Pediatric Annals

Feature Article 

The Role of Motivational Interviewing in Children and Adolescents in Pediatric Care

Nikita Desai, BS

Abstract

Motivational interviewing (MI) addresses patient ambivalence about a desired goal in a directed, patient-centered manner. MI intervention is established as a therapeutic tool within the pediatric population with positive outcomes for obesity, asthma, medication adherence, and HIV management. MI is especially promising within the adolescent population where increasing independence tends to contribute to poorer health outcomes. Multidisciplinary adaptation of the MI format works well to address traditionally difficult pediatric care issues such as obesity. In the future, MI training of physicians may incorporate an online medium for wider distribution. More research is required to determine the most efficacious style and to support the generalizability and reproducibility of MI interventions for widespread application. [Pediatr Ann. 2019;48(9):e376–e379.]

Abstract

Motivational interviewing (MI) addresses patient ambivalence about a desired goal in a directed, patient-centered manner. MI intervention is established as a therapeutic tool within the pediatric population with positive outcomes for obesity, asthma, medication adherence, and HIV management. MI is especially promising within the adolescent population where increasing independence tends to contribute to poorer health outcomes. Multidisciplinary adaptation of the MI format works well to address traditionally difficult pediatric care issues such as obesity. In the future, MI training of physicians may incorporate an online medium for wider distribution. More research is required to determine the most efficacious style and to support the generalizability and reproducibility of MI interventions for widespread application. [Pediatr Ann. 2019;48(9):e376–e379.]

Motivational interviewing (MI) is an established therapeutic tool used to improve care of children and adolescents. Its efficacy within the pediatric population has been shown to aid with obesity,1–5 asthma,6 medication adherence,7–10 and HIV management.11 MI is administered in a directive, patient-centered manner meant to explore and resolve ambivalence between a patient's current values and behaviors, as well as determine their long-term goals. MI builds upon patient autonomy, patient-physician collaboration, and patient-mediated change talk, in contrast to the more confrontational, authoritative, and educational type of medicine traditionally practiced in the clinic setting.

What is MI?

MI evolved to address patient ambivalence about a therapeutic goal in a directive, patient-centered manner. It was first developed and later defined by Rollnick and Miller12 and Miller and Rollnick13 in the setting of adult alcohol abuse. Important tenets of MI are reflective listening, use of open-ended questions, expressions of acceptance and affirmation, elicitations and reinforcement of change talk from patients, monitoring patient's readiness to change, and establishment of the patient's autonomy. A physician taps into the patient's own intrinsic motivation to fulfill a therapeutic goal by guiding directed discussions aimed at encouraging the patient to explore his or her motivations.

MI is collaborative in the sense that it allows patients to participate in their own care through expression of concerns and values. The use of open-ended questions, as opposed to close-ended questions such as “yes/no” queries, is fundamental to MI. Reflective listening by the physician is critical to clarify the meaning behind a patient's statements in an open, nonconfrontational environment. Along with clarification, the physician can selectively provide affirmative and reinforcing statements related to the patient's remarks. The goal is to help the patient identify his or her motivation for change, thus evoking “change talk.” If the patient expresses resistance to change, the physician should acknowledge the patient's views and continue to work through the process. The efficacy of MI depends upon exploring a patient's ambivalence to augment their readiness and intrinsic motivation to change. Rollnick and Miller12 argue that the alternative—persuasion techniques and aggressive measures—hinder patient change and break rapport.

Evidence Supporting the Use of MI within the Pediatric Population

MI intervention has been successfully applied in multiple conditions in adults. In response to this proven success, much work has been done and continues regarding the use of MI within the pediatric population.

Adolescent Medication Adherence and Maintenance of Chronic Conditions

Unlike with younger patients, adolescent patients are primarily responsible for complying with medication adherence. The negative repercussions from lapses in adherence affect teens suffering from a myriad of illnesses, including depression and/or bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), type 1 diabetes, and asthma.

Depression/bipolar disorder. Hamrin and Iennaco7 studied adolescents age 12 to 18 years to assess if adherence to psychotropic medications (selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and mood stabilizers) improved with brief MI intervention. The participants received two brief MI sessions during their standardized monthly medication appointments over the course of 4 months. Researchers found improvements in adherence rates between baseline and post-intervention.7 The importance of these findings was 3-fold: (1) brief MI sessions can easily be incorporated within standard visits, (2) improvement is seen with a limited number of MI sessions, and (3) long-term benefits of better adherence include stabilization of depression and/or bipolar disorder starting in the adolescent years. Notably, MI works well in patients showing ambivalence toward medications or in those who express there are barriers to taking medications.7

ADHD. MI-based therapy in patients with ADHD has shown statistically significant effects on parent-rated ADHD symptom severity, organization, time management and planning problems, disruptive behavior, observed daily homework recording, parent–teen contracting, parent implementation of home privileges, and parenting stress.8

Type 1 diabetes. Patients with type 1 diabetes (T1D) require regular medication adherence and monitoring. Current interventions have mainly targeted adolescents, likely due to the established declines in adherence and glycemic control that occurs during adolescence. During this time of increasing ambivalence, MI can improve self-efficacy and adherence behaviors.14 Previous studies of teens with poorly controlled T1D have had limited success at improving blood glucose monitoring and glycemic control.9 One such intervention focused on adolescents age 14 to 17 years with T1D. MI was effective in improving HbA1c of patients with poorly controlled diabetes and also was effective in increasing well-being and quality of life.10 A more recent study considered the feasibility and outcomes of MI with cognitive-behavioral therapy and family-based contingency management (CM) to improve care of poorly controlled type 1 diabetes in adolescents.9 CM is an incentive-based intervention with systemic reinforcement of desired behaviors. This study found that for adolescents age 12 to 17 years (n = 17), combining MI and CM appeared to work very well in improving poorly compliant teen adherence to medications and maintenance for T1D. MI increases motivation and readiness for change, whereas CM reinforces positive changes.

Asthma. Asthma medication adherence is a pressing issue in adolescents, with worse rates in racial and ethnic minorities. This lack of adherence contributes to disproportionately high morbidity and mortality in these patients.6 The first study to consider MI intervention for improving asthma medication adherence in black adolescents who live in urban neighborhoodss recruited participants based on recent visits to the emergency department for asthma exacerbation or treatment and having a daily asthma controller medication. Participants were age 10 to 15 years (n = 65). Post-intervention, both motivation and readiness to change improved significantly in these adolescents.6 MI is a promising tool because it does not assume adolescents are starting at a point where they are ready and willing to change.

Obesity. Obesity is one of the chronic disorders in pediatrics that requires counseling of patients and their families by physicians. The Expert Committee on Pediatric Obesity within the American Academy of Pediatrics recommends physicians engage in MI-style counseling.15 MI is particularly useful in this area of care because it addresses modifiable behaviors both the child and his or her family can engage in through open dialogue.

Many studies have considered and modified MI intervention to address pediatric obesity.1,2,4,5,16 The Healthy Habits, Happy Homes program enrolled 121 families with children age 2 to 5 years. Families received four MI sessions at home, four telephone coaching calls, monthly educational packages, and weekly text reminders about new behaviors. Post-intervention, children showed increased sleep duration and significantly reduced body mass index (BMI).1

Another study considered short-term and long-term efficacy of MI. The study enrolled 372 patients age 4 to 7 years into an intervention arm (n = 187) or control arm (n = 185). The intervention group received five pediatrician-led MI sessions focusing on physical activity and diet. The control group had their usual twice yearly pediatric visits.4 The primary outcome was individual BMI score variation. Post-intervention, a significant difference was observed in BMI between the groups,4 but follow-up at 24 months found no difference between groups for change in BMI. Several improvements in behaviors were evident in the MI group in the short term, but almost no improvements were observed during the follow-up period. It may be advisable to incorporate boosters and maintenance strategies for MI interventions.5

A recent study used a multidisciplinary MI intervention with primary care physicians (PCPs) and registered dieticians (RDs). Enrolled children were age 2 to 8 years with a BMI >85th percentile and ≤97th percentile.2 The participants either received no MI discussion, PCP-led MI discussions, or dual PCP and RD-led MI discussions. The children who received both PCP and RD intervention had the greatest decrease in BMI percentiles. Additionally, positive behavioral changes were greatest in the children with the dual MI intervention.

HIV infections. Youth living with HIV (YLH) often participate in risky behaviors, including a triad of sexual risk behavior, poor medication adherence, and substance use.11 An abbreviated intervention called “Healthy Choices” focused on boosting motivational readiness for change and building self-efficacy toward risk behaviors. Targeted YLH were age 16 to 24 years, with a total of 186 participants randomized into either intervention plus HIV specialty care (n = 94) or HIV specialty care alone (n = 92). At baseline, researchers screened for substance abuse with the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) test, for risky sexual behavior by asking if youth engaged in unprotected sex, and for medication nonadherence by asking youth if they were <90% adherent in the past month. The intervention group received 10 weeks of four 1-hour long MI sessions and specialty care. Despite low completion rates, YLH participants in the intervention group had significant improvements in depression and motivational readiness compared to the control group.11

Of added interest is the long-term effect of the MI intervention on preventing risky behavior in YLH. A 15-month follow-up looked at 143 of the original participants who were identified with substance abuse problems and stratified them into high, moderate, and low-risk groups based on amounts used.17 Marijuana and alcohol were the most abused substances. After the intervention, alcohol and marijuana abuse were significantly reduced, and fewer YLH fell into the high-risk trajectory for alcohol abuse.17

Future Uses of MI in Pediatric Management

Suicide Prevention in Adolescents

Increasing suicide rates among adolescents have made interventions aimed at prevention paramount. The efficacy of MI combined with means restriction counseling is an area of active research.18 MI is potentially very helpful in suicidal patients because many are ambivalent about completing the act and thus have the intrinsic motivation to pursue treatment. Means restriction counseling is efficacious because it impedes patient access to lethal means during high-risk periods. Future applications of MI in treating patients with suicidal thoughts is promising because it allows for acceptance of a patient's perspective, establishes a therapeutic alliance, and creates a collaborative relationship where the patient feels comfortable confiding in the physician.18 Although MI has currently only been explored in the adult realm, it may play an emerging role in adolescent suicidal management.

Online-Directed MI Training of Physicians

Despite the role of MI in treating pediatric patients, adequate training of physicians in the technique remains challenging. Most prior interventions have used intensive in-person training. A novel study explored the use of online MI intervention training to help physicians improve their technique.19 The online training program, Teen CHAT, was developed to help treatment of overweight adolescent patients. Intervention group physicians received online MI training followed by a summary report detailing modifiable factors to address obesity, whereas the control group physicians only received the summary report. Researchers assessed physician intervention outcomes on adolescents age 12 to 18 years with BMI ≥85th percentile.

After 3 months, physicians who received both the online MI training and the summary report had significantly higher use of MI techniques with less MI inconsistent behaviors such as directive tone and yes/no queries. Of note, these physicians also displayed increased empathy and the use of more open-ended questions. Although adolescents in both arms had similar changes in BMI, adolescents who worked with an MI-trained physician responded positively to their physician's empathy and MI approach, demonstrating a future openness to more behavioral modifications. Collectively, these findings suggest that a brief MI training delivered via an online module improves physician MI techniques. Thus, online instruction of the MI technique may supersede intensive in-person training and allow for wider distribution.

Child-Parent Versus Child-Only MI Intervention

It remains questionable if younger children can benefit from MI, which addresses patient ambivalence and works toward agenda setting. The ability to assess and modify behavior is still developing in young children. A solution to this issue is MI intervention with parental involvement, either with the child or during individual MI sessions. This approach has successfully addressed obesity during a home-based intervention.1 MI can encourage changes in both parental and child behaviors. Within the pediatric population, MI interventions aimed at adolescents have had great success in multiple issues.6,7,11 During this period of increasing autonomy, ambivalence toward self-care contributes to adolescents responding well to the empathetic, open-ended style of MI. However, the most effective format of MI remains under evaluation.

Summary and Future Directions

MI interventions are increasingly playing a role in pediatric practice. Support continues to accumulate for the efficacy of MI in addressing some of the most challenging issues present in child health care. Specifically, the MI approach has helped with management of chronic conditions and in fostering a positive therapeutic alliance. The scope of MI in pediatric care continues to expand with explorations for modifications for improved efficacy.

Despite the promising findings, more research is needed to determine a consistent style of MI intervention that can be used in the clinical setting. Generalizability and reproducibility remain key issues hindering the widespread application of MI. Furthermore, there is a pressing need for studies with more diverse samples involving randomized control trials with longer follow-up.

More studies comparing the outcome of a child alone receiving MI intervention versus child-parent MI intervention may help elucidate any benefit of one over the other.

Despite the challenges and limitations of current MI research, it has many promising implications in practice. MI may prove to be an indispensable intervention to reduce depression, suicidal ideation, and suicide rates within adolescent medicine. Another change in MI may involve online training for all physicians as opposed to intensive in-person trainings that limit the distribution of this technique. Finally, within a hospital setting, an interdisciplinary team-based MI intervention may help target traditionally difficult issues such as obesity. Ultimately, there is much promise for the use of MI in pediatric care.

References

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Authors

Nikita Desai, BS, is a fourth-year Medical Student, Wayne State University School of Medicine.

Disclosure: The author has no relevant financial relationships to disclose.

Address correspondence to Nikita Desai, BS, Wayne State University School of Medicine, Scott Hall, 540 E. Canfield Avenue, Detroit, MI 48201; email: ndesai@med.wayne.edu.

10.3928/19382359-20190816-01

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