The issue of privacy has been mentioned in Chapter 1. Although privacy in interviews with adults is often emphasized, children’s needs for privacy are frequently overlooked. Ensure that the child’s interview is free of intrusions and cannot be overheard.

Ideally the room should contain small chairs and a table suitable for preschoolers, or at least a place where you can join the child at his or her level. It can often be very helpful for the adult professional to get down on the floor at the same level as the child. This approach helps engage the child and is less intimidating.

When interviewing children, toys and drawing materials should be available. Toys help build rapport, decrease anxiety, and can be used in exploring the child’s wishes, fears, impulses, and relationships. However, too many toys and activities can be distracting. Useful play materials include nontoxic washable markers and/or crayons, paper, building blocks, male and female dolls, a dollhouse with accompanying figures and furniture, and a toy telephone. Board games may help engage a child initially, but, as outlined by Morrison and Anders, their use rarely leads to clinically meaningful information. They are typically highly structured and provide little opportunity for imaginative play.

Confidentiality

Parents and children should be informed early in the interview about issues of confidentiality. Children should not be assured of absolute confidentiality because issues about self-harm or abuse may arise. If children are assured that nothing will be shared with any other person and, subsequently, an issue such as abuse surfaces during the interview that must be disclosed to others, it can lead to feelings of betrayal. Such situations can result in a serious disruption of the therapeutic alliance. We find it useful to inform the child in developmentally appropriate terms that what is discussed is confidential unless it involves someone’s safety (e.g., people hurting themselves or being hurt by others). With young children, it is helpful to explore their understanding of the concept of safety.

An example of how to discuss confidentiality follows: “I will not tell anyone what you and I talk about without you saying it’s all right, unless it has to do with someone’s safety.” “Do you know what safety means?” (Often the child, depending on the age, can provide an explanation. It is still helpful to clarify what you mean by safety). “If you, or someone you know, is hurting themselves or being hurt by someone else, then that’s a problem with safety.”

The clinician and the child can decide together what information can be discussed with parents. Often a focus on themes, rather than specific comments, can be shared with the child’s permission. “I will be meeting with your parent(s), but we can decide together what is okay to share with them.” Parents are sometimes reluctant to have their child interviewed alone. They may be worried about what the child will say about them or their home situation. Parents should be reassured that it is a routine part of the assessment to get the child’s perspective.

Length

Interviews about behavioral and emotional problems often require more time than the assessment of physical problems. The clinician, parents, and child must have the opportunity to establish rapport, and exploration of psychiatric issues can be stressful. We recommend that 45 minutes to 1 hour be set aside for the first encounter regarding a mental health problem. The child’s age, developmental stage, and ability to be seen alone will influence the proportion of time spent with the child alone, parents alone, and the child and parents together. It is most important to establish a positive rapport with the patient and family, rather than adhering to a rigid schedule for the assessment. For example, some young children can tolerate being seen alone for very brief periods only. The clinician should structure the length of time with each person accordingly.

Key Point

Set aside 45 minutes to 1 hour for the first encounter when interviewing children and families about emotional and behavioral problems. Subsequent interviews should generally be scheduled for similar lengths, until the assessment is completed.

Obtaining the Presenting History

The following guidelines outline the approach to obtaining presenting history from the parents and children:

1. Encourage each person to describe the problem in his or her own way. An open inquiry followed by more focused questions later in the interview provides the most information. Examples of open versus more directive questions are provided in Chapter 1. At times a child will respond repeatedly with “I don’t know.” It is important to determine whether the patient genuinely does not understand or whether this response is to avoid answering the question. Rephrasing the question or giving examples can assist with the former situation. When avoidance is suspected, it can be helpful to ask the patient directly, but in a nonthreatening way, whether the repeated “I don’t know” means he or she is having trouble comprehending or whether there are barriers to answering the question. It can be useful to explain how such responses can be confusing, and that an alternative such as “I don’t want to talk about that” is preferable if indeed that is the case.

2. Seek detailed descriptions of the behavioral or emotional symptoms; ask for specific examples of the behavior.

3. Avoid leading questions that suggest the answer. An example of a leading question is “I bet that really made you angry, right?” A better question would be, “How did you feel when that happened?” Young children, particularly, may be prone to conform to an interviewer’s expectations.

4. Ask about the impact of the problem. How much does the behavior affect the child’s and family’s functioning? For example, if the problem is oppositional behavior: How often is the behavior happening? What happens in response to the behavior? Who in the family is most affected by the child’s behavior? What is that like for the child? When [child’s name] behaves like that, what is it like for other family members?

5. Ask about the presence of the chief complaint across a range of activities and situations. For example, is the child fearful at night only?

6. Ask about historical data, such as developmental milestones using direct questions; an open approach works best for relationships and feelings.

The following case example illustrates how information from multiple sources is important in addressing emotional and behavioral symptoms and in moving toward a diagnosis and treatment plan.

Case History 1

History. Emma (age 7) and her parents were referred by their family physician because of Emma’s teacher’s concerns about her withdrawn behavior at school and her lack of friends. According to her parents, Emma played well at home with her 4-year-old sister and often helped with chores around the house. She appeared happy and enjoyed doing errands with her mother. Neither parent had observed any problems with Emma. They thought she was likely just shy at school and would become more sociable with time. Her second grade teacher noted early on that Emma did not interact with her classmates and often wanted to stay in the classroom during recess. Emma appeared to understand her schoolwork and completed it without difficulty. However, she resisted saying anything in class and refused to work in groups with other children. She often stayed behind in the classroom until everyone else had left. When Emma was interviewed individually, she initially denied any problems and said that her parents and her sister were her friends; she did not need anyone else. As the clinician probed further, Emma admitted to being very lonely but feeling too self-conscious to interact with peers. She acknowledged feeling so worried about meeting other children that she hated school. Together the clinician and Emma talked about sharing this information with her parents. At first Emma was hesitant but then agreed that it was important for her parents to know how she had been feeling. Both parents were supportive of Emma as she told them, assisted by the clinician, about how she had been feeling at school. They agreed to meet with the teacher to discuss ways of helping Emma with her anxiety about interacting with classmates and were referred to a child psychiatrist for further assessment to determine whether Emma needed additional treatment for her anxiety symptoms.

Specific features of the interview with parent(s)

1. Studies show it is essential to interview both parents (if there is more than one available) when assessing an emotional or behavioral problem. Reports by one parent of the perspective of the other are often inaccurate. Often details of the personal, family, and social background can be obtained from the parents only, particularly when assessing younger children.

2. Ask the parents about their own childhood. Useful questions include:

• Who was in your family?

• Tell me about your family when you were growing up.

• What is your best memory of growing up?

• What is the worst (or most painful) memory of your childhood?

• What happened in your family when someone got in trouble?

• Whom did you go to for help?

3. Inquire about relationships between the parents and grandparents. For example, say to parents:

• Tell me about the relationship between your parents (both then and now).

• How did you and your mom get along?

• How did you and your dad get along?

5. Explore additional issues as listed in Chapter 1. Some aspects of the history (e.g., family violence) are more appropriately discussed with each parent separately. However, parents sometimes learn more about their partner when interviewed together about past and family history.

Key Point

It is essential to interview both parents (if there is more than one available) to gain their individual perspectives. They can sometimes vary considerably.

Specific features of the interview with the child

1. Maintain a reasonable physical distance from the child to avoid intrusiveness or intimidation.

2. Ask for the child’s preferred name and ensure that you introduce yourself to the child.

3. Explain clearly the purpose of the interview, and give a brief description of what will be covered.

4. Begin with nonthreatening general questions. Allow the youngster to describe the family situation, recreational activities, and interests. Examples of such inquiries include, “Tell me who’s in your family” or “Tell me what you like to do after school.”

5. Follow the child’s lead, but do not let the interview become disorganized. Once a topic is introduced, try to maintain the focus until the necessary information is obtained.

6. Avoid note-taking as much as possible. If notes are necessary, explain the purpose of the notes to the child.

7. Tailor the length of the interview to the individual child and to the nature of the problem; if the child appears tired or upset, do not hesitate to shorten the session.

Specific features of a family interview with parents and children

Family discord and disruption are strongly linked to psychiatric problems in children. The importance of family dynamics has been highlighted in Chapter 1; it is essential to assess (even briefly) the interpersonal relationships and interactions with at least the parent(s) and child with the presenting complaint and preferably the child’s siblings. Family interviewing is occasionally contraindicated, for example, in child abuse when the alleged perpetrator is a family member or when there is the potential for violence. Guidelines for family interviewing in the course of a psychiatric assessment are as follows:

1. Respect confidentiality; do not reveal information obtained during individual sessions unless permission is obtained.

2. Elicit information from all family members; do not allow one family member to dominate the session.

3. Do not focus solely on the problems. Ask also about strengths and positive attributes of the family. For example, what do family members enjoy doing together?

4. Adopt a neutral stance, but always be prepared to identify and deal with any inappropriate behavior. For example, if a parent makes cruel or degrading comments to a child, address the inappropriateness in a direct but empathic manner. “I sense that you are angry, but comments such as those will not be helpful to [child’s name]. Try talking about what bothers you without making critical comments to [child’s name].”

5. Pay careful attention to nonverbal messages, behaviors, and expressions in assessing family functioning. For example, watch for the youth who rolls his or her eyes in response to a parent’s statement or the parent who casts angry glances at a partner.

Information from collateral sources, including schools and community agencies

Information from teachers, child care personnel, and other community agencies can help greatly in the psychiatric assessment of children and youth. However, contact with the school or outside agencies should only occur after signed permission is obtained from the parent(s) and the child is informed ahead of time. Teachers can provide valuable details about the academic progress and a description of the child’s relationships with peers and school personnel. School information is essential if the child is having difficulties in the school setting. Personal contact (by telephone or interview) with the teacher who knows the child best usually results in the most comprehensive data. It is also important to explore the teacher’s perception of the child’s difficulties and ask about the teacher’s attitudes toward him or her. Contact with social workers or access to reports from community agencies is particularly helpful in dealing with children in foster care or adopted children.

Key Point

Contact the school to find out about the child’s academic performance and his or her relationship with peers. First obtain permission from the parent(s) and inform the child of this plan.

Assessing Symptoms

Child and adolescent psychiatric disorders are commonly divided into the broad categories of emotional and behavioral problems. The following sections suggest specific approaches to assessing symptoms in these two areas. Classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders IV (DSM) or the World Health Organization International Classification of Diseases (ICD) provide detailed information about the criteria used in making a specific diagnosis. The DSM and ICD are both classification systems for the identification of psychiatric disturbances in children and youth. (DSM-V should be available in 2013.) Morrison and Anders provide a useful summary of DSM-IV, as it applies to children, for those who are interested in further information. They emphasize that DSM-IV is a “snapshot” in time, and the criteria frequently change as new information about mental disorders in childhood and adolescence becomes available from clinical studies.

Eliciting information about behavioral problems

When determining whether a behavior problem is abnormal, the clinician must assess its frequency, duration, and context. For example, some behaviors, such as temper tantrums, are normal at certain ages (between 18 months and 4 years) or at low frequency. The clinician should explore the circumstances of the behavior and the outcome. For example, in the case of antisocial acts against others, who was the victim? Was it someone familiar to the child or a stranger?

Disruptive behavioral problems

Disruptive behavior is one of the most frequent categories of disorder brought to the attention of pediatricians. Bear in mind that some oppositional behavior is developmentally normal in early childhood and adolescence. What distinguishes disruptive behavior problems from other psychiatric conditions is the destructive, intrusive, and sometimes dangerous behavior that affects others.

Many children are inaccurate reporters of attentional or other disruptive behavioral problems. They may be unaware of their own excessive activity or may underreport aggressive behavior. Careful attention should be given to reports by children, parents, and teachers of behavioral problems and to the level of agreement among them.

Some issues to consider when assessing children and youth with behavioral problems are the following:

• Has there been a recent change in the family that could affect the child?

• What is the frequency and severity of punishment? (Be alert for child maltreatment; see later section.)

• Are there family stresses that worsen the behavior?

• Does the child have an understanding of the symptoms?

Some specific questions about disruptive behavioral problems include:

• Have you ever been in trouble with the teacher?

• Some kids your age steal things—what about you?

• Have you been in any fights at school?

• Have you ever been expelled from school?

• Do you know anyone who carries a weapon, such as a knife or a gun?

Examples of questions about anger and aggression include:

• What makes you angry?

• What do you do when you get angry?

• Do you use fighting to work out your problems with other kids your age?

Substance abuse

Many adolescents and some younger children experiment with drugs, whereas a smaller number of youth actually use them on a regular basis. Use of alcohol and tobacco by youth exceeds use of other classes of drugs. The true extent of child and adolescent substance abuse is difficult to determine because of such factors as difficulty differentiating casual from regular usage. Many youth who misuse substances have other psychiatric conditions, such as disruptive behavior problems, anxiety, or depressive disorders. In assessing substance abuse, the following questions may be helpful:

1. Ask about alcohol, smoking, and other drug use directly, including frequency, duration, and most recent use. Ask, “What experiences have you had with alcohol?” rather than “Do you drink alcohol?” As a lead-in to this area of questioning, it can be helpful to inquire about drug and alcohol use at the child’s school. For example, “How common is it for kids at your school to use marijuana?”

2. Ask about the desired effect of drug or alcohol use (e.g., to get high, to feel less nervous, or to forget about problems).

3. Ask specifically about any problems arising from drug or alcohol use, such as parental concern, withdrawal symptoms, and legal involvement. For example, “Does anyone hassle you about how much you drink? Has anyone ever told you they think you have a drug problem? The day after a party, do you ever feel like you need a drink?” and “Have you ever been in trouble with the police?”

4. Inquire about associated risk-taking behavior, including the use of needles and sexual practices.

5. Remember to ask about abuse of prescription or over-the-counter medications.

Key Point

When exploring risk-taking behaviors, such as drug use, ask specific and direct questions. For example, “How much alcohol do you drink?”

These questions can assist in determining the extent and pattern of substance abuse. Although occasional or experimental use should not be overemphasized, youth often underreport drug and alcohol use and deny associated impairment. The pediatrician must maintain a high index of suspicion and carefully ask adolescents about drug and alcohol consumption.

Eating disorders

Eating disorders include a variety of conditions, such as anorexia nervosa and bulimia nervosa. Anorexia and bulimia can be difficult to detect, particularly in the early stages. Any child or adolescent presenting with a possible eating disorder should be asked about attitudes toward eating and weight. The patient’s impression of his or her body image (current and ideal) should be explored in detail; often asking the youth to draw a picture of himself or herself or talking with the family can identify disturbances of body image that may be denied or minimized during an interview.

Examples of questions include:

• Have you ever lost so much weight that someone said you were too thin?

• Are there any parts of your body you do not like?

• Do you think you are too fat?

• Have you tried to lose weight?

• Have you ever tried to lose weight by making yourself throw up?

Patients with eating disorders are often reluctant to disclose information about eating behaviors. It can be useful to ask youth about the existence of any rules they follow with regard to when, where, and what they eat.

Eliciting information about emotional disorders

Determining the presence of an emotional disorder, such as depression or anxiety, can be difficult because some features of these conditions are extremes of normal emotions. An emotional symptom becomes abnormal when it is

1. Intruding on the child’s life or is associated with significant distress

2. Persistent rather than transient

3. Occurring across activities, that is, a child is worried about doing well in several areas of his or her life

4. Associated with impairment, that is, the child reports feeling sad, and school reports indicate deterioration in academic functioning

Depression

Major depressive disorder occurs in approximately 5% of adolescents and is more common in girls than in boys. Serious clinical depression is much less common in children than in adolescents but does occur, especially if there is a history of depressive disorder in one or both of the parents. In children, studies have found that it occurs either equally in boys and girls or is more common in boys. In assessing depressive disorder in a young person, consider the following:

1. Determine whether the patient has a sad affect. This may be expressed as downcast eyes, a quiet voice, slowed down speech or movements, and lack of spontaneous speech.

2. Consider that in depressed children and teenagers, irritability, rather than sadness, can be the primary mood disturbance. Ask whether the child has been grumpier than usual with family and friends.

3. Ask how much of the time the child feels sad or down. Occasional feelings of sadness are common, but if symptoms are persistent or frequent, it suggests depression. Younger children may have difficulty determining how long feelings of sadness have been present. It can be helpful to relate time to meaningful events in a child’s life (e.g., the end of the school year).

4. Listen for expressions such as “feeling empty” or “hopeless.” These statements often indicate the presence of a depressive disorder. Morrison and Anders suggest asking children about three wishes. This can help elicit statements about hopelessness or a wish for death (see “Suicidal Ideation and Behavior”).

5. Ask about interest in friends, school, and energy level. Typically, depressed teenagers lose interest in some activities but may report feeling better when in the presence of their friends.

6. Inquire about changes in eating and sleeping patterns. Depressed youth may show either a decrease or increase in weight and amount of sleep.

7. Ask about suicidal thoughts and behavior (see “Suicidal Ideation and Behavior”).

Anxiety

Anxiety disorders are very common and occur in between 8% and 27% of children and adolescents. Like depression, anxiety falls on a continuous spectrum from normal to abnormal. As with sadness, a central question is the degree of impairment: Is the symptom(s) interfering with the child’s ability to participate in developmentally appropriate activities?

Other diagnostic considerations that may help determine the presence of pathologic anxiety include:

1. What is the level of distress experienced by the child or adolescent?

2. When the anxiety-provoking situation is not present, what is the child’s level of anxiety?

3. What is the age and developmental level of the child? A 4-year-old child who experiences anxiety upon separation from a parent presents a different clinical picture from a 13-year-old with the same symptomatology.

In determining whether emotional symptoms are abnormal, consider the intrusiveness and impact of the problem on the child’s life. For example, how much is anxiety interfering with their daily activities?

While older children and adolescents will generally understand the concept of anxiety, younger children should be asked about things that frighten or worry them. Children may manifest or express anxiety through physical symptoms; headaches and stomach aches are particularly common. Although parents are often aware of these common physical symptoms, children may not mention other symptoms, such as sweating, palpitations, dizziness, trouble breathing, and fear of dying.

One of the types of anxiety conditions that until recently was thought to be rare in children and adolescents is obsessive-compulsive disorder. Based on recent studies, it is now clear that this condition often begins in childhood and may affect as many as 1% to 2% of adolescents. Children may keep their obsessive thoughts and compulsive behavior a secret. It is important to ask whether children experience an urge to check things repeatedly or have a specific order in which they have to do certain tasks.

Case History 2

History. Robert (age 13) had always been an excellent student who was well-liked by his peers. In eighth grade, his marks began to slip, and his mother noticed that he was tired and subdued much of the time. She and Robert’s father had separated two years earlier, but he was able to spend time with both parents and had appeared to adapt to the situation reasonably well. When Robert’s mother met with the teacher, she was informed that Robert was not completing his assignments. Robert’s mother expressed confusion because her son typically spent 3 hours a night in his room on homework. Robert was referred to the school guidance counselor who developed a rapport with him. He confided to the counselor that he had trouble completing his work because of the tasks he had to do before starting on his assignment. At first the counselor thought Robert was referring to chores but, on further questioning, she realized that he was referring to certain rituals. Robert explained that he had to count things in his room (such as the books on the shelf) and the number of words on the pages of his assignment before he could do his homework. If he lost count he had to start over and frequently became so tired that he did not finish his assignment. According to Robert, he had to follow these rituals to ward off bad things from happening, such as his mother or father becoming ill. Robert admitted that it sounded crazy, but he could not stop himself from counting.

As in this case, there is often considerable overlap among symptoms of anxiety and depressive disorders in both childhood and adolescence.

Suicidal ideation and behavior

Suicidal behavior is uncommon in childhood and early adolescence but increases significantly in older adolescence. Many people wrongly assume that young children do not experience suicidal thoughts and are not at risk for attempting suicide. Large surveys show that up to 20% of high school students experience thoughts of suicide, and about 10% exhibit suicidal behavior. Ask the child or youth directly about thoughts of suicide. These questions should be asked without the parent present. Examples of the way these questions can be asked include, “Have you ever thought that life is not worth living?” and “Have you ever thought about taking your own life or not being alive anymore?”

When there is suicidal ideation or a youth has attempted suicide, the next step is to assess intent by asking about the events and precipitants leading up to the episode or associated with the thoughts of suicide. Children vary in their level of comprehension about death, depending on their age and developmental stage. In evaluating suicidal ideation or behavior, the clinician should explore the child’s concept of what would happen. Examples of possible questions to ask include:

• What do you think would happen if you tried to kill yourself?

• Do you think you would die?

• What happens when people die?

Suicidal thoughts and behavior should be asked about routinely. Children will not usually volunteer this information, and parents are often unaware that their children are experiencing suicidal thoughts. When asking about possible precipitants or stressors, it is important to avoid minimizing problems. While the break-up of a relationship or being embarrassed among peers may not seem like major stressors to some, such experiences can be extremely demoralizing and may be associated with feelings of hopelessness among youth.

Risk of completed suicide increases with certain associated features:

1. Clear intent

2. Planned suicidal act with a lethal method

3. Presence of a psychiatric disorder, particularly depression, delinquency, and substance abuse

4. Hopelessness about change in the future

5. Male gender

6. Poor family supports

7. Previous attempt

8. Recent loss or other negative life event

Somatoform disorders

Somatoform disorders are a group of psychiatric disturbances that includes conditions characterized by physical symptoms that may resemble other medical conditions, but the symptoms have no identifiable anatomical or physiological cause. Examples include somatization disorder, conversion disorder, and hypochondriasis. The assessment of such conditions calls for a careful history about the onset, precipitating, aggravating, and relieving factors associated with the symptoms. It can sometimes be helpful to consider the patient’s affect associated with the description of the physical complaints (e.g., the youth who appears disinterested when describing serious symptoms). Nevertheless, it is essential to remain alert for the presence of medical illness and to remember that a patient can have an underlying physical illness and psychiatric symptoms associated with the condition.

Psychosis

Children and adolescents can show the same symptoms of psychotic illness as do adults, although such symptoms are uncommon in childhood. The two main features of psychotic disorders are hallucinations and delusions. The clinician should differentiate the presence of these potentially serious symptoms from other more common and benign phenomena (e.g., imaginary companions and fantasies).

Inquiry about hallucinations should include auditory and visual experiences. The questions can be incorporated into the systems review focusing on eyes and ears:

• Do you have any problems with your eyes?

• Do you ever see things that other kids do not see?

A delusion is a false belief that cannot be changed by logical argument or evidence against it. Such beliefs often involve bizarre or unusual thinking. Few studies have carefully assessed delusions in childhood; they are rare before late adolescence. Among psychotic youth, delusions are often paranoid or persecutory. For example, a teen may complain of being followed or poisoned. Sometimes, delusions have religious themes. A useful question is, “Have you ever had thoughts that scare you or upset you?” Although children may have erroneous views about people or events, actual delusions are rare in childhood.

Inquiring about child maltreatment

(See Chapter 21.)

Children and adolescents are often victims of some type of maltreatment, including physical abuse, sexual abuse, neglect, emotional abuse, or exposure to domestic violence. It is estimated that between one in three and one in four adults reported experiencing either physical or sexual abuse during childhood. Much less is known about the prevalence of other types of maltreatment. In most regions, it is the responsibility of child protection agencies to carry out investigative interviews when child maltreatment is suspected. Nevertheless, the pediatrician should include questions about child maltreatment in any psychiatric assessment.

Examples of questions to elicit concerns about child maltreatment:

• What things do you worry about?

• What happens in your family when someone gets in trouble?

• Has anyone ever touched you in a way that made you feel uncomfortable or upset?

• Has anyone ever made you do something sexually you did not want to do?

This clinical area presents an exception to the earlier comments about note-taking. If a child or youth discloses information about any type of maltreatment, attempts should be made to document the statements verbatim. It is helpful to record the wording of questions asked by the clinician and the child’s response. It is generally not advisable to ask detailed questions about a disclosure of maltreatment because, in many jurisdictions, a child protection agency worker needs to obtain the disclosure. Similarly, use of anatomically correct dolls should be reserved for specialized interviews requested by the child protection agency and performed by a clinician trained in their use. Children should not be subjected to multiple interviews by clinicians without specialized training in this area.

Although videotaping offers a complete record of an interview, there are problems associated with it. Videotapes may be used inappropriately; for example, details about how the child was interviewed may take precedence over the child’s verbal statements. At this time, there are not sufficient advantages to recommend videotaping psychiatric interviews, even if abuse is suspected.

Interviewing patients with mental retardation

As in any clinical encounter, the clinician should adapt the duration, format, and questions of an assessment to what the child and family can tolerate. In addition to cognitive impairment, patients with mental retardation may have other behavioral and emotional problems, such as aggression, self-injury, hyperactivity, depression, and anxiety. Sometimes the psychiatric assessment of children and youth with mental retardation is neglected, particularly when verbal skills are impaired. There is evidence that emotional disorders are present to a greater degree in patients with mental retardation compared to those without, but often such problems are not recognized. The following are some important considerations when interviewing a pediatric patient with mental retardation:

1. Before meeting the child, learn about his or her life situation, living arrangements, and school experience.

2. Be clear about the reason for the visit, and explain carefully what will be done.

3. Ensure that the patient is seen alone, even if there is difficulty in communicating with the patient.

4. As the interview progresses, check to ensure that the patient understands the questions.

5. Be flexible about the pace and duration of the interview.

Morrison and Anders suggest that one of the major challenges in interviewing mentally retarded children and adolescents is to “pitch the questions at just the right level—neither so complex as to confuse nor so simple as to insult.” They recommend paying close attention to the patient’s response to the first open-ended question, as a way of gauging how to conduct the remainder of the interview.

Cultural considerations

(See Chapter 2.)

Each culture has its unique developmental pathways and varied expressions of emotional dysfunction. The way in which a child with psychiatric disturbance presents can be strongly influenced by cultural factors. The following principles should be followed in assessing cultural determinants:

1. Ask the child or parents for help in understanding their specific culture.

2. When seeing a patient from a culture with which you are unfamiliar, learn from the literature about specific cultural factors.

3. Consult with colleagues. Sometimes a patient or family may appreciate the opportunity to see a clinician who has an in-depth understanding of their culture. For example, some clinicians have spent considerable time learning about Aboriginal health and may be able to provide important insights about emotional and behavioral problems of someone who is Aboriginal.

Physical Examination

The physical examination has been discussed in detail in other chapters of this book. It is an important part of any psychiatric assessment for several reasons, as described here:

1. Behavioral and emotional problems can have physical causes or sequelae. For example, psychosis can occur as a side effect of certain medications. Eating disorders can lead to significant electrolyte disturbance and dehydration.

2. Various conditions (e.g., anorexia nervosa) may impair growth.

3. Certain psychiatric symptoms and/or conditions may be missed if a physical examination is not carried out, for example, anorexia nervosa.

Standardized Interviews and Questionnaires

Structured psychiatric interviews and rating scales for both children and parents have been developed to improve the validity and reliability of observations and information about emotional and behavioral problems. Generally, these tools are most useful for research purposes; however, there are a few measures that may be helpful to the clinician.

Structured interviews are comprehensive and decrease the chance that an area will be forgotten. They were developed originally to improve the quality of information collected during mental health assessments. However, they are typically time-consuming and may interfere with building rapport.

Questionnaires or rating scales that ask about behavior can be useful for obtaining information from multiple sources. Generally, these scales are focused on behaviors and do not ask in-depth or detailed questions. Such scales can be particularly helpful when seeking information from schools. Several teacher questionnaires have satisfactory reliability and validity, including:

1. Conners Rating Scales—Revised (CSR-R) help in assessing attention deficit and hyperactivity symptoms: http://www.pearsonassessments.com/crsr.aspx

2. Child Behavior Checklist (CBCL) asks about behaviors: http://www.aseba.org

3. Revised Behavior Problem Checklist asks about behaviors: http://www3.parinc.com/products/product.aspx?Productid=RBPC

Each of these instruments has parallel versions for completion by parents so that systematic information can be obtained about a list of behaviors. These are screening instruments, however, and should not be used for making specific diagnoses.

Key Point

Questionnaires, such as the Conners Teacher Rating Scale, can be useful in collecting information about behaviors but should not be used for making specific diagnoses.