Pediatric Motivational Interviewing.pdf

REVIEW ARTICLE Brief Interventions and Motivational Interviewing With Children, Adolescents, and Their Parents in Pediatric Health Care Settings

A Review

Sarah J. Erickson, PhD; Melissa Gerstle, BA; Sarah W. Feldstein, MS T

here physical interventions cient is means increasing but of also (BIs), targeting the demand and psychosocial in behavioral, for particular physicians health developmental, Motivational in of pediatric their child interviewing and settings and social adolescent to problems address (MI), patients. offer not within only an Brief effi- the

the context of pediatric practice. This review addresses the patient-centered care foundation of and empirical support for brief pediatric interventions, including educational and media-based inter- ventions, MI-based prevention and intervention with health risk behaviors, procedural pain con- trol, and adherence to treatment recommendations. In addition, developmental considerations and future directions for BI research in pediatric practice are summarized.

Physicians in pediatric health care set- tings address complex challenges in pro- viding comprehensive care to children, adolescents, and their parents. Toward this end, BIs have been used in pediatric set- tings to aid in the prevention, early detec- tion, and brief treatment of behavioral, developmental, and social problems asso- ciated with health care concerns to serve children and their families more effec- tively. Brief interventions encompass a di- verse range of theoretically based ap- proaches, intervention targets, and delivery methods to address such issues as educa- tional and media-based interventions, MI- based prevention and intervention with health risk behaviors, procedural pain con- trol, and adherence to health care recom- mendations. One particularly efficacious form of BI used extensively with health risk behaviors is MI.1 Motivational interview- ing uses a patient-centered and directive approach that addresses the ambivalence and discrepancies between a person’s cur- rent values and behaviors and their fu- ture goals. Motivational interviewing has primarily been used with adults and ado- lescents, whereas BIs have primarily tar- geted parents to address pediatric health

concerns. Collectively, these interven- tions have been shown to improve pedi- atric health outcomes ranging from ad- herence2 to functional status.3

PATIENT-CENTERED CARE

Common to all forms of BI, a patient- centered interaction style encourages and facilitates discussion of psychosocial is- sues that may both directly and indi- rectly influence health-related outcomes. In particular, patient-centered communi- cation (ie, communication characterized by partnership building, empathy, inter- personal sensitivity, and information giv- ing) has been associated with increased parent satisfaction, adherence to pediat- ric treatment recommendations, and dis- closure of psychosocial problems.4 In ad- dition, satisfaction with health care has been linked to decreased utilization of health care services5 and decreased mal- practice litigation.6Furthermore, patient- centered care has also been associated with a more accurate recall of diagnosis and medical advice,7increased symptom reso- lution, and improved pain control.8

From a humanistic perspective, a client- centered or patient-centered orientation re- Author Affiliations: Department of Psychology, University of New Mexico,

quires therapists to integrate 3 elements Albuquerque.

into their work to effect positive thera-

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012

confrontation, Table 1. Four Underlying Principles of Motivational Interviewing*

education, and authority, MI is centered on support of the patient’s autonomy, collaboration, and the evocation of the patient’s ideas regarding change.

Underlying Principles Exemplar Statements

Through the validation and support of a patient’s belief that it would be beneficial and value-congruent to fol- Express empathy Acceptance facilitates change.

low recommended treatment protocols, the directive ap- Skillful reflective listening is fundamental. Ambivalence is normal. Develop discrepancy The client rather than the counselor should

present the arguments for change. Change is motivated by a perceived

proach of MI supports a patient’s inherent and natural potential to move toward change.1

The transtheoretical model of intentional behavior changeprovidesaframeworkforunderstandingthestages discrepancy between present behavior

ofbehaviorchange.16Inthismodel,itispositedthatchang- and important goals or values. Roll with resistance Avoid arguing for change.

Resistance is not directly opposed. New perspectives are invited

but not imposed. The client is a primary source in finding

ers progress through 5 stages: precontemplation (not yet consideringchange),contemplation(consideringchange), preparation (planning and committing to change), action (making the behavior change), and maintenance (main- taining and sustaining long-term change).17Motivational answers and solutions.

interviewing requires that health care professionals un- Resistance is a signal to respond differently. Support self-efficacy A person’s belief in the possibility of change

is an important motivator. The client, not the counselor, is responsible for choosing and carrying out change.

derstand their patient’s stage of change to target their in- tervention effectively.18,19Rollnick and Miller15posit that moving beyond a patient’s readiness to change is likely to increase the client’s resistance to treatment. Thus, with The counselor’s own belief in the person’s

overt risk behaviors like smoking, it may be tempting for ability to change becomes a self-fulfilling prophecy.

health care professionals to highlight the likely harms of certain behaviors (eg, smoking is the most preventable

*Adapted from Miller and Rollnick.1

source of morbidity and mortality for adolescents; it is a risk factor for cancer and heart disease). However, lectur- ingadolescentswhoarenotyetreadytoquitabouttheharm peutic effects: empathy, unconditional positive regard,

they are likely to incur by smoking is unlikely to be effec- and genuineness.9Within a collaborative relationship be-

tiveinreducingthefrequencyofthebehaviorandmayeven tween patient and health care professional, a profes-

produce iatrogenic effects.18 In contrast, MI includes ac- sional can solicit a patient’s ideas, thoughts, and per-

ceptingapatientwhereheorsheisintheprocessofchange spectives on adhering to treatment recommendations and

as well as encouraging any proactive movement toward can explore the likely outcomes of related decisions. More-

healthier behaviors. over, patient-centered communication fosters rapport with

The foundation of MI requires that health care pro- both the child or adolescent and their parents. In some

fessionals follow 4 principles: genuine expression of em- settings, particularly those with younger children, the de-

pathy, development of discrepancy between the pa- velopment of a therapeutic alliance with the child’s par-

tient’s current behavior and his or her treatment goal, ents may be most salient to treatment adherence be-

rolling with the client’s resistance, and support of the pa- cause parents are responsible for managing younger

tient’s self-efficacy (Table 1).1 Operationally, MI relies children’s health care services and adherence.10 Regard-

on the health care professional’s use of open questions; less of the child’s age or functional status, developing rap-

reflective listening; affirmation, such as through com- port with parents can yield beneficial results for the en-

pliments or statements of understanding; provision of tire family, such as increasing family involvement in the

summary statements to unify and reinforce discussed ma- prevention or treatment process.11,12 Furthermore, chil-

terial; and eliciting change talk. These techniques sup- dren who actively participate in the health care visit dem-

port the principles through conveying acceptance of the onstrate greater visit satisfaction and enhanced recall of

patient, understanding of the patient’s ambivalence, col- prescribed regimens.13

laboration with the patient in reflecting and reviewing available options, and ultimate support for the patient’s MI-SPECIFIC ELEMENTS

autonomy to select and enact change (Table 2).1

In contrast to closed questions, which generally re- Motivational interviewing, posited by its creators as “a

quire a simple yes/no or numeric answer, open ques- way of being with people,”1 is a client-centered, collabo-

tions do not direct a patient to respond in a particular rative, and directive treatment approach that has proven

manner. Instead, they enable a patient to think through efficacious in several behavioral health fields.14,15In con-

and provide richer, fuller responses. Reflective listening trast to communication styles that elicit patient resis-

is a method both of resonating with a patient and of clari- tance, MI enhances a patient’s intrinsic motivation to

fying the meaning of his or her statements. To demon- change by exploring their perspective and ambivalence.

strate support of a patient’s efforts, a health care profes- Rather than a set of techniques or a way of coercing treat-

sional may use affirmations. Summary statements include ment adherence, MI explores how a person feels about

integrating the full picture of the pros and cons of a pa- the status quo and about change through an explora-

tient’s behavior, followed by checking in with patients tion of the person’s values, interests, and concerns. In con-

to make sure that they feel you have reflected their situ- trast to more traditional medical approaches that rely on

ation accurately. When practicing MI, it is important to

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012

Table 2. Primary Techniques of Motivational Interviewing

Techniques Exemplar Statements

Open-ended questions How does smoking fit with your role as lead singer in the chorus?

How does smoking fit with your dreams of becoming a pro basketball player? How do you feel about smoking? Closed-ended questions How many cigarettes did you smoke today?

Did you take your medication? Reflective listening You’re tired of being different from the other kids.

It is embarrassing not being able to eat the same things as your friends. You have already done this for 10 years; having to stick with this diet for longer doesn’t seem fair. Affirmations Coming in every week for treatment is really tough. You are handling a difficult treatment protocol really well.

I’m impressed with how mature you are. Absolutely! It is really tough to do all that you need to do when you’re not feeling well. And sticking to your

diet makes it easier for you to do your chores, complete your homework, and hang out with your friends. Summary statements It’s important for you to fit in with your friends. Sometimes adhering to your chest physiotherapy regimen makes that tough.

On the other hand, when you don’t adhere to your therapy, you notice that you don’t feel as well. And when you don’t

feel as well, it’s even harder for you to keep up with the energy of your friends. Is there anything that you want to add that I may have missed? Evocation of change talk I will quit smoking.

I will exercise more. vs I wish I could quit smoking.

I wish I could lose weight. Importance and ability rulers To a child with diabetes mellitus who indicates that the importance of checking their glucose is a “3”:

Why are you at a “3” and not a “1”? What would be necessary for you to feel like you could get from a “3” to a “5”?

have patients identify their own reasons, ability, and need

behavior.10 In contrast to more prescribed treatment re- for change (also known as “change talk”).

gimes, MI conveys information to the client in a neutral Ambivalence frequently plays a key role in psychologi-

and empathic manner,20 and resistance is perceived as a cal difficulties. Rather than interpreting ambivalence as

normal response to a perceived threat (such as confron- pathological or an indication of someone’s moral or be-

tation or coercion).21 havioral weakness, MI construes ambivalence as a resolv- able issue that, once resolved, will move a person toward

DEVELOPMENTAL CONSIDERATIONS change. Another set of MI techniques often used to ex- plore ambivalence includes the importance and ability rul-

Although providing children with accurate and devel- ers. Using these rulers can help patients express their sub-

opmentally appropriate explanations of their health con- jective evaluation of the importance of changing the target

dition and treatment recommendations is an essential behavior as well as how able they feel to enact the change.

component of health-related interventions, there has been The exploration of why a patient attributes a certain level

limited research examining how children of different ages of importance to a behavior, as opposed to less impor-

understand and conceptualize health and illness. The ex- tance, helps the health care professional and patient have

tant empirical research suggests that pediatricians and a more concrete understanding of the patient’s ratings of

parents both tend to overestimate the ability of younger importance and ability for change. For example, patients

children and underestimate the ability of older children may describe the importance of medication adherence and

to understand illness-related concepts.22,23 Current theo- a health care professional can ask them why they are at that

ries posit that the way in which children conceptualize certain level as opposed to a lower number. This can en-

illness changes over the course of development in accor- hance a person’s feelings of self-efficacy. In addition, ex-

dance with their developing theories of biology.24In short, ploration and elaboration of the pros and cons of the am-

children use the knowledge they have about biology to bivalent behavior, brainstorming about the extremes of the

develop their individualized biological theories (about consequences of changing and not changing the behavior

the nature of infection, for example), which in turn in- at hand, and contemplation of goals and values are strat-

form their understanding of health and illness. egies that can be used to evoke change talk.1

In this way, using a developmental framework is es- The efficacy and brevity of MI is ideal for health care

sential in providing appropriate health care interven- settings.19 Contrary to more prescriptive medical inter-

tions to children and adolescents. Because developmen- ventions, MI incorporates reasonable and attainable treat-

tal competencies evolve and unfold over the course of ment goals proposed by the client and clarified in col-

development in relation to other competencies and con- laboration with the health care professional. The health

texts, no intervention is likely to be effective from early care professional is able to provide information about the

childhood throughout adolescence. Specifically, appro- consequences of completing or electing not to complete

priate intervention in health care settings requires an un- treatment goals. With the client, the role of the health

derstanding of children’s causal reasoning, language abil- care professional is to examine and discuss any appar-

ity, and self-understanding, as well as their environmental ent discrepancies between treatment goals and current

context.25

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012

its. Causalreasoningcapacitieshavedirectimplicationsfor

One method used to circumvent such time constraints the child’s ability to benefit from interventions. Because

is the use of media-based interventions (eg, pamphlets, vid- youngerchildrenhavealimitedabilitytounderstandhealth-

eotapes, compact discs). Limited research has shown that related issues in relation to internal rather than external

this type of intervention has been effective as a means of sources,interventionswithyoungerchildrenneedtobecon-

educating parents regarding many pediatric concerns, in- crete and focused on behavioral recommendations for the

cluding children’s antibiotic use,28-30 breastfeeding,31 po- child. Health care professionals cannot assume that the

liovirus vaccinations,32 acute fever,33 sun protection,34 en- recommendations will generalize but rather must convey

copresis,35 anesthesia,36 lead poisoning,37 and pesticides.38 specificbehavioralexpectationsthatincludeexamplesacross

For example, children who participated with their par- settings and situations. More broadly, children’s ability to

ents in an adjunctive Internet therapy program for pedi- considerandconsolidateinformationismoderatedbysuch

atric encopresis demonstrated greater improvements in toi- factors as sex, culture, interest, and motivation.26 In addi-

leting behaviors than did children who did not receive the tion,becausetheabilitytolinkpasteventswithcurrenthealth

Internet intervention.35In addition, media-based interven- behavior or problems emerges in middle childhood, early

tions have also had success in educating children and par- childhood interventions should focus on current corre-

ents about childhood chronic illness, including asthma,39,40 lates of health-related behavior. Because of these limita-

cystic fibrosis,41 leukemia,42 and congenital heart dis- tions, most interventions with younger children largely rely

ease.43 A limitation of these interventions is that they of- on parents, with relatively less child involvement.

ten aim to increase knowledge, and it is unclear how knowl- Language skills must also be considered in imple-

edge gains translate to behavior change. menting efficacious intervention strategies. Children’s abil-

Computerized assessments are another form of media- ity to label their experience and understand the recom-

basedinterventionthathavebeenusedlessfrequently.Com- mended treatment approach may enhance or limit a child’s

puterized assessments can help tailor prescribed regi- ability to engage in and benefit from an intervention. Fur-

menstoimprovehealthoutcomeswithoutaddingsignificant thermore, children’s expressive abilities, in part a func-

time to the medical visit. For example, adolescent girls who tion of culture and English proficiency,27 are significant

completed a computerized assessment of their health be- determinants of their participation in interventions.

haviors in the waiting room and then discussed the print- Finally, self-understanding is another developmental

out with their health care professional demonstrated im- competency deserving consideration in the health care set-

provement in nutrition and physical activity level.44 ting. Over the course of childhood, with a dramatic peak

An essential component of educational interventions in adolescence, children become increasingly concerned

isassessingthechild’sgeneralfunctionalstatusand,inpar- with developing coherence and consistency among their

ticular, identifying psychosocial problems that may be af- beliefs, values, and behavior. In this way, adolescents are

fectingcurrenthealthissues.Althoughthisprocessislargely actively constructing identity and asserting greater inde-

doneintheexaminationroom,self-administeredquestion- pendence from parents. This striving can serve as a sig-

naires can aid in screening for problems and, thus, help nificant incentive for behavior change, particularly if cur-

to shape the pediatrician’s focus, especially in regard to rent health-related behavior is in conflict with their self-

psychosocial concerns. Psychosocial dysfunction in chil- identified goals. During this period, adolescents are often

dren and adolescents has become a primary concern in pe- included to a greater, even exclusive, extent in interven-

diatric practice1; as many as half of child health care vis- tion efforts while parental involvement is more limited and

its involve psychosocial concerns, such as behavioral, so- even negotiated with the adolescent.

cial, or educational difficulties.45 However, parents may Because children have relatively little control over se-

feel uncomfortable initiating conversation about psycho- lecting and modifying their environment, it is important

social difficulties and prompts from the pediatrician may to understand the larger context within which a child func-

ease any distress or embarrassment. One of the most fre- tions. In addition to affecting current functioning, social

quently used psychosocial questionnaires with pediatric environments, including family, peers, school, and the

populations is the Pediatric Symptom Checklist,46 a 35- larger community, may influence a child’s efforts to modify

item parent-completed questionnaire designed to assess health-related behavior. For example, nonadherence or en-

a wide variety of psychosocial dysfunction, including so- gagement in health risk behavior may be reinforced, either

matic complaints, emotional problems (eg, anxiety, de- intentionally or unintentionally, by individuals in the child’s

pression), and behavioral problems (eg, school difficul- environment. Peer groups become especially salient in late

ties, aggression) in children and adolescents (aged 4-16 childhood and adolescence when health risk behaviors dra-

years).Ithasprovenfeasibleforroutinescreeningbynon– matically increase. In this way, the environmental con-

mental health professionals.47 text for the targeted behavior must be considered and in- corporated in the intervention approach.

MI-Based Prevention and Intervention With Health Risk Behaviors EMPIRICAL SUPPORT FOR BI IN HEALTH CARE SETTINGS

OfallBIstargetinghealthriskbehaviorsinpediatrichealth care settings, MI has accumulated the most empirical sup- Educational and Media-Based Interventions

port. With the exception of adolescent substance use in- terventions, the majority of the literature addressing the One of the primary obstacles to implementing interven-

efficacy of MI with children, adolescents, and parents re- tions in medical settings is the brief nature of medical vis-

mains primarily theoretical.48-50However, empirical sup-

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012

Dietary porthasaccumulatedforMIinterventionsaimedattobacco

Control. Although a relatively new health risk use,19,51,52 alcohol use,53-56 and dietary control.57 Because

behavior area for using MI techniques, Berg-Smith et al57 most adolescents do not self-refer for health-risk behav-

implemented an MI approach with a large sample of 13- iorintervention,thesebehaviorsarelikelytoemergewhen

through 17-year-old patients who had high levels of li- adolescents seek other services in health care settings.

poprotein cholesterol and needed to reduce their intake of total fat, saturated fat, and cholesterol. Concordant with TobaccoUse.Althoughmostchildrenandadolescentslimit

the patient’s transition into high school, MI matched the their cigarette use to experimentation, between 15% and 20%ofyouthsmokeatleast1cigarettedaily.58Manyyouth believe that substance use is normative and therefore find it neither necessary nor desirable to quit.21 Whereas em- pirical studies with adult samples show moderate success withsmokingcessation,59MIhasaccumulatedlimited,but promising,evidenceasaBIforadolescentsmoking.Brown

patient’s movement from family-based care to self-care. Postintervention, the MI group displayed reengagement in goal setting, as well as increased and renewed adher- ence to their specialized diets, resulting in decreased con- sumption of calories and dietary cholesterol. In addi- tion, health care professionals and participants reported high levels of acceptance of the intervention. et al52 and Colby et al19 found small effects, but not sta- tisticallysignificantgroupdifferences,betweenMIandbrief advice conditions in increasing quit attempts. However, Brown et al52found that youth who received MI reported greaterself-efficacyregardingtheirabilitytoquitand,among youth who reported greater ambivalence, MI proved more efficacious than brief advice.

Emerging Areas for MI Research. The efficacy of MI is being evaluated in several new health-risk behavior areas, including risky sexual behavior and marijuana use. For example, the use of MI and narrative therapy may help reduce high-risk sexual behavior and increase contra- ceptive use with a sample of girls,64and motivational en- hancement therapy (ie, MI with feedback) is currently Alcohol Use. In comparison with the extensive re- search evaluating BI, and more specifically MI, to re- duce alcohol use with adults,60,61 the literature evaluat- ing brief strategies with adolescents is more limited.

being used with marijuana-using adolescents in commu- nity-based treatment centers. Although these areas do not yet have the same level of empirical support as previ- ously reviewed areas, data are forthcoming. Adolescents’ pattern of drinking appears to be unique in terms of higher levels of heavy episodic drinking (ie, drink- ing 5 drinks per occasion), decreased likelihood of meet- ing criteria for dependence, and increased likelihood of meeting criteria for abuse.53,62,63

Barnett et al,53 Monti et al,55 and Spirito et al56 have researched the effectiveness of MI in reducing alcohol use with adolescents (aged 13-19 years) seeking emergency health services. With older adolescents (aged 18-19 years), they found that the MI-intervention group and the stan- dard hospital care group displayed equivalent levels of alcohol use reduction.53,55However, at the 6-month follow- up, adolescents who received MI showed significantly greater harm-reduction behavior over the standard care group. Specifically, the MI-intervention group dis- played decreased episodes of drinking and driving, al- cohol-related injuries, and alcohol-related problems (ie, with parents, friends, police, school). With a sample of 16- through 20-year-olds engaged in polysubstance use, McCambridge and Strang54 found a similar harm- reduction effect. Rather than commencing abstinence, adolescent participants who received MI subsequently engaged in moderate alcohol and substance use, repre- senting a significant decrease in alcohol intake. As the authors indicate, the true benefit of MI with tradition- ally unreachable adolescent populations may be its abil- ity to initiate any reduction in alcohol or substance use.54

Use of MI With Children, Adolescents, and Parents. Al- though MI has consistently demonstrated efficacy in changing adult behavior, questions remain about the vi- ability of MI with school-aged children. In particular, it is not clear whether younger children, with more lim- ited abilities to form long-term goals and to experience ambivalence between future goals and current behav- ior, may demonstrate the same levels of benefits with MI. In contrast, MI appears to be highly effective in in- creasing self-efficacy to enact change in adolescents.52 In addition to MI’s demonstrated efficacy with adolescent substance use,53-56 MI is amassing support as a BI with adolescents who are highly ambivalent or who may be ambivalent about following a prescribed health care regi- men. As a supportive, flexible, idiographic, brief, and au- tonomy-based intervention, MI overlaps well with ado- lescents’ competing attentional demands, developing identities, and desire to assert independence.57,65 In ad- dition, MI has shown promise as an intervention with parents of younger adolescents.10,53

Intervening with parents’ health risk behaviors for the benefit of their children, for example, reducing substance use behaviors with the aim of improving parenting, shows promise as an efficacious treatment.66In addition, address- ing other parental behaviors, such as smoking in order to reduce children’s passive smoke exposure51,67-69 and at- tending to children’s dental care needs to prevent dental Similar to findings with older adolescents, there were

caries,70is gaining empirical support. Although there is lim- no significant differences in drinking behavior between

ited research on the outcome of effective treatment rela- younger adolescents (aged 12-17 years) who received MI

tionships with children, adolescents, and their parents,10 vs those who received standard care.53,56However, Spirito

anecdotal and descriptive literature on therapeutic work et al56 hypothesize that to effect change in alcohol-

with children support the use of methods that resemble MI, related behaviors with younger adolescents, parental com-

such as an emphasis on the use of open questions, declara- munication skills and monitoring behaviors may war-

tive and summary statements, and joining with the child.71 rant specific consideration.

Clearly, more systematic empirical research is warranted.

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012

addition, Procedural Pain Control

behavioral interventions targeting dietary rec- ommendation adherence, which reinforce adaptive be- Strong support has been generated for the use of psycho-

haviors and modify maladaptive behaviors, have been logical interventions in pediatric populations for procedure-

found to be successful with children with cystic fibro- related pain. Brief cognitive-behavioral interventions, such

sis.78 In fact, a meta-analysis revealed that behavioral in- as breathing exercises, imagery, modeling, reinforcement,

terventions focused on improving nutritional status by and behavioral rehearsal, are a well-established treatment

increasing caloric consumption are comparable with more for procedural pain in children and adolescents with can-

invasive interventions such as oral supplementation and cer. They have also been found to be effective in reducing

enteral and parenteral nutrition.79 distress and pain associated with routine immunizations,

Overall,briefmulticomponenttreatmentpackageshave dental treatments, and burn treatments.72 For example, to

beenthemostfrequenttypeofevaluatedinterventionused address distress associated with immunizations, parent-

to promote adherence in a variety of childhood chronic ill- directed behavioral interventions initiated both before the

nesses. Multicomponent interventions have been found to immunization delivery and used during the actual immu-

effectivelypromoteadherencetomedicalregimensinchil- nization, such as the use of visual items, pacifiers, and the

drenandadolescentswithasthma,type1diabetesmellitus, parent’s voice, were effective in reducing infant distress and

andjuvenilerheumatoidarthritis.2Infact,multicomponent salivary cortisol levels.73 In addition, deep-breathing dis-

packagesevidencethestrongestsupportforsuccessfullyde- traction techniques that were generated by using a party

creasing nonadherence in pediatric cases of type 1 diabetes blower were found to reduce distress levels in young chil-

mellitus2andforpreventingtheanticipateddecreasedmedi- dren.74In fact, Tsao et al75demonstrated in a laboratory set-

cation adherence in juvenile rheumatoid arthritis.80 ting the efficacy of a 5-minute behavioral intervention on

In addition, MI has provided another means of BI to pain reactivity, finding that children trained in distraction

promote diabetes mellitus–related adherence. Research methods (ie, vividly imagining a pleasant scene or activ-

investigating the effects of MI with adolescents with dia- ity) had the highest pain tolerance.

betes mellitus is in the initial stages, but preliminary re- sults suggest that MI promotes better metabolic con- Adherence

trol65 and that MI delivered in a group format effects an adaptive shift in illness perception, which may later in- Immunizations. Efforts to improve adherence to immu-

fluence self-care behaviors.81 nization recommendations have been largely successful in

In summary, across chronic illness categories, al- pediatric populations but almost one fifth of children in

though few in number and variable in methodological the United States lack at least 1 basic immunization.76 A

rigor, brief psychological interventions have demon- review of BIs aimed at improving vaccination coverage for

strated various levels of efficacy in increasing adherence all ages found that the most effective interventions were

with children and adolescents with chronic illness. the use of client reminders/recall notices, health care pro- fessional reminders (eg, in patient medical records), mul-

SUMMARY AND FUTURE DIRECTIONS ticomponent interventions including either education or expanding access as one component, reduction of out-of-

Brief interventions, including MI, have begun to accu- pocket costs, and assessment and feedback to health care

mulate empirical support as efficacious approaches to professionals regarding performance in delivering vacci-

treating a wide range of behavioral, developmental, and nations. There is also sufficient evidence for incorporat-

social disturbances in children and adolescents within ing interventions to improve vaccination coverage in home

pediatric settings. Specifically, BIs in pediatric care have settings; in Women, Infants, and Children program set-

targeted educational and media-based interventions, MI- tings; and in child care, school, and college settings in the

based prevention and intervention of health risk behav- form of vaccination requirements.77

iors, procedural pain control, and adherence to treat- ment recommendations. Childhood Chronic Illness. Brief psychological inter-

In spite of recent advances, future research must re- ventions have also been conducted to promote adher-

flect the complexity of health-related behaviors and their ence to recommended treatment regimens in children and

relationship to individual and contextual systems at vari- adolescents with chronic illnesses. Although the num-

ous levels of analysis over time.82 In BI outcome re- ber of empirically supported adherence interventions is

search attending to the predictive value of individual (eg, relatively small, there is considerable support for adher-

comorbid conditions, developmental level) and contex- ence-related interventions involving children and ado-

tual (eg, peer influences, family conflict) characteristics lescents with asthma, cystic fibrosis, type 1 diabetes melli-

and the bidirectional dynamics between them (eg, pa- tus, and juvenile rheumatoid arthritis.2

rental modeling of health risk behavior) is needed. In this These BIs can involve educational, organizational, or

way, interventions best matched to patient characteris- behavioral strategies in isolation or combined in multi-

tics and current health-related issues may be identified. component packages. For instance, educational inter-

Although support is amassing for BI efficacy with a ventions, which typically include imparting verbal or

variety of health-related issues, effectiveness has not yet written information to children and parents, and orga-

been adequately addressed. Larger and more diverse nizational interventions, such as increasing the level of

samples, more detailed descriptions of intervention ap- physician supervision, have demonstrated support in pro-

proaches, and greater methodological rigor are needed moting adherence in pediatric patients with asthma.2 In

to demonstrate the generalizability of BI. In addition, some

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012

studies have begun to compare the relative efficacy of dif- ferent forms of BI. Continued effort in this direction is needed to identify the relative efficacy of various ap- proaches for various health-related issues and for vari- ous types of patients.

In addition, BI outcome research must evaluate the ways in which parental involvement may optimize health- related outcomes. Identifying the most beneficial way to involve parents with respect to health-related interven- tion target, developmental level, nature of parent-child relationship, and the type of proposed treatment would represent significant progress.

Accepted for Publication: May 23, 2005. Correspondence:Sarah J. Erickson, PhD, Department of Psychology, Logan Hall, 1, University of New Mexico, MSC03 2220, Albuquerque, NM 87131-1161 (erickson @unm.edu).

REFERENCES

1. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change.

2nd ed. New York, NY: Guilford Press; 2002. 2. Lemanek KL, Kamps J, Chung NB. Empirically supported treatments in pediatric

psychology: regimen adherence. J Pediatr Psychol. 2001;26:253-275. 3. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-

analysis of controlled clinical trials. J Consult Clin Psychol. 2003;71:843-861. 4. Nobile C, Drotar D. Research on the quality of parent-provider communication in pediatric care: implications and recommendations. J Dev Behav Pediatr. 2003; 24:279-290. 5. Worchel FF, Prevatt BC, Miner J, Allen M, Wagner L, Nation P. Pediatrician’s com- munication style: relationship to parent’s perceptions and behaviors. J Pediatr Psychol. 1995;20:633-644. 6. Levinson W. Doctor-patient communication and medical malpractice: implica-

tions for pediatricians. Pediatr Ann. 1997;26:186-193. 7. O’Keefe M, Sawyer M, Roberton D. Medical student interviewing skills and mother-

reported satisfaction and recall. Med Educ. 2001;35:637-644. 8. Stewart MA. Effective physician-patient communication and health outcomes: a

review. CMAJ. 1995;152:1423-1433. 9. Rogers CR. A Way of Being. Boston, Mass: Houghton Mifflin; 1980. 10. DiGiuseppe R, Linscott J, Jilton R. Developing the therapeutic alliance in child-

adolescent psychotherapy. Appl Prev Psychol. 1996;5:85-100. 11. Dishion TJ, Kavanagh K, Schnieger A, Nelson S, Kaufman NK. Preventing early adolescents substance use: a family-centered strategy for the public middle school. Prev Sci. 2002;3:191-201. 12. Patterson GR, Forgatch MS. Therapist behavior as a determinant for client non- compliance: a paradox for the behavior modifier. J Consult Clin Psychol. 1985; 53:846-851. 13. Lewis CC, Pantell RH, Sharp L. Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention. Pediatrics. 1991; 88:351-358. 14. Miller WR, Rollnick S. Talking oneself into change: motivational interviewing, stages

of change, and therapeutic process. J Cogn Psychother Int Q. 2004;18:299-308. 15. Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother.

1995;23:325-334. 16. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change:

application to addictive behaviors. Am Psychol. 1992;47:1102-1114. 17. DiClemente CC, Velazquez MM. Motivational interviewing and the stages of changes. In: Miller WR, Rollnick S, eds. Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Press; 2002:201-216. 18. Stein RJ, Haddock CK, O’Byrne KK, Hymowitz N, Schwab J. The pediatrician’s role in reducing tobacco exposure in children. Pediatrics. 2000;106:e66 Avail- able at: http://pediatrics.aappublications.org/cgi/content/full/106/5/e66. Ac- cessed September 28, 2004. 19. Colby SM, Monti PM, Barnett NP, et al. Brief motivational interviewing in a hos- pital setting for adolescent smoking: a preliminary study. J Consult Clin Psychol. 1998;66:574-578. 20. Resnicow K, DiIorio C, Soet JE, et al. Motivational interviewing in public health settings. In: Miller WR, Rollnick S, eds. Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Press; 2002:251-269.

21. Lawendowski LA. A motivational intervention for adolescent smokers. Prev Med.

1998;27:A39-A46. 22. Perrin EC, Perrin JM. Clinicians’ assessments of children’s understanding of illness.

AJDC. 1983;137:874-878. 23. Rubovits DS, Wolynn TH. Children’s illness cognition: what mothers think. Clin

Pediatr (Phila). 1999;38:99-105. 24. Kalish WC. What young children’s understanding of contamination and conta- gion tell us about their concepts of illness. In: Siegal M, Peterson CC, eds. Chil- dren’s Understanding of Biology and Health. Cambridge, England: Cambridge University Press; 1999:99-130. 25. Toth SL, Cicchetti D. Developmental psychopathology and child psychotherapy. In: Russ SW, Ollendick TH, eds. Handbook of Psychotherapies With Children and Families. New York, NY: Kluwer; 1999:15-44. 26. Renninger KA. Developmental psychology and instruction: issues from and for practice. In: Damon W, Sigel IE, Renninger KA, eds. Handbook of Child Psychol- ogy. Vol 4. 5th ed. New York, NY: John Wiley & Sons; 1998:211-274. 27. Canino IA, Spurlock J. Culturally Diverse Children and Adolescents: Assess- ment, Diagnosis, and Treatment. 2nd ed. New York, NY: Guilford Press; 2000. 28. Bauchner H, Osfanian S, Smith K, Triant R. Improving parent knowledge about

antibiotics: a video intervention. Pediatrics. 2001;108:845-850. 29. Taylor JA, Kwan-Gett TS, McMahon EM Jr. Effectiveness of an educational in- tervention in modifying parental attitudes about antibiotic usage in children. Pediatrics. 2003;111:e548-e554. 30. Wheeler JG, Fair M, Simpson PM, Rowlands LA, Aitken ME, Jacobs RF. Impact of a waiting room videotape message on parent attitudes toward pediatric anti- biotic use. Pediatrics. 2001;108:591-596. 31. Khoury AJ, Mitra AK, Hinton A, Carothers C, Sheil H. An innovative video suc- ceeds in addressing barriers to breastfeeding among low-income women. J Hum Lact. 2002;18:125-131. 32. Dunn RA, Shenouda PE, Martin DR, Schultz AJ. Videotape increases parent knowl- edge about poliovirus vaccines and choices of polio vaccination schedules. Pediatrics. 1998;102:e26. Available at: http://pediatrics.aappublications.org/cgi/ content/full/102/2/e26. Accessed April 10, 2005. 33. Sarrell M, Kahan E. Impact of a single-session education program on parental knowl- edge of and approach to childhood fever. Patient Educ Couns. 2003;51:59-63. 34. Geller AC, Sayers L, Koh NK, Miller DR, Steinberg Benjes L, Crosier Wood M. The New Moms Project: educating mothers about sun protection in newborn nurseries. Pediatr Dermatol. 1999;16:198-200. 35. Ritterband LM, Cox DJ, Walker LS, et al. An internet intervention as adjunctive therapy for pediatric encopresis. J Consult Clin Psychol. 2003;71:910-917. 36. Lee A, Chui PT, Gin T. Educating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions. Anesth Analg. 2003; 96:1424-1431. 37. Kersten HB, Moughan B, Moran MM, Spector ND, Smals LE, DeLago CW. A vid- eotape to improve parental knowledge of lead poisoning. Ambul Pediatr. 2004; 4:344-347. 38. Sklansky DJ, Mundt MP, Katcher ML. Pesticides and your children: a random-

ized controlled evaluation of a pamphlet. WMJ. 2003;102:57-62. 39. Homer C, Susskin O, Alpert HR, et al. An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial. Pediatrics. 2000;106:210-215. 40. Shegog R, Bartholomew LK, Parcel GS, Sockrider MM, Mâsse L, Abramson SL. Impact of a computer-assisted education program on factors related to asthma self-management behavior. J Am Med Inform Assoc. 2001;8:49-61. 41. Davis MA, Quittner AL, Stack CM, Yang MC. Controlled evaluation of the STAR- BRIGHT CD-ROM program for children and adolescents with cystic fibrosis. J Pediatr Psychol. 2004;29:259-267. 42. Dragone MA, Bush PJ, Jones JK, Bearison DJ, Kamani S. Development and evalu- ation of an interactive CD-ROM for children with leukemia and their families. Pa- tient Educ Couns. 2002;46:297-307. 43. DeMaso DR, Gonzalez-Heydrich J, Erickson JD, Grimes VP, Strohecker C. The experience journal: a computer-based intervention for families facing congeni- tal heart disease. J Am Acad Child Adolesc Psychiatry. 2000;39:727-734. 44. Patrick K, Sallis JF, Prochaska JJ, et al. A multicomponent program for nutrition and physical activity change in primary care. Arch Pediatr Adolesc Med. 2001; 155:940-946. 45. Sharp L, Pantell RH, Murphy LO, Lewis CC. Psychosocial problems during health

supervision visits: eliciting, then what? Pediatrics. 1992;89:619-623. 46. Jellinek MS, Murphy JM, Burns BJ. Brief psychosocial screening in outpatient

pediatric practice. J Pediatr. 1986;109:371-378. 47. Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM, Kelleher KJ. Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pedi- atric primary care. Arch Pediatr Adolesc Med. 1999;153:254-260. 48. Atkinson C, Woods K. Motivational interviewing strategies for disaffected second-

ary school students: a case example. Educ Psychol Pract. 2003;19:49-64.

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012

age 49. Corcoran J. The transtheoretical stages of change model and motivational in-

contraceptive use among adolescents at high risk for early childbearing. Fam terviewing for building maternal supportiveness in cases of sexual abuse. J Child

Syst Health. 2002;20:183-204. Sex Abus. 2002;11:1-17.

65. Channon S, Smith VJ, Gregory JW. A pilot study of motivational interviewing in 50. Hohman MM. Motivational interviewing: an intervention tool for child welfare case

adolescents with diabetes. Arch Dis Child. 2003;88:680-683. workers working with substance-abusing parents. Child Welfare. 1998;77:

66. Carroll KM, Libby B, Sheehan J, Hyland N. Motivational interviewing to enhance 275-289.

treatment initiation in substance abusers: an effectiveness study. Am J Addict. 51. Borrelli B, McQuaid EL, Becker B, et al. Motivating parents of kids with asthma

2001;10:335-339. to quit smoking: the PAQs project. Health Educ Res. 2002;17:659-669.

67. Curry SJ, Ludman EJ, Graham E, Stout J, Grothaus L, Lozano P. Pediatric- 52. Brown RA, Ramsey SE, Strong DR, et al. Effects of motivational interviewing on

based smoking cessation intervention for low-income women: a randomized trial. smoking cessation in adolescents with psychiatric disorders. Tob Control. 2003;

Arch Pediatr Adolesc Med. 2003;157:295-302. 12(suppl IV):iv3-iv10.

68. Emmons KM, Hammond SK, Fava JL, Velicer WF, Evans JL, Monroe AD. A ran- 53. Barnett NP, Monti PM, Wood MD. Motivational interviewing for alcohol-

domized trial to reduce passive smoke exposure in low income households with involved adolescents in the emergency room. In: Wagner EF, Waldron HB, eds.

young children. Pediatrics. 2001;108:18-24. Innovations in Adolescent Substance Abuse Interventions. Amsterdam, the Neth-

69. Winickoff JP, Hillis VJ, Palfrey JS, Perrin JM, Rigotti NA. A smoking cessation erlands: Pergamon; 2001:143-168.

intervention for parents of children who are hospitalized for respiratory ill- 54. McCambridge J, Strang J. The efficacy of single-session motivational interview-

nesses: the Stop Tobacco Outreach Program. Pediatrics. 2003;111:140-145. ing in reducing drug compensation and perceptions of drug-related risk and harm

70. Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their among young people: results from a multi-site cluster randomized trial. Addiction.

young children: one-year findings. J Am Dent Assoc. 2004;135:731-738. 2004;99:39-52.

71. Greenspan SI, Greenspan NT. The Clinical Interview of the Child. 3rd ed. Wash- 55. Monti PM, Colby SM, Barnett NP, et al. Brief intervention for harm reduction with

ington, DC: American Psychiatric Publishing Inc; 2003. alcohol-positive older adolescents in a hospital emergency department. J Con-

72. Powers S. Empirically supported treatments in pediatric psychology: procedure- sult Clin Psychol. 1999;67:989-994.

related pain. J Pediatr Psychol. 1999;24:131-145. 56. Spirito A, Monti PM, Barnett NP, et al. A randomized clinical trial of a brief mo-

73. Felt BT, Mollen E, Diaz S, et al. Behavioral interventions reduce infant distress at tivational intervention for alcohol-positive adolescents treated in an emergency

immunization. Arch Pediatr Adolesc Med. 2000;154:719-724. department. J Pediatr. 2004;145:396-402.

74. Bowen AM, Dammeyer MM. Reducing children’s immunization distress in a pri- 57. Berg-Smith SM, Stevens VJ, Brown KM, et al. A brief motivational intervention

mary care setting. J Pediatr Nurs. 1999;14:296-303. to improve dietary adherence in adolescents. Health Educ Res. 1999;14:

75. Tsao JC, Fanurik D, Zeltzer LK. Long-term effects of a brief distraction interven- 399-410.

tion on children’s laboratory pain reactivity. Behav Modif. 2003;27:217-232. 58. Centers for Disease Control and Prevention. Surveillance summaries, May 24,

76. Centers for Disease Control and Prevention. National, state, and urban area vac- 2004. MMWR. 2004;53(SS-2).

cination coverage among children aged 19-35 months—United States, 2003. 59. Rollnick S, Butler CC, Stott N. Helping smokers make decisions: the enhance-

MMWR Morb Mortal Wkly Rep. 2004;53:658-661. ment of brief intervention for general medical practice. Patient Educ Couns. 1997;

77. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding inter- 31:191-203.

ventions to improve vaccination coverage in children, adolescents, and adults. 60. Poikolainen K. Effectiveness of brief interventions to reduce alcohol intake in

Am J Prev Med. 2000;18:97-140. primary health care populations: a meta-analysis. Prev Med. 1999;28:503-

78. Bernard RS, Cohen LL. Increasing adherence to cystic fibrosis treatment: a sys- 509.

tematic review of behavioral techniques. Pediatr Pulmonol. 2004;37:8-16. 61. Miller WR, Wilbourne PL. Mesa Grande: a methodological analysis of clinical trials

79. Jelalian E, Stark LJ, Reynolds L, Seifer R. Nutrition intervention for weight gain of treatments for alcohol use disorders. Addiction. 2002;97:265-277.

in cystic fibrosis: a meta analysis. J Pediatr. 1998;132:486-492. 62. Masterman PW, Kelly AB. Reaching adolescents who drink harmfully: fitting

80. Rapoff MA, Belmont J, Lindsley C, Olson N, Morris J, Padur J. Prevention of non- intervention to developmental reality. J Subst Abuse Treat. 2003;24:347-

adherence to nonsteroidal anti-inflammatory medications for newly diagnosed 355.

patients with juvenile rheumatoid arthritis. Health Psychol. 2002;21:620-623. 63. Miller WR, Westerberg VS, Waldron HB. Evaluating alcohol problems in adults

81. Knight KM, Bundy C, Morris R, et al. The effects of group motivational interview- and adolescents. In: Hester RK, Miller WR, eds. Handbook of Alcoholism Treat-

ing and externalizing conversations for adolescents with type-1 diabetes. Psy- ment Approaches: Effective Alternatives. 2nd ed. Needham Heights, Mass: Allyn

chol Health Med. 2003;8:149-158. & Bacon; 1995:61-88.

82. Cairns RB, Cairns BD, Rodkin P, Xie H. New directions in developmental re- 64. Cowley CB, Farley T, Beamis K. “Well, maybe I’ll try the pill for just a few

search: models and methods. In: Jessor R, ed. New Perspectives on Adolescent months . . . ”: brief motivational and narrative-based interventions to encour-

Risk Behavior. New York, NY: Cambridge University Press; 1998:245-265.

Chloroform, effective in flatulent colic, also useful in hepatic or saturnine colic, often used in combination with opium. Morphine, hy- podermically, repeated in 15 minutes, gives more relief than any other remedy in all forms of colic.

—On the treatment of colic, from Materia Medica Pharmacy and Therapeutics, 1906

(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 159, DEC 2005 WWW.ARCHPEDIATRICS.COM

www.archpediatrics.com American Medical Association. at University All of rights Utah, reserved.

on January 26, 2012