Promoting Healthy Behaviors in Pediatrics

Abstract

After completing this article, readers should be able to:Please read the following and watch the video clip (Fig 1).Most pediatric clinicians realize that well-intentioned clinical plans can sometimes fall flat or backfire. Everyday practice is rife with times when one might wonder about which prescriptions go unfilled, whether home safety advice is being “tuned out,” or whether families will return for recommended follow-up visits. In pediatrics, in which “the family is the patient,” ensuring positive changes in health behaviors is daunting, especially in the face of perceived barriers such as lack of time and reimbursement for counseling.The true obstacles to high-quality care often are interpersonal and can include how practitioners deal (or fail to deal) with their feelings of discouragement or discomfort when faced with particularly “resistant” patients. Integrating motivational interviewing (MI) into one’s practice can be a very satisfying way to overcome some of these barriers. MI allows the clinician to stay more connected in a therapeutic relationship with patients by helping them identify how, when, and what behaviors they can change to improve their own health.MI is a supportive counseling style that guides patients toward positive health-related behaviors by helping them resolve ambivalence toward changing. (1) MI seeks to enhance the self-efficacy of patients to facilitate these changes, helping patients move through the continuum of change proposed in the Transtheoretical Model of James Prochaska and Carlo DiClemente, progressing from not yet interested in change (precontemplation), to the contemplation of change, to making preparations, to taking action, to the maintenance of change, to dealing with relapse into old behaviors. (2) MI is not a form of psychotherapy or even a set of techniques; it is a style of communication that is patient-centered.In MI, the clinician is a guide or coach who brings expert knowledge of healthy behaviors into a healing relationship, while patients bring their own expertise about their lives, perspectives, goals, values, and beliefs. Clinical expertise is conveyed to the patient, with permission, in an authoritative manner that is tailored to patients' individual readiness and willingness to understand how their health interacts with their attitudes, beliefs, and behaviors. When expressed with empathy, this communication conveys to patients the message that they are responsible for and capable of solving their own problems by overcoming barriers to change.Approaches that are authoritarian (“You should…” or “You must…”) or overly permissive without direction (“Whatever you feel is best…”) can undermine the efficacy of communication for the clinician or patient. Generally, directing the patient in a more authoritative manner is most appropriate in times of crisis, such as when hospitalization is needed or a patient is suicidal. Permissively following along with a patient's thoughts and feelings may be needed at times when patients need to “vent” to someone who is nonjudgmental, such as during acute loss and grief. MI is the most effective approach for the gray zones that exist between these situations, in which one of many possible options would be appropriate, scenarios that are much more typical in our everyday clinical encounters when we want to guide lifestyle behavioral changes effectively.The foundation of MI is the “spirit” in which we approach a clinical encounter. Cultivating our interpersonal styles to be more empathetic, supportive, flexible, and affirming provides the bedrock on which patients feel empowered to change. Patients often feel somewhat ambivalent about changing their behaviors as they weigh their options for leading healthier lives: wanting to do something different to change, while also wanting to stay the same, or not entirely confident in their ability to change. The clinician’s task is to support and guide patients as they work to resolve their own ambivalence.Traditional care often focuses on the clinician’s impression about what the patient “should” do or needs, whereas the spirit of MI encourages collaboration. It is the patient, not the physician, who decides ultimately what health behaviors and outcomes are acceptable, given individual and cultural preferences, tolerance for risk, and knowledge base. MI sessions turn to patients to identify which health outcomes they hope for, which health goals they are aiming for, the advantages and disadvantages of obtaining these goals, the concrete actions they can take to work toward these goals, and what barriers they can imagine might prevent change.In a typical pediatric encounter, the clinician might ask parents of a preschool-age child who has asthma to describe their understanding of how asthma causes problems for their child; how they picture poorly controlled versus well-controlled asthma would look for their child; or what they wish would be different about their child’s asthma. The purpose of these open-ended questions is to continue a therapeutic conversation that engages the family’s strengths and resources, helping them create change from within.Continuing the example of asthma, the family might think that asthma medications are confusing and hard to administer to their preschool-age child, and at the same time they might have a very good understanding of asthma triggers. In this case, the clinician could collaborate with the family to identify how these triggers affect the child, and how each prescribed medication functions regarding those triggers. The family, in turn, might come up with a new plan to administer controller medications more often during certain times of the year, when seasonal allergen triggers would be more prevalent. This type of collaboration is likely to improve adherence and longitudinal follow-up.MI is most useful when patients are unsure or ambivalent about change. A hallmark of readiness to change is “change talk.” These communications include statements that demonstrate a patient’s readiness or intentions to change and may reflect patients’ desires, abilities, reasons, or needs to change, as well as their commitment to change. For example, a third-grade child who is failing at school owing to attention-deficit/hyperactivity disorder might say, “I really want to get my homework done, but I just can’t,” or the parent who refuses a vaccine for her newborn might state that she knows her child should get vaccinated. A clinician who hears change talk can use MI to help the patient move toward commitment to change and to take steps to do so. Change talk is elicited through open-ended questions that evoke patients’ values, aspirations, and goals and through reflective listening to demonstrate the clinician’s understanding of the patient’s perspective.Although change talk often can be positive, and MI can proceed smoothly into helping patients formulate goals and action plans, patients often verbalize ambivalence or apparent resistance to change. This type of expression often occurs within the same sentence as a change statement, such as, “I know I should remember to check my blood sugars more often, but it’s really hard to do it at school when everyone’s looking at me.” At these times, the clinician must resist the “righting reflex” that seeks to “fix” the patient’s or parent’s problems; instead, MI can be used to explore the patient’s or parent’s views of the advantages and disadvantages of working to change. MI is effective for “rolling with” resistance, by using strategies that include focusing on areas of common ground; refocusing the conversation toward patient and parent autonomy; and by using complex reflections (see the section, Incorporating Motivational Interviewing into Pediatric Practice).As an example, parents in an outpatient weight-management clinic might discuss a of they have to change for their child, and these changes have not a clinician in such a to with new more or on parents likely would even more changes in which the clinician is the one in of change, patients and parents can even more in not they are behavioral or change the of MI can be to help patients and parents with to resolve In the of the clinician could use MI to help families their own individual for changing their goals, a plan that their own for to and barriers to changing these and to deal with these they to MI into an can when the clinician provides patients and parents with and care home and For example, during a typical pediatric for a child from a clinician may that the child needs to with such how it the might ask an open-ended to understand what the or child are the for the child home or might ask the family or child to discuss how they plan to the child at an approach could to the of goals to toward has include of to or of child and or MI also has in that the patient’s of or acute hospitalization or as asthma in an acute also may the use of a child’s must be into most on MI on who have at spirit of MI even when we with or use of and with that MI can be used to help at through appropriate of MI, and by as of change on of the child (see the section, in Motivational in pediatric care has in a This of counseling may not be particularly and is support for counseling in this For example, it how well this style for child and or of pediatric demonstrate that MI can change health behaviors. of the to have on and more that MI is for counseling about in type and of follow-up for health common pediatric such as medication and the use of and also to be by using MI, these have and The of MI with may on how well the clinician the spirit and of MI into the encounter. of MI in the pediatric have of but clinical that MI is more effective in these using MI that These include permission, using open-ended affirming the patient, reflective and patients’ about the state of the often the patients’ of change for example, the parents of a with this a and it something that you might get when you or you about how is The can tailored to or patients’ readiness to change, by a reflective or on the of MI to more that or patients’ This of the way that the of MI will be within that a child or parent for to talk about change to and conveys for or her appropriate to being of to or can be well in this When an to use MI during a of in a child who the clinician can ask the child, it be we more about or to more about you to talk to about it with in the or with of the a patient or parent this to or she is likely to be in the of change, and the clinician could ask it would be to discuss could include that the patient or parent is not yet to discuss this and to that it is up to the patient or parent to when or she might help with this and to a time in the to return and check in to discuss it how well or she is questions to patients’ and for whereas questions are more useful for and to or questions are those that in a of or a as or of a often that open-ended questions will take for patients or parents to with MI has that time is by open-ended open-ended questions the and for the more and questions also may be perceived as to who may feel or when many questions in a open-ended questions with and that are more useful with to their understanding of the motivational and readiness to change include for and “I approach is to ask the child to or the of a time when of a really good or a The clinician can such by and A of often is very through these which also can evoke change type of used in MI, often to as a can help different of change. 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