her baby any less food and cites her family members as evidence that she should feed her baby more. The pediatrician acknowledges the importance of listening to respected family members, who no doubt raised healthy babies themselves. The pediatrician then discusses with the mother the pros and cons of continuing to feed her baby the way she has been as well as the advantages and disadvantages of trying to reduce the child’s formula intake at least over the short-term. The baby’s mother is able to acknowledge a number of drawbacks regarding the current feeding pattern and has difficulties identifying any benefits of it. However, she is able to acknowledge that something needs to be changed regarding how much the child is fed. The mother and pediatrician briefly discuss the benefits and drawbacks of both reducing and increasing the amount of food the infant is being fed. The pediatrician asks the mother to consider the pros and cons of both conditions given the child’s current growth chart. The mother is able to hesitantly acknowledge that the baby might not spit up as much if she is fed less. The pediatrician then discusses with the mother ways in which her family members’ input may make attempting a change difficult and problem-solves with the mother how to address issues she raises, such as how to relay confidence that she has consulted with her physician and is making healthy decisions for her baby. In an effort to collaborate more with the baby’s mother, the pediatrician offers to do a phone follow-up within the next 2 weeks to assess progress and re-examine whether additional changes need to be made. The baby’s mother is receptive to this idea and agrees to reduce the amount of formula she is feeding the baby over the next 2 weeks. She will call the pediatrician if the problem does not improve.

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