Jennifer L. Hudson, Carol Newall, Sophie C. Schneider, and Talia Morris
Internalizing disorders, including anxiety and depression, typically begin early in life and are one of the most common forms of psychopathology found in children and adolescents (Rapee, Schniering, and Hudson 2009). It can be difficult to assess for these disorders in children, as the symptoms are often unseen and can be dismissed as simply a “phase” or part of the child’s personality. In contrast to other childhood disorders, such as oppositional defiant disorder, internalizing disorders can sometimes be missed by parents and teachers as the symptoms are not always observable and children may underreport their experience, to avoid causing trouble. It is vital that clinicians are able to competently detect and assess internalizing disorders, given the considerable interference caused by them within the family and across the lifespan (Merikangas et al. 2010). Undertaking a competent assessment is a fundamental step when determining the child’s diagnostic profile. Moreover, it is during assessment that the therapist will develop a better understanding of the disorder-related maintaining factors, thereby becoming able to select the most appropriate intervention for the child.
Our aim in this chapter is to describe therapist competencies required for conducting a competent and thorough assessment of children and adolescents with anxiety and depressive disorders. First we will outline each of the individual competencies and discuss them in detail. Next we will outline issues that arise when conducting a competent assessment of anxiety and depression. Finally we will discuss some common obstacles to conducting a competent assessment and strategies for overcoming them.
Over the last 15 years, clinical psychology has witnessed a paradigm shift toward the use of empirically supported treatments (Chambless and Hollon 1998). Not too far behind this movement is the shift toward adopting evidence-based assessments (EBAs). An evidence-based assessment framework (Hunsley and Mash 2007) demands that the therapist rely on both theory and empirical research in his or her choice of assessment procedures. As a result of this movement, a few key papers have emerged that have documented guidelines for the evidence-based assessment of anxiety and depressive disorders in children and adolescents (Klein, Dougherty, and Olino 2005; Silverman and Ollendick 2005). These guidelines are based on the rich body of research devoted to developing and evaluating assessment procedures for children and adolescents diagnosed with internalizing disorders.
Recently, Sburlati, Schniering, Lyneham, and Rapee (2011, p. 94) have added to these guidelines by outlining five key therapist competencies for conducting a thorough assessment of child and adolescent anxiety and depressive disorder. These competencies are:
Each of these competencies will be discussed in detail.
Applying the EBA framework to psychological assessment is a crucial therapist competency, without which the success of treatment cannot be properly established. As mentioned above, there is an abundance of publications detailing different assessment methods for anxiety and depression in children and adolescents (Beidel and Alfano 2011; Brown-Jacobsen, Wallace, and Whiteside 2011; Schniering, Hudson, and Rapee 2000). The large number of assessment tools and the variation in tested populations, however, make it difficult for therapists to judge which assessment methods they should use in clinical practice for any given client. Fortunately, there has been a growing focus in recent years on providing criteria to evaluate the utility of psychological assessment measures by using the EBA framework (Hunsley and Mash 2007). EBA requires that a psychologist’s choice of assessment methods should be guided by a broad set of considerations. First, for a psychological assessment method to accurately capture an internalizing disorder, it must be highly reliable. The reliability of a measure refers to the consistency of a client’s score across differing clinicians (inter-rater reliability), across time points (test–retest reliability), and within the measure itself (internal consistency). For example, if an assessment measure does not have high test–retest reliability, a clinician is unable to conclude whether treatment changes over time reflect real changes for their client or are due to an unreliable measure.
Second, it is important that the assessment measure selected by the therapist has established normative data or criterion-related cut-off scores to aid a clinician in correctly interpreting his or her client’s score against a larger relevant population. Norms may be used to compare a client to the general population or to specific subgroups. It is important, too, that these norms have been created from both clinical and nonclinical samples and are sensitive to age and gender. A clinician also needs to consider the child’s cultural background, as norms can differ across cultures, some behaviors being considered desirable in one culture and atypical in another. Furthermore, without these norms, it is difficult for a clinician to competently conclude if his or her client’s symptoms or functioning differ from those of the general population.
Third, the EBA framework requires that an assessment method have high validity. Specifically, is it measuring what it purports to measure? For instance, a scale that purports to measure anxiety might merely be capturing state arousal. A competent clinician should examine both the content validity (the degree to which a measure indexes all components of the construct being measured) and the construct validity (the degree to which the theoretical construct being assessed was actually measured) of a measure. A particularly good measure will also show evidence of incremental validity, that is, evidence that the measure adds unique information over and above other assessment methods. Furthermore, the EBA framework suggests that a measure should give evidence of validity generalization, which supports the use of that measure across age, gender, socioeconomic status, ethnic groups, and differing contexts – home, school, primary care, and inpatient settings.
Using the EBA framework, a competent clinician must also decide if an assessment measure demonstrates clinical utility. When the practical aspects of the measure are taken into account – and these include costs, administration difficulty, duration, availability of the measure, and norms – are the data gained from this measure going to demonstrate satisfactory clinical benefit? In particular, is there published evidence that the measure in question is able to detect clinical change? Table 7.1 provides therapists with a list of evidence-based assessment measures that are commonly utilized in the assessment of anxiety, depression, and related self-harm and suicide and can be used within a multi-method, multi-informant EBA.
Table 7.1 Examples of evidence-based measures for anxiety, depression, depression and self-harmself-harm/suicide.a
| Measure | Delivery method | Reporter | Age group | Length |
Anxiety |
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| ADIS C/P-IV (Silverman and Albano 1996) |
Semi-structured interview | C/P | All | 1–3 hours |
| SPAI-C (Beidel, Turner, and Morris 1995) |
Self-report scale | C | 8–14 years | 20–30 minutes |
| SASC–R (la Greca and Stone 1993) |
Self-report scale | C | 7–13 years | 10 minutes |
| MASC (March, Parker, Sullivan, Stallings, and Conners 1997) |
Self-report scale | C | 8–19 years | 15 minutes |
| SCAS (Spence 1998) |
Self-report scale | C/P | 6–18 years | 10 minutes |
| SCARED (Birmaher et al. 1997) |
Self-report scale | C/P | 8–18 years | 10 minutes |
| PAS (Edwards, Rapee, Kennedy, and Spence 2010) |
Self-report scale | P/T | 3–5 years | 10 minutes |
Depression |
||||
| K-SADS (Puig-Antich and Chambers 1978) |
Semi-structured interview | C/P | 6–18 years | 20–60 minutes |
| CDRS-R (Poznanski and Mokros 1999) |
Self-report scale | C/P | 6–12 years | 15–20 minutes |
| CDI (Kovacs 1992) |
Self-report scale | C | 7–17 years | 15–20 minutes |
| SMFQ (Angold, Costello, Messer, and Pickles 1995) |
Self-report scale | C/P | 8–18 years | 5–10 minutes |
| RADS (Reynolds 1987) |
Self-report scale | C | 12 years + | 5–10 minutes |
Self-harm and suicide |
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| SITBI (Nock, Holmberg, Photos, and Michel 2007) |
Structured interview | C/P | 12–19 years | 3–15 minutes |
| BSI (Beck and Steer 1991) |
Self-report scale | C | 12–17 years | 5–10 minutes |
| SIQ (Reynolds 1988) |
Self-report scale | C | 12–18 years | 10 minutes |
aEquivalences:
C = Child;
P = Parent;
T = Teacher;
ADIS C/P-IV = Anxiety Disorders Interview Schedule for Children for DSM-IV;
SPAI-C = Social Phobia and Anxiety Inventory for Children;
SASC-R = Social Anxiety Scale for Children-Revised;
MASC = Multidimensional Anxiety Scale for Children;
SCAS = Spence Children’s Anxiety Scale;
PAS = Preschool Anxiety Scale-Revised;
SCARED: Screen for Child Anxiety-Related Emotional Disorders;
K-SADS = Schedule for Affective Disorders and Schizophrenia for School-Age Children;
CDRS-R = Children’s Depression Rating Scale-Revised;
CDI = Children’s Depression Inventory;
SMFQ = Short Mood and Feelings Questionnaire;
RADS = Reynolds Adolescent Depression Scale;
SITBI = Self-Injurious Thoughts and Behaviors Interview;
BSI = Beck Scale for Suicide Ideation;
SIQ = Suicidal Ideation Questionnaire.
The above criteria can be used to select high-quality assessment tools, including interviews, questionnaires, and observational methods. It is generally agreed that a competent assessment is one in which multiple methods of data collection are conducted (Kazdin 2003; Silverman and Ollendick 2005). Selecting which combination of measures to use for assessment should be guided by a consideration of the strengths and limitations of each method.
Structured or semi-structured interviews are considered the gold standard of assessment for internalizing disorders (Morris and Greco 2002). Research has shown that clinicians conducting unstructured interviews will often not ask about all-important elements of the relevant psychopathology and will make fewer diagnoses than in a semi-structured interview (Zimmerman 2003). A semi-structured interview ensures that a clinician covers the relevant disorder they are assessing, while also allowing for clinical judgment on differential diagnoses. During the interview the clinician is required to make an assessment of the frequency, severity, and duration of symptoms, as well as of the situations in which the child’s symptoms occur. In addition, the therapist must also assess functional impairment as a consequence of the child’s symptoms.
Although questionnaire methods typically don’t provide enough information for making a diagnosis in isolation, they are useful tools to quickly gain information on a client’s current symptoms. Due to the standardization of such measures, self-report measures are also useful for tracking changes in these symptoms over time. Therapist training for the administration and interpretation of self-report measures is less than is required for structured interviews. These factors, together, make self-reports particularly valuable in clinical settings.
Observational methods are an under-utilized method for the diagnosis of anxiety disorders or depressive disorders. However, they possess clinical utility and can be useful for examining the level of fear and anxiety displayed by a client when exposed to threatening stimuli. Behavioral approach tests (i.e., client-led steps of increasing difficulty toward a feared object or situation, in a controlled environment) for fears such as of dogs, needles, talking in front of others, and separation from caregivers can be conducted in clinical settings (Ollendick, Lewis, Cowart, and Davis 2012). Observational methods can also be useful for understanding specific factors – such as parental over-involvement – that may be maintaining the child’s anxiety (Hudson and Rapee 2001).
Competent clinicians should utilize a multi-informant approach to assess for internalizing disorders in children and adolescents (Kazdin 2003; Silverman and Ollendick 2005). It is standard to assess the child and at least one parent or caregiver. This is because children may have a limited repertoire in their vocabulary to fully articulate the extent of their internalizing difficulties, or may exhibit reluctance to discuss the functional impairments related to their internalizing problems. Parents are often very helpful when filling in the narrative gaps of the child’s ongoing problems across situations and across time. They are also sometimes the only source of information for certain assessment queries, such as first onset of the disorder – which may have occurred very early in the child’s life, before the child was able to remember it. There are also certain diagnoses that can only be established through parent report; these include oppositional defiant disorder and conduct disorder.
Teachers and other health care providers can give additional information, though it is not always practical – or even possible – to access this information. Sending a questionnaire and consent form to parents to release information to the teacher or other health care workers can be a practical method. Engaging a child’s teacher is particularly helpful in determining whether problems are context-specific to the home. This can be important for case formulation and sometimes diagnosis, in disorders such as attention deficit/hyperactivity disorder.
It is important that therapists not disregard the importance of gaining the child’s perspective on the problem. Internalizing disorders, by nature, are not always observable. A child’s report is sometimes more critical than those gleaned from parents and teachers, as the child often reports lower levels of internalizing symptoms (Jensen et al. 1999). Also, depressed parents may have a lower threshold for detecting depression in their children (Klein et al. 2005). Taken together with reports from other sources, such as parent and teachers, the child’s perspective can provide important information, which may not be accessible if one consults only those other sources.
When undertaking a multi-method, multi-informant approach to assessment, data from all sources need to be integrated to generate a well-informed diagnostic profile. However, this is often a challenge for clinicians. Therapists are encouraged to be aware that some children may not be comfortable with revealing sensitive information in a face-to-face setting. In such cases self-report measures can be incrementally useful for filling in the gaps from the structured interview.
There is an extensive body of literature showing discordance between parent and child reports for anxiety and depression (Comer and Kendall 2004; De Los Reyes and Kazdin 2005). There are a number of different possible options for clinicians to decide how best to combine multi-informant reports. These include adopting the “and” rule, which requires several informants to corroborate the diagnosis, and the “or” rule, which assumes that a diagnosis is present if any informant reports it (Comer and Kendall 2004). De Los Reyes and Kazdin (2005) promote the use of the attributional bias contextual model, which suggests that informants are discrepant because of their discrepant attributions of the child’s problems. The authors provide useful guidelines for clinicians as to how to best conceptualize informant discrepancies. Another procedure, referred to as the “best estimate” procedure, most closely mimics clinical practice and requires the competent clinician to use his or her best judgment on how best to combine the information (Klein et al. 2005).
As part of the “best estimate” procedure, it is important to take into account the age of the child and the symptoms being assessed. For example, a child’s anxiety problems may not be observable to parents, or may manifest differently at school and at home. Symptoms may also have differing impacts for the child and the parents. For instance, parents will often report a higher level of interference for separation anxiety than will children. As a general guide, a child’s report will tend to carry more weight the older she or he is. However, even very young children provide valid information and should not be ignored in a competent assessment.
There is a high degree of comorbidity between childhood psychopathologies (Costello, Mustillo, Erkanli, Keeler, and Angold 2003). In particular, the majority of children diagnosed with an anxiety disorder will meet criteria for at least one other anxiety disorder (Benjamin, Costello, and Warren 1990; Kashani and Orvaschel 1990). There is also a high degree of overlap between anxiety and depression, anxious children being 8 to 29 times more likely to have a co-occurring depressive disorder (Costello et al. 2003; Ford, Goodman, and Meltzer 2003; Seligman and Ollendick 1998). Children with anxiety and depressive disorders also have an increased risk of externalizing disorders (Ford et al. 2003). A competent clinician will need to carefully consider the likely comorbid patterns that often occur with anxiety and mood disorders in children and adolescents. A structured or semi-structured interview covering all internalizing disorders is considered the best method for differential diagnosis in children and adolescents.
It is important to gather information on the full spectrum of child and youth psychopathology in order to make differential diagnoses, including developmental disorders and externalizing disorders. Sometimes there is a significant degree of confusion regarding child symptoms that frequently leads to misdiagnosis. For instance, children with generalized anxiety disorder (GAD) may appear inattentive in some situations (e.g., the classroom) due to high-degree engagement with worried thoughts, which results in an inability to concentrate on the task. Such symptoms should be considered as related to the diagnosis of GAD rather than to attention deficit hyperactivity disorder – inattentive type. Similarly, children with separation anxiety disorder who refuse to participate in activities requiring separation from their caregiver should not be given an additional diagnosis of oppositional defiant disorder purely on the basis of their opposition during feared situations. Such behaviors should be conceptualized as fearful avoidance rather than as a true behavior disorder.
Given the high occurrence of somatic symptoms in anxiety and depressive disorders, a clinician should also ensure that the child has received a medical work-up, to rule out any medical conditions that could explain the child’s somatic symptoms. Further, there is a high degree of comorbidity between internalizing disorders and physical conditions – for instance asthma (Katon, Richardson, Lozano, and McCauley 2004). A medical examination will also allow the potential detection of comorbid physical conditions.
A thorough assessment should consider broader factors that have important clinical implications for child and adolescent clients. These factors include the child’s developmental level and functioning within systems such as the family unit, peers, and schools.
It is important for the clinician to gain information about the child’s developmental history and stage in order to ensure that the assessment methods selected are appropriate. A child’s developmental level refers to his or her cognitive, biological, emotional, and social functioning, and how it compares against predictable age-related functioning in his or her developmental cohort. The therapist needs to consider not only the child’s difficulties with internalizing problems, but also the normative skills, present or absent, that could impact on how well the child responds to the model of treatment selected. For instance, studies have shown that the effect of cognitive behavioral therapy (CBT) depends on age (e.g., Durlak, Furnham, and Lampman 1991), which suggests that some children may not have the developmental ability needed for cognitive therapy to be successful (Reinecke, Dattilio, and Freeman 1996).
While the child’s chronological age provides a guideline regarding his or her developmental abilities, children differ in terms of their developmental profile. Hence the therapist should not use age as the only determinant of the child’s abilities, but rather should be informally assessing for the child’s abilities irrespective of age. This requires knowledge of child development research (seen in Chapter 5) and the ability to assess for this feature during the assessment session. The therapist who is able to take into account the child’s developmental abilities at assessment stage will be able to select the most appropriate model of intervention for that child.
At assessment, the therapist must also have a sound knowledge base of developmental norms in order to make reliable diagnostic judgments (Holmbeck, Devine, and Bruno 2010). For instance, very young children, around the 24 months of age, will peak in behaviors that mimic obsessive–compulsive symptoms (Zohar and Felz 2001). However, these “compulsive” behaviors can be a part of normal development when they do not significantly interfere with daily functioning and when there is no family history of obsessive–compulsive disorder (Leckman, Bloch, and King 2009). Similarly, cognitive biases observed in children may be a reflection of a normal developmental progression rather than a symptom of an internalizing disorder. For instance, young non-anxious children have been found to endorse catastrophic and personalizing biases more than older non-anxious children (Leitenberg, Yost, and Carroll-Wilson 1986), which suggests that these biases are a reflection of developmental progression rather than symptomatic of a childhood anxiety disorder. More broadly, it is also worth noting that fear, anxiety, and sadness are normal human emotions, experienced universally. Young children experience a large number of fears (fear of separation, fear of the dark), and this is characterized as a normal developmental process (Gullone 2000).
A competent therapist will need to be able to extract from assessment how many of these child characteristics are indicative of normal development and how many represent more serious symptoms of an internalizing disorder. For parents, and for clinicians, it can be difficult to determine the point at which the frequency, severity, and duration of these emotions and behaviors are abnormal and require intervention. A semi-structured interview such as the ADIS-C/P is a useful guide, given that it takes into account the level of interference as a way of determining disorder diagnosis in clinical judgments. Beyond the semi-structured interview, the clinician can also determine the specific degree to which life is altered as a result of the symptoms: What is the child missing out on? How would life be different if these symptoms were removed? Determining the degree of interference is crucial in deciding on the clinical nature of the problem. A multi-informant assessment will also make this decision easier, as the clinician can determine whether the behaviors are observable to others outside the home. However, regardless of the technique used at assessment, a competent therapist should stay abreast of the developmental literature, to help guide his or her diagnostic judgment and case formulation at assessment (Holmbeck et al. 2010).
Finally, not only is developmental sensitivity integral to determining diagnoses, it is also important in choosing the format for the assessment. For preschool children, clinicians may choose to rely solely on parent report (e.g., Hudson, Dodd, and Bovopoulos 2011; Rapee, Kennedy, Ingram, Edwards, and Sweeney 2005). In contrast, for adolescents, self-report is given more weight in deciding on the diagnostic profile.
Given the importance of a child’s or adolescent’s family and social environment, the therapist needs to fully appreciate systemic issues surrounding the child or the adolescent in order to accurately assess his or her ongoing difficulties and devise a treatment plan that takes into account these important factors (Friedberg and McClure 2002). Within the family unit, consideration should be given to family functioning, parent behaviors (e.g., overprotection, lack of autonomy granting, critical parenting), and parent psychopathology, since these factors can function as maintaining influences on the internalizing problems, or as potential obstacles or strengths during intervention. For instance, parental mental health problems pose a risk for childhood internalizing problems (Gravener et al. 2012) that can limit optimal treatment outcomes for the child (Cobham, Dadds, and Spence 1998; Hudson et al. 2013), and are linked to parent attrition from treatment (Lyneham and Rapee 2006; Waters, Wharton, and Cobham 2009).
A therapist who takes current or past parental anxiety or depression into account at assessment may devote more time to establish rapport, trust, and psycho-education around anxiety and depression with the parent. This may be especially important for young children, given that parents play a more influential role in younger children’s lives than in that of adolescents, when peers become the dominant social influence. Although some of the research suggests that treatment of parental mental health disorder may have limited impact on the child’s treatment outcomes (Cobham et al. 1998), providing the parent with the appropriate rationale for each intervention technique and with psycho-education about childhood internalizing disorders may increase parental engagement and willingness to allow the child to participate in certain treatment techniques that are anxiety-provoking for the parent (e.g., exposure therapy), thus preventing attrition from the program.
Taking into account a multi-informant approach at assessment across various settings – for instance, paying heed to whether the child exhibits problems at school, or to the teacher’s perspective – also allows the therapist to evaluate whether the child’s internalizing problems manifest themselves across contexts. This approach is particularly informative, given that, if the problems only arise in a specific setting, there may be situationally based factors that maintain them – such as bullying at school, parent disciplining styles, family dispute, or stress at home. Therefore, when assessing the child, a therapist who has thoroughly assessed familial, school, and peer factors can also plan to target these maintaining factors during treatment (e.g., address the issue of bullying with the child, the parents, and the teachers). Teachers may also be a unique source of information about the child’s social development and peer engagement, given that they are more likely than parents to observe the child with other children. For instance, a teacher’s report of poor social skills suggests that some of the child’s anxious thoughts about social evaluation are not distorted and that treatment may need to prioritize the development of social skills in the course of the intervention.
Children and adolescents with internalizing disorders are at an elevated risk of self-harm and suicide (Dougherty, Klein, Olino, and Laptook 2008; Hill, Castellanos, and Pettit 2011). Although self-injurious behaviors are more common in adolescents, it is important for the clinician to be aware that young children can also experience self-injurious thoughts and behaviors, and can attempt suicide. Therefore it is essential to routinely assess for the presence and severity of these problems in children of all ages. There is a number of structured and semi-structured interviews developed for the purpose of assessing self-injurious thoughts and behaviors – interviews that are suitable for use with children and adolescents (see Table 7.1). Before beginning an assessment for self-harm and suicide, a competent clinician should have a pre-existing framework for dealing effectively with self-harm/suicidal thoughts and behaviors if they are disclosed. It is vital to provide information to families about referral options, including access to emergency treatment and out-of-hours assistance. Also, when discussing these issues with the child, it is important to provide age-appropriate information about a clinician’s duty of care and the limits of confidentiality. This is needed so as to not damage the therapeutic alliance in case it is necessary to inform the parent about previously undisclosed risk. A clinician will take into consideration the age of the child and the relevant legislation that may guide his or her decisions in this area.
In addition to assessing for self-harm and suicide, clinicians should be mindful of other forms of risk to children and adolescents, such as domestic violence in the home and abuse or neglect of children and adolescents. A clinician is to be mindful that, when assessing parental disciplining techniques, there is no risk to the child or adolescent. There are also considerations specific to children with internalizing disorders. For instance, there have been cases where parents were so protective of their anxious child that these children would log extensive absenteeism from school. This is considered borderline abuse and can be subject to mandatory reporting. Alternatively, a clinician may find out that the child’s excessive anxiety is coming from considerable violence occurring at home between the parents. It is important to be aware that one of the best predictors of child physical abuse is domestic violence between the parents.
A competent therapist will need to have knowledge of his or her national and local guidelines for mandatory reporting. Clinicians must keep themselves updated in the matter of child protection policies in their country and always seek supervision from experienced colleagues when assessing the risk of harm.
As mentioned above, anxiety and depressive disorders are frequently comorbid, particularly during adolescence, after the emergence of puberty (King, Gullone, and Ollendick 1990; Seligman and Ollendick 1998). Thus, when a child is displaying either anxiety or depression, a competent clinician needs to assess for both conditions. Recent evidence has also emerged showing that anxiety-disordered children with comorbid mood disorders have worse end-point outcomes after treatment (Rapee et al., 2013). Thus determining the degree of comorbidity between anxiety and depression is useful at the outset of treatment.
The domains of anxiety and mood disorders also overlap somewhat. For example, children with either disorder frequently report somatic and concentration problems. Even the best EBA self-report measures cannot perfectly distinguish between different disorders. Good assessment measures will converge most with the domains they are meant to be tapping, but some overlap is expected. This means that children who have one condition might be more likely to score higher on measures assessing the other condition, even if only one condition is “purely” present.
Novice clinicians often find it difficult to determine a diagnostic profile when the child and the parent have completely different views on the problem. For example, the adolescent may report that he or she has no fear or anxiety, while the parents report excessive fear and avoidance of numerous situations. Some children and adolescents may be unwilling participants in the assessment process, and this can be caused by a number of factors – such as stigma associated with mental health problems, not being told about the assessment, or conflict with the parents (to name just a few). Children and adolescents rarely seek treatment on their own and, as a result, the assessment process is likely to create some discomfort for the child. It can be useful for clinicians to determine the child’s perspective on seeking treatment and whether he or she has an understanding of why he or she had been referred to the clinic at the beginning of the child clinical interview.
Disagreement between reporters is a common problem when assessing internalizing disorders in children and adolescents. In the section on integrating sources of the data we have identified a number of methods that have been proposed in the literature and that can be useful in determining the final diagnostic profile.
A frequent problem experienced by clinicians is determining the appropriate level at which to pitch interview questions. Novice therapists often “talk down” to older children or adolescents, or they do the opposite – they “pitch too high” in the case of younger children. A key to this is to use a tone of voice that is respectful to the child as an individual and to avoid patronizing tones or childish voices. The first assessment is a critical period for developing an alliance with the child (see Chapter 6), so accurately determining the level at which to pitch your questions is important.
For many children and adolescents who are already fearful or sad, attending an assessment can be an extremely overwhelming and terrifying experience. Use the skills identified in Chapter 6 to allay the child’s concerns by engaging in non-threatening activities (play, games, drawing) at the start of the assessment. Normalizing fear and sadness is also a critical part of the assessment, designed to reduce the child’s concerns about being “weird” and to increase the chances that the child will disclose his or her own fears and sadness.
Adopting an evidence-based approach to guide the assessment of child and adolescent anxiety and depression is the key to a competent and thorough assessment. A multi-method (e.g., interviews, questionnaires), multiple-informant (e.g., child, parent, teacher) approach is likely to result in the most thorough assessment of the child’s problem, allowing the clinician to accurately determine the child’s clinical diagnosis and to differentiate specific disorders. This can be a challenging task for the clinician who assesses child and adolescent internalizing disorders, due to the high degree of comorbidity and to the higher levels of informant discrepancy. Finally, the clinician should consider the child’s difficulties in the context of that child’s environment (e.g., cultural background, school, family, peers) and of his or her developmental level and stage.