Adolescent and parent motivation for change affects psychotherapy outcomes among youth with poorly controlled diabetes

Self-efficacy, motivation, social support, and alliance as predictors of youth psychotherapy outcomes in usual care

OBJECTIVE

We examined how youth self-efficacy, motivation for treatment, social support, and therapeutic alliance relate to psychotherapy outcomes of patients receiving services at outpatient community clinics. We hypothesized that (1) these variables would increase throughout the course of therapy, (2) baseline scores would predict initial ratings of distress, (3) baseline scores would predict the rate of change in symptoms throughout treatment, and (4) changes in these variables would be associated with symptom change over the course of treatment.

METHOD

Participants included 150 adolescents at community outpatient treatment centers. Data was collected prior to beginning treatment, and every three weeks afterward until termination. We used hierarchical linear modeling (HLM) to address our hypotheses.

RESULTS

We found that (1) youth ratings of self-efficacy, social support, and motivation increased throughout treatment, (2) initial self-efficacy and social support were associated with initial levels of distress, (3) ratings of youth self-efficacy at intake predicted its rate of change over therapy, and (4) changes in all variables during therapy were related to lower distress at termination.

DISCUSSION

Results suggest that these variables may affect the trajectory and course of treatment in community-based treatment settings. These results may have implications for treatment planning to maximize treatment effectiveness.

Relationships examined: Parent and child readiness to change and sociodemographic characteristics in family based weight loss treatment

BACKGROUND

Family based treatment is an effective, multipronged approach to address obesity as it plagues families.

OBJECTIVE

To investigate the relationships among sociodemographic characteristics (e.g., education and income), body mass index (BMI) and race/ethnicity with readiness to change for parents enrolled in the Primary care pediatrics, Learning, Activity and Nutrition (PLAN) study.

METHODS

Multivariate linear regressions tested two hypotheses: (1) White parents will have higher levels of baseline readiness to change, when compared to Black parents; (2) parents with higher income and education will have higher levels of readiness to change at baseline.

RESULTS

A positive relationship exists between baseline parent BMI and readiness to change (Pearson correlation, 0.09, p < 0.05); statistically significant relationships exist between parent education level (-0.14, p < 0.05), income (0.04, p < 0.05) and readiness to change. Additionally, a statistically significant relationship exists, with both White (β, -0.10, p < 0.05), and Other, non-Hispanic (-0.10, p < 0.05) parents exhibiting lower readiness to change than Black, non-Hispanic parents. Child data did not indicate significant relationships between race/ethnicity and readiness to change.

CONCLUSIONS

Results demonstrate that investigators should consider sociodemographic characteristic factors and different levels of readiness to change in participants enrolling in obesity interventions.

Self-Determination Theory and Preventive Medication Adherence: Motivational Considerations to Support Historically Marginalized Adolescents With Asthma

INTRODUCTION

Using self-determination theory, we explored relationships between autonomous motivation (AM) and perceived competence (PC) with previously validated measures of motivation and adolescent-reported asthma medication adherence.

METHOD

Data were from adolescents (n = 260) enrolled in the School-Based Asthma Care for Teens study and taking preventive medication at baseline. Eligible adolescents (aged 12-16 years) had physician-diagnosed persistent asthma or poor control.

RESULTS

Adolescents taking daily preventive medicine reported higher AM and PC for adherence, whereas adolescents likely to miss ≥1 dose in the next 2 weeks had lower AM and PC. Adolescents taking medicines as prescribed, with plans to continue, and those feeling able to follow provider care plans, had higher AM and PC. Findings remained significant in regressions with control variables.

DISCUSSION

Many factors interfere with adolescent medication-taking. Clinicians' efforts to build AM and PC with patients and caregivers may be key to promoting adherence in this group.

Improving Diabetes Management in Emerging Adulthood: An Intervention Development Study Using the Multiphase Optimization Strategy

Background

Poor diabetes self-management in emerging adulthood (age 18-25 years) is associated with poorer diabetes health and diabetes complications. Emerging adults’ focus on individuation and independence underlies their poor diabetes outcomes, offering a lever for behavior change. Self-determination theory (SDT) suggests that interventions leveraging emerging adults’ innate developmental need for autonomy may offer a route to improving diabetes outcomes by increasing feelings of responsibility for and control over diabetes self-management activities.

Objective

This research project will use the multiphase optimization strategy to test the efficacy of three autonomy-supportive intervention components to elicit a clinically significant improvement in metabolic control, assessed by a 0.5% improvement in hemoglobin A_1c (HbA_1c), among older adolescents and emerging adults (16-25 years) with poorly controlled type 1 diabetes (T1D; HbA_1c≥9.0%).

Methods

A question prompt list (QPL) is a tool to empower patients to assume a more active role during medical visits by asking questions and stating concerns. The motivation enhancement system (MES) is a brief counseling intervention that uses motivational interviewing communication strategies to build intrinsic motivation and self-efficacy for self-management. Text message reminders to complete diabetes care tasks may increase self-efficacy for diabetes self-management. After refining these intervention components for emerging adults, we will conduct a component selection experiment using an eight-arm full factorial design: 2 (QPL yes or no)×2 (MES yes or no)×2 (Text yes or no). Participants will complete 3 study visits: baseline, treatment end at 2 months, and a follow-up at 6 months. The primary outcome is metabolic control, which will be measured via HbA_1c. Secondary outcomes include diabetes management and diabetes clinic attendance. SDT constructs of intrinsic motivation, self-efficacy, and the quality of the patient-provider relationship (ie, relatedness) are hypothesized mediators. Depression symptoms and emerging adults’ gender are hypothesized moderators. We will use the mixed-effects linear model for the analysis of variance of a factorial design to analyze continuous longitudinal experimental data; the generalized linear model will be used with categorical outcomes (eg, treatment attendance). The experiment was powered to detect the main effects of the intervention on the primary outcome.

Results

A total of 20 participants have enrolled and completed a qualitative interview after reviewing one or more intervention components. Analysis of interview data are underway, with a report of these results anticipated in the fall of 2020. The clinical trial will be launched in the fall 2020, with participants enrolled through May 2023 and data collection continuing through November 2023.

Conclusions

At the end of this experiment, we will have empirical evidence to support a large-scale, multisite effectiveness trial of an intervention package that has been optimized for older adolescents and emerging adults with poorly controlled T1D.

Trial Registration

ClinicalTrials.gov NCT04066959; https://clinicaltrials.gov/ct2/show/NCT04066959

International Registered Report Identifier (IRRID)

DERR1-10.2196/20191

Targeting parental motivation for change in childhood obesity: development and validation of the PURICA-S scale

BACKGROUND

The high prevalence of overweight and obesity in childhood and adolescence call for effective and sustainable intervention strategies. Parental motivation for change may be a key factor in sustained behavioral improvement towards a healthy weight status of their offspring. In this study, we developed a new short instrument to assess parental motivation for change to facilitate motivation-tailored family interventions that promise improved effectiveness.

METHODS

The preexisting gold-standard instrument to assess motivational stages for change was adapted from the self to the parental perspective in a structured multistep Delphi procedure. The new instrument to assess parental motivation for change related to a health problem of their children was psychometrically evaluated in a sample (N = 193) of parents of children or adolescents with overweight or obesity. Confirmatory factor analysis, internal consistency, construct, and criteria validity were analyzed to test the psychometric properties of the new instrument.

RESULTS

As a result of the Delphi procedures, all 16 items were successfully transferred to the parental perspective. The hypothesized four-factor structure of the new instrument was approved, and internal consistency and criteria validity were good to very good (albeit with inconsistent findings for the subscale precontemplation).

DISCUSSION

In our investigated target group of parents with children with overweight or obesity, the new instrument to assess parental motivation for change proved to be a practicable, valid, and time-efficient short measure. The new instrument will enable more specific motivational stage-directed interventions that promise higher effectiveness of family-based interventions to fight childhood obesity. However, the subscale precontemplation seemed not fully suitable for the population investigated here and needs to be applied very carefully in future studies.

Ready or Not: Examining Self-Reported Readiness for Behavior Change at Intake Assessment for Adults With an Eating Disorder

We explored whether a single-item self-report measure (i.e., the Readiness Ruler) was an appropriate measure of treatment engagement in adult outpatients with eating disorders. In total, 108 women diagnosed with an eating disorder completed the Readiness Ruler and measures of symptom severity at intake to a hospital-based outpatient treatment program. Treatment engagement was operationalized as attendance to a minimum of one session of a cognitive-behavioral therapy (CBT) treatment group, the number of CBT group sessions attended, and whether the participants dropped out of the CBT group prematurely. Results suggest that the Readiness Ruler was not associated with attending the CBT group. Among the participants who attended the program, the Readiness Ruler was not associated with the number of CBT group sessions attended or CBT group dropout. Higher Readiness Ruler score was associated with more severe symptomatology. In conclusion, the Readiness Ruler may not be a good predictor of CBT group treatment engagement for individuals with eating disorders and may instead be a proxy for symptom severity.

Building Motivation in African American Caregivers of Adolescents With Obesity: Application of Sequential Analysis

Objective

We sought to examine communication between counselors and caregivers of adolescents with obesity to determine what types of counselor behaviors increased caregivers' motivational statements regarding supporting their child's weight loss.

Methods

We coded 20-min Motivational Interviewing sessions with 37 caregivers of African American 12-16-year-olds using the Minority Youth Sequential Coding for Observing Process Exchanges. We used sequential analysis to determine which counselor communication codes predicted caregiver motivational statements.

Results

Counselors' questions to elicit motivational statements and emphasis on autonomy increased the likelihood of both caregiver change talk and commitment language statements. Counselors' reflections of change talk predicted further change talk, and reflections of commitment language predicted more commitment language.

Conclusions

When working to increase motivation among caregivers of adolescents with overweight or obesity, providers should strive to reflect motivational statements, ask questions to elicit motivational statements, and emphasize caregivers' autonomy.

Group Qigong for Adolescent Inpatients with Anorexia Nervosa: Incentives and Barriers

Background

Qigong is a mind-body intervention focusing on interoceptive awareness that appears to be a promising approach in anorexia nervosa (AN). In 2008, as part of our multidimensional treatment program for adolescent inpatients with AN, we began a weekly qigong workshop that turned out to be popular among our adolescent patients. Moreover psychiatrists perceived clinical benefits that deserved further exploration.

Methods and findings

A qualitative study therefore sought to obtain a deeper understanding of how young patients with severe AN experience qigong and to determine the incentives and barriers to adherence to qigong, to understanding its meaning, and to applying it in other contexts. Data were collected through 16 individual semi-structured face-to-face interviews and analyzed with the interpretative phenomenological analysis method. Eleven themes emerged from the analysis, categorized in 3 superordinate themes describing the incentives and barriers related to the patients themselves (individual dimension), to others (relational dimension), and to the setting (organizational dimension). Individual dimensions associated with AN (such as excessive exercise and mind-body cleavage) may curb adherence, whereas relational and organizational dimensions appear to provide incentives to join the activity in the first place but may also limit its post-discharge continuation. Once barriers are overcome, patients reported positive effects: satisfaction associated with relaxation and with the experience of mind-body integration.

Conclusions

Qigong appears to be an interesting therapeutic tool that may potentiate psychotherapy and contribute to the recovery process of patients with AN. Further analysis of the best time window for initiating qigong and of its place in overall management might help to overcome some of the barriers, limit the risks, and maximize its benefits.

Child self-reported motivations for weight loss: impact of personal vs. social/familial motives on family-based behavioral weight loss treatment outcomes

PURPOSE

Parent motivation is related to successful treatment outcome among children enrolled in obesity treatment. However, the impact of child weight loss motivation on treatment outcome has not been investigated. The current study evaluated weight loss motives among treatment-seeking, overweight children, and their relationship to treatment outcome.

METHODS

The current study is a secondary analysis of a primary study examining a parent-only and parent + child childhood obesity treatment. Study participants included 77 children (aged 8-12, 58 % female). Assessments were completed at baseline, post-treatment, and at 6-months post-treatment. Children completed standardized height and weight procedures. In addition, they completed a checklist of reasons children may be motivated to lose weight. Motives were divided into two scales reflecting personal and social/familial reasons to lose weight. Regression analyses were used to calculate associations between the number of weight loss motives endorsed and treatment completion, sessions attended, and child BMI.

RESULTS

A greater number of social/familial motives were significantly predictive of session attendance, treatment completion, and a lower child BMI at the post-treatment assessment.

CONCLUSIONS

Children who are motivated to lose weight because of family/social influences may be more highly engaged in treatment and lose more weight, as compared to children who are less motivated by family and social reasons.

"Just like talking to someone about like shit in your life and stuff, and they help you": Hopes and expectations for therapy among depressed adolescents

OBJECTIVE

To explore hopes and expectations for therapy among a clinical population of depressed adolescents.

METHOD

As part of a randomized clinical trial, 77 adolescents aged 11-17, with moderate to severe depression, were interviewed using a semi-structured interview schedule. The interviews were analysed qualitatively using framework analysis.

RESULTS

The findings are reported around five themes: "the difficulty of imagining what will happen in therapy," "the 'talking cure,'" "the therapist as doctor," "therapy as a relationship," and "regaining the old self or developing new capacities."

CONCLUSIONS

Differing expectations are likely to have implications for the way young people engage with treatment, and failure to identify these expectations may lead to a risk of treatment breakdown.

The role of motivation in family-based guided self-help treatment for pediatric obesity

BACKGROUND

Identifying factors associated with effective treatment for childhood obesity is important to improving weight loss outcomes. The current study investigated whether child or parent motivation throughout the course of treatment predicted reductions in BMI.

METHODS

Fifty 8- to 12-year-old children with overweight and obesity (BMI percentiles 85-98%) and their parents participated in a guided self-help weight loss program, which included 12 brief sessions across 5 months. Parents and interventionists reported on child and parent motivation level at each session. Multilevel slopes-as-outcome models were used to examine growth trajectories for both child and parent BMI across sessions.

RESULTS

Greater interventionist-rated child motivation predicted greater reductions in child BMI; parent motivation did not. However, interventionist-rated parent motivation predicted greater reductions in parent BMI, and its impact on BMI became more pronounced over the course of treatment, such that sustained motivation was more important than initial motivation. Children who were older, Latino, or who had lower initial BMIs had slower reductions in BMI.

CONCLUSIONS

This study suggests that motivation may be an important predictor of reduced BMI in child obesity treatment, with sustained motivation being more important than initial motivation. In particular, interventionist-rated, but not parent-rated, motivation is a robust predictor of child and parent BMI outcomes. Future research may evaluate whether motivational interventions can enhance outcome, with particular attention to improving outcomes for Latino children.