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.