TBD Meeting (3552-12)

BELLEVUE, WASH. – Motivational interviewing techniques aren’t just a method for getting adolescents to pursue positive changes, but are a balm for the frayed nerves of physicians and parents, according to Dr. Cora C. Breuner.

A physician talking to an adolescent about, say, the dangers of smoking may be tense and frustrated because it seems impossible to connect with the teenager, who doesn’t like the direction of the discussion. If a parent is present, he or she is tense and frustrated too because the doctor doesn’t seem to be reaching the teen, Dr. Breuner added.

The problem usually is that the adolescent is in the early steps of motivation to change, but the physician and parents want action.

"You can’t get someone to go there without going through the previous steps. It’s impossible," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle. "There’s a huge disconnect between what we want to do and what they want to do," she said at the annual meeting of the North Pacific Pediatric Society.

The foundation of motivational interviewing is that change is not imposed, but elicited from the client. It’s the teenager’s task, not the counselor’s, to articulate and resolve his or her ambivalence, with the counselor’s directive assistance. The therapeutic relationship is more like a partnership or companionship than an expert/nonexpert dichotomy.

A good way to start is by talking about ambivalence, a word that adolescents love once you explain what it means. Dr. Breuner describes it as, "You’re kind of not sure. You feel two feelings, and it’s kind of crazy. You feel one thing and you think the other." That usually clicks with teenagers "because that’s their life, really," she said.

When discussing a problem behavior with an adolescent patient, she said she always writes the five stages of motivation to change on the white board in her office and describes them:

1. Precontemplation. This stage is also known as denial. The teenager may be thinking, "I don’t have a problem. You’re crazy. I’ve been smoking a long time. It’s no big deal. Everybody smokes. My mom and dad smoke."

2. Contemplation. "Maybe I have a problem, but I don’t want to do anything about it."

3. Preparation. "I have a problem and I want to do something about it, but not now. Maybe in a month."

4. Action. "I want to do something about it now. I need to stop doing this."

5. Maintenance or prevention of relapse. "How do I keep not smoking when all of my friends do?" (Or, depending on the problem, "How do I not drink when everybody around me drinks all the time? How do I stop spending so much time on the Internet, or so much time exercising, or talking, or working so hard?")

Dr. Breuner said she writes the stages on the board and asks the patient, "Where do you think you are?" Adolescents’ eyes go from glazed to engaged, and they always circle either "precontemplation" or "contemplation." Physicians and parents recognize that they are at "action."

The tension in the room instantly eases, she said. The physician and parent calm down because they’re no longer obsessing that the teenager will never listen to them. They’re now trying to understand the teen’s frame of reference and reinforce the teen’s motivation.

Dr. Breuner said she then breaks down the stage that the teen circled into a scale of 1-10. If a patient is in denial about smoking being a problem, that’s a 10 and the next stage, "contemplation," would be a 1. Dr. Breuner asks the patient where on that scale he or she fits in. If the adolescent picks, say, 8, Dr. Breuner asks what it might take to get the teen to be a 7.

The patient may say, "Tell me a little bit more about why it’s bad to be a smoker" (or bad to eat too much, or to exercise too little, or to keep his or her phone by the bed). Dr. Breuner provides some quick information in a nonjudgmental tone and ends with, "Come back and we’ll talk a little more about that."

Early follow-up is extremely important for motivational interviewing. Don’t wait 6 months for a follow-up visit, she said. Monitor the teen’s degree of readiness to change, but don’t jump ahead. Express acceptance of where the patient is in the stages, and affirm his or her freedom of choice and self-direction.

"Just try that. It’s so cool, because it works every time" to ease tensions in guiding the adolescent toward change, she said.

What doesn’t work is to argue that the patient has a problem and needs to change, or to offer direct advice or prescribe solutions to the problem without encouraging the patient to make his or her own choices. It doesn’t work when the counselor does most of the talking, functions as a unidirectional information delivery system, imposes a diagnostic label, or behaves in a punitive or coercive manner.

"That authoritative, ‘I’m perfect and you’re not’ approach – it doesn’t work," she said.

The tenets of motivational interviewing are a hot topic in medicine today, although they have been around since the 1970s, Dr. Breuner said. She drew on a 1995 article to describe motivational interviewing in her talk (Behav. Cogn. Psychother. 1995;23:325-34).

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Motivational interviewing techniques aren’t just a method for getting adolescents to pursue positive changes, but are a balm for the frayed nerves of physicians and parents, according to Dr. Cora C. Breuner.

A physician talking to an adolescent about, say, the dangers of smoking may be tense and frustrated because it seems impossible to connect with the teenager, who doesn’t like the direction of the discussion. If a parent is present, he or she is tense and frustrated too because the doctor doesn’t seem to be reaching the teen, Dr. Breuner added.

The problem usually is that the adolescent is in the early steps of motivation to change, but the physician and parents want action.

"You can’t get someone to go there without going through the previous steps. It’s impossible," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle. "There’s a huge disconnect between what we want to do and what they want to do," she said at the annual meeting of the North Pacific Pediatric Society.

The foundation of motivational interviewing is that change is not imposed, but elicited from the client. It’s the teenager’s task, not the counselor’s, to articulate and resolve his or her ambivalence, with the counselor’s directive assistance. The therapeutic relationship is more like a partnership or companionship than an expert/nonexpert dichotomy.

A good way to start is by talking about ambivalence, a word that adolescents love once you explain what it means. Dr. Breuner describes it as, "You’re kind of not sure. You feel two feelings, and it’s kind of crazy. You feel one thing and you think the other." That usually clicks with teenagers "because that’s their life, really," she said.

When discussing a problem behavior with an adolescent patient, she said she always writes the five stages of motivation to change on the white board in her office and describes them:

1. Precontemplation. This stage is also known as denial. The teenager may be thinking, "I don’t have a problem. You’re crazy. I’ve been smoking a long time. It’s no big deal. Everybody smokes. My mom and dad smoke."

2. Contemplation. "Maybe I have a problem, but I don’t want to do anything about it."

3. Preparation. "I have a problem and I want to do something about it, but not now. Maybe in a month."

4. Action. "I want to do something about it now. I need to stop doing this."

5. Maintenance or prevention of relapse. "How do I keep not smoking when all of my friends do?" (Or, depending on the problem, "How do I not drink when everybody around me drinks all the time? How do I stop spending so much time on the Internet, or so much time exercising, or talking, or working so hard?")

Dr. Breuner said she writes the stages on the board and asks the patient, "Where do you think you are?" Adolescents’ eyes go from glazed to engaged, and they always circle either "precontemplation" or "contemplation." Physicians and parents recognize that they are at "action."

The tension in the room instantly eases, she said. The physician and parent calm down because they’re no longer obsessing that the teenager will never listen to them. They’re now trying to understand the teen’s frame of reference and reinforce the teen’s motivation.

Dr. Breuner said she then breaks down the stage that the teen circled into a scale of 1-10. If a patient is in denial about smoking being a problem, that’s a 10 and the next stage, "contemplation," would be a 1. Dr. Breuner asks the patient where on that scale he or she fits in. If the adolescent picks, say, 8, Dr. Breuner asks what it might take to get the teen to be a 7.

The patient may say, "Tell me a little bit more about why it’s bad to be a smoker" (or bad to eat too much, or to exercise too little, or to keep his or her phone by the bed). Dr. Breuner provides some quick information in a nonjudgmental tone and ends with, "Come back and we’ll talk a little more about that."

Early follow-up is extremely important for motivational interviewing. Don’t wait 6 months for a follow-up visit, she said. Monitor the teen’s degree of readiness to change, but don’t jump ahead. Express acceptance of where the patient is in the stages, and affirm his or her freedom of choice and self-direction.

"Just try that. It’s so cool, because it works every time" to ease tensions in guiding the adolescent toward change, she said.

What doesn’t work is to argue that the patient has a problem and needs to change, or to offer direct advice or prescribe solutions to the problem without encouraging the patient to make his or her own choices. It doesn’t work when the counselor does most of the talking, functions as a unidirectional information delivery system, imposes a diagnostic label, or behaves in a punitive or coercive manner.

"That authoritative, ‘I’m perfect and you’re not’ approach – it doesn’t work," she said.

The tenets of motivational interviewing are a hot topic in medicine today, although they have been around since the 1970s, Dr. Breuner said. She drew on a 1995 article to describe motivational interviewing in her talk (Behav. Cogn. Psychother. 1995;23:325-34).

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH. – Motivational interviewing techniques aren’t just a method for getting adolescents to pursue positive changes, but are a balm for the frayed nerves of physicians and parents, according to Dr. Cora C. Breuner.

A physician talking to an adolescent about, say, the dangers of smoking may be tense and frustrated because it seems impossible to connect with the teenager, who doesn’t like the direction of the discussion. If a parent is present, he or she is tense and frustrated too because the doctor doesn’t seem to be reaching the teen, Dr. Breuner added.

The problem usually is that the adolescent is in the early steps of motivation to change, but the physician and parents want action.

"You can’t get someone to go there without going through the previous steps. It’s impossible," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle. "There’s a huge disconnect between what we want to do and what they want to do," she said at the annual meeting of the North Pacific Pediatric Society.

The foundation of motivational interviewing is that change is not imposed, but elicited from the client. It’s the teenager’s task, not the counselor’s, to articulate and resolve his or her ambivalence, with the counselor’s directive assistance. The therapeutic relationship is more like a partnership or companionship than an expert/nonexpert dichotomy.

A good way to start is by talking about ambivalence, a word that adolescents love once you explain what it means. Dr. Breuner describes it as, "You’re kind of not sure. You feel two feelings, and it’s kind of crazy. You feel one thing and you think the other." That usually clicks with teenagers "because that’s their life, really," she said.

When discussing a problem behavior with an adolescent patient, she said she always writes the five stages of motivation to change on the white board in her office and describes them:

1. Precontemplation. This stage is also known as denial. The teenager may be thinking, "I don’t have a problem. You’re crazy. I’ve been smoking a long time. It’s no big deal. Everybody smokes. My mom and dad smoke."

2. Contemplation. "Maybe I have a problem, but I don’t want to do anything about it."

3. Preparation. "I have a problem and I want to do something about it, but not now. Maybe in a month."

4. Action. "I want to do something about it now. I need to stop doing this."

5. Maintenance or prevention of relapse. "How do I keep not smoking when all of my friends do?" (Or, depending on the problem, "How do I not drink when everybody around me drinks all the time? How do I stop spending so much time on the Internet, or so much time exercising, or talking, or working so hard?")

Dr. Breuner said she writes the stages on the board and asks the patient, "Where do you think you are?" Adolescents’ eyes go from glazed to engaged, and they always circle either "precontemplation" or "contemplation." Physicians and parents recognize that they are at "action."

The tension in the room instantly eases, she said. The physician and parent calm down because they’re no longer obsessing that the teenager will never listen to them. They’re now trying to understand the teen’s frame of reference and reinforce the teen’s motivation.

Dr. Breuner said she then breaks down the stage that the teen circled into a scale of 1-10. If a patient is in denial about smoking being a problem, that’s a 10 and the next stage, "contemplation," would be a 1. Dr. Breuner asks the patient where on that scale he or she fits in. If the adolescent picks, say, 8, Dr. Breuner asks what it might take to get the teen to be a 7.

The patient may say, "Tell me a little bit more about why it’s bad to be a smoker" (or bad to eat too much, or to exercise too little, or to keep his or her phone by the bed). Dr. Breuner provides some quick information in a nonjudgmental tone and ends with, "Come back and we’ll talk a little more about that."

Early follow-up is extremely important for motivational interviewing. Don’t wait 6 months for a follow-up visit, she said. Monitor the teen’s degree of readiness to change, but don’t jump ahead. Express acceptance of where the patient is in the stages, and affirm his or her freedom of choice and self-direction.

"Just try that. It’s so cool, because it works every time" to ease tensions in guiding the adolescent toward change, she said.

What doesn’t work is to argue that the patient has a problem and needs to change, or to offer direct advice or prescribe solutions to the problem without encouraging the patient to make his or her own choices. It doesn’t work when the counselor does most of the talking, functions as a unidirectional information delivery system, imposes a diagnostic label, or behaves in a punitive or coercive manner.

"That authoritative, ‘I’m perfect and you’re not’ approach – it doesn’t work," she said.

The tenets of motivational interviewing are a hot topic in medicine today, although they have been around since the 1970s, Dr. Breuner said. She drew on a 1995 article to describe motivational interviewing in her talk (Behav. Cogn. Psychother. 1995;23:325-34).

Dr. Breuner reported having no relevant financial disclosures.

BELLEVUE, WASH.  – When tired parents complain that their child wakes up frequently at night – and wakes them up – you can offer them a hardball approach or softball approach to dealing with the problem.

The hardball approach is far more effective and more quickly resolves night wakings, but some parents find the idea of it intolerable. For them, there’s the softball approach, Dr. Charles H. Zeanah Jr. said at the annual meeting of the North Pacific Pediatric Society.

Photo credit: a-fitz/iStockphoto.com

The goal of both strategies is to teach the child to fall asleep on his or her own. Waking during the night is normal at age 3-6 months, and 30% of infants are "signalers" who cry and expect someone to respond. By 8 months of age, 60%-70% of infants self-soothe after waking during the night. Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, he said.

"Somewhere between 6 and 9 months of age, I may start to think of it as a disorder or impairment, not just for the child but [also] for the parent," said Dr. Zeanah, professor of clinical pediatrics and psychiatry and director of child and adolescent psychiatry at Tulane University, New Orleans.

First, take a good history of family structure and routines around bedtime, limit-setting behaviors, distress, what tactics the parents have tried, and whether the parents agree on what needs to be done.

"It’s amazing how many people don’t have a bedtime routine," he said. "The key question is, ‘Is the child put down while awake?’ " Learning how to fall asleep at bedtime on his or her own, without "signaling," allows the child to fall back asleep after waking during the night.

Before talking about the hardball or softball approach to teaching a child to fall asleep on his or her own, Dr. Zeanah plays a little "hard to get" with the parents, to assess their commitment to an intervention. He tells them that there’s no evidence that night wakings cause a mental illness or severely damage a child. "I know it’s annoying, but I’m not sure if you want to do something about this" night-waking problem, he says.

Tired parents usually do want to intervene.

The first steps are to create a set bedtime and establish a consistent bedtime routine (such as reading a story) that ends in the child’s room. Finish the routine before the child falls asleep.

Then he explains the hardball approach: If the child cries when you leave, wait 5 minutes, go back and soothe the child without using words (for instance, by patting or rubbing the child’s back), then leave again. If the child cries again, repeat until the child falls asleep. Over the ensuing days, gradually increase the 5-minute interval to longer stretches between soothings.

"The rigidity of this is the key," Dr. Zeanah said, and it works. In 30 years of practice, he has never seen a child last more than a week before learning to fall asleep on his or her own.

If a parent can’t handle letting the child cry because they fear the child is scared to be alone, he explains the softball approach: When the child cries, go in and sit in a chair next to the child’s bed without interacting with the child, which takes any fear out of the situation. Sit in the chair until the child falls asleep. The next night, move the chair a couple of feet toward the door. Move a little more toward the door each night until the chair is outside the door, but visible to the child when you sit in it. Then pull the chair back so just your knees are visible, and eventually so the parent can’t be seen.

"It’s not as effective" as the hardball approach, but helps in some cases, he said.

With either approach, he asks parents to call him early in the morning after the first night of the intervention to let him know how it went. Check in with parents frequently during the intervention to encourage them and make adjustments, he advised.

With the hardball approach, "by the third night, there’s usually no reason to call," he said.

Dr. Zeanah reported having no financial disclosures.

BELLEVUE, WASH.  – When tired parents complain that their child wakes up frequently at night – and wakes them up – you can offer them a hardball approach or softball approach to dealing with the problem.

The hardball approach is far more effective and more quickly resolves night wakings, but some parents find the idea of it intolerable. For them, there’s the softball approach, Dr. Charles H. Zeanah Jr. said at the annual meeting of the North Pacific Pediatric Society.

Photo credit: a-fitz/iStockphoto.com

The goal of both strategies is to teach the child to fall asleep on his or her own. Waking during the night is normal at age 3-6 months, and 30% of infants are "signalers" who cry and expect someone to respond. By 8 months of age, 60%-70% of infants self-soothe after waking during the night. Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, he said.

"Somewhere between 6 and 9 months of age, I may start to think of it as a disorder or impairment, not just for the child but [also] for the parent," said Dr. Zeanah, professor of clinical pediatrics and psychiatry and director of child and adolescent psychiatry at Tulane University, New Orleans.

First, take a good history of family structure and routines around bedtime, limit-setting behaviors, distress, what tactics the parents have tried, and whether the parents agree on what needs to be done.

"It’s amazing how many people don’t have a bedtime routine," he said. "The key question is, ‘Is the child put down while awake?’ " Learning how to fall asleep at bedtime on his or her own, without "signaling," allows the child to fall back asleep after waking during the night.

Before talking about the hardball or softball approach to teaching a child to fall asleep on his or her own, Dr. Zeanah plays a little "hard to get" with the parents, to assess their commitment to an intervention. He tells them that there’s no evidence that night wakings cause a mental illness or severely damage a child. "I know it’s annoying, but I’m not sure if you want to do something about this" night-waking problem, he says.

Tired parents usually do want to intervene.

The first steps are to create a set bedtime and establish a consistent bedtime routine (such as reading a story) that ends in the child’s room. Finish the routine before the child falls asleep.

Then he explains the hardball approach: If the child cries when you leave, wait 5 minutes, go back and soothe the child without using words (for instance, by patting or rubbing the child’s back), then leave again. If the child cries again, repeat until the child falls asleep. Over the ensuing days, gradually increase the 5-minute interval to longer stretches between soothings.

"The rigidity of this is the key," Dr. Zeanah said, and it works. In 30 years of practice, he has never seen a child last more than a week before learning to fall asleep on his or her own.

If a parent can’t handle letting the child cry because they fear the child is scared to be alone, he explains the softball approach: When the child cries, go in and sit in a chair next to the child’s bed without interacting with the child, which takes any fear out of the situation. Sit in the chair until the child falls asleep. The next night, move the chair a couple of feet toward the door. Move a little more toward the door each night until the chair is outside the door, but visible to the child when you sit in it. Then pull the chair back so just your knees are visible, and eventually so the parent can’t be seen.

"It’s not as effective" as the hardball approach, but helps in some cases, he said.

With either approach, he asks parents to call him early in the morning after the first night of the intervention to let him know how it went. Check in with parents frequently during the intervention to encourage them and make adjustments, he advised.

With the hardball approach, "by the third night, there’s usually no reason to call," he said.

Dr. Zeanah reported having no financial disclosures.

BELLEVUE, WASH.  – When tired parents complain that their child wakes up frequently at night – and wakes them up – you can offer them a hardball approach or softball approach to dealing with the problem.

The hardball approach is far more effective and more quickly resolves night wakings, but some parents find the idea of it intolerable. For them, there’s the softball approach, Dr. Charles H. Zeanah Jr. said at the annual meeting of the North Pacific Pediatric Society.

Photo credit: a-fitz/iStockphoto.com

The goal of both strategies is to teach the child to fall asleep on his or her own. Waking during the night is normal at age 3-6 months, and 30% of infants are "signalers" who cry and expect someone to respond. By 8 months of age, 60%-70% of infants self-soothe after waking during the night. Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, he said.

"Somewhere between 6 and 9 months of age, I may start to think of it as a disorder or impairment, not just for the child but [also] for the parent," said Dr. Zeanah, professor of clinical pediatrics and psychiatry and director of child and adolescent psychiatry at Tulane University, New Orleans.

First, take a good history of family structure and routines around bedtime, limit-setting behaviors, distress, what tactics the parents have tried, and whether the parents agree on what needs to be done.

"It’s amazing how many people don’t have a bedtime routine," he said. "The key question is, ‘Is the child put down while awake?’ " Learning how to fall asleep at bedtime on his or her own, without "signaling," allows the child to fall back asleep after waking during the night.

Before talking about the hardball or softball approach to teaching a child to fall asleep on his or her own, Dr. Zeanah plays a little "hard to get" with the parents, to assess their commitment to an intervention. He tells them that there’s no evidence that night wakings cause a mental illness or severely damage a child. "I know it’s annoying, but I’m not sure if you want to do something about this" night-waking problem, he says.

Tired parents usually do want to intervene.

The first steps are to create a set bedtime and establish a consistent bedtime routine (such as reading a story) that ends in the child’s room. Finish the routine before the child falls asleep.

Then he explains the hardball approach: If the child cries when you leave, wait 5 minutes, go back and soothe the child without using words (for instance, by patting or rubbing the child’s back), then leave again. If the child cries again, repeat until the child falls asleep. Over the ensuing days, gradually increase the 5-minute interval to longer stretches between soothings.

"The rigidity of this is the key," Dr. Zeanah said, and it works. In 30 years of practice, he has never seen a child last more than a week before learning to fall asleep on his or her own.

If a parent can’t handle letting the child cry because they fear the child is scared to be alone, he explains the softball approach: When the child cries, go in and sit in a chair next to the child’s bed without interacting with the child, which takes any fear out of the situation. Sit in the chair until the child falls asleep. The next night, move the chair a couple of feet toward the door. Move a little more toward the door each night until the chair is outside the door, but visible to the child when you sit in it. Then pull the chair back so just your knees are visible, and eventually so the parent can’t be seen.

"It’s not as effective" as the hardball approach, but helps in some cases, he said.

With either approach, he asks parents to call him early in the morning after the first night of the intervention to let him know how it went. Check in with parents frequently during the intervention to encourage them and make adjustments, he advised.

With the hardball approach, "by the third night, there’s usually no reason to call," he said.

Dr. Zeanah reported having no financial disclosures.