Key points

Introduction

Several risk factors for child maltreatment may be reduced through successful parental behavior change. These risk factors include substance use, partner violence, depression, harsh punishment, and management of children’s medical health. Because the US Preventive Services Task Force concludes that there is insufficient evidence on the effectiveness of preventing child maltreatment directly among children who do not already have signs of maltreatment, prevention efforts may be best aimed at addressing these risk factors that may lead to maltreatment ( Box 1 ). Although health care providers may try to encourage behavior change in parents to reduce risk factors, many providers use ineffective techniques to promote behavior change.

Introduction

Several risk factors for child maltreatment may be reduced through successful parental behavior change. These risk factors include substance use, partner violence, depression, harsh punishment, and management of children’s medical health. Because the US Preventive Services Task Force concludes that there is insufficient evidence on the effectiveness of preventing child maltreatment directly among children who do not already have signs of maltreatment, prevention efforts may be best aimed at addressing these risk factors that may lead to maltreatment ( Box 1 ). Although health care providers may try to encourage behavior change in parents to reduce risk factors, many providers use ineffective techniques to promote behavior change.

Extent of the problem: health care provider–centered approach

Health care providers strive to offer the best care possible to their patients, and, in pediatrics, this may include helping parents of their patients to help themselves. This help includes encouraging changes in lifestyle or health behavior in parents, which affect how well parents care for their children, thus improving their children’s health. However, it can also be frustrating to health care providers when they discover that parents have not followed through with recommendations. That frustration may grow as the provider spends another appointment telling parents the same information and hoping that they follow through.

One factor affecting the parent’s adherence is not what the health care provider says, but how the provider communicates that information. Research has shown that a primary barrier to effective behavior change intervention has been a health care provider–centered, rather than a patient-centered, approach to communication about change. Provider-centered communication is often well intended and fostered by the desire to help patients or prevent suffering. That is, after assessing for behaviors that can lead to poor outcomes, the health care provider may then focus on what they perceive to be the barriers to health and often elicit little input from the parents of their pediatric patients. Providers then attempt to address the barrier by telling parents that their behavior is problematic and try to persuade parents to change to what the providers see as appropriate, potentially provoking parent defensiveness or resistance. When parents become defensive or resistant to change, providers may view them as unmotivated, unwilling, or unable to make behavior changes to improve the health of their child. However, this perception of parents may serve only to exacerbate any potential or existing problems, because it could contribute to providers feeling helpless and frustrated and could prevent providers from taking an active role in assisting parents to change.

More often, parents are not unmotivated, but instead, not yet convinced of the problem or the need for change. For instance, when a parent smokes in a car through an open window, she might believe she is protecting her child and not realize how much secondhand smoke she is exposing her child to, or how much that smoke likely contributed to her child’s recent asthma attack. When parents seem unwilling, they are more likely not committed to making a change at that time. For example, a parent may see as many benefits as drawbacks to continuing to feed his diabetic child the sugary foods his child prefers to avoid battles at dinnertime, and thus exploring the pros and cons of this behavior more thoroughly with the father may help. In addition, when parents seem unable, they may need help believing in their ability to change, such as a mother who has recently relapsed who feels discouraged in her efforts to quit drinking and may feel empowered from a discussion of what worked for her the last time she was successful. If providers set aside their possible assumptions about their patients’ parents, and instead try to understand the parents’ thoughts and feelings, the providers can both feel personally empowered to influence parents in a positive way and can help empower parents to make difficult changes in their behavior.

Sequelae of the problem: increasing barriers to change

Providers may create barriers to their own goals as well as to their patients’ families’ goals, by failing to use parent-centered communication. Research has shown that taking a more paternalistic approach instead of a collaborative one may both distance the parent from the provider and contribute to worse health outcomes for the pediatric patient. When parent and provider agendas or treatment goals do not align or when there is a mismatch between a provider’s strategies to address a health behavior and a parent’s willingness to change that behavior, the parent’s resistance to change is likely to increase.

Another way that providers may be increasing barriers to change for their patients and patients’ parents is by taking a more one-dimensional view of behavior change. When providers focus only on certain dimensions of change, such as concentrating solely on the parent’s health education (eg, on the link between secondhand smoke and the child’s asthma) and ignoring the parent’s feelings (eg, she is afraid she cannot cope with stress without smoking) or how ready the parent is to try to change, the intervention is likely going to be unsuccessful.

A more multidimensional view of change is captured in the transtheoretical model, a comprehensive framework that integrates key constructs of several theories of behavior change into one. Intentional behavior change (when people actively monitor and try to modify their behavior) can be thought of as a series of stages that individuals negotiate by engaging in different behaviors and undergoing a variety of cognitive or emotional experiences.

Thus, a parent may not be able to change all at once but instead moves through stages of thinking, planning, and acting to change a behavior. Parents are also at different levels of readiness to change; although they are thinking about changing, they may not be ready to actively make a change yet. Readiness is a dynamic and fluctuating state of motivation. Interacting with readiness is a person’s confidence to change, or one’s personal evaluation of their ability to exercise control or perform a behavior. A parent may not feel ready to change because they have tried in the past without success and have little confidence in their ability to modify a behavior.

Both readiness and confidence are states that belong to the parents; providers can neither force them to be ready to change nor can providers be confident for them. However, readiness and confidence are modifiable by parents and can be influenced by providers. To influence these states, providers can help change the way parents understand or view particular risk factors or behaviors, they can increase awareness of the impact of these behaviors on their children, and they can empower parents to act. In these ways, providers can promote treatment adherence and engagement in terms of both children’s and parents’ health.

To decrease resistance and address other problems of provider-centered approaches, providers can learn a person/parent-centered communication technique called motivational interviewing (MI), which has 30 years of research supporting its use in health care settings. MI is not a stand-alone therapy; rather, the provider uses the MI style of interaction to empower the parent to identify their own reasons for change, perceived barriers to change, and strengths to overcome those barriers, as well as to engage the parent in collaborative goal setting. By using MI, the provider can align with the parent in achieving goals that are in the best interest of the child’s health, as well as strengthen the parent-provider relationship.

In the example given earlier, it is likely not the case that the parent learns that her smoking exacerbates her child’s asthma and then quits the following day. Instead, although the educational piece has given her a reason to quit smoking, she may also need to consider ways to assist her in quitting (eg, telephone counseling, nicotine replacement therapy), what worked and did not work when she tried in the past, and what else she could do other than smoking to help her cope with stressful situations before she makes the quit attempt. Using MI techniques, the provider could help this parent to think about these other aspects of change and support her confidence to change, potentially moving her forward through the stages and increasing her likelihood of successfully quitting smoking.

Preparing for MI

When preparing to incorporate MI into practice, the first step is for providers to learn to approach patient interactions in a manner that encompasses the spirit of MI. This spirit is the provider’s mind-set, which informs the whole intervention and involves 3 key components: (1) collaboration, or developing a partnership that honors the patient’s expertise and perspective; (2) evocation, or exploring a patient’s preferences, goals and values in an effort to ignite their motivation for change; and (3) autonomy, which involves affirming a patient’s right and capacity for self-direction.

This MI mind-set can be different from the disease model of providing health care, in which providers focus on what they see as going wrong, and then they take actions to try to make things right. For example, the provider may screen for a certain illness, and then give the patient a certain medication to treat that illness. Although this model may be effective for some illnesses, it has been found to be ineffective for behavior change. This finding is partly because the power to take action lies with the parent alone; that is, although the health care provider may affect how the parent thinks about a behavior, only the parent performs the behavior. The spirit of MI focuses on the parent’s agency in taking action, rather than the provider’s. In pediatrics, when the provider approaches the situation with a true understanding that the parents will make their own decisions about themselves and their children, they are less likely to engage in a power struggle with parents or use techniques that contribute to parents not following through with recommendations. MI allows parents to be the more active participants, rather than providers.

When MI is used effectively, the provider no longer has to shoulder the commonly perceived burden of talking patients into doing something. Instead, the provider notices that people talk themselves into changing based on their own values and goals rather than the provider’s and ask for guidance when they do wish the provider to help them make decisions. The provider does not try to convince the parent to change a behavior, or make the parent see the situation from the provider’s point of view; instead, the provider tries to understand the parent’s thoughts, feelings, and behavior from the parent’s point of view. This strategy can help the provider express empathy for the patient’s circumstances, emotions, and understanding of behavior and barriers, rather than simply trying to impose their perspective of what the parent needs to do. This strategy also allows parents to bring up their own concerns about their own behaviors and work toward addressing them. For example, a parent may voice concern over their own occasional drunk driving, and may wish to work on ways to ensure that they do not drink and drive with their children in the car, even although they are not ready to stop drinking.

The spirit of MI also focuses on strengths, whereas the disease model focuses on weaknesses. When providers concentrate on telling parents about their weaknesses, or how parents’ behaviors are wrong, parents try to defend their actions and may become more resistant to change. Instead, with MI, providers use the interview to help parents identify their own goals, strengths, and skills and then, how to use those strengths to achieve their goals. The parent then owns the plan.

In addition, if providers are using MI, they allow for parents to come up with their own behaviors to change, which may be different than the parental behaviors that the providers would target for change. For example, a mother in a major depressive episode may feel guilty that her depression is not allowing her to be the parent she wants to be. The provider approaches this interaction using the MI spirit and talks with the mother about her goal (ie, to be a better parent), helps her verbalize her motivation to reach that goal, explores the mother’s motivations and barriers to change, and helps her identify possible solutions. Although the provider’s solution (adhering to an antidepressant medication regimen) does not match the mother’s solution (engaging in psychotherapy), the MI-consistent strategy is for the provider to empower the mother to try the solution in which she is motivated to engage (ie, psychotherapy) and, thus, is more likely to move the mother toward her goal of being a better parent.

By using an MI approach, providers can assess parents for risk factors for child maltreatment and build good rapport and set the stage for addressing any problems in a collaborative manner. To remain true to the MI spirit, please see Table 1 for tips that help establish this rapport and meet parents where they are in their readiness to change their behaviors.

Effectiveness of MI

The process to become proficient in MI typically involves rigorous training. However, it is often the case that interventions include components or adaptations of MI, and even trials of less faithful deliveries of the techniques have shown equivalency to other active treatments across health behaviors and particularly positive effects on treatment engagement and retention. In a meta-analysis of 72 MI treatment outcome studies, MI was found to have small to medium effect for the improvement of health outcomes regarding alcohol, smoking, human immunodeficiency virus/AIDS, drug abuse, treatment compliance, gambling, partner violence, water purification/safety, eating disorders, and diet and exercise. In particular, MI may be used for multiple risk factors for child maltreatment, such as substance use, partner violence, depression, unbalanced discipline, and parental management of children’s medical health conditions. Evidence for the effectiveness of MI when used with these risk factors is reviewed in the next sections.