CLIMATIZACIÓN 1 OBJETO

One way to discuss a child’s development is to consider three broad areas of matura-tion and growth: gross and fine motor abilities, language acquisimatura-tion, and psychosocial skills. In this discussion, our primary focus is on how children’s psychosocial develop-ment affects the use of MI and, in particular, the opportunities we have to engage with patients and their families. Naturally, a child’s motor and language skills also influence how therapeutic relationships develop.

We begin by reviewing psychosocial development stages and how these pertain to MI (Fig. 11.1). Subsequently, we discuss strategies that are particularly well suited to each individual stage.

Very Young Children

• Before their first birthday, most children begin to exhibit a growing sense of auton-omy and independence, combined with increasing cognitive and problem-solving abilities. Some of the changes parents describe in their children include the following:

• expressing anxiety around strangers, often as early as 8–9 months

• readily expressing pleasure/displeasure with specific toys, activities, people, and places

KEY POINT

Family as patient – Both patient and family can be engaged to promote healthy behaviors.

145Pediatric Settings

• actively responding to positive interactive behaviors such as holding, cuddling, and praising, in addition to verbal prohibitions against biting, hitting, and kicking

• demonstrating familiarity with daily routines

• recognizing and responding to pleasure/disapproval from their caregivers

• energetically exploring the world around them, both indoors and out

• frequent vocalizations, babbling, and acquiring simple words to indicate desires and intentions

• By 18  months, children devote more energy to social interactions, such as the following:

• learning the concepts of choice and preference, and becoming assertive about their wishes

• saying “No!’’ as a way of asserting autonomy

• expressing frustration with the tension between insisting on independence ver-sus physical and emotional dependence

• increased mobility, which allows the child to actively pursue people, objects, and activities of interest

Toddlers

• Between 2 and 3 years of age, most children engage in parallel play in which:

• groups of two or more children play alongside one another without interacting or exchanging toys; a child may observe other children and modify his or her behavior in response

• they often wish to assert a choice yet have difficulty choosing

• 3-year-olds engage in trial-and-error learning and:

• look forward to pleasurable activities and fear less desirable events

• enjoy mastering new skills, whether gross/fine motor or language toddlers (ages 1–3): interactions are primarily with parents

engage patients directly using open-ended questions by age 3

use the same MI approach to engage parents

preschool (ages 4–6): children respond well to praise and firm rules explain medical advise to both child and parent

school age (ages 7–10): speak directly to patient

continue affirmations and limit setting

give patients the opportunity to take responsibility for their own health

adolescents (ages 11–21): with early adolescents, separate patient from parents for part of the encounter clearly explain patient confidentiality and the circumstances under which it can be broken young adolescents respond well to the

spirit of MI and OARS

older adolescents can often work with the full scope of MI

FIGURE 11.1 Engaging patients across developmental stages.

Motivational Interviewing146 • benefit from being included in family discussions

• need frequent reminding about safety hazards such as cars and hot stoves

A key point when engaging with young children is to approach the encounter in a relaxed, nonthreatening manner. Avoid using closed questions that invite “Yes” or

“No” answers; instead, offer choices wherever possible: “Which ear would you like me to look into first?”

Preschoolers: 4–6 Years

• Beginning around age 4, children start to play collaboratively with others, and:

• are driven by curiosity and a desire to explore

• respond well to praise and clearly stated rules

• are narcissistic but are beginning to be aware of how those around them feel

• The major transition in this age group is starting school:

• they are expected to obey rules, play well with peers, avoid disruptive behavior, and tolerate negative consequences when rules are broken

• team sports allow children the chance to learn sportsman-like conduct, improve physical competencies and coordination, and build friendships

• language skills of comprehension and self-expression continue to expand

• the ability to assume responsibility for simple tasks such as tidying up toys enhances autonomy and feelings of both competence and independence Children in this age group typically possess an ability to talk about their family, friends, and experiences. Similarly, they are capable of understanding basic explana-tions concerning what is happening and why, and they are more likely to cooperate if they are addressed directly. Remember that a child’s vocabulary sometimes exceeds his or her comprehension: therefore, use clear, simple words and expressions.

School Aged: 7–12 Years

• 7–8-year-olds:  ongoing cognitive and emotional development, combined with improving communication skills, leads to more mature independence:

• newly formed conscience allows greater comprehension of rules, relationships, and morals

• problem-solving abilities improve as children demonstrate greater attentive-ness, cooperation, and a capacity to focus on most aspects of a problem

• the growing influence of peers may produce internal conflict as children dis-cover differences between competing value systems, and family conflict as par-ents/caregivers adapt to new expressions of independence

• By age 9–12  years, a child’s independence from family becomes increasingly evident:

• parents acknowledge independence by providing youngsters opportunities to earn privileges in return for doing various household chores

• many children are susceptible to negative peer pressure; this may be minimized by supporting the child’s self-esteem and confidence

• vulnerable children begin to engage in risk-taking behaviors as a result of peer pressure such as drug/alcohol use, smoking, or gang involvement

147Pediatric Settings

• some children begin to mature sexually and become aware of sexual themes and images in popular culture; it is important that they have access to accurate age- and culturally appropriate information from multiple sources

While parents of school-aged children maintain a key role in our therapeutic relation-ships, as trainees, we are now able to engage directly with our younger patients. As before, remember that a child’s vocabulary and demeanor may not accurately reflect his or her comprehension of a given situation.

Adolescents: 13–21 Years

• In early adolescence (ages 13–14 years), children have a strong need to be part of a peer group, even as they pursue independence:

• emboldened by a close group of friends, adolescents may disregard caution to sat-isfy their curiosity—occasionally this may be misinterpreted as overconfidence

• the temptation to explore new experiences, especially those considered “cool” or likely to increase one’s social status, is difficult to resist for adolescents unable to appreciate potentially negative consequences of their actions, or for those with low self-esteem who fear being ostracized by the group

• a profound desire for independence combined with mood swings may cause conflict with family members and rebellion against household rules

• During middle adolescence (15–17  years), teens often become heavily involved with school and school-related activities such as sport, drama, band, and so on

• these activities present important and enjoyable opportunities for building posi-tive self-esteem through physical, intellectual, and emotional challenges

• physical appearance is especially important at this time

• friends become a primary source of both correct and incorrect health information:

• many experiment with risk-taking behaviors such as tobacco, alcohol, and other drug use, and unsafe sexual practices

• adolescents with chronic medical conditions often begin to question the necessity of long-term medications

• interest in dating and physical intimacy/curiosity increases

• By age 18–21 years, physical development finishes, whereas cognitive development continues:

• most older teens have established a self-identity and have begun to refine their moral, religious, and sexual values

• they have a rational conscience and are able to compromise and make wise decisions

• typically, autonomy increases as parental guidance decreases; however, life stressors and one’s access to drugs and alcohol increase

• young people now begin to look ahead to adulthood, especially with regard to career choices

Given the extremely wide variations in maturational level over the course of adoles-cence, chances are high that you will encounter an equally broad continuum of indi-vidual patients, ranging from those who resemble fragile schoolchildren to those who

Motivational Interviewing148 appear to function as adults. Attune yourself to subtle nuances of facial and verbal expression in your interactions with young people; often, these are as important, if not more so, than the actual words they use.

The marked differences in psychosocial development between young children and late adolescents illustrate why some elements of MI are more important than others, depending on a patient’s age and maturity level. The following case studies help demonstrate how MI strategies may be tailored to suit different children’s needs.