Motivational Interviewing: A Tool for Pediatricians

Motivational interviewing (MI) is a patient-centered, evidence-based technique designed to explore ambivalence and empower individuals toward meaningful behavior change. Rooted in compassion, partnership, and reflective engagement, MI fosters intrinsic motivation by emphasizing patient autonomy in their care. Originally developed to address substance use disorders, MI has been adopted across various health care settings, including pediatrics, in which time constraints and the need for effective communication are paramount. MI enables pediatricians to navigate complex conversations with patients and even caregivers of younger children or patients with cognitive delay, particularly in outpatient and primary care settings, using a structured yet flexible individualized framework.MI was developed in 1983 by Miller to promote reflection and behavioral change in adults with unhealthy alcohol use. Since then, MI has expanded into diverse settings, including pediatrics, with use in areas such as substance use, obesity, and vaccine hesitancy. MI helps patients navigate the Transtheoretical Model of Stages of Change, including precontemplative: is not yet considering change and is unaware that there is a problem;contemplative: recognizes problems but uncertain about change;preparation: is ready to make changes and begin planning;action/maintenance: implements changes and works to sustain them; andrelapse: reverts to previous behaviors.MI relies on 4 key communication strategies: (1) expressing empathy; (2) embracing resistance; (3) reinforcing self-efficacy; and (4) promoting cognitive discrepancy and patient reflection. The OARS approach embodies these principles through open-ended questions: encourage patients to explore their thoughts;affirmation: reinforce strengths and positive behaviors;reflection: paraphrase responses to show understanding; andsummary: highlight key points and next steps.MI is valuable in adolescent sexual health counseling, helping clinicians explore teens’ behaviors nonjudgmentally. For example, a study implementing MI-based interventions in emergency departments showed increased uptake of HIV testing (6% vs 33%; P = .02) and emergency contraception (0% vs 80%; P = .01) compared with controls. Similarly, another study found that MI interventions used in the Teen Options to Prevent Pregnancy program significantly reduced repeat pregnancy rates among postpartum teens, lowering them from 38.6% to 20.5% (P < .001).Alex is 15 years old and reports enjoying condomless sex. Her pediatrician, recognizing Alex is in the precontemplative stage, uses MI first with an invitation and then open-ended questions such as “What have you liked about sex and your relationships? What have you heard to make you feel concerned about sex?” This strategy explores Alex’s perceptions of risks and benefits. Her pediatrician focuses on rapport-building and harm reduction, such as sexually transmitted infection and emergency contraception, first to foster trust and sustainable change.MI has been shown to reduce vaccine refusal rates. For example, the Motivational Interviewing Tool to Improve Vaccine Acceptance Randomized Clinical Trial (MOTIVE RCT), which used MI for vaccine-hesitant parents, resulted in an increase in vaccination rates (32.4% vs 43.9%, P < .01) and a decline in vaccine refusals per 100 patients (31.5% vs 17.6%, P < .01).Cameron, an 8-month-old, has not received vaccines. His parents are concerned about side effects and are willing to consider vaccines but want to learn more. To explore this contemplative stage, their pediatrician begins by asking, “What concerns you most about vaccines?” (open-ended question). This is followed by “It’s clear you want the best for Cameron” (affirmation). Their pediatrician then reflects, “It makes sense you are overwhelmed—you have done a lot of reading and research” (reflection). Lastly, the pediatrician summarizes, “It sounds like you are worried about the side effects you have read about online, but you also want to take action to protect Cameron from catching infections” (summary). A conversation on evidence-based information and shared decision-making can happen now.Healthy lifestyle management is an area of MI research with mixed results. The recent BMI2+ RCT showed no significant impact on body mass index (BMI); however, the study was affected by taking place during the COVID-19 pandemic and revealed racial and cultural differences in MI outcomes. These findings highlight the need for further research on MI’s optimal implementation in healthy lifestyle management. Nonetheless, the MI framework remains a valuable tool to support self-efficacy and behavior change without judgment.Riley, a 16-year-old with a BMI at the 99th percentile, is in the preparation stage of change and has expressed interest in making healthy lifestyle changes. Their pediatrician uses MI by asking an open-ended question—“What changes have worked for you in the past?”—before collaboratively developing a behavior change plan with Riley. This plan outlines the following: Specific changes to implement: First, solicit ideas from patients that they would be open to trying and then move into offering options. If they do not have suggestions—which is not uncommon—the clinician can offer a selection of evidence-based options to explore together. This supports autonomy while gently guiding the conversation forward. Some patients may need more support or structure than others and recognizing that MI may not resonate equally with everyone can help tailor the approach to individual needs.Motivations for change: Reflect with patients on reasons for change with open-ended questions such as “What has motivated you to make these changes?” or “Why do you feel now is the time to make such changes?” to foster self-efficacy and commitment. It may also help to better understand confidence in making change by asking, “On a scale of 1 to 10, how confident do you feel in making this change? Why that number rather than a higher/lower number?”Steps to overcome barriers: Identify barriers with “What challenges do you anticipate experiencing?” and explore the patient’s ideas on troubleshooting. Offering solutions with collaborative input can help if no immediate steps are identified. An example of seeking collaborative input includes “Some people try doing [X] and find that it helps them. What do you think about trying something like that?” This frames the clinician as a partner in the process, inviting the patient’s input while providing guidance.Support systems and accountability measures: Ask open-ended questions such as “Who in your life can help you with addressing [list barrier] or [list specific behavior change]?” Developing insight on when to ask for help may also be instructive.Relapse is a natural stage of behavioral change, marked by returning to previous behaviors or struggling to maintain change. While challenging, it offers a valuable opportunity for reflection and growth. Strategies include normalizing relapse, exploring what led to the relapse, identifying barriers, and revisiting past contingency plans. Table 1 outlines each stage of change along with practical strategies to guide patients through them, including how to address relapse with empathy and support.MI is a patient-centered approach that fosters behavior change by prioritizing patient autonomy and intrinsic motivation. The OARS approach (open-ended questions, affirmation, reflection, summary) facilitates the effective delivery of MI in a clinical setting. While evidence supports MI’s efficacy in areas such as vaccine hesitancy, sexual health, and substance use disorder treatment, fields like healthy lifestyle management require further study. Pediatricians can integrate MI into routine clinical encounters to build trust and strengthen clinician-patient-caregiver partnerships to promote sustainable, long-term health and wellness. Resources for further reading and learning are listed below.Comment: Once I received training in MI, I found it truly transformed how I interacted with patients and their parents. Instead of the past approach to tell patients what was best for them and sometimes talking “at them,” MI strives to create a more patient-centered, nonjudgmental approach that enhances the partnership between the clinician and patient, incorporating careful listening, respecting the autonomy of the patient, and empowering them to making a health behavior change. So many important constructs exist that are emphasized in this In Brief. Empowerment of patients to be partners in designing their behavior change, acknowledgment that patients are the “experts” of their lives, and consideration of their perspective and expertise are essential in making behavior changes and demonstrating respect that they know the best strategies themselves but may need some guidance in discovering them. I especially like the concept of using the “ruler” method; ie, on a scale of 1 to 10, what number would you give as to your confidence to effect this change? And then following up with why that number (and not a slightly lower number or higher number) helps patients to reflect on their motivation and the values/principles they bring to the conversation about behavior change. Because so many aspects of our health behaviors can hinder our physical and emotional health, incorporating these strategies is imperative to our work in building a healthier society.Janet Serwint, MDEditor Emeritus, In BriefThank you to Dr Mim Ari (Department of Internal Medicine) and Dr Khalid Afzal (Department of Child and Adolescent Psychiatry) for their thoughtful review of the manuscript.