Tel Hai Academic College

The Hebrew University of Jerusalem, Israel

Shahaf, Community Services for Eating Disorders, Israel

Parents as sole agents of change

Barriers and Facilitators

Prof. Moria Golan

Managing Pediatric Obesity

2

Who is in the room?

Targeting parents as the exclusive agents of

change – current research

Barriers and facilitators for program’s success

• Recruitment

• Challenging parents' resistance

• Challenging team difficulties/barriers

• Conclusions3

Outline

Prof. Moria Golan, Israel

Why Parents?

Early

Continual

Sequential

Time-sensitive

Children are more influenced by their parents

4Prof. Moria Golan, Israel

5

Change in Children n=270 Mothers n=198 Fathers n=163

BMI z score

BMI

Mean ±SD

t , p= Mean

±SD

T , p= Mean±SD

T , p=

-0.5 0.2 2.76, 0.006

-0.70±1.2 4.0, 0.02 0.00±3 0.7, NS

Physical

Activity hr +0.4± .14 3.08, 0.002 +0.46±0.7 4.2, .000 +0.4±0.1 3.08,0.02

Sedentary

Activity hr -0.3 ± .11 2.5, 0.013 - 0.4±0.7 3.7, .000 -0.0±0.3 0.8, NS

Exposure to

stimulus -1.08 ±.14 2.19, 0.02 - 1.3±1.5 9.9,0.00 -1.5±0.3 6.35, .001

Self

control*0.2 ±1 2.85, 0.01

Family Obesogenic Load Score** d -5.7 ±7.7 t=12.6 p<0.001

* measured using Go No Go Task ** using Golan’s FEAHQ

Change in Obesogenic factors

Paired samples test at 12 month follow-up (after program termination)

((Golan et al, Int J Child Obes 2006;1:66

Prof. Moria Golan, Israel

Similar results by other researchers

& clinicians about this approach

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USA - University of Florida: Janicke et al, “parent- only

intervention may be a viable and effective alternative to family-

based treatment of childhood overweight” Total cost per child for the

parent-only were 521$ vs. $872 for the child and parent condition

Arch Pediatr Adolesc Med 2008;162: 1119.

Australia, Flinders University:, Magarey et al have shown

that targeting parents only resulted in 10% weight loss in

moderately obese preadolescents and can be maintained 2

yrs from baseline, which justifies an investment in parents

only interventions. Pediatrics 2011;127:214

USA-Boutelle et al, University of California: “A parent only treatment

could provide similar results to parent and child in child weight loss and

other relevant outcomes, and potentially could be more cost-effective and

easier to disseminate. Obesity 2010 ;19:574

Europe –Maastricht University, Jansen et al, “Tackling childhood

overweight: treating parents exclusively is effective”

Int J Obes 2011;35:501

•Australia, University of Queensland, West et al found that

parents-only intervention reduced child body size and resulted

in an improvement in parenting skills and confidence both

immediately after intervention and at 12-month follow-up

compared to waiting list Behavior Research and Therapy

2010;48 : 1170

Belgium-Moens & Braet, Ghent University: Significant

decrease in adjusted BMI has been noted only in the parent-led

group compared to waitlist control. At 1-yr follow-up all

children showed a decrease of 7% in adjusted BMI while the

reference group showed an increase in adjusted BMI over that

period. Behavioral and Cognitive Psychotherapy2012, 40:pp 1-18

Prof. Moria Golan, Israel

Parent-only vs. parent-child (family-focused)

approaches : a systematic review and meta-

analysis Jull & Chen obesity reviews (2013) 14, 761–768

Meta-analysis showed no significant difference in z-BMI from

baseline to end of treatment between the conditions (three trials)

or to end of follow up (two trials).

Parent-child interventions for children are typically resource -

intensive, making for greater difficulties creating scalable

approaches. Interventions that focus on parents may be more

scalable and have higher cost-effectiveness. 7

Recruitment & Compliance

Only 20% of participants seek therapy by internal

motivation

Only one third of families in need of services actually

receive it.

Approximately one third of participants drop out from

the programs

Majority of patients do not complete one-half of the

maintenance visits – WHY?

Parents prefer their kids will be ‘fixed’ rather than

participate in a family-based program 8Prof. Moria Golan, Israel

Patient engagement and attrition

in pediatric obesity

Primary barrier: The parent or child perceiving no

benefit from the visits (36%),

Inability of caregivers to miss work (64%)

Transportation difficulties (59%)

Cost of clinic visits (23%).

9

Hample et al, Pediatrics 2011;128;S59

Prof. Moria Golan, Israel

Passive and Active Recruitment

Passive recruitment involves disseminating information

in the target population through various channels (e.g.,

flyers, advertisements, mailings, and public service

announcements), prompting prospective participants to

contact project staff.

Active recruitment involves bringing the project staff

directly into contact with prospective participants, i.e.,

telephone or in-person appeals by project staff and

medical providers.

10Prof. Moria Golan, Israel

Ways to Increase Recruitment

Utilize many channels of communication during recruitment.

Communication of respect and benefit of participants

Recruiters should be trained to be culturally sensitive, speak clearly, and listen respectfully.

Minimize participants burden and give them control

Framing of program, program location in community, convenient hours ( be flexible ), public transportation line ,free parking, provide child care, refreshments.

Compensation for expenses , incentives (Stickers, Raffle)

Allocate resources. Recruitment often takes longer than anticipated and

requires many phone calls outside of normal working hours.

Warren et al, Int J Pediatr Obesity. 2007; 2: 7385

11Prof. Moria Golan, Israel

Behavioral Change

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People don’t like change

‘The only person who truly welcomes a change is a baby with a full diaper.’

And yet they are ambivalent

Make them see

•They don’t know why? Educate them

Teach them skills

Why is it so hard to change habits?

•They don’t see?

•They don’t know how?

•They don’t care?Scare them

Common health professional views and responses:

The need to change or manage behavior in relation to a health problem

is complex

Improved HCP-patient communication may improvedisease management

There is a gap between the expectations and communication needs of HCPs and patients

Appropriate treatment choice and improved diseasemanagement are associated with the wayHCPs communicate with their patients

There is a need to improve communicationbetween HCPs and patients

Parent Centered Approach

Parents Centered Approach

“People don’t care what you know until they know that

you care and respect them” 15

Prof. Moria Golan, Israel

When people do change?

“We are usually convinced more easily by reasons we havefound ourselves than by those which have occurred to

others”

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Blaise Pascal

Using the suitable communication skills – Motivational Communication

Improvement in the interaction patient – physician

Patient is less defensive

Increased internal motivation for change

Increased chance for behavioral change

Motivational Interviewing

Stephen Rollnick and William Miller, who worked in addiction

treatment, developed the motivational interviewing approach to

behaviour change in the 1980–1990s

Based on work by Carl Rogers on ‘non-directive counseling’ in 1953

and Prochaska and Di Clemente, 1984

•www.motivationalinterview.org

• Motivational interviewing is a collaborative,person-centered

form of guidingto elicit and strengthen

motivation for change

William R. Miller Stephen Rollnick

Multiple levels of engagements

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Group process

Parent

participation

Initial

attendanceRecruitment Retention

Therapy

Process

Therapeutic

relationship

Treatment

acceptability

(Lau, Ho, Webster-Stratton & Reid, 2010)

Prof. Moria Golan, Israel

Medical approach•Tell – Ask – Tell

•Assumes people are rational (no one is rational about

change)

Motivational Interviewing

• Elicit– Provide–Elicit

• Assumes that the people have knowledge about the

problem

• Assumes that the person respond to information

“Dance vs. Wrestle”

What works in Motivational Communication?

Empathize/Elicit what is your understanding about what have you heard about what do you want to know

Provide Info, Advice, Choice Some of what I say may differ from what you have hears

Elicit What do you make of that? Where does that leave you? Exercise

Spirit of Motivational Interviewing

Reasons for change come from the patient and not from the HCP

The ability to change is not a personality trait, but the result of the interactions in the relationship

The HCP is directional in his/her way to explore the patient’s ambivalence

Motivational Interviewing E

mp

ath

y

Collaboration

Explores beliefs and concerns of the patient.

Considers the patient as a partner and the

relationship as a partnership

Em

pow

erm

en

t

Evocation

Elicits reasons, values and resources to change

Autonomy

Accepts and respects choices and decisions of the

patient

Compassion

Listen More Effectively

- Open-Ended Questions

- Affirm Current Efforts

- Reflect Emotions or Intentions, Mirror Intensity

- Summarize Content

Respect the Ambivalence

Choose Goals that Gain Leverage

Postpone the Need to Intervene

Brief Motivational Interviewing

Small blow on coals is enough

to fan the flame

BMI- Brief Motivational InterviewingHansen, ABG et al. Ugeskr Læger 2009;171(43):3132

Ask 4 questions:

1. What do you know about the connection between

obesity and the child’s health?

2. What do you already do to promote healthy habits in

your home?

3. On scale 0-10, how important is for you to improve the

obesogenic environment at home/control your child’s

health?

4. On scale 0-10, how confident are you in your ability to

improve the obesogenic environment at home?

How much time would it take?

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Ways to Increase Recruitment & EngagementMotivational Interviewing spirit & skills

(Miller & Rollnick, 2002)

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Give Good Initial Rationale (Ask-Tell-Ask)

(tied to caregiver’s goals, language & expectancies(

Collaborative language

Listening/looking for ambivalence and inquiring

Clarification of parent’s point of view

– use OARS, rolling with resistance, eliciting

and reinforcing change talk (MI)

OARS – Open ended questions, Affirmations, Reflections, SummariesProf. Moria Golan, Israel

Multiple levels of engagements

28

Group process

Parent

participation

Initial

attendanceRecruitment Retention

Therapy

Process

Therapeutic

relationship

Treatment

acceptability

(Lau, Ho, Webster-Stratton & Reid, 2010)

Prof. Moria Golan, Israel

ENGAGEMENT DEFINED

Broadly:

An active process whereby the professional and an

individual make a commitment to work together to

accomplish mutually agreed upon goals

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• Reminders call

• Contact those who missed sessions/ send letter with the missed content

• Emphasis on collaboration vs. didactic prescriptions

• Non blaming and non confronting approach

• Focus on parents strengths, knowledge and resources

• Identification of concrete, practical issues to be addressed

• Development of a plan to overcome barriers to ongoing

involvement with the agency Prof. Moria Golan, Israel

Engaging families in treatment

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I. Signs of Engagement1. Attendance

2. Decreased negativity

3. Trust

4. Agreement on goals

5. Active/Emotional involvement

6. Follow through

II. Signs of Disengagement1. Missed Appointments

2. Expressed blame and negative affect

3. Distrust

4. Lack of Agreement

5. Avoidance Prof. Moria Golan, Israel

Problems Encountered Parent ambivalence

– “does not look overweight, weight fluctuates, pediatrician has not

mentioned this as a problem, will grow out of it”

Parents find limit setting around food very hard– Feel like they are depriving the children: “How can I not buy her

an ice cream every day at the pool when other kids are getting

one? ”

Influence of other social systems (fathers, grandparents,

friends)

– Fathers often not on board and will bring in unhealthy food

– Grandparents as daycare providers or babysitters challenging

– Example: one mother told us her friend confessed to taking her 4

year old daughter for an ice cream every time she babysat

because she felt mom was depriving her 31

Resistance arises from the interpersonal interaction

between therapist and client, not some personality flaw

of the client!!!

Counseling should be a dance, not a wrestling match

Ways to handle resistance effectively include:

–Simple reflection, amplified reflection, double-sided

reflection, shifting focus, reframing, emphasizing

personal control, and siding with the negative32

Rolling With Resistance

Prof. Moria Golan, Israel

Eating out very difficult to impact

– Parent don’t like to cook or don’t know how

– Belief that dinner needs to be an elaborate meal

– Parent desire for fast food

– See eating out as the only “treat” parent gets or only social time

Difficulties with time management and organization– Parents feel they have no time to do their own exercise or for child

to play

– Parents feel they have no time to cook

– Parent job demands & school and child activity demands

Parent food preferences and dislikes– Not unusual for parent to have limited vegetable and fruit likes

– Parents eating in response to stress

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Problems Encountered (cont)

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Impacting

Personal Appeal-> Internalization

Professionalism-> Identification

Authority-> Pleasing

Kelman , 1974. Further thoughts on the process of compliance, identification

and internalization. IN: Tedesci JT (ed). Perspectives on social power

Prof. Moria Golan, Israel

Ways to Increase Retention

Well trained program facilitators

Communication of respect and benefit of participants

Minimize participants burden and give them control –convenience, be flexible

Compensation for expenses , incentives (stickers, raffle)

Buddy System• Refreshments

• Phone call reminders, newsletters and birthday cards

• Instrumental or tangible support, enlist support from others

Be patient yet persistent

Intensive follow-up and contact with subjects, maintain a good tracking system

(Coday et al, 2005; Robinson et al, 2007; Nicholson et al, 2011).

35Prof. Moria Golan, Israel

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Management of

weight-related

issues

Therapeutic

Environment

Family

Environment

Counseling Environment

Parallel Process in Team Supervision

Cohesion Coalitions

System:

Family or

organization? Parenting

style

Organization

culture

Counseling

style

Prof. Moria Golan, Israel

CONCLUSIONS

Retention and engagement are fluid and continuously shaped by

participants’ program experience, personal networks, and

cultural norms and standards as well parental factors, provider

characteristics and the nature of parents-providers relationships.

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Novel ways are needed to increase recruitment, retention, follow-

up assessments as well remote treatment options.

Adequate resources should be allocated for staff supervision,

family incentives and data management.

Treatments shown to be efficacious require a second-stage

feasibility study to determine their effectiveness in the real world,

and then third phase, multi-site testing for effectiveness in

different settings. Prof. Moria Golan, Israel

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Key Message For Clinicians

Parents and clinicians are only ‘good enough’

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moriag@netvision.net.il

http://www.shahaf-ltd.co.il/n/default.asp?ID=42