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Testing of a Web-Based Program to Facilitate Parental Smoking Cessation Readiness in Primary Care


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To test the efficacy of a self-administered web-based computer intervention designed to facilitate readiness to alter tobacco use or secondhand smoke exposure among parents of children visiting a pediatric primary care clinic. The computer program included an assessment of the participant's smoking behavior and personalized feedback. Self-identified smoking parents of children presenting to a general pediatric outpatient clinic completed measures of motivation and readiness to cease smoking. Participants were then randomly assigned to complete the computer program or receive treatment as usual. One month after completing the intervention, participants were contacted either in person or by phone to complete measures of motivational readiness to engage in smoking cessation. Compared to treatment-as-usual parents, intervention parents reported increased readiness to change their smoking at follow-up. This effect appeared to strengthen, favoring the intervention condition, when analyses included only those participants who identified at baseline that they were contemplating quitting smoking in the next 6 months. Results of this small study supported the integration of a brief computerized tobacco intervention in the pediatric primary care setting and provided some evidence for efficacy. Brief, self-administered, and computer-based interventions such as this can be disseminated and deployed at relatively little cost or burden to existing practices, which makes small effects more meaningful and justifiable. Future investigations should investigate this intervention with larger samples and with expanded measures of parent smoking behavior.
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Training in Motivational Interviewing as a Best Training Practice in
Pediatric Psychology: Relationship to Core Competencies
Stephen R. Gillaspy
and Catrina C. Litzenburg
University of Oklahoma
Thad R. Leffingwell
Oklahoma State University
Mary Beth Miller
Oklahoma State University and Brown University
This article describes an innovative Motivational Interviewing (MI) training that is
included in the current training program for psychology interns and fellows (trainees)
at 1 institution and outlines how this training experience aligns with multiple core
training competencies for pediatric psychologists. MI is an evidence-based approach to
behavior change counseling that is efficacious in motivating change in many health-risk
behaviors. The training module adds systematic practice with simulated patients and
objective feedback regarding adherence and fidelity to MI principles and strategies to
traditional didactics. This state-of-the-art training is particularly beneficial to our
pediatric psychology trainees, as it impacts treatment interventions with their patients
and families and maps onto several of the new pediatric psychology competencies.
Specific examples of training components are provided and demonstrate how the MI
training module aligns with the pediatric psychology competencies in several clusters:
crosscutting knowledge competencies in pediatric psychology, interpersonal, profes-
sionalism, and application. MI training is well-suited to be included in competency-
based training in pediatric psychology.
competencies, motivational interviewing, pediatric psychology, training
The Society of Pediatric Psychology recently
proposed and defined six competencies that are
integral to training in pediatric psychology: sci-
ence, professionalism, interpersonal skills, ap-
plication of science, education, and systemic
approach, in addition to cross-cutting knowl-
edge (Palermo et al., 2014). Training in Moti-
vational Interviewing (MI) is particularly suited
to meeting these competencies and has been
successfully integrated into our pediatric train-
ing program for psychology interns and fellows
(trainees). Over the past seven years, this MI
training module has progressed from one to two
hours of didactic lectures; to a daylong work-
shop with live demonstrations of MI; to the
current module, which adds systematic practice
with simulated patients and objective feedback
regarding adherence and fidelity to MI princi-
ples and strategies to traditional didactics. The
current article describes this innovative MI
training and outlines how this experience aligns
with multiple core competencies for pediatric
Why Motivational Interviewing?
Obesity, tobacco use, and alcohol use have
been identified as significant problems contrib-
uting to poor health outcomes among pediatric
populations. Pediatric psychologists need to be
prepared to address these health behaviors in
primary care and specialty medical settings. The
Stephen R. Gillaspy and Catrina C. Litzenburg, Depart-
ment of Pediatrics, University of Oklahoma Health Sciences
Center, College of Medicine; Thad R. Leffingwell, Depart-
ment of Psychology, Oklahoma State University; Mary
Beth Miller, Department of Psychology, Oklahoma State
University and Department of Psychiatry and Human Be-
havior, Alpert Medical School of Brown University.
Correspondence concerning this article should be ad-
dressed to Stephen R. Gillaspy, Section of General & Com-
munity Pediatrics, University of Oklahoma Health Sciences
Center, College of Medicine, Department of Pediatrics,
1200 Children’s Avenue, Suite 12400, Oklahoma City, OK
73104. E-mail:
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Clinical Practice in Pediatric Psychology © 2015 American Psychological Association
2015, Vol. 3, No. 3, 225–232 2169-4826/15/$12.00
American Academy of Pediatrics (AAP) has
issued position statements recommending that
pediatricians address obesity, tobacco, and al-
cohol use with patients (Barlow, 2007; Com-
mittee on Environmental Health, Committee on
Substance Abuse, Committee on Adolescence,
& Committee on Native American Child, 2009;
Committee on Substance Abuse, 2010). Brief
interventions utilizing the style of MI have been
featured in each of these policy recommenda-
tions as an evidence-based approach to address-
ing these health behaviors. The MI style is a
patient-centered approach that utilizes specific
interpersonal communication strategies to guide
patients toward an intrinsically motived and
committed decision to change health behaviors
while avoiding unsolicited advice, direct per-
suasion, or confrontation (Miller & Rollnick,
2013; Leffingwell, 2004). Although the core of
the MI style is a patient-centered approach uti-
lizing reflective listening and empathy within a
collaborative relationship, the style also in-
cludes a number of specific strategies and prin-
MI has been found in adults to reduce sub-
stance misuse disorders (e.g., smoking, alcohol,
drug dependence) and enhance health behaviors
(e.g., exercise, diet; Burke, Arkowitz, & Men-
chola, 2003; Hettema, Steele, & Miller, 2005)
and in adolescents is effective addressing sub-
stance misuse (Jensen et al., 2011) and other
health behaviors (Cushing et al., 2014). The
opportunities for the pediatric psychologist to
utilize MI are numerous, including issues of
engagement and adherence to medical regimens
(e.g., diabetes, vaccinations, and transplant medi-
cations), and health-related lifestyle changes (diet
and physical activity).
Both theory and research indicate structured
practice with ongoing supervision and training
are integral to MI proficiency (Barwick et al.,
2012; Fu et al., 2015; Madson, Loignon, &
Lane, 2009; Miller & Rollnick, 2013), although
the importance of continued training may vary
based on baseline performance (Martino et al.,
2011). The majority of MI training programs
focus primarily on didactics and introductory
MI skills practice (Barwick et al., 2012; Madson
et al., 2009). The long-term impact of such
trainings is difficult to determine, as studies
vary considerably in methodology (Barwick et
al., 2012). However, in a randomized controlled
trial, Miller and colleagues (2004) demonstrated
that including feedback and individual coaching
to a more traditional workshop enhanced clini-
cians’ maintenance of clinical proficiency at 4,
8, and 12 months posttraining. Therefore, the
current training module incorporated MI coding
of structured practice sessions in order to pro-
vide trainees with feedback on their use of MI
skills and suggested areas for continued im-
MI Training Module
Training began with a 4-hr module aimed to
enhance psychology trainees’ understanding
and use of brief motivational interventions.
Content includes the evidence-base for MI in
medical settings, fundamental concepts of MI
theory and practice (including both global skills
and specific behaviors), and video examples of
MI-consistent and MI-inconsistent patient en-
counters. Trainees were provided with a copy of
workshop slides, transcripts of video examples,
a list of skills and behaviors that would be
coded during the simulated encounters, relevant
policy statements from the AAP, and several
peer-reviewed articles regarding the efficacy
and implementation of MI in health care set-
Training also included live practice using MI
and personalized feedback on MI adherence
during the simulated practice encounters. Be-
fore and immediately after the workshop, train-
ees participated in a brief (10 minutes) en-
counter with a professionally trained simulated
patient presenting with one of three medical
concerns, which are randomly assigned: child-
hood ear infections secondary to parental to-
bacco use, childhood obesity, or adolescent al-
cohol abuse. Simulated patients were given
limited information regarding the purpose of the
encounter in order to prevent expectations from
influencing their behavior. They were, however,
instructed to be ambivalent regarding the target
behavior (i.e., neither completely resistant nor
highly motivated to change).
After the encounter, trainees were provided
with detailed personalized feedback on MI per-
formance. Feedback included adherence based
on the MI Treatment Integrity (MITI) coding
scheme (Moyers et al., 2010) and self-report
measures completed by the trainee, the simu-
lated patient, and the trained observer. Within
the MITI code, cut-points for both beginning
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
proficiency and expert competence were pro-
vided. Beginning proficiency is indicated by
global MI ratings above 3.5, 90% MI adher-
ence, at least 50% open (vs. closed) questions,
at least 40% complex (vs. simple) reflections, a
1:1 reflection to question ratio, and allowing the
patient’s responses to constitute at least 40% of
the conversation. Competency is indicated by
global ratings above 4.0, 100% MI adherence,
at least 70% open questions, at least 50% com-
plex reflections, a 2:1 reflection to question ra-
tio, and patients’ talking at least 50% of the
Advanced doctoral students with training in
the MITI system reviewed and coded the pre-
and posttraining encounters. They then pro-
vided trainees with detailed written feedback
regarding their adherence to MI in each encoun-
ter via electronic mail. Written feedback in-
cluded adherence to the five global MI skills
and use of specific MI behaviors (e.g., open
questions, complex reflections) in comparison
with proficiency and competency standards.
The global skills are intended to capture the
proscribed “spirit” or attitude of the MI conver-
sation: Evocation (vs. imparting or inserting
knowledge); Collaboration (vs. one-up, author-
itarian relationship); Autonomy-supportive (vs.
controlling); Direction (vs. avoidant, dis-
tracted); and Empathy (vs. dismissive, disre-
Feedback also included self-ratings of behav-
ior change counseling skill (Lane et al., 2005)in
comparison with simulated patients’ and obser-
vational coders’ ratings of their performance.
Trainees received written positive reinforce-
ment for MI-consistent behaviors and were pro-
vided with suggestions for strategies to use in
future practice. Trainees also had the opportu-
nity to view additional coder comments as
pop-up notes within the video recording itself.
MI Training Module in Relation to
Pediatric Psychology Competencies
MI is well-suited to be included in compe-
tency-based training in pediatric psychology,
relating to cross-cutting knowledge competen-
cies in pediatric psychology, interpersonal
skills, professionalism, and application of sci-
ence (see Table 1). To further illustrate how this
training aligns with specific competencies, one
trainee’s practice encounters with simulated pa-
tients targeting childhood obesity are described
below. The trainee completed the encounter be-
fore (pretraining) and immediately after (post-
training) the didactic portion of the MI training.
The trainee was given the following instruc-
You are seeing Mary Jones, the single parent of Brandy
Jones, an 8 year-old female. They are visiting the
Pediatric clinic today for Brandy’s yearly well-child
visit. The encounter will begin at a transition point
during the clinical visit. The physician has completed
the evaluation, including charting of Brandy’s BMI
(96.3 percentile), and asked you to speak with Ms.
Jones about Brandy’s weight.
Cross-Cutting Knowledge
The MI training module allows psychology
trainees to apply knowledge of concepts in clin-
ical child psychology (e.g., family systems) and
pediatric psychology (e.g., common barriers to
maintaining healthy weight). Within the MI
training module, trainees learn about the evi-
dence-base of MI interventions. They are pre-
sented with meta-analyses reporting effect sizes
and various practice guidelines that recommend
use of MI (Barlow, 2007; Committee on Envi-
ronmental Health, Committee on Substance
Abuse, Committee on Adolescence, & Commit-
tee on Native American Child, 2009; Commit-
tee on Substance Abuse, 2010). Completing
training in MI provides trainees the option of
choosing an empirically supported intervention
in instances when they may otherwise rely on
skills that are less effective (e.g., nondirective
empathic listening). This is particularly trouble-
some within a fast-paced, outcome-oriented
health care environment in which pediatric psy-
chologists work.
Psychology trainees are informed that at this
institution pediatric medical residents have
completed a similar training as part of a Resi-
dency Training Grant awarded to the first author
by the Health Resources and Services Admin-
istration (HRSA) but are reminded that, as ex-
perts in human behavior, psychologists are par-
ticularly well-suited to implement health
behavior change interventions. In the encounter,
a physician has already determined that Bran-
dy’s weight is a concern and identified a need
for behavioral health intervention. This scenario
Sample feedback forms are available from the first
author or at
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
is common in pediatric psychology settings and
requires trainees to understand the roles of other
disciplines and interprofessional teams, which
prepares them for clinical practice because pe-
diatric psychologists do not work in isolation.
Although the encounter described above is
common in pediatric psychology, these encoun-
ters may quickly become difficult, uncomfort-
able, and even damaging to the relationship
between not only the patient/family and psy-
chologist, but also the interprofessional team as
a whole. The MI training module provides psy-
chology trainees with specific instruction on
how to facilitate effective communication that
is tailored to the needs and understanding of all
parties involved. This goal is accomplished via
not only instruction on the microskills (or spe-
cific behaviors) of MI, but also the global rat-
ings or dimensions that are consistent with an
MI approach (i.e., being collaborative, evoca-
tive, autonomy supportive, directive, and em-
pathic). Trainees learn and demonstrate how to
“roll with resistance” rather than using a con-
frontational approach. This approach allows for
maximum preservation of the relationship while
also being evidence-based. Unlike with more
confrontational approaches, brief interventions
utilizing the MI approach are likely to
strengthen working relationships between pa-
tients and clinical staff.
Before the encounter the simulated patient
(Ms. Jones) was given the following instruc-
tions: “You are generally cooperative and open,
but may become defensive if you feel like you
are being told what to do or being caused to feel
guilt or shame about Brandy’s weight and lack
of regular exercise.” During the pretraining en-
counter (i.e., before the didactic portion of MI
training), the trainee began the encounter by
saying, “I understand Dr. Smith is concerned
Table 1
Pediatric Psychology Competencies Associated With Motivational Interviewing Training Module
1.1 Values and understands the scientific foundation underlying the practice of pediatric psychology
1.8 Understands the roles of other disciplines in health service delivery systems
3.1.A Exhibits professionalism in interactions with patients, research participants, and their families
3.2.A Provides clinical care to children and families, implementing appropriate personal boundaries
3.3.A Works effectively with colleagues from other disciplines to maintain a climate of mutual
respect and shared values
3.1.B Works effectively with diverse patients and families, as well as diverse professionals in
providing coordinated care
4.1.A Uses and facilitates accurate, clear, and effective communication with and between patients,
their families, other health-care professionals, community institutions, and systems involving
the patient
4.1.B Supports a team approach to the maintenance and promotion of health and treatment of disease
4.2.B Develops and maintains relationships with patients, their families, other professionals,
communities, and other systems involving patients
4.3.B Effectively manages challenging relationships and interactions
5.1.A Applies the concept and value of evidence-based practice and its role in scientific and applied
5.3.C Implements evidence-based wellness, health promotion, and prevention interventions appropriate
to the health concern
5.1.D Provides consultative/liaison services to health-care professionals across disciplines and systems
related to health and behavior
5.2.D Translated and communicates relevant clinical findings as they bear on health-care consultation/
liaison questions
Note. From “Recommendations for Training in Pediatric Psychology: Defining Core Competencies Across Training
Levels,” by T. M. Palermo et al., 2014, Journal of Pediatric Psychology, 39, pp. 969, 972, 974, 976. Copyright 2014 by
Oxford University Press. Reprinted with permission.
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about Brandy’s weight. Let me share some
ideas of things you can do to help with that.”
This response was counter to the MI approach
and was met with defensiveness and frustration
on the part of the simulated patient. Similarly,
the psychology trainee spent 72% of the en-
counter time talking and focused on the physi-
cian’s reasons for addressing Brandy’s weight,
rather than evoking the parent’s concerns or
reasons for change.
During the posttraining encounter, when the
trainee has learned to demonstrate respect or
autonomy and desire for collaboration immedi-
ately, the trainee began the encounter with, “I
understand you and Dr. Smith briefly discussed
Brandy’s BMI. Would it be OK if we spent a
little time today visiting about Brandy’s
weight?” The psychology trainee spent 58% of
the encounter time talking and asked open-
ended questions to elicit how Ms. Jones thinks
and feels about Brandy’s weight while also ac-
knowledging challenges to behavior changes
she faces. This psychology trainee’s demonstra-
tion of increased competence in MI skills illus-
trates improved ability to navigate conversa-
tions about behavior change, which is a primary
component of work as a pediatric psychologist.
As a patient-centered approach, the spirit of
MI is explicitly one of respect and cultural
sensitivity. By participating in the MI training
module, trainees learn a way of being with
people that allows psychologists to serve as
models of professionalism for other disciplines
within interprofessional teams. Psychology
trainees learn that evoking the patient’s own
values and reasons for change prevents the im-
posing of the trainee’s values on the patient,
which is an important component of profession-
During the previously described pretraining
encounter, the trainee stated, “I know it must be
important to you as a mother that Brandy is at a
healthy weight.” This statement, while likely
true, is not consistent with an MI approach. It is
presumptive and lacks respect for Ms. Jones’
perspective. Conversely, during the posttraining
encounter, the trainee asked Ms. Jones a scaled
question: “Ona1to10scale, how important is
it to you today to get Brandy’s weight under
control?” In response to the trainee’s follow-up
question—“Why did you say a 6 and not a
3?”—Ms. Jones offered her sense of responsi-
bility as a mother as a consideration. The trainee
then demonstrated further curiosity by asking,
“Why else are you a 6 and not a 3?” Ms. Jones
then discussed her concerns regarding Brandy’s
increased risk of negative weight-related health
effects as an African American female. This
exchange allowed the trainee to gather a lot of
useful information that likely would not have
otherwise been available. The trainee would
then have the opportunity to share this informa-
tion, using Ms. Jones’ own words, with the
other members of the interprofessional team.
These are skills that psychology trainees will
apply across settings and populations.
The MI training module closely relates to the
application cluster, as it requires psychology
trainees to demonstrate fidelity to MI via en-
counters that are videotaped and coded. The
feedback provided to trainees illustrates how
they are taught to use skills that are consistent
with MI, but also to be flexible in implementing
those skills. For example, the trainee discussed
earlier received feedback that s/he asked nine
questions during the encounter, 60% of which
were open questions and the “best example”
being, “How did you make the decision to
maintain a healthy weight for Brandy in the
past?” A second trainee also demonstrated be-
ginning proficiency in using open-ended ques-
tions (50% to 70%), but discussed completely
different values with Ms. Jones than the first
trainee. Both trainees demonstrated fidelity to
an evidence-based intervention (MI), but did so
in a flexible manner.
The MI training module utilizes the Clinical
Skills Education and Testing Center (CSETC).
The CSETC is a state-of-the art facility that
features a suite of training exam rooms
equipped with audio and video observing and
recording equipment, as well as simulated pa-
tients demonstrating the most common health
behavior targets (obesity, tobacco use, binge
drinking, or other behavioral health issues).
This facility allows trainees to practice the MI
style in a setting very similar to the real-life
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
clinical setting. The technology of the CSETC
also allows for high-quality feedback to be pro-
vided via coding of recorded interactions. This
program makes innovative use of the availabil-
ity of the Motivational Interviewing Treatment
Integrity (MITI) coding system, a psychometri-
cally sound observational coding system for
evaluating fidelity to the MI style. The MITI has
been found to be a reliable and valid measure of
MI competency, and is sensitive to changes
resulting from training (Moyers et al., 2005).
The MITI is highly useful as a training tool
because the outputs of the coding provide very
specific feedback about well-specified behav-
iors including aspects of the “spirit” of MI (evo-
cation, collaboration, autonomy/support, direc-
tion, and empathy) as well as the use of specific
strategies by the interviewer (including open-
ended questions and reflections). This feedback
is useful to a trainee in making attempts to
modify their behavior over the course of multi-
ple trials to demonstrate greater competence
with the MI style.
The MI training described above is the result
of several years of training and modifications
aimed to better meet the needs of our trainees.
We recognize that use of the CSETC and its
resources (e.g., simulated patients, videotaping)
is unique and may not be available to other
training sites. Nevertheless, we propose that
implementing an MI training module that sim-
ilarly adheres to the core competencies for pe-
diatric psychologists is feasible at any training
site. We consider the following components es-
sential to any MI training module.
First, to achieve the cross-cutting knowledge
competency, trainings must include presenta-
tion of the evidence-base for MI along with
presentation of relevant practice guidelines.
Second, emphasize the role of pediatric psy-
chologists within interprofessional teams. For
example, although MI training is also recom-
mended for our physician colleagues, pediatric
psychologists are particularly well-suited to
successfully implement MI techniques because
we are behavioral health specialists. Third,
stress MI as not only an efficacious behavior-
change technique, but also as an interpersonal
strategy that fosters professionalism. This may
be accomplished by focusing on the global
skills of MI. Fourth, provide opportunity for
trainees to practice MI skills. This may be done
in varying degrees of real-world application.
For example, trainees may engage in practice
with other trainees or presenters who may take
on the role of patient/caregiver. We are in the
process of evaluating the efficacy of our MI
training module in its current iteration; how-
ever, we consider opportunity to practice skills
learned during traditional didactics to be vital to
achieving the application competency. Fifth,
provide trainees with feedback on their applica-
tion of MI skills. Again, this does not require
resources akin to those of the CSETC, but may
be accomplished by providing live MITI coding
either by a trained coder or the trainees them-
selves. The purpose of providing feedback is
not necessarily for coders to demonstrate fidel-
ity to the coding system, which requires exten-
sive training, but for trainees to obtain concrete
examples of how they were/were not faithful to
the spirit of MI.
In addition to defining competencies integral
to training in pediatric psychology, the Society
of Pediatric Psychology Task Force (Palermo et
al., 2014) defined behavioral anchors based on
three developmental/training periods: (a) early
graduate training or readiness for practicum; (b)
end of graduate training or readiness for intern-
ship; and (c) end of internship/ postdoctoral
fellowship or readiness for entry to practice.
Although we believe that trainees should re-
ceive MI training in graduate school, we think
the training module described is best suited at
the internship/fellowship level. To continue to
improve one’s MI skills and develop compe-
tency, there must be the opportunity to fre-
quently use the skills and receive feedback. As
clinical training is the primary focus of intern-
ship and fellowship, the current training module
appears most appropriate at this time.
In the current MI training module we did not
adjust or modify the training based on baseline
performance as suggested by Martino and col-
leagues (2011). Rather, we believe the person-
alized feedback trainees receive based on com-
pletion of the pre- and post-practice encounters
with standardized patients serves to represent a
measure of their baseline performance. Such
personalized feedback should provide the level
of proficiency of MI skills and highlight areas
need for improvement. Ideally, this feedback
should be reviewed with the trainee’s supervisor
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
so that training plans can be adjusted to ensure
further development of MI skills. In the future
as MI training becomes more standard in grad-
uate school and trainees present to internship
and fellowship with more extensive MI experi-
ence, our current training model may need to be
modified to account for a higher baseline per-
MI is an evidence-based approach to behav-
ior change counseling that is effective in moti-
vating change in many health-risk behaviors.
Given the numerous opportunities for applica-
tion and strong evidence base with common
clinical problems, competency in MI is one skill
every pediatric psychologist should have in
their “clinical tool box.” Not only is MI an
evidence-based approach that can be used to
benefit treatment interventions with patients and
families, the training module also maps onto
several of the new pediatric psychology compe-
tencies. Specifically, the module relates to
cross-cutting knowledge competencies in pedi-
atric psychology, interpersonal, professional-
ism, and application. Finally, the training mod-
ule takes advantage of innovative technology
through the use of a state-of-the-art clinical
skills training center, a resource that should be
more frequently utilized in pediatric psychology
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New York, NY: Guilford Press.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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J., & Pirritano, M. (2004). A randomized trial of
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Received November 30, 2014
Revision received May 20, 2015
Accepted May 24, 2015
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... O uso de tecnologia dura por meio da computação e com função de incentivadora da abstinência (10,28% das ocorrências nesta revisão integrativa) tem se mostrado cada vez mais como prática de acompanhamento/apoio por meio do envio de SMS, e-mail, além das redes sociais e aplicativos [26][27][28] . ...
... O envio e recebimento de mensagens por meio de smartphones e e-mail foram amplamente citados, mostrando-se efetivos na intervenção intensiva para cessação do tabagismo, não havendo ainda configuração voltada para a APS 44 . Com relação a programas na Web, há dificuldade em demonstrar sua eficácia em comparação com cuidados habituais, embora em situações específicas a intervenção por e-mail mostre-se eficiente quando há desejo prévio em abandonar o hábito [26][27][28] . ...
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Resumo O hábito de fumar, ou tabagismo, preocupação da Atenção Primária à Saúde (APS), é um grave problema de saúde pública e a principal causa de morte evitável no mundo. A relevância de ações, cujo foco seja facilitar a cessação deste vício, motiva a discussão de estudos que apresentam diferentes abordagens para tal enfrentamento visando contribuir para a formação dos profissionais da APS. Utilizou-se as bases de dados Lilacs, Medline e Web of Science considerando as produções científicas recentes (2010 a 2015). Os descritores foram combinados a operadores boleanos e, após análise dos artigos encontrados, 75 são discutidos nesta revisão por apresentarem estratégias de maior prevalência na APS. Conclui-se que a abordagem individual breve ou intensa a partir do método dos 5A's (Modelo Transteórico) é a mais adotada, assim como os fármacos adesivos de Nicotina e Bupropiona. O uso crescente de tecnologia dura necessita de novos estudos que averiguem os seus impactos no tratamento a tabagistas. Evidenciou-se a necessidade de o profissional de saúde ser mais bem preparado para abordar o tema com os usuários, além de carecer do estímulo e das condições próprias para atuar na equipe de APS refletindo diretamente os avanços científicos em sua prática clínica.
... Therefore, results of this study also provide support for interventions that are tailored to reduce hardships, such as social service consultation, assistance accessing critical resources (eg, job training programs, food assistance, public benefit programs), legal advocacy, and home visitations. [42][43][44] These types of interventions could address nearly all the survey items. In addition to the immediate benefits of improving selfefficacy, motivation, and trust, these interventions may also improve parents' ability to access smoking cessation interventions and maintain improvements. ...
... 45 Indeed, results of this study suggest that the effectiveness of evidence-based smoking cessation interventions may be increased by targeting relevant sources of hardship. [42][43][44][45] There were several limitations to this study. First, our sample was composed primarily of African American and white children. ...
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A better understanding of how poverty-related hardships affect child health could highlight remediable intervention targets. Tobacco smoke exposure may be 1 such consequence of family hardship. Our objective was to explore the relationship between family hardships and tobacco exposure, as measured by serum cotinine, a tobacco metabolite, among children hospitalized for asthma. We prospectively enrolled a cohort of 774 children, aged 1 to 16 years, admitted for asthma or bronchodilator-responsive wheezing. The primary outcome was detectable serum cotinine. We assessed family hardships, including 11 financial and social variables, through a survey of the child's caregiver. We used logistic regression to evaluate associations between family hardship and detectable cotinine. We had complete study data for 675 children; 57% were African American, and 74% were enrolled in Medicaid. In total, 56% of children had detectable cotinine. More than 80% of families reported ≥1 hardship, and 41% reported ≥4 hardships. Greater numbers of hardships were associated with greater odds of having detectable cotinine. Compared with children in families with no hardships, those in families with ≥4 hardships had 3.7-fold (95% confidence interval, 2.0-7.0) greater odds of having detectable serum cotinine in adjusted analyses. Lower parental income and educational attainment were also independently associated with detectable serum cotinine. Family hardships are prevalent and associated with detectable serum cotinine level among children with asthma. Family hardships and tobacco smoke exposure may be possible targets for interventions to reduce health disparities. Copyright © 2015 by the American Academy of Pediatrics.
... Second, smokers who reported having plans to quit smoking at baseline and completed the push-pull practice task were found to have more negative implicit attitudes toward smoking at follow-up. This is consistent with a study that found that a web-based intervention among smoking parents in a pediatric clinic was found to be effective in increasing motivation to quit only for those who were already contemplating behavior change (Gillaspy et al., 2013). Thus, effects of web-based smoking cessation interventions may be stronger among smokers who have at least some interest in changing their behavior. ...
Implicit attitudes have been shown to predict smoking behaviors. Therefore, an important goal is the development of interventions to change these attitudes. This study assessed the effects of a web-based intervention on implicit attitudes toward smoking and receptivity to smoking-related information. Smokers (N = 284) were recruited to a two-session web-based study. In the first session, baseline data were collected. Session two contained the intervention, which consisted of assignment to the experimental or control version of an approach-avoidance task and assignment to an anti-smoking or control public service announcement (PSA), and post-intervention measures. Among smokers with less education and with plans to quit, implicit attitudes were more negative for those who completed the approach-avoidance task. Smokers with more education who viewed the anti-smoking PSA and completed the approach-avoidance task spent more time reading smoking-related information. An approach-avoidance task is a potentially feasible strategy for changing implicit attitudes toward smoking and increasing receptivity to smoking-related information.
Tobacco smokers with co-occurring pain report greater difficulty quitting, face unique cessation challenges, and may benefit from targeted smoking interventions. We developed and tested a brief motivational intervention aimed at increasing knowledge of pain-smoking interrelations, motivation to quit, and cessation treatment engagement among smokers in pain. Nontreatment seeking daily cigarette smokers with chronic pain (N = 76, 57.9% women, 52.6% White) were randomized to the targeted or ask, advise, refer (AAR) intervention. The targeted intervention included personalized feedback and pain-smoking psychoeducation to help participants develop discrepancy between continued smoking and desired pain outcomes. At postintervention, the targeted intervention (vs. AAR) increased knowledge of pain-smoking interrelations and several indices of motivation to quit smoking (ps < .01). Participants who received the targeted intervention were also more likely to accept information about and report intention to engage evidence-based cessation treatments (ps < .05). Increased knowledge of pain-smoking interrelations mediated postintervention effects on motivation to quit and willingness to learn about treatments. At 1-month follow up, gains in knowledge of pain-smoking interrelations were maintained (p = .009). Participants who received the targeted intervention were more likely to report having subsequently engaged cessation treatment (p = .019), but this was not mediated by increased knowledge of pain-smoking interrelations. Smokers with chronic pain may benefit from targeted interventions that address smoking in the context of pain. Smokers in pain may become increasingly motivated to quit and engage cessation treatment as they become aware of how smoking may exacerbate their pain. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Background: Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to quit smoking. Objectives: To determine whether or not motivational interviewing (MI) promotes smoking cessation. Search methods: We searched the Cochrane Tobacco Addiction Group Specialized Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. Date of the most recent search: August 2014. Selection criteria: Randomized controlled trials in which motivational interviewing or its variants were offered to tobacco users to assist cessation. Data collection and analysis: We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We counted participants lost to follow-up as continuing smoking or relapsed. We performed meta-analysis using a fixed-effect Mantel-Haenszel model. Main results: We identified 28 studies published between 1997 and 2014, involving over 16,000 participants. MI was conducted in one to six sessions, with the duration of each session ranging from 10 to 60 minutes. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio (RR) 1.26; 95% confidence interval (CI) 1.16 to 1.36; 28 studies; N = 16,803). Subgroup analyses found that MI delivered by primary care physicians resulted in an RR of 3.49 (95% CI 1.53 to 7.94; 2 trials; N = 736). When delivered by counsellors the RR was smaller (1.25; 95% CI 1.15 to 1.63; 22 trials; N = 13,593) but MI still resulted in higher quit rates than brief advice or usual care. When we compared MI interventions conducted through shorter sessions (less than 20 minutes per session) to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651). Single-session treatments might increase the likelihood of quitting over multiple sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing. Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports. Authors' conclusions: Motivational interviewing may assist people to quit smoking. However, the results should be interpreted with caution, due to variations in study quality, treatment fidelity, between-study heterogeneity and the possibility of publication or selective reporting bias.
Worldwide, roughly 40% of children are exposed to the damaging and sometimes deadly effects of tobacco smoke. Interventions aimed at reducing child tobacco smoke exposure (TSE) have shown mixed results. The objective of this study was to perform a systematic review and meta-analysis to quantify effects of interventions aimed at decreasing child TSE. Data sources included Medline, PubMed, Web of Science, PsycNet, and Embase. Controlled trials that included parents of young children were selected. Two reviewers extracted TSE data, as assessed by parentally-reported exposure or protection (PREP) and biomarkers. Risk ratios and differences were calculated by using the DerSimonian and Laird random-effects model. Exploratory subgroup analyses were performed. Thirty studies were included. Improvements were observed from baseline to follow-up for parentally-reported and biomarker data in most intervention and control groups. Interventions demonstrated evidence of small benefit to intervention participants at follow-up (PREP: 17 studies, n = 6820, relative risk 1.12, confidence interval [CI] 1.07 to 1.18], P < .0001). Seven percent more children were protected in intervention groups relative to control groups. Intervention parents smoked fewer cigarettes around children at follow-up than did control parents (P = .03). Biomarkers (13 studies, n = 2601) at follow-up suggested lower child exposure among intervention participants (RD -0.05, CI -0.13 to 0.03, P = .20). Interventions to prevent child TSE are moderately beneficial at the individual level. Widespread child TSE suggests potential for significant population impact. More research is needed to improve intervention effectiveness and child TSE measurement.
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Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults. Pediatrics 2009; 124: 1474-1487
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Objective: We sought to systematically review and meta-analyze the literature comparing motivational interviewing (MI) with a control condition for adolescent health behavior change. In the current article, we reviewed only studies targeting health behaviors other than substance use (e.g., sexual risk behavior, physical activity, diet). Method: Systematic literature searches of PsycINFO, PubMed/Medline, and ERIC were conducted through June 2013. Databases were combined, and studies were screened for inclusion or exclusion. To be included in the current review, studies were required to (a) compare the efficacy of at least 1 session of MI intervention with a control condition using a between-groups design and (b) examine a non-substance-use health behavior in adolescents. Fifteen studies met criteria for inclusion and were described qualitatively and quantitatively. Results: Using a fixed-effects model, we found that MI interventions produced a small, but significant, aggregate effect size for short-term postintervention effects-g = .16; 95% confidence interval (CI) [.05, .27]-compared with control conditions. Moreover, this effect was sustained at follow-up assessments averaging 33.6 weeks postintervention, n = 8, g = .18, 95% CI [.05, .32]. Conclusions: MI interventions for adolescent health behavior appear to be effective. In addition, the magnitude of the aggregate effect size does not appear to differ meaningfully from reports of interventions targeting only substance use in adolescents. However, significant lack of clarity exists regarding interventionist training requirements necessary to ensure intervention effectiveness.
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As a field, pediatric psychology has focused considerable efforts on the education and training of students and practitioners. Alongside a broader movement toward competency attainment in professional psychology and within the health professions, the Society of Pediatric Psychology commissioned a Task Force to establish core competencies in pediatric psychology and address the need for contemporary training recommendations. The Task Force adapted the framework proposed by the Competency Benchmarks Work Group on preparing psychologists for health service practice and defined competencies applicable across training levels ranging from initial practicum training to entry into the professional workforce in pediatric psychology. Competencies within 6 cluster areas, including science, professionalism, interpersonal, application, education, and systems, and 1 crosscutting cluster, crosscutting knowledge competencies in pediatric psychology, are presented in this report. Recommendations for the use of, and the further refinement of, these suggested competencies are discussed.
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Objective This systematic review sought to determine the current state of the literature on the effectiveness of training health and mental health professionals in motivational interviewing (MI).Method Data sources: The following databases were searched: MEDLINE/PreMEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and CENTRAL Cochrane Central Trials Register. Inclusion criteria were empirical studies of any year that employed any research design to evaluate the effectiveness of training health or mental health professionals in MI. Studies with main outcomes other than behavioral or organizational were excluded. To minimize bias, dual review was employed. Full data abstraction was conducted independently by two reviewers. A qualitative synthesis of the findings and risk of bias data are reported.ResultsA total of 22 studies were included in this review. Seventeen of the 22 studies reported significant practitioner behavior change relative to motivational interviewing skills, notwithstanding variation in training approach, population, outcome measures, and study quality.Conclusion This review demonstrates practitioner behavior change on MI skills utilizing a variety of training and outcome methods. Future work of high methodological rigor, clear reporting, and that attends to training as one part of the implementation process will help to elucidate the factors that lead to the uptake of new practices.
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Traditionally smoking cessation studies use smoker and nonsmoker categories almost exclusively to represent individuals quitting smoking. This study tested the transtheoretical model of change that posits a series of stages through which smokers move as they successfully change the smoking habit. Ss in precontemplation ( n = 166), contemplation ( n = 794), and preparation ( n = 506) stages of change were compared on smoking history, 10 processes of change, pretest self-efficacy, and decisional balance, as well as 1-mo and 6-mo cessation activity. Results strongly support the stages of change model. All groups were similar on smoking history but differed dramatically on current cessation activity. Stage differences predicted attempts to quit smoking and cessation success at 1- and 6-mo follow-up. Implications for recruitment, intervention, and research are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This study was designed to quantitatively evaluate the effectiveness of motivational interviewing (MI) interventions for adolescent substance use behavior change. Literature searches of electronic databases were undertaken in addition to manual reference searches of identified review articles. Databases searched include PsycINFO, PUBMED/MEDLINE, and Educational Resources Information Center. Twenty-one independent studies, representing 5,471 participants, were located and analyzed. An omnibus weighted mean effect size for all identified MI interventions revealed a small, but significant, posttreatment effect size (mean d = .173, 95% CI [.094, .252], n = 21). Small, but significant, effect sizes were observed at follow-up suggesting that MI interventions for adolescent substance use retain their effect over time. MI interventions were effective across a variety of substance use behaviors, varying session lengths, and different settings, and for interventions that used clinicians with different levels of education. The effectiveness of MI interventions for adolescent substance use behavior change is supported by this meta-analytic review. In consideration of these results, as well as the larger literature, MI should be considered as a treatment for adolescent substance use.
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Motivational interviewing (MI), an evidence-based counseling approach, has received much recognition from a wide variety of health care professionals. Because of the rising interest in MI, there is increasing demand for training in this counseling approach. The MI training community has answered this call and as a result placed much emphasis on studying the MI training process. The purpose of this article is to provide a systematic review of the published research on MI training. Our goal is to provide a consolidated account of MI trainings outlining the populations receiving training, methods used, and training outcomes. We also identify which aspects of the (W. R. Miller & T. B. Moyers, 2006) eight stages of learning MI each study addressed. Recommendations for advancing the MI training research are highlighted.
Alcohol use continues to be a major problem from preadolescence through young adulthood in the United States. Results of recent neuroscience research have substantiated the deleterious effects of alcohol on adolescent brain development and added even more evidence to support the call to prevent and reduce underaged drinking. Pediatricians should be knowledgeable about substance abuse to be able to recognize risk factors for alcohol and other substance abuse among youth, screen for use, provide appropriate brief interventions, and refer to treatment. The integration of alcohol use prevention programs in the community and our educational system from elementary school through college should be promoted by pediatricians and the health care community. Promotion of media responsibility to connect alcohol consumption with realistic consequences should be supported by pediatricians. Additional research into the prevention, screening and identification, brief intervention, and management and treatment of alcohol and other substance use by adolescents continues to be needed to improve evidence-based practices. Pediatrics 2010; 125: 1078-1087
To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians. Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training. Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence. Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency. Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians. Published by Elsevier Ireland Ltd.