 Hi my name is Sarah Burns and I'm with the Low Incidents team with Alberta Education and I'm here to introduce Sheila Moody or Dr. Sheila Moody with the School of Communication Sciences and Disorders with Western University. She will be presenting on facilitating change in an individuals and or family behavior. Dr. Moody is an assistant professor at the Western University and she's also a research associate at the National Centre for Audiology and her recent research interests have focused on how to use the knowledge translation and implementation science frameworks during research projects to facilitate change with individuals or families. We will be, I just want to draw your attention to the, is it the chat line that you will be entering your questions for and we will be holding the questions until the end of the presentation and and then we can go over them at the end with Dr. Moody. So okay sorry that's a little bit of a correction there is a Q&A spot on the screen for you to enter your questions. We have Yvonne Nicol as our interpreter and Sandra Burns as our captioner today. So without any further ado I'd like to put the mic towards Sheila and she'll do her presentation. Thank you Sheila for being here today. Hello everyone and hopefully my voice is loud enough for you and clear enough for you to all hear and if there's any problems I guess we'll just type them into the message line there and we'll try and deal with them as we come up. So thank you for that kind introduction I'm happy to be joining you here today. What I think is a very interesting topic and what I would like to start by saying to you is that the things that I'm going to be presenting to you today really are just an introduction to this topic. There's lots of things we can talk about and I think you'll see by the end of it that there are lots of things to learn and so I see this as an introduction to hopefully our relationship building and something that we can continue to work on together some of it may be new all that may be new to some of you parts of it may be new to some of you but I hope what you'll find at the end is that it's interesting to all of you and that you'll be able to see how it could be applied in your practice when you're working with individuals and or families. One of my interests is in family-centered early intervention and on this slide you'll see both my email and my lab website and so you could go to the lab website and maybe find some resources there that are helpful to you but always I encourage you to please email me if you have questions or you hear something interesting that I'm talking about today that you'll want to learn more on because we really only have you know one hour together to cover a lot of material. Next slide please. So I looked at your website and I came up with some desired outcomes based on that so I would really like to assist in the understanding at the system level that considerations of capability opportunity and motivation can be used to deliver equitable services that are effective and efficient and I also want to underscore the importance of collaborative continuing education opportunities so these are new ways to practice that are coming down the pipe for many of us and we need continuing education opportunities to be able to take advantage of them and collaborative practice to implement this revised understandings of best practice and pediatric rehabilitation and also in family-centered early intervention and I also want to educate attendees here today about new considerations so that we can enable and ensure appropriate supports for students families our colleagues and systems we all know it's important to talk to each other using common language that we understand and so hopefully we can support a dialogue and conversation and start that today that I'm hoping will continue for a long period of time to come so as I develop this presentation I realize again that it will be an introduction for you or perhaps a new way of thinking and I'm happy to and I hope that we will continue our discussions. Next slide please. So again this visual which I took off the RCSD website and which I know may not be in use anymore because websites are things that change things become obsolete and they don't always get updated but I wanted to look at the fact that this already talks about the importance of considering capability that support for functional needs and opportunity support for environmental access it doesn't address clearly how motivation might be used and hopefully I'll talk today about that and you consider how and you can consider over time how it fits into this framework because motivation is necessary for success in terms of behavior implementation or change so my agenda is to introduce you to a way that you can bring about behavior change and or behavior development again it is an introduction and you might feel that at the end of the hour that it was a lot of information so if you remember nothing else do what I first did when I first started learning about the science of behavior change I asked myself and I'm going to talk to you about this today when you're looking at someone's behavior and when you're thinking about you know why are they doing the things that they do or what reason or rationale do they have to do the things they do I say to myself is the issue here capability is it opportunity or is it motivation it might be a combination but you can look and think about how these three components can affect behavior and then you can figure out how you might go about developing an intervention to target that level and I'm going to talk to you more about that I always like to say what could you implement on Monday and the capability opportunity motivation question is something you can start with right away when I first started learning about it I found that I quickly moved into using it with my young people in my house so when my teens came home and I was like why are they doing that I would say to myself hmm is that capability opportunity or motivation and again I used it so often that sometimes the kids say to me today mom don't come be me I would say that capability opportunity and motivation affects behavior and this model can be used to bring about not only um individual or family behavior but I think you can see how it might be applied to organizational change so this conversation today is important hopefully for clinicians and for managers if you're really interested I'll I've put some references at the end of the presentation that will be helpful for you and you can also email me and my email address is on the first page of the slides next slide please here's the problem if we measure at assessment or at other times what is wrong with this person and what can I do for them then we might miss the boat in terms of being client or family centered the question should be who is this person and what would they need the problem is our healthcare context doesn't provide us with the time to practice this way which I probably don't need to tell you folks but I would argue it is not cost effective or patient centered to not practice this way because what happens is we end up going in circles and not changing behavior not understanding why it's occurring trying something different trying something different again and that really is not a cost effective way to practice I remember many years ago doing a study where we asked people now in their late 30s or early 40s to tell us about their experiences as young people in the triad of care between their audiologist their parents and themselves so these are kids that were growing up in the in the care system and they were too young to come to the appointments by themselves and as they grew up and became more autonomous one young person said in our interviews I am more than a hearing loss appointment after appointment we often treat the impairment or the problem but I don't always meet with success because we don't deal with the participation issues and or the environmental issues and or the system level issues next slide please so the problem is that pediatric rehab is moving towards the adoption of system views of the complex array of factors and processes that influence client change but the field still operates predominantly from a unidirectional medical perspective where something is provided to fix the client rather than operating from a more contemporary realist views of change as an evolving cascading phenomenon that can be mobilized by intervention so I would argue that this is true for any type of rehabilitation even though this quote from Dr. King is about pediatric rehab but it's true for any type of rehab any type of family system intervention and really when you think about some of the changes we have at the organization level that needs to be done we often do the same thing right we try to fix rather than figure out what is what is the complex array of factors that is in processes that are causing the problem and which might influence change next slide so we're going to start we're going to get started I'm going to start with you first I'm talking about the international classification of functioning disability and health so that's the ICF and then I'm going to talk to you about at the same time the child and youth version the ICF-CY so this is put out by the world health organization so if you're not familiar with these two frameworks or models I encourage you to become familiar with you I'm going to introduce you to them today I'm going to give you two references that you can look at and read about to get a general understanding because I think they're really important to how we want to practice and they're really important when we think about who is this person and what do they need next slide please so this figure is from an article that I wrote with my colleague Marlene Bugato in 2016 and basically it's the visual representative the center part of the ICF so the ICF looks at body functions activities and participation and tries to figure out you know how the environmental factors fit in there and how personal factors fit in there to impact overall function or disability so disability is a consequence of people with impairment or illness encountering restricted opportunities so it's important to focus on developing or finding ensuring opportunities are afforded by the environment so that people can be what they wish to be and do what they wish to do that's sort of an overarching way of looking at this ICF we spend much of our clinical time focused on the one square body functions or impairment and ignoring all the other squares in this visual but if we truly want to provide equitable support supports and services we must look at all the other squares and their impact on function and disability so the opportunities afforded to a person to be and do the activities they wish to participate in the environmental and personal factors are all transactional so what that means is they change as people change across the course of their lifespan so you can see outside of that I talk about human development across time so these are things that aren't static so the things that child participates in that are important in their everyday life at even six months of age are going to be different when they become more mobile at one year of age so a person can experience a high quality of life and have an impairment and many many do that is in part because they are participating in activities that are valuable to them and participating in an equitable way so we need to ensure that more individuals experiencing an impairment have this opportunity so that experience and participation are equitable and that is in part why it is important to have these conversations at the system level this kind of practice takes time and training and it takes new ways to have conversations for example I am currently learning how to use motivational interviewing and solution focused coaching more because they are both useful tools in facilitating behavior change but developing these skills takes time and you know people have to pay for that time and pay for the money so it's important that we think at the system level that these things are important because if we are going to change to this new way of practice it's going to take time and experience and opportunity next slide please so this is a little bit more complicated slide so you can see in the left hand side you can see it's still that boxes of the ICF CY because it's a child but you see now I've added another section up at the top because kids don't live by themselves they live in a family context so if you're going to think about the how this child is going to have activities and participation and how they're going to experience and take opportunities and blossom as they grow up you have to think about how the parent is functioning within this context so the parent and the child are inextricably linked and we have to be able to deal with the parents activities and participation and their body functions so maybe they've become depressed for example because the child has a disability we have to deal with both of these things and we have to think about both of these things and so the nice thing about this model is it allows us to start to think about what are the factors that could be happening in this child's and family's life that he's contributing to behaviors or causing behaviors or limiting behaviors and we can start to piece all of these things out next slide please so this comes from an article I wrote in 2018 so I've been thinking about this for a while and trying to build it over time to think about how can I teach clinicians about all of these kind of things and so when we think about the parenting and context we have to think about not only the child do that doing being becoming and belonging are impacted by the transactional nature of the family context as well as life changing context so let's look first at the list of favorable outcomes so if you look at their empowerment and knowledge child well-being family well-being for example self-determination I wonder how many of these desired outcomes we measure in practice but if we ask our children or families what their desired outcomes of intervention are would be this is the kind of list that we would likely get from them in many times so if we treat and intervene on what we measure and we don't measure any of this guess what we treat only the body function or the impairment now I will say that we don't have great ways to effectively and efficiently measure some of these desired outcomes but I think rehabilitation is moving towards the development of better ways of measuring and intervening well-being for example is one of the areas getting a great deal of attention right now children and parents live in context family context and systems context and that is important to remember so the parenting in context some of their environmental factors for example social support or the family's attitudes of environments to a child's disability can affect the environmental factors of the child so this is back and forth that goes on between the parent and the child and so when you have a child with an impairment you have to understand how parenting is happening in context next slide please so we must understand more than the impairment activity limitations and participation restrictions of the child we must understand the child's everyday life situations and the context of their everyday in this case listening situations or their everyday life situations okay next slide please so I've given you an introduction to the international classification of functioning disability and health and I think that's an important place to start our conversation today before I move into other models that I really wanted to share with you because again it's a pretty straight it looks complicated but it's actually a fairly straightforward model to start to implement into practice so now I want to move to what I'm going to call the COM BE model because it's the newer behavior change theory that's out there that I wanted to introduce you to if you have not heard of it before it's being used frequently and lots within disability work and rehabilitation right now and it's being showed to be a very structured and well organized way to look at behavior to look at behavior change to look at in developing interventions that will lead to successful behavior change next slide please so within a capability and behavioral change theory framework disability is understood to be a limitation of opportunities that results from the interactions between an individual's impairment or an illness in concert with their personal characteristics their available resources and their environment and so then again and again you will see this in this kind of literature coming up over and over again it's not just about the person it's about resources it's about environment it's about opportunities afforded to them next slide please so what is important about participation this is a this is not my work this is um this work comes from Karen um Hamel it's called Karen Wally Hamel and she's at the University of British Columbia um I'd love to spend a lot of time talking to her one day because I think she's a really interesting person and researcher and I love to read a lot of her stuff so she would be someone that I would encourage you to to look up if you're interested in and to engage with her literature so one of the articles I read recently about hers that I'd like to make you bring to your attention and make you remember is she talks about things like what is important about participation and I want you to remember this slide because I use this kind of slide when I'm starting to think about questions I might ask my teens who are doing things that I want to better understand so I'm going to talk to you at the end about a case example of what if the teen stops wearing their assistive listening device so what is it about what is important to them about participation that might encourage them to change the behavior and put that device back on for example one of the things we're going to talk about a little bit is about autonomy or a sense of choice of control we all know teens want it and we need to understand how to help them get it and have choice but also understand the repercussions or the consequences of their decisions participation builds competence and accomplishment through doing it leads to belonging acceptance safety and respect it provides the ability and opportunity to do and to engage personally in meaningful valuable activities it provides the ability and opportunity to contribute to the well-being of self and others to support and do things for others and engage in meaningful and reciprocal relationships that build social connections and social engagement and ultimately inclusion so when we think about and doing things so that our children and families can participate it's not just about having them do something it's about all of these other things that are products of being able to participate next slide please so the center of behavior change work is simply a behavior system the comm b system in this case that proposes that for any behavior to occur the person performing the behavior needs to have the physical and psychological capability to perform the behavior the social and physical opportunity to perform the behavior and the more motivated to perform the target behavior than any other behavior in the moment in time that the target behavior is performed so the comm b framework or model proposes that intrapersonal capability and motivation and environmental opportunity influences on behavior interact in that capability opportunity and motivation influence behavior capability and opportunity influence motivation and behavior influences all three components right so if you have if you're doing a behavior and you're doing it capably and you're having lots of opportunity to do it wow you're probably going to be more motivated to do it over time so this is this is a system that all works together and it's a system that works from behavior to capability opportunity and motivation or vice versa so a behavior change intervention is defined as a single or multiple sessions of motivational discussion focused on increasing the individual's insight and an awareness regarding specific health behaviors and their motivation to change next slide please so physical and psychological capability is the ability to be capable to enact behavior right so do they have the skills do they have the knowledge do they have the self-confidence physical and social environment that enables or supports the opportunity to perform the behavior so do the people have physical and social and sorry does the individual have the physical and social environment that enables or supports the opportunity to perform the behavior and of course we know that motivation sometimes is automatic so sometimes is autonomous or self-endorsed or internal and sometimes is more reflective so physical capability refers to having the necessary skills and physical abilities to perform the behavior well psychological capability refers to the required knowledge and mental capacity to perform it having the required physical ability to walk to school as an example of capability social and physical opportunity are defined as all factors that lie outside the person performing the behavior and that makes the behavior possible or prompted so the presence of appropriate and easy to see markers along the path to school and appropriate signage for drivers are examples of physical opportunity for walking to school ensuring that businesses in the area make education or educate their customers about the safe walking paths is part of the social circle that they can use to be fried social opportunity for doing so and motivation refers to the cognitive processes that energize and direct to behavior and includes reflective motivation such as conscious decision making I'm going to walk to school as well as automatic motivation such as habits or emotional responses I'm going to address my anxiety around walking to school so that really is just a very quick sort of explanation of behavior change theory and a very easy way for you to start to think about how would I apply this in my work so you would you know you apply it by first saying you know is the target behavior is it something they're capable of do they have the opportunities to do it is there something I need to do around helping them become motivated to do it so and then there are ways which I'm going to talk about towards the end of the presentation of looking at each of these areas and asking appropriate questions about them next slide please so our behaviors are influenced by psychology and context so another theory that's interested for you guys to know about if you don't already know is the bioecological theory of development by Brompton Brenner nice long name there and that posits again that human development is transactional it changes over time in which an individual's development is influenced by his or her interactions with various aspects and spheres of their environment so when we talk about opportunity and when we talk about capability and we know that these families don't it's not about just about the child and that's not just about the family it's about how those that system or community functions in larger systems to ensure that this child is going to develop to their optimum potential and this family is going to develop to their optimum potential as well all right next slide so when whether parents can perform effectively in their child rearing roles within the family depends on the role demands stresses and supports emanating from other settings parents evaluations of their own capacity to function as well as their view of their child are related to such external factors as flexibility of job schedules adequacy of child care arrangements presence of friends and neighbors who can help out the quality of health and social services and the neighborhood safety so if we only look at the impairment or we only look at the um family and wonder why they're not doing something as clinicians we often become very sort of judgmental about why they're not doing what we've asked them to do right things would be better if they just you know put those hearing aids on the child as soon as he got up in the morning and had them on their ears all day long to understand why they might not be doing that we have to understand the context in which they're parenting and we have to understand the challenges that they're facing or the in regards to opportunity and sometimes you know motivation in order to help them develop the skills and help them see how they can change over time to be able to effectively implement um what what we would hope would be beneficial to both the child and the parents excuse me next slide please so I'm going to start by talking to you more about opportunity right capability opportunity motivation so I'll start with capability so again Karen Wally Hamill at UBC suggests we query ourselves do their circumstances actually allow them to do and be what they wished that's opportunity so understanding opportunity in terms of capability which I'll talk about next allows us to determine whether a person is able to do the things she or he would value doing and whether their circumstances actually allow them to do what they would like to do so having a good understanding of the social determinants of health is important when we think about opportunity there should and must be equality of opportunity in order for an individual or family or community to realize their potential there must be context which enable optimal opportunity for participation and we need to understand the socially structured inequalities that may exist at an economic institutional cultural political legal or religious level that may limit the achievement of opportunity for example health literacy so sometimes we give people pamphlets and we do this often with our teens but we don't have often ask ourselves to look closely at the literature and want them to read and ask ourselves does the team actually have a health literacy level that understand helps them enable or understand the repercussions of their behavior do we measure that do we measure health literacy not very often and there are ways to measure it are we sure that we use language and conversation that enables them to understand how opportunity is affected by their behavior or do we just lecture them tell them what they should be doing think more often than not we we fall back on lecturing because we don't have the skill set often to actually take them down a motivational interview kind of opportunity to help them understand and help us understand where the behavior is coming from the other problem is excuse me the other problem is that we're not often given the time within the clinical context to have these very very important conversations but over and over again what we're seeing from the benefits of a calm be kind of approach to working with people is that it actually is more cost effective in the long run because you're actually able to determine where you should intervene rather than keep coming back over and over and over again to try something new so in my practice I find that there are several reasons that teens stop wanting to use their DM systems they feel unsure that the teacher wants to wear the mic they don't feel comfortable explaining it to their friends they're tired of having to deal with the hassle of charging or remembering to bring it to class so these are the systems these are the assistive hearing device systems and sometimes I just ask them what do you already know about having the opportunity to wear this hearing assistive device because they may already know about all the opportunities and reasons why they need to wear it and telling them about why they need to wear it isn't taking us down the right path so you could also say to them I'm concerned about this decision that you're making may I share why and that's one of the things that I think is sort of interesting about the motivational interviewing approach is because it teaches you to ask permission to share information and if the person says no they don't want it then we're to respect that information that decision and take a different path to try and offer them the information the interesting thing to remember is that opportunity can affect motivation next slide please I'm not going to spend very much time on this slide but this is another slide from Jillian King's work and it really says living a meaningful life is important and that you can develop behaviors and develop strategies for different environments and contexts that will allow you to use resiliency and facilitate processes that actually help to add a cumulative and cascading positive experience across multiple contexts and that's what we want for our kids and that's what we want for our families so let's talk next next slide about capability so capability is about the individual family or community having the physical strength knowledge and skills and stamina to perform the behavior they must have the freedom and opportunity to choose what they wish to do and to be and the opportunities to act on these wishes in other words are people able to do the things that they would value doing and do their circumstances actually allow them to do and be what they want to next slide and finally motivation um the individual or the family or the community must be more highly motivated to do the behavior than not to do it or to engage in a competing behavior if people are to be motivated then they need to believe that there is a reasonable possibility that their choice might be transformed into a desired outcome or action and that it is likely to increase capability so your next slide please so this slide is adapted from an article by chain at all and that's just come out recently and the reason I want to bring it to your attention is because we can try and affect motivation in a variety of ways so we can affect motivation in a situational sense so in this situation what is happening we can affect it in a contextual sense so a broader sense and our ultimate goal is that the person would internalize have internalized motivation to do a behavior and what we know from self-determination theory is that which is a self-determination theory is a theory of human motivation that has demonstrated efficacy um it it emphasizes the importance of the kind of motivation that drives people's behavior alongside considerations of how much they are motivated so what's self-determination theory says that the satisfaction of the needs for autonomy choice individual choice or personal choice competence feeling able to do something and relatedness the social support the support of kind of network mediates the associations between autonomous motivation and behavioral persistence in multiple contexts including health behavior change so what we want to be able to do is just to move people in terms of motivation from away from being um amotivated so not having any motivation to externally motivated so they've got some motivation it's might be some external kind of impact on that but leading eventually to an internalized motivation and we do know that motivation affects how you feel about yourself or how you feel about something that you want to do it often affects your ability to cognitively feel like you can do it to think that you can do that behavior and actually perform the behavior so the interesting thing about this slide is that it works back and forth right i've got these double arrows going on here because if you feel like you can't do it then why would you be internally motivated to try and do something because you're worried that you're going to fail at it so being motivated is a very important part of the calm being and we'll and you often find that this is the one area that people over and over and over again sort of need help with in terms of interventions next slide please so when we think about behavior change there are according to the work done by this group out of the UK who are the leaders in terms of the science of behavior change there are sort of 14 kind of principles places where you can go to think about intervening to help with the behavior change so do they have the knowledge do they have the skills do they have social or professional role or identity beliefs about their capabilities beliefs about the consequences goals memory attention and decision processes environmental context and resources social influences emotion behavioral regulation optimism intentions and reinforcement so the nice thing about the work that's coming out of the behavioral sciences and the behavioral change science is that we have a lot of people thinking about how you can intervene in these 14 kind of ways next slide please so when you hear people talking about calm be you'll often hear them say about the calm be wheel and this i'm just showing you this that when if anyone calls it a wheel to you you'll know what they're talking about and basically what the calm be wheel says in the in the green part you'll see capability opportunity and motivation and you can see the physical and psychological things that I've already talked to you about and then as you move out it gets broader and broader saying that you can change a person's behavior you can use any of these intervention functions such as persuasion or modeling or coercion and coercion actually works sometimes but you can also look at the the gray area on the outside you can change behavior by policy categories right so having good policy actually can help individuals change their behavior as an example um I've written some clinical practice guidelines and when the colleges say the guidelines will be put into practice and the clinicians will use those guidelines they will often be used because that's a form of motivation isn't it that's a form of changing someone's behavior because there's actually potential for a desired outcome from a policy level if they don't right so there's different ways you can change someone's behavior regulations one of them legislations another so you can see how this can work at multiple different levels next slide please this slide here is just to show you um as we've talked today hopefully i'm introducing you to a new way of thinking about things susan michie and her colleagues at um university college in london have this tool that i've provided due the link to and they've provided a list of 74 behavior change techniques that can be coupled with 26 different ways put to put them in action so i encourage you as you start to think about how would i implement this very what seems like a very complex subject into practice go ahead and play with that tool because what it will say is are you looking at capability and here's different ways you can um target capability and there's a nice little tool that will give you different ideas in there so i encourage you to try that out we don't have a lot of time to talk about it today but again if you want to learn more about it i'm happy to to to uh walk through that with you next slide please so just so that you can see that this kind of calm be behavior model and behavior change wheel is being used in clinical practice and in research now so phiona barker and her colleagues use this model of behavior and the behavior change wheel to develop an intervention to improve hearing aid use in adult oral rehabilitation so they looked at all the factors that were affecting the behavior and then they used the calm be model and that that theory and technique tool to determine ways to change their behavior um around hearing aid use and there's lots of other examples as well um that are out there uh related to all kinds of things and you know and i know um it's really hard to change your behavior right i've been on a sabbatical this year i started in january and i'm going back to work full time in january and over that course of the year i was like i'm going to change all these behaviors like i'm going to exercise every day i exercised every day for some days and then i stopped exercising so even your own behavior and i can calm be myself so there you go it's not easy to change so i'm going to go through two case examples one that i've put in here and then another one that i had talked with sarah about that i don't have slides in um but but we but i'll still talk to you about it in the last 10 minutes that we have together so the first example i'll talk to you about is a case example of capability opportunity and motivation around the parents of an infant newly diagnosed with hearing impairment so the parents have the hearing aids they we think they know how to put them on but they're not having the child wear them all waking hours so one would think you know that this would be highly valuable to the parents so as clinicians we try to we say to ourselves you know why aren't the parents putting the hearing aids on and it's our job to figure that out so um my phd student david cindy which some of you may know because he's been around for a long time but now he's working on his phd so anyone who's ever done um the listening games for littles for example um would know of david cindy for example so his work his phd work was to take the combi model take this um framework of understanding behavior and figure out for example why parents weren't keeping hearing aids on all waking hours and he developed an intervention that um were you going to use to target behavior change for parents so if any of you are interested in this you'll find all of the this 12 video series on the family centered early intervention website that can be used in practice so next slide so for example this one is just showing parents the top one will show them that by the time a child is one year of age a typically hearing child will hear about 7.6 million words and um a child whose parents aren't really talkative may only hear about 2.2 million words so we want them to put the hearing aids on and we want them to be really talkative but if a child is late to get hearing aids and they um don't have talkative parents they may only hear like 1.7 million words so that's a big difference so these this is a a sort of way of introducing parents to what we would say salience of consequence so this is a consequence but also to educate them to try and motivate and persuade them so there's different ways that we can try and target behavior and in the videos we don't just use one sometimes we use three or four different interventions under the hood to try and help our parents develop new behaviors or change their behavior so those were just some salience of consequence um looking at their knowledge level trying to persuade them of um changing behavior but we have a whole other video that says maybe you know all of this but you just don't have strategies to keep your hearing aids on this baby who keeps pulling them out of their ears so we also have to understand that that might be an issue for them and we've developed um some strategies around that as well the second you can just leave this slide up for now the second um case example that I want to talk to about let's go back to that um teenager who doesn't want to wear their hearing assistance technology remote microphone at school and I think in Alberta my understanding is we might call it a DM okay so they've decided they're not going to wear it anymore and this is not an uncommon problem it seems to happen all the time and what do we do about it so what we've found is that many cases like these the use of motivational interviewing techniques could be helpful um and so that's one of the reasons I would like you to encourage you to think about that so one of the things I've learned questions I've learned to ask from my friends who do motivational interviewing is just to say to them I'm curious to know more about why you're not wearing why you don't want to wear it anymore right so coming at it from a curiosity perspective is as opposed to why aren't you doing this helps to open a ability to have a conversation with them we need to understand why it's valuable or what is valuable to you about being able to participate in class because then you can build on those values to understand the advantages of doing it and one of the things I think we don't do enough is to look to see if the team actually understands what stigma is when I looked at the literature I didn't see a lot of literature out there that said teams understand what stigma is they experience it but they're not always good about explaining what is to them so a lot of the behavior change theories will help along that okay I'm just going to try and wrap up here shortly so if you can go to the next slide please so there's much to learn about facilitating behavior change the good news is there are great researchers out there who are trying to put it into understandable language that clinicians can use and that organizations can use and I'd like to encourage you that to remember that you cannot be what you need to be by remaining what you are so we need to try and adopt some of these new approaches to practice so that we can be what we need to be for the families and children we serve thank you very much the next couple of slides which you I think you'll get these handouts we'll have some references that you can refer to and please let me know if there's anything you heard about today you want to know about more and I think we have a few minutes for questions here thank you Dr. Moody this is Sarah Burns if anybody has any questions I'm able to read if you can type them out I'll read them to Dr. Moody that was a great overview and if anybody's ever tried to not bite your nails I think the comm method might be effective for this and we are having ongoing conversations about how to work with teenagers and I think the suggestion of examining motivations is right up there with all the other suggestions that we have gathered over the last few weeks so thank you so much it's very timely so I'm not seeing any questions from anybody is it I'm just going to check and see if there's anything that came through the chat people are free to and I welcome you to email me certainly the whole self-determination theory approach you know autonomy relatedness competence is really a nice approach for working with our team but we also have to have the language to be able to engage them in conversation and I find the motivational interviewing approach is really a nice way of trying to engage them in conversation but it does require a lot of practice to be able to be good at it and I'm certainly not an expert in it I would love to be an expert in it and I hope to become an expert in it but there certainly are people who are I have a colleague here at Western named Jennifer Irwin who has been using it for years very successfully here because sometimes when you're working with teenagers the lack of success often makes you feel or question your methodology but I'm glad that the opportunity to learn new ways of doing this is available to us thank you Dr. Moody I'm not seeing any questions I'm seeing some positive comments about your presentation thank you so much I'll reach out to regarding some other things that you've shared with me thank you thank you very much everyone have a good night take care thank you Vaughn