Exploring the use of Motivational Interviewing with a disengaged primary-aged child

Abstract

Research suggests motivational interviewing (MI) techniques are both widely-used by educational psychologists (EPs) and effective in supporting young people of secondary age. To date, there has been no published research investigating the use of MI with primary-aged children. This study details the use of a short MI-based intervention with a primary-aged pupil identified as disengaged. A case-based approach was employed, using pupil and teacher interviews and observational fieldnotes to assess the usefulness of the intervention. Data were analysed using thematic analysis and the intervention checked for adherence to the MI spirit and principles. Here the process, structure and outcomes of the intervention are exemplified through an illustrative case study with a nine-year-old boy. Results indicate that the adapted intervention had a significant impact on learning motivation and classroom behaviour. The implications of the findings are discussed in relation to the use of school-based therapeutic interventions by EPs.

Keywords:

• motivational interviewing
• motivation
• therapeutic intervention
• primary school children
• disengaged

Introduction

Background to Motivational Interviewing

Motivational Interviewing (MI) was first described by Miller (1983) who combined and adapted elements of Rogers’ client-centred therapy, Festinger’s (1957) theory of cognitive dissonance and Bem’s (1967) self-perception theory. MI gained increasing interest in the late 1980s and in 1991, the seminal text Motivational Interviewing: Preparing people to change addictive behaviour, was published (Miller & Rollnick, 1991). Over the years, MI has been modified and adapted for use in many clinical areas, including addictive behaviours, mental health and medical management (Miller & Rose, 2009). The majority of research over the last 30 years has investigated the use of MI with adults and a considerable volume has yielded positive results (Burke, Arkowitz, & Menchola, 2003; Miller & Rose, 2009). The central premise of MI, and what potentially distinguishes it from other therapeutic approaches, is the idea that the client may be ambivalent about change and may see advantages in maintaining a behaviour, such as alcohol or drug use, which is perceived by others to be problematic. Atkinson and Woods (2003) highlight its potential usefulness in work with child and young people, where the impetus for referral is typically from a third party.

Miller and Rollnick (2002) describe three overarching aims pertaining to the “spirit” of MI and four practical principles defining the practitioner role. These are paraphrased in Figures 1 and 2.

Figure 1. The spirit of MI (from Miller & Rollnick, 2002).

Figure 2. The principles of MI (from Miller & Rollnick, 2002).

The notion of active listening is fundamental to MI and characterised by the mnemonic “OARS”, which stands for open-ended questions, affirmations, reflections and summaries (Miller & Rollnick, 2002). Frey et al. (2011) describe the importance of change talk, which occurs after the client’s motives for change have been established (Miller & Rollnick, 2002). It is elicited by the practitioner, who highlights the advantages of the change and the disadvantages of the current situation, while retaining a “non-expert” role, which allows the client to begin to weigh up the advantages and disadvantages of current and future behaviour.

MI as an intervention

Miller and Rollnick (2009) note that MI involves a complex set of skills and significant training and supervisory input. Indeed the complexity of MI is demonstrated by issues in assessing practitioner competence (Moyers, Martin, Manuel, Hendrickson, & Miller, 2005). There have been a number of attempts to offer frameworks for MI, which may have arisen out of practitioner need for greater structure. These may be particularly relevant to the non-specialist and include the Menu of Strategies (Rollnick, Heather, & Bell, 1992), Motivation Enhancement Therapy (Miller, Zweben, DiClemente, & Rychtarik, 1994) and guidance for the ‘competent novice’ (Rollnick, Butler, Kinnersley, Gregory, & Mash, 2010). However, Miller and Rollnick have voiced concerns that these sort of models might be diluting or simplifying MI (Rollnick & Miller, 1995; Rollnick, Miller, & Butler, 2008.)

The other framework frequently used to support MI has been the Trans-theoretical Model (TTM) (DiClemente & Prochaska, 1982), also referred to as the Model of Stages of Change within an educational context (McNamara, 1992). This provides a visual representation of the stages that clients may pass through when addressing behavioural change. Frequently MI and the TTM have been used in conjunction in both educational and clinical settings (for example, Erol & Erdogan, 2008; Kamen, 2009) and within educational settings they are often seen as synonymous (Atkinson & Amesu, 2007). In recent times, Miller and Rollnick have increasingly distanced MI from the TTM (Miller & Rollnick, 2009). However, without this sort of structure, MI may be inaccessible to the non-specialist without extensive training and supervision, rarely available to professionals working in educational or youth settings (Atkinson, 2014). Despite this, research suggests that MI is a widely-used approach for educational psychologists (EPs). Thirty-one per cent of a sample of 455 practitioner EPs reported using MI, making it the fourth most popular therapeutic approach after Solution Focused Brief Therapy, Personal Construct Psychology and Cognitive Behavioural Therapy (Atkinson, Bragg, Squires, Muscutt, & Wasilewski, 2011).

MI with children and young people

MI by its nature is not directive or authoritarian and, as such, it is argued that its techniques are best suited for young people who require a more collaborative and non-confrontational approach (McCambridge & Strang, 2004). The majority of research with young people has focused on substance related behaviours, including smoking (Colby et al., 1998), drinking (Monti et al., 1999) and marijuana use (Stephens, Roffman, & Curtin, 2000). More recently MI techniques have been used to support young people suffering from depression (Brody, 2009) and self-injurious behaviour (Kamen, 2009). In Sweden the use of MI techniques with overweight children aged five to seven was investigated (Söderlund, Nordqvist, Angbratt, & Nilsen, 2009). The study looked at the barriers and facilitators to nurses’ application of counselling techniques, but did not consider the efficacy of MI as an intervention. This research is a rare example of MI techniques being used with young children; although closer inspection suggests that although the children were theoretically the focus of the techniques, these tended to be used with the parents rather than the children.

In the early 1990s, McNamara (1992) perceived the benefits of MI within education, advocating its use by educational practitioners in a positive, non-threatening manner to explore pupils’ reluctance to change. It has since been utilised with young people in the educational sectors with growing interest and encouraging results (Atkinson & Amesu, 2007; Atkinson & Woods, 2003; Kittles & Atkinson, 2009; McNamara, 2001, 2009). Manthey (2011) found MI impacted on the behaviour of individuals attending post-secondary education, noting that MI helped increase autonomy and independence.

Frey et al. (2011) proposed that MI will be used increasingly within educational settings because of its flexibility and the encouraging evidence-base it is producing. They also observe that MI has mainly been used with adults, adolescents and pre-adolescents rather than younger children, adding “… the study of MI with young children is only just beginning. It may be plausible that MI could be utilised with young children with some effectiveness” (p. 2). Additionally, Woods, McArdle, and Tabassum (2014), having undertaken a systematic review of UK literature relating to the use of MI with children and young people in schools, call for “Case study research to explore the use of MI with younger children e.g. of primary school age, and establish its possible effectiveness through age-appropriate adaptations” (p. 2).

McNamara (2009) proposes that interventions for younger children with social, emotional and behavioural difficulties have predominantly focused on behavioural interventions, and are thus limited in their capacity because they assume that behaviour is changed extrinsically. He adds that interventions for younger children are shifting towards those that focus on thoughts, feelings, intrinsic motivation and collaboration, which are properties incorporated in MI. However, the use of MI techniques with primary school children is currently an under-researched area and at the time of writing, no published research could be identified that investigated its use with this population.

Methodology

The research employed an exploratory case study approach (Yin, 2009) involving two units of analysis:

•	To investigate whether MI techniques can be used successfully with younger children and remain true to the overarching spirit and principles of MI (process).
•	To investigate whether MI techniques can facilitate and elicit behaviour change in younger children (outcome).

Participant

The case study described here involves a pupil identified opportunistically through consultation with the school’s special educational needs coordinator (SENCo) and class teacher. The participant was a mainstream pupil of White British heritage, aged 10, identified, by his teachers, as having social, emotional and behavioural difficulties. Because previous research indicates that language and communication difficulties may be a barrier to accessing MI (Kittles & Atkinson, 2009) an additional inclusionary criterion was an average range score in a standardised language assessment. Pupil, parent and teacher consent was established at the outset via a face-to-face meeting and information letter.

The intervention comprised four, weekly sessions of MI, delivered by the first author. The intervention was adapted from the Facilitating Change 2: Motivational Interviewing using the menu of strategies resource (Atkinson, 2013) which employs a young-person friendly version of the Menu of Strategies intervention proposed by Rollnick et al. (1992). The intervention is fundamentally based around the principles of MI, including the spirit and principles (Miller & Rollnick, 2002). However, additionally it incorporates aspects of the TTM in order to help both the facilitator and the young person understand notions of ambivalence about and readiness for change.

It should be noted that the case study here is part of a larger dataset, with the original research involving three participants. However, it was felt that, within the scope of this article, it would be most helpful to present one case example in depth. Details of and outcomes for the other participants are described in the Appendix to this article. More detailed information about all of the cases in this research is provided by Cryer (2013).

Data collection and analysis

Because this study was the first to look at the effectiveness of MI with a primary-aged pupil, qualitative techniques were adopted to allow an explorative, descriptive and detailed case study to determine the appropriate area of focus for quantitative research to be conducted in the future.

The researcher collected data from the following sources:

•	Transcription of audio recording of four MI sessions.
•	Materials from MI sessions, which included the completed work sheets and activities.
•	Researcher diary, which included notes written by the researcher during the interventions sessions, and researcher reflections written a short time later.
•	Self-formulated assessment form, which allowed the first author, as facilitator of the intervention, to make a session-by-session assessment of the adherence of the intervention to the spirit and principles of MI (see Figures 1 and 2). This was achieved by identifying each of the components individually and providing a corresponding rating. For example, for autonomy, “On a scale of 1-10 (10 being autonomous at all times and one not being autonomous) where do you think the young person was?” This was important in order to ensure the fidelity of the intervention as being MI based, although limitations include the fact that the measure was self-report and not standardised.
•	Semi-structured interview with pupil, which was developed to be short and interactive to engage the child and enable him to voice his opinions without finding it difficult to formulate his words. Scaling questions and pictures were used to ensure that the interview was age-appropriate.
•	Semi-structured interview with the teacher, which included eight short questions relating to the child’s behaviour pre- and post-intervention, and current situational factors, which might contribute to changes in behaviour.

Data from all sources were analysed using Thematic Analysis, as described by Braun and Clarke (2006). Emergent themes and codes were checked for construct validity and reliability by an independent researcher for inter-coder agreement.

Results

Because the case study was exploratory, the methods used yielded qualitative data. Successful outcomes in relation to thoughts, feelings and observable behaviour were reported via the teacher and pupil interviews.

Case study – Neil

Neil (aged 10) lived with his mother and older brother. Neil’s parents were in the process of a divorce, although he was in regular contact with his father, who lived close to the family home. It is possible that his parents’ divorce and his resultant feelings of bereavement and loss may have contributed to his lack of engagement. However, Neil’s teacher did not believe this to be the sole trigger and reported a significant decrease in Neil’s motivation and self-esteem over the last 18 months, with specific concerns about Neil becoming disengaged from curriculum activities. Before the MI intervention, Neil’s class teacher described his behaviours as:

•	Arrives late most days and looks tired.
•	Rarely makes eye contact.
•	Seems forlorn and rarely smiles or laughs.
•	Will not volunteer answers and looks annoyed if asked a question.
•	Takes a long time to initiate a task and often does not finish his work.
•	Generally unmotivated within the classroom.

Neil initially presented as a quiet, shy boy, who was losing confidence in his own ability, and feeling apathetic towards education. At the end of the sessions, he appeared more confident in expressing his own opinions and demonstrating his skills. This change was observed by his teachers, who noticed a difference in Neil’s behaviour at school.

Description of the intervention

Four sessions of MI were facilitated by the first author. All lasted between 45 minutes and one hour. Table 1 portrays the activities used (from Atkinson, 2013) and details about each session with Neil. Specific adaptations to the programme, to make it accessible to Neil, are shown in italic typeface.

Table 1. Outline of the Motivational Interviewing (MI) sessions.

Session	Activities	Description
Session one	Words that describe me	Allows child to begin to consider that different individuals have different skills and assets.
	My skills profile	Aimed at eliciting individual’s strengths and skills.
	Opening discussion	Uses a worksheet and coloured felt tip pens. Helps child to develop an understanding of the different aspects of his life.
Session two	A good day	Aspects of a good day discussed using a work sheet and coloured felt tip pens.
	A not so good day	Aspects of a not so good day discussed, as earlier.
	My lessons	Considers lessons child enjoys, does not enjoys and the respective reasons.
	Favourite and least favourite lessons	Considers what others would see child doing in these lessons using role-play to explore behaviours and emotions.
Session Three	What would someone see-good lesson/not-so-good lesson	Develops an understanding of the discrepancy between child’s behaviour in different lessons
	The good things and less good things about....	Identifies potentially problematic behaviours and facilitators and barriers to change.
	Weighing it up	Uses practical materials and activity to create weighing scales. Each facilitator and barrier is put onto the corresponding side. Use of role play, with child as the set of scales.
	Thinking about change	Considers motivation and ability to change
Session four	Looking into the future	Considers child’s future life; for example, job, health, hobbies.
	Using my skills to change	Reflects on child’s skills and how these might support change.
	Using the wheel of change to think about change	Considers position on wheel of change [adaptation of the Trans-theoretical Model (TTM)].

Themes from transcripts and notes about the intervention and from subsequent discussions with Neil and his teacher will now be detailed. Within the text, emergent codes are italicised. The first thematic map (Figure 3) details themes emerging in relation to the use and adaptation of the MI materials.

Figure 3. Themes emerging in relation to adaptation of MI materials.

The first superordinate theme related to Neil’s engagement with activities and yielded a number of sub-themes. There was evidence that Neil enjoyed self-concept activities. He engaged well with tasks which required him to think about his skills and strengths. Neil noted that he enjoyed these activities and thought pupils his age would enjoy them too. The activities generate a profile of the individual’s skills, which Neil enjoyed discussing. Neil also enjoyed practical elements and was able to develop his self-awareness most effectively during the practical activities. As an adaptation to the intervention, practical elements were consequently increased, such as the use of role play. This suggests that using MI approaches in a practical manner might appeal to younger pupils, which might be an area for further research. It was evident that Neil was enjoying the sessions and appeared happier and more relaxed as the intervention progressed.

Neil demonstrated a need for clarification, and asked lots of questions. These however decreased as the sessions continued. Neil’s “clarification questions” tended to regard whether he was conducting the activities correctly or how he should tackle a task. However, there were times when Neil asked for clarification about issues important to him when discussing his feelings openly.

One theme of particular interest was pupil adaptations, as it offered a perspective into the feasibility of using MI techniques with younger children. The adaptations Neil made tended to be minor but relevant and interesting. For example he helped himself to develop a clearer picture of the completed activities by placing stars (provided by the facilitator) next to points he considered to be particularly important. Neil also chose to use coloured felt tips (available during all sessions) for the activities and often used different colours for opposite phenomena, for example, orange for “not so good” and green for “good”. Neil’s teacher felt that the individual attention from the facilitator, somebody external from school, was important and he appeared more comfortable with somebody who he perceived as neutral and commented that he enjoyed the relationship with the facilitator. This perhaps suggests an important role for peripatetic practitioners and emphasises the importance of the collaborative relationship between client and practitioner.

The theme of life changes depicts the difference between being a young child and thinking about exams, secondary school and possibly even adult life. MI techniques appeared to allow Neil the opportunity to consider his life carefully, in some detail. In a busy school environment, this is perhaps an opportunity that does not occur often. Coded as freedom when younger/increased responsibility now, the MI activities provided Neil with opportunities to consider his life when he was younger. Neil reflected with some sadness on his time in the lower end of primary school, particularly on the transition away from the “freedom” of his early school days. He tended to describe his past with words such as “fun” and “play” and his current situation with words such “work” and “exams”.

The MI based activities aim to elicit conversations about future aspirations with a view to building internal motivation to achieve goals. It is perhaps not surprising then that Neil was able to consider specific future elements, for example, car, house, job and family structure. This was enabled through using worksheets, although his decisions were perhaps reflective of his age, for example, he decided that he would drive an expensive sports car when he was older. However, even at such a young age, Neil was able to identify realistic goals such as having a family and playing football as a hobby.

Another feature of the MI intervention was the information it yielded about the pupil’s perceptions, feelings and preferences. Key themes here are presented in Figure 4.

Figure 4. Information elicited using the MI intervention.

An important organising theme emerging from the MI was related to Neil’s home circumstances. Neil mentioned a positive family network in relation to some of his personality traits, positive memories and in sibling interactions. His thoughts and feelings about his family appeared to contribute to his self-concept and have a major influence in his life. Although only two of the MI activities specifically ask about family, Neil often brought family members into discussions and this became a theme throughout the sessions. However, although Neil’s teacher felt that a recent parental divorce had had a big impact, Neil acknowledged the event but he did not discuss it in detail. The MI activities appeared to allow Neil to consider how family relationships impacted upon him. When Neil spoke of his friends and hobbies, he appeared excited and he was eager to share details about them, discussing his cycling and computer skills. This theme reflects a clear, positive aspect of Neil’s life.

The MI activities required Neil to consider the aspects of school that he liked under school is positive. Neil’s comments suggested that in many cases he enjoyed lessons at school and the activities allowed him to reflect on the reasons why he enjoyed some lessons over others. Neil’s understanding of positive feelings linked with certain lessons and output of work also appeared to increase. Throughout the sessions it was clear that Neil was motivated by praise and reward. Within the MI sessions Neil placed a lot of value on receiving rewards and praise, for example, moving up a set and receiving a prize.

Under the theme of school is negative, Neil reflected on boredom at school; when he did not like a lesson or an activity, he viewed it as “boring”. He was asked to elaborate on his reasons for feeling bored, but at the time felt unable to do so. Neil discussed the pressure of school life, particularly in terms of peer groups and exams. Neil’s teacher also felt that he had a lot of work pressure on him and felt that this may have been a contributing factor to his decreased motivation.

The final overarching theme emerging from the data analysis centred on the outcomes for the pupil from using MI techniques. These are summarised in Figure 5.

Figure 5. Outcomes of the MI intervention.

The organising theme here relates to behaviour/motivation change. More specifically, coded as increased self-efficacy, Neil seemed to increase his belief that he could complete tasks and achieve goals he did not think possible prior to the sessions. During an earlier session, Neil explained that to achieve the top prize in class you have to be “One of the good ones”; however, just before the last MI session, he achieved this goal. The teacher also recognised Neil’s increased perception of his ability and felt that this was reflected in his increased work output. More generally, within increased teacher awareness/behaviour change, it appeared that Neil’s teacher had developed an increased understanding of his needs. She commented that she was providing him with more encouragement and praise to achieve tasks and that her increased awareness and “noticing” had possibly supported behavioural change. Neil’s teacher had ensured he felt “noticed” by providing him with a significant part in the school play so that he felt important.

Reaching potential now derived mainly from the teacher’s comments in the semi-structured interviews. It was evident that Neil’s teacher felt he had always had the potential to achieve, but that this had not been realised prior to the intervention. Between the third and fourth sessions, Neil had achieved the weekly school award for “most effort made by a pupil”. Neil’s teacher felt the most significant change was increased pupil autonomy. This depicts Neil’s improved work output without the support or encouragement he had previously required. He was reportedly able to start activities without being reminded and improved his ability to work independently. The evidence collated indicates clear changes in Neil’s presentation and observable behaviours. However, it is recognised that these changes can be attributed to other factors separate to the intervention. If it is accepted that the changes are likely to be a result of the intervention, it is not possible to determine whether the changes are unique to MI techniques or to factors such as: relationship with facilitator, additional attention from teacher and the opportunity to work with an EP on a weekly basis.

Evaluation of the intervention

The intervention was a child-friendly development of the Brief MI (Rollnick et al., 1992) and therefore should be considered an adaptation of MI. This is consistent with previous meta-analyses of MI which report adaptations to be typical (Barnett, Sussman, Smith, Rohrbach, & Spruijt-Metz, 2012; Burke et al., 2003). However, it is vital that the MI intervention embodies its spirit and principles. For this purpose, a self-formulated assessment was devised, which allowed the first author, as facilitator, to offer an interpretation of the adherence to the MI spirit and principles during the sessions with Neil. Outcomes are shown in Table 2.

Table 2. Adherence to Motivational Interviewing (MI) spirit and principles.

Spirit and principles	Session one	Session two	Session three	Session four
Autonomy	6^a	7	8	9
Collaboration	10	10	10	10
Evocation	8	7	8	10
Express empathy	9	10	10	10
Develop discrepancy	10	10	9	10
Roll with resistance	9	9	9	9
Support self-efficacy	10	10	10	10

^a Ten indicates element of spirit/principle demonstrated at all times; one spirit/principle not demonstrated.

These values in Table 2 suggest a generally strong adherence to the MI spirit and principles. In the first and second sessions Neil asked questions and sought the researcher’s approval for many of the tasks, making it more challenging to allow him to remain autonomous. However, Neil’s autonomy increased as he attended more MI sessions and this appeared to be a result of both the researcher–participant relationship and Neil’s increase in self-efficacy. From the spirit tripartite, “collaboration” appeared to be important, as over the sessions Neil was able to build up a collaborative and respectful relationship with the facilitator, although the authors acknowledge this element is not unique to MI.

While there is evidence to suggest the MI techniques were suitable and appropriate, there were some aspects of the MI activities which Neil found more challenging, for example, open-ended, higher-order language questions. When the practical and kinaesthetic elements of the techniques were increased, Neil was better able to reflect and consider more complex thoughts.

It is important to acknowledge that Neil was at a time in his life when he was experiencing changes, for example, increased academic pressures and consideration of secondary school. Motivational techniques being used prior to the MI intervention focused on external motivators (rewards and sanctions) and although these were having a minimal impact on his behaviour, his overall levels of motivation and resiliency were low. The work sheets and activities used in the MI sessions provided Neil with opportunities to discuss aspects of his self and increase knowledge and understanding of his current status, skills and abilities. During and after the sessions, Neil’s belief in his own ability and knowledge of his individual skills increased; this was evident from the teacher and pupil comments. Neil’s behaviour and motivation also increased during the course of the MI sessions; also evident from teacher and pupil comments. A follow up conversation with members of school staff indicated that Neil’s levels of motivation had remained high five months post-intervention. It should be noted that this article does not assert that the observed changes in Neil were solely a result of MI. It is accepted that this is a single case study with methodological limitations and results cannot be generalised. However, this research offers an opportunity to perceive how MI techniques might be used by EPs working in primary schools.

Discussion

In his compendium of (mainly educational psychology) practice, Motivational Interviewing: Theory, Practice and Applications with Children and Young People, McNamara (2009) questions “Can [MI] be used effectively when working with young children?” (p. 209). This case study research offers tentative indications that MI techniques may be useful in supporting primary-aged children, albeit towards the upper age range, who experience difficulties with disengagement. The discussion will briefly explore some of the possible advantages of using the approach, before discussing opportunities for using MI with younger children and future areas of research.

McNamara (2009) posits that the answer to the question earlier is likely to depend on the skills of the therapist to translate MI theory and practice into child-friendly language which is understandable and meaningful to the child. In the case described, it was felt that the combination of using a pack of MI-based materials specifically aimed at young people and making appropriate and flexible adaptations to the activities helped to enable positive outcomes for the pupil. MI itself, having arisen from practice, can be theoretically complex and may require additional structure (for example, the TTM or a practitioner framework) in order to make it accessible to the non-specialist (Atkinson, 2014). Additionally, while the intervention in question is based on MI constructs and techniques, it is useful to note that adapting materials for younger children requires the therapeutic intervention to become further removed from how MI might look within adult clinical settings, essentially a dyadic talk-based approach. Kamen (2009), when using the TTM alongside MI with adolescents who were self-harming, acknowledged that the approach used required its own empirical validation and it may be appropriate for MI-based interventions with younger children to be viewed in a similar light.

Another interesting consideration is that the MI intervention appeared useful in harnessing important assessment information about the child’s context and views. This supports findings from Kittles and Atkinson (2009) that MI can have a role in assessment, even as a “one-off”. It is also synonymous with research by Atkinson et al. (2011) which revealed a strong assessment component of work undertaken by EPs. While time available to EPs for ongoing therapeutic intervention can present a barrier, it is typical for them to assume a caseworker, rather than therapist role, coordinating ongoing support through parents, school-based staff and other professionals, as well as optimising affective and educational factors in the child’s school environment. The role of the teacher here as facilitator is interesting, for instance, rewarding Neil’s behaviour and improving his status through offering him a part in the school play. Asay and Lambert (1999) attribute up to 40% of change to extra-therapeutic factors, and the ability of EPs to spot potential “levers for change” outside the therapeutic relationship may be instrumental in improving outcomes.

Another factor which appeared to be facilitative of pupil engagement was the relationship between the facilitator and the pupil. Asay and Lambert (1999) found that the relationship between the client and the counsellor was pivotal to successful therapy, potentially accounting for 30% of the client change. Noteworthy in this research is the fact that the practitioner was required to adhere to the spirit and principles of MI (assessed using the self-evaluation sheet), which emphasise the importance of collaboration and empathy – key components of the client–counsellor relationship (Asay & Lambert, 1999). Furthermore, this research supports the previous assertion that the perceived neutrality of the EP’s peripatetic role can help to set the child at ease (Atkinson et al, 2011; Cooper, 2006).

There are limitations to this research. Barriers to engagement may have been reduced by selecting a child with verbal abilities within the average range, and further research is required into how MI interventions might be made more accessible to pupils with language difficulties, whether of primary or secondary age. Furthermore, the design chosen was an exploratory case study design (Yin, 2009) and while it was felt appropriate because MI with younger children had not been previously studied, the research provides only a small window into the use of MI with younger children and associated benefits and challenges. While outcomes lend support to the growing body of small-scale studies into MI, there is a need to look at its efficacy on a larger scale to be certain that positive results would be found with different children, schools and practitioners. This case study does not offer robust evidence of the use of MI techniques with younger children; it only offers an insight into the experience of using MI approaches with one pupil. It is acknowledged that more than one case study is required to ensure validity and furthermore that the Halo Effect (Nisbett & Wilson, 1977) may have contributed to the overall positive findings and therefore care must be taken when considering the results.

In their recent paper “The Promise of Motivational Interviewing in School Mental Health”, Frey et al. (2011) anticipate an expansion of MI within the context of school mental health, noting its previously untapped potential. They highlight a number of systemic interventions which contain an MI component, including Participation Enhancement Intervention (Nock & Kazdin, 2005), the Ecological Approach to Family Intervention and Treatment (EcoFIT) (Dishion & Stormshak, 2007), Classroom Check-up (Reinke, Lewis-Palmer, & Merrell, 2008) and First Step to Success (Frey et al., 2008). Moreover, they claim that the MI principles should form the basis of conversations with students, parents and teachers. These could potentially be supported by the school-based consultation approach proposed by Blom-Hoffman and Rose (2007) which utilises MI skills and principles in supporting consultations in which there might be ambivalence about change.

UK EPs are clearly at the forefront of school-based MI practice, with 31% of a representative sample claiming to use it as a therapeutic intervention (Atkinson et al., 2011). MI may be particularly appealing to EPs because of its distinctive feature of not assuming client readiness for change. This is important when the concern holder is typically not the child, as it allows consideration of different factors which can cause the child to be ambivalent about, or even resistant to change. Following expectations from Frey et al. (2011) about the growth of MI in school-based practice, further research could usefully illuminate the scope and scale of its use both within an individual therapeutic context and also more systemically. This research could also usefully provide empirical validation for its use in different settings by including larger scale studies employing control groups, supporting the call by Frey et al. (2011) for more rigorous designs to assess efficacy and effectiveness.

To replicate and develop this research further, it was felt that the self-formulated assessment was useful in focusing on the MI aims and principles. It was simple and clear to use and enabled reflection on the adherence of the core features of MI during each session. In addition, it was felt that the use of a clear and structured format (Atkinson, 2013) helped to retain focus and increased usability. In replication, changes to this current research might include: using a greater number of participants; employing a mixed-methods approach, harnessing both quantitative and qualitative data in order to improve the validity of reported outcomes; exploring the use of MI when delivered by teachers or paraprofessionals supported by MI; and exploring the use of MI with other vulnerable groups, including post-school learners. It is interesting to note that some research (Söderlund et al., 2009) had used the approach with parents, rather than the children themselves and this potentially warrants further investigation.

This case study provides an example of how MI techniques might be used with a primary-aged child. Although the results are positive, it cannot be asserted from this research alone that they can be attributed directly to the intervention. As an exploratory case study, this research elicits more questions than answers, which the authors hope might be answered in time, through further research and practice.

Appendix.

Outcomes for the other pupils receiving the intervention

Table

Pupil details/family context	Presenting concerns at referral	Outcomes of intervention (based on teacher report)
Tom (aged 10) Lives with mother and father. Middle child of three. Sibling has autism diagnosis. Reported family conflict.	• Banging head on desk during lessons. • Picking at skin on finger until it bleeds. • Low self-esteem. • Social/friendship difficulties. • Decrease in motivation and level of work output.	• Noticeable increase in self-esteem. • Had not picked at fingers or banged head since receiving the MI input. • Increased participation in classroom activities. • Changes in teacher/parental behaviour to support Tom. • Feeling happier (pupil report).
Ben (aged 10) Baby sibling and older half sister, with whom there have been recent familial issues regarding contact. No longer has a relationship with father.	• Talking while the teacher is talking. • Making noises and saying things to make the class laugh. • Refusing to answer the teacher’s questions. • Fighting with peers in the playground. • Seems ‘unbothered’ in the classroom.	• Minimal changes in the classroom. • Continues to struggle to manage feelings of anger. • Increased willingness to listen and learn. • Improved understanding of own emotions.