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