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.