Assessing And Interviewing Children And Adolescents

Assessing And Interviewing Children And Adolescents

There are book chapters, perhaps too journal articles and maybe even entire books devoted to this topic. However, these are accessible to anyone and often quite general. As a preceptor of students and residents, and even from my nonmedical colleagues, I wish to simply share what I have learned from my experience and practice.

Age considerations

In the first place, when assessing children, especially of a younger age, one has to interview the parents to get the whole picture. That almost goes without saying. However, you would be surprised at how often parents of even quite young children ask whether they are to join us in the assessment session.  Young children are simply not able to tell their story. Until they reach the pubertal age of the development of abstract thinking, they simply do not have the language to describe much of what is happening to them. They lack insight and often even awareness.

The effects of their illness

It also appears to be the case that many of those sent our own way, because of the neuropsychiatric problems that they come with, have time and memory impairments that further hinder them from being able to tell their stories.  This appears to be particularly true of those with disorders that affect attention such as the Disruptive Behavior Disorders and Anxiety Disorders, and to a lesser extent the Mood Disorders, let alone the Autism Spectrum Disorders and those affected by toxins [think FASD] and other congenital or inherited developmental disorders. This is especially true of children with ADHD and those who have attachment issues or have been traumatized. Of course, these groups comprise a significant proportion of any C/A referral base or caseload. One is often amazed at how little they remember of their life, let alone be able to put it in a rational chronological structure. If you think about it though – if you are too anxious, which could also be because of sensory and communication overload, or too inattentive/distracted to pay attention, it’s not surprising your memory may be deficient. You may take in information but one’s working memory is too short to allow it to be encoded for later recall.

Another factor that must be borne in mind is that whenever one is facing a depressive mood disorder, the assumption is that much of what the child will tell you may be negatively distorted because of their perspective. It almost goes without saying of course, that those with psychotic disorders are not going to be reliable historians in many aspects of their history. They still deserve full respect though as they can remember how you treated them and if that is not good, it does not bode well for building trust and rapport.

Different modalities

Play

One unique feature of children that relates to their inability to talk is play. It is not uncommon to obtain nothing from a younger child by having them sit in a chair across from you. However, take them to the playroom and give them some toys, and you begin to learn all kinds of details about their lives. This is true whether you give them some direction as to what to play with and how, or conduct a playroom session in a totally non-directive away.

A couple of special tools deserve mention here. One is the dollhouse. Just watching how a child organizes a home, who they put into it and what they say about what is going on gives a lot of information about their world. The same can be true for how they play in a sandbox. How organized or chaotic is their play? What are the themes you observe? Even if you do not have these devices it is still good to have some toys in your evaluation room – toys suitable for both genders, including some building toy. Watching their play her can also be informative. Without such aids it would be easier to lose their attention, interest and compliance.

Special areas

1.  For parents/guardians

Younger children will come with their parents as a matter of course. Indeed, initially, parents may well be hesitant to leave younger children alone with you. Some of them probably would not stay alone with you either. However, especially for the initial assessment, if the adolescent allows it, it is good to have the parents or guardians in for the first part of the interview, and then again to wrap up at the end when one makes one's findings and recommendations known. This sometimes needs to be explained to the adolescents as one meets them in the reception area. I tell them I would like to hear the parents’ perspective. This is important for reasons already alluded to – the child may not be aware of the reason for referral or be able to tell you what the problem is. They may also think they are in trouble and be in denial mode. It is worth reassuring them that this is not the case. You just want to talk with them and their parents about what is going on.  I also explain to the child and adolescent that the reason the adult is included is that there are some areas about their life that are important for us to know about that they may not know well or have a good memory for. This includes the details about family of origin, including the important family history of mental illness and other important factors there. It also includes the history of the pregnancy, birth and early years in development. Of course, the child is reassured we can have 1:1 time.

2. For adolescents

There are a couple of key areas that it is often best to save for the one-to-one part of the interview with adolescents.  These have to do with use of drugs and alcohol and sexuality.  With these areas, and also the following three areas, it maybe important to reinforce with the child or adolescent the confidentiality that may be invoked.

3. Child abuse

It is important to ask about this. If you don’t ask about this on the Royal College Oral Fellowship exam, I believe it is an automatic failure. With a younger child you can certainly ask the parents if they think their child has ever been abused in anyway. With the pre-/adolescent this is something you need to ask without the parent present. At the same time, given the emotions about this, the denial that may have already gone on at different levels, don’t push for it. You often don’t get this on the first try even when it has occurred. It may just be too painful to bring up. Of course, it may be totally repressed too. It takes time to build up the trust to get at that sometimes. Even if it is disclosed in the first session, particularly when you are doing perhaps a one-off consult, is not the time to go into it further and the child may be gently dissuaded from going there, although that is seldom the issue. You must be prepared to put the child together before they leave if they do break down somewhat talking about this.

4.  Suicide

This is another area it is obviously important to ask about. Again, if you don’t ask about this on the Royal College Oral Fellowship exam, it is an automatic failure. If there have been details about suicide in the referring information, and one knows that the parents know about it, which is often the case if you are seeing them after having already been to the ER because of this, it may be possible to discuss this adequately with the child or adolescent in the presence of the adult. However, if there has been no cause for it to be mentioned, this is another subject area that could then be kept for when one sees the child or adolescent alone. This is because they may have thought about it that they have not wanted to frighten their parents with this knowledge. Naturally, one needs to assess the level of suicidality and then come to the point of discussing whether the adult does need to be informed for the sake of helping and protecting the child.

5. Self-harm

This is something that those around the child often struggle with even more than outright suicidality as they see their child repeatedly harming themselves. It is often not as difficult for the child to discuss as suicidality though. By and large one could take the preceding paragraph here and replace suicidality with self-harm.

4. Failure, Sports, Love & Going Abroad; Medical Student Years – part 3 [Updated 2015 11]

I think it can be helpful in writing something like this, hopefully for the benefit of those coming after, to be open and honest about all aspects of one’s experience. We know there are always those who are nearer the bottom of the class - the Bell curve and all that, and some who even fail. I do not think I would be as good a mentor to those if I had never experienced something like that.

In those days the results of our exams, which in the undergraduate years were mostly multiple choice and given in December and at the end of the academic year, were posted for all to see as simply 'pass/ fail.'  To our dismay, one of my friends and I discovered that we had failed the exams midway through our 2nd year. We were given the opportunity to make up for it with an oral exam, which, as you can imagine, could be even more trying. However, we did pass that. Just the same, that is an experience no one wants. 

Perhaps, as I intimated in one of the previous segments, I had overdone the balance in life. Perhaps I needed to focus harder on my studies and do a little less outside the classroom and my studies at home. What else can one learn from that experience? It does help to keep one on one's toes and humble, which is not a bad thing. But I also learned that, at least in medical school in those years, once you made it 'in,' the faculty really wanted to see their investment pay off. They worked hard to get those who got in make it through. So I carried on.

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I just remembered something that again has to do with balance in life that would probably have fit better in the previous "chapter." We in psychiatry know that physical activity is good for the brain, not to mention the whole body. We also know of studies that have shown a certain degree of exercise to be equivalent in bringing about positive changes in certain areas of the brain functionally that correspond to those also attributed to medication.

Some of you may remember that the 60s were the first time that there was developed in certain circles a concern for the physical fitness of young Canadians. They were often compared to the Swedes. The Army came out with a set of exercises called 5 BX which some of you may also know of, and which I began to do in high school and continued through much of my college and into my medical school years. It was often made easier to do to music. General knowledge also seems to have it that vigorous exercise should not be done at the end of the day. All through college the exercises were the last thing I did, in the large mens' washroom - my own room was too small - before a shower and 'hitting the sack,' and I slept well. 

Even though I came from the prairies, believe it or not, I had not been introduced to curling until in University, when a year of Physical Education was still mandatory. Thus it was that some of my best friends and I formed a curling team and put in a couple of years of curling at a club in Fort Garry in Winnipeg before the demands of clerkship and residency preempted that. However, ever since my Junior High days, I had enjoyed soccer and so I did play a few games with our medical school team, which was not the same as our curling in terms of a demanding schedule. 

I certainly recommend keeping up physically, as I think it keeps your body in better shape for those hours when you have to sit at the desk or in front of the computer screen nowadays. I believe it also helps to keep one healthier into one's older age, which is where I am beginning to be at now. I also think that we do not present a very good example to our patients if we are obese and out of shape, let alone smoke or drink too much. Fortunately, due largely to the influence of my faith background, illicit drugs were never a temptation and nor was excessive alcohol consumption appealing, let alone smoking. Staying away from all of that is also good for health.

*******

Now, some of you may have been in romantic relationships before starting medical school. Some may wonder whether you should get married before, during or after medical school and/or residency. Those can be important questions. One of my best friends in medicine had already been a teacher and he and his wife already had 2 small sons at the start of medical school. I know it was difficult for him to sometimes keep up with his studies, but he was fortunately quite intelligent. Another was married and had their first child during medical school. The fellow who failed with me had a girlfriend.

Our medical student chapter of the Christian Medical and Dental Society often had joint meetings with the Nurses Christian Fellowship. The School of Nursing and Nurses Residence were just down the block from the Medical School and residences where a number of medical students and residents lived. Thus, it was not surprising that we often met together. The student nurses were welcome at our fall retreats too. There was one young woman there from Hong Kong, whom I kind of liked, and who currently nurses in Vancouver. However, she was already "going with" another medical student, also from Hong Kong. However, one fall when we were meeting together, a young woman from Taiwan who was taking her Masters in Pharmacology and living in the nurse's residence at the time, just happened to pass through the lounge of the Nurses Residence while we were waiting for a meeting to begin, and our mutual friend introduced us.

We were introduced because I was already beginning to work on going to Taiwan for a medical student elective in tropical medicine. In those days we had a 3 months elective at the end of our 3rd year, and many of us tried to get something overseas, internationally or exotic if we could. I had no extra funds for this but a Reader's Digest fund and another organization related to the Christian Medical Society took care of that. This girl was from Taiwan and our mutual friend thought it would be good to have a connection there that could put me in touch with some real Taiwanese people who could enrich my experience there, which did happen. You see, I was arranging to go to our denominational mission hospital that was largely medically staffed by Canadians and some Americans, both in medicine and nursing, although they were actively training both nurses and doctors. Now that is one of the largest hospitals in the city of Hualien on the east coast of Taiwan.

One of my classmates from Hong Kong and this girl then arranged to go out for dinner with me just days before I left for Taiwan to give me some lessons in using chopsticks and teach me some introductory phrases of Mandarin. This was January in Winnipeg and when we left the restaurant the parking lot was in a foot of snow. In spite of that, the young lady accepted my invitation to join me in a party at my brother's apartment in another part of Winnipeg. Before the night was over, I believe she had helped push me out of the continually rising snowdrifts. Not saying that was what won my heart, but we started writing each other when I was in Taiwan. And she did arrange for me to be shown around Taipei by her brother one weekend and even have dinner with her family! At the time they only knew we had met; they did not know anything more. Nor did I know much more then. 

When I returned to begin my clerkship year, we started spending serious time together. Needless to say, that added a different element of enjoyment to that year of my medical school. Unfortunately, in those days mixed marriages were still not that acceptable and her family was very opposed. That created considerable stress for us, especially her, and she returned to Taiwan, leaving me alone, halfway through my 4th year, precisely when I was in that primary care rotation out of town that I had fought for. Knowing she was soon returning to Taiwan, I was able to arrange a rotation in Selkirk, maybe 35 miles away, so I could see her before she left, instead of somewhere hours away from Winnipeg. 

Anne - that was her English name - had a plan to get her family on side and come back and we would get married. She was still not back when final exams and graduation functions came. Our mutual good friend accompanied me to the last. I had one scary moment during the exams when we were doing a problem-solving question and I "observed" abdominal pain too long in a pregnant woman and her appendix ruptured and she lost the pregnancy. However, I still passed. I have always been a bit on the conservative side in medicine in some ways, and most of the time it has served my patients and I well.

To be continued at some point as chapter V.

3. Social Activism: Community and First Nations care; Medical Student Years - part 2 [Updated 2015 11]

You may be asking, all right, you seem to have been very involved in what one might call extracurricular activities, but what about within the medical school itself? When I was working as an orderly, I always remember one of my evaluation visits where the Nursing Supervisor under whom I worked, knowing of my attempts to get into medical school, indicated that she was somewhat surprised that I was not forthcoming with more observations about what I saw in my work and perhaps even suggestions about how things could be improved. That struck a bit of a nerve.

You will recall also how I stated that I had perhaps failed my medical school admission interview because I was too honest with my views. There is something to be said for suppressing those sometimes if one has a greater purpose in mind, I suppose. In any case, those same values were soon found to be common ground with a number of my fellow medical students. There were a number of us that were a very community-minded lot. One went on to become a psychiatrist; whose name some of what you would know if I mentioned it. Another went on to become a Medical Officer of Health in Winnipeg. Another was at the forefront of work with refugees, gender-troubled individuals and then HIV/AIDS patients in Toronto. It was an interesting mixture of students. The last-mentioned and a couple of others where quite radical Marxist-Leninists at the time, and here I was, what some would call an evangelical Christian in their midst!

There was no primary care rotation in Winnipeg at the University of Manitoba at the time and some of us thought that was an oversight. There had been one years earlier but with the ascendancy of specialties, that had been dropped. We began meeting regularly to plan how we could get this back on the curriculum. We even enlisted the advice and support of the Deputy Minister of Health for the province. The government at the time was New Democratic, flush with the national acceptance of Medicare and national hospitalization, so they were quite supportive of anything to do with service to the community. Happily, by the time I got to 4th year, we had a six-week primary care rotation in place. We also made sure that it would be offered with emphasis on going to rural sites because we knew there was a problem getting graduate physicians to leave the larger centers.

Something else we worked at along the same lines to help us gain experience in medicine in a practical sense was volunteering at what was known as The Klinic With a K. This was essentially a public health facility run at that time out of a home near downtown for poorer folks in the neighborhood. There have, I believe, always been medical students who have been interested in serving the underprivileged. It goes with the territory of being young and idealistic. I took my term of service there as well.

Some of the things we did as medical students were also fun. The medical school was known for its annual Beer and Skits, a wild collection of theatrical performances put on by the students for any and all. Those of you who know me might think I was too serious for that and indeed, I am not sure that I actually ever took an active part. However, I did don some Halloween costumes and go with some of my classmates to some of the children's wards to entertain the young inpatients at Halloween. Photography has always been a hobby of mine since learning it from my father at a young age. That plus my own artistic ability led me to be a part of the Manitoba Medical School Asklepios Yearbook committee for a couple of years, which even allowed me to design the covers from 1974-6.

Then, there was the Northern Medical Unit. This was a branch of the Faculty of Medicine that was responsible for providing medical services to remote nursing stations. These served mainly Indian Reserves. Having grown up in the north and really enjoying that lifestyle, I jumped at the chance to join some of my classmates to acquire some gainful summer employment as a student after years 2 and 3 in a couple of different northern communities. 

Who wouldn't jump at the chance to go up north where you could hike and fish – oh, and do things like suture wounds and prescribe medication after only 2 years of medicine! Of course, being a student, we had to work under the supervision of the nursing head of the clinics, which sometimes led to trying situations with nurses who had something of an ax to grind against the medical profession, but there were visiting physicians who supported and mentored us as well, so those were also learning experiences in more ways than one. One of my colleagues in these ventures was the classmate who later became Winnipeg's Medical Officer Of Health while another was later to become the head of the Winnipeg Health Authority, then our alma mater's Dean! These experiences also further fostered my own strong feelings for First Nations peoples who had been my school classmates growing up, and whom I still advocate for, but that is another whole story.

So, even though one is in medical school, and perhaps especially so, one can get involved with things that do bear fruit, especially if one works at it with like-minded individuals. You can get accomplish more as a team than alone.

2. Balance and Support; Medical Student Years [Updated 2015 11]

In my last entry I left off referring to the supportive environment that I quickly found myself in when I was in medical school. Not only did I find good friends in my class, and graduate physicians who performed a mentoring role; I found a supportive environment in many ways in a church congregation that I once again found myself a part of.

I also mentioned in the previous contribution that I had learned something of the importance of balance in life. This extended to the belief not only that one should be doing things that amounted to service within the community; I should also keep in touch with my creative side and nature to balance the rigorous demands of medical school. I might have overdone that. However, I lived to tell the tale; I did graduate with my MD 4 years later.

I served in that church first of all with the choir. I learned to sing a natural tenor when I was entering adolescence and have been fortunate to sing in a number of very good choirs. I had sung in this church choir when I had lived in Winnipeg earlier. At this point they were short of a conductor and with my musical background (I also knew how to play piano to a certain extent) I was asked to lead the choir! Believe it or not, I think I actually skipped a few medical school classes to cram in some music conducting classes at the college I had graduated from 5 years previously (If you are keeping track of years here you might wonder where the 5 came from - remember, I had written of actually working for one full year as a nursing orderly before starting university and ended up putting in another year after graduation, waiting for my ultimate acceptance into medical school). After working on one Christmas performance with this choir though, I threw in the towel. Or was it because they had found somebody more qualified by that time? I know they did at some point because I sang under him.

But I later found myself as one of the leaders of the Young Adult Group in this congregation and for several years also served as member and ultimately chairperson of the Music Committee, which oversaw things like hiring the choir conductor. That was a learning experience when it came to finding out all about pipe organs! Our church had purchased a building that had a pipe organ in it and the instrument needed repair. What did we know about pipe organs?

The supportive group of physicians I mentioned, which crossed all specialty lines including family physicians? That was the local chapter of the Christian Medical Society. It was lead at the time by Dr. Alan Ronald, who became a personal mentor and friend. Some of you may recognize his name in conjunction with starting one of the first Infectious Disease Units in a teaching hospital, which later morphed, with the help of my classmate Frank Plummer and others, into a world-class HIV/AIDS program with its connections in Africa, and ultimately led to Winnipeg's acquiring the National Virology Laboratory.

We were welcomed into these physicians' homes on a monthly basis for sessions that usually included food, always good for a hungry bachelor medical student, as well as a presentation or discussion on some topic relevant to medicine. There was even an annual fall retreat at a Camp on Red Rock Lake (more good food, prepared by staff, even better) in the Canadian Shield, which was a wonderful getaway place for some of the students. I liked it too much one fall; I was the last to leave and my car battery was dead from arriving late the opening evening and forgetting to turn off my lights!  In those pre-cell phone days, I was fortunate the local payphone had not been turned off for the winter and I was able to call a 'tow truck' to come and give me a 'boost.' 

Along with this, there was also a student chapter of CMDS. After a couple of years, I found myself as its president. This meant arranging monthly meetings to discuss certain topics or have guest speakers, usually in a side room off the cafeteria at one of the hospitals over lunch. Some of the physicians from the group mentioned previously were only too glad to be our resource at times. Then, come spring of my first year in medicine, Dr. Ronald was very instrumental in my being sent, all-expenses-paid, to the CMDS Student Conference, that year held near San Francisco in a mountain retreat.

I even found time to go to the odd concert and actually had student-rate season tickets for the Manitoba Theatre Center my first year in medicine. You may wonder how I financed this? I guess I had some savings from my work. I got a student loan as well. In those days, of course, tuition was less than $500 a year and one could live on less than $4000 a year quite well (The maximum student loan then was $3500). And I was driving a car I had purchased new two years earlier, thanks to a kindly bank manager. My residence for year 1 was literally not much more than a 3rd floor attic garret in walking distance from the medical school though. Life was good! I was even improving my self taught guitar playing skills and beginning to write songs!