Every interview with a young person with mental distress will be unique. Sometimes you will need to calm a screaming child or warm up a reluctant adolescent before you can ask any diagnostic questions. In moments like those, it sometimes feels like you are wasting time. You have other people to see and other tasks to attend to. However, good interviewers learn to receive these moments as part of the interview itself. They watch and listen to the child or adolescent for clues about whether the distress is internal or external and what events bring her into and out of engagement with a practitioner.
Every young person is also unique, so we begin an initial encounter by getting to know the child or adolescent we are seeing. We use different strategies depending on the child’s age and developmental status, the location in which we are meeting, our familiarity with the patient, the patient’s sense of humor, and many other variables. Before introducing ourselves to a patient, we like to know how long she has been waiting and with whom. A child who has sat calmly for 15 minutes in a waiting room will likely have different needs from the same child who has been waiting hours to see you in the emergency department. When we meet a patient, we prefer to open the conversation with a topic in which the child or adolescent is already engaged. If a young child brings a stuffed animal to an appointment or wears a colorful shirt, we ask about it. If an adolescent brings a book or is listening to music, we ask her to describe the book or song. The point is not to make an aesthetic judgment about the stuffed animals, clothes, books, and music with which a young person presents but to understand how she thinks.
Asking about something that the patient is consciously (or unconsciously) presenting to you also builds the therapeutic alliance. Imagine if you walked into a medical encounter 72and your physician began asking you about her interests but waved off any attempts to discuss your own. You, like most of us, would feel ignored and would likely be reluctant to engage in treatment with the physician. Now imagine if you visited another physician and she knew your name, said it correctly, and then asked how you came by your name. You would likely be more engaged with this second physician and her treatment. You can (and should) extend the same engaging courtesy to the children and adolescents you meet as patients.
We favor beginning every interview by introducing yourself, asking the young person her name, assessing her expectations for the encounter, clarifying any misperceptions, and giving a sense of how long the encounter will last. Caregivers, rather than young people themselves, set up most evaluations, so verbally acknowledging this right away (“So, your mom wanted you to see me....”) shows a young person that you can see things through her eyes.
When the encounter is limited to 30 minutes, we believe that you can successfully develop a therapeutic alliance and perform a diagnostic interview. Before we explain how, we need to offer a few caveats.
• Any psychiatric examination that obtains all the information from a single source is incomplete. This is especially true when interviewing a child or an adolescent. You should disclose to the person you are interviewing that you will be speaking to some of her adult caregivers about her health and what you will be discussing. See Chapter 3, “Common Clinical Concerns,” and Chapter 10, “Selected DSM-5 Assessment Measures,” for tools to use in interviewing adult caregivers.
• A successful psychiatric examination ultimately provides access to the internal world of a person. The thoughts, impulses, and desires of a young person can be engaged in many ways. In what follows, we offer an interview that is best suited for a young person who can tolerate direct questions. When interviewing a child or an adolescent who cannot do so because of age, impairment, or disinterest, we recommend focusing on the most essential portion of the examination and spending the remainder of your time developing a therapeutic alliance.
• A skilled psychiatric examination always includes an account of the relationships that constitute a person’s existence. 73This is especially true with children and adolescents, whose dependence on other people is more apparent than it is for the average adult. During every interview with a young person, we always ask questions such as “Who do you live with?” “How do you spend your days?” “Who cares for you?” and “Who can you trust?” These kinds of questions naturally lead into other critical questions about the caregivers in a young person’s life.
With these caveats in mind, we offer the following as a guideline for a diagnostic interview that uses DSM-5 (American Psychiatric Association 2013) criteria. The interview does not include prompts for DSM-5 categories that are uncommon in childhood and adolescence—namely, the neurocognitive, gambling, paraphilia, personality, and sexual dysfunction disorders. (We do, however, provide guidance for assessing personality traits in Chapter 10.) We have taught a version of this interview to students, residents, fellows, and faculty. Until you develop the habits of an experienced practitioner, it helps to practice a structured interview. This helps in becoming comfortable asking about intimate concerns, remembering to screen all patients for the major categories of mental illness, and developing good interview habits.
Of course, a structured interview has a downside. We have sometimes witnessed practitioners read one question after another, without stopping for the usual pauses that signify human speech or even looking at the patient. In The Pocket Guide to the DSM-5™ Diagnostic Exam (Nussbaum 2013), we called these kinds of interviewers psychiatric robots who ask things like “I hear you are suicidal, but can you spell world backward?”—questions that show more fidelity to an outlined interview than attention to the specific person before you. These kinds of interviewers speak so stiffly and stay so determinedly on script that when witnessing them, you wonder which of their joints need to be oiled first. Trust us, we both have performed the psychiatric robot interview ourselves at some point during our careers. We wrote this guide in part so that you can learn from our mistakes.
What we found (and still find) challenging is providing the right amount of structure for the interview. An excitable person will need to be calmed, a sad person must be encouraged, and sometimes the same person will need both in the same interview. Fortunately, you always have the best possible 74guide: the person before you. Follow her lead. Observe her body language. If she appears disinterested, it is time to alter your approach.
As you use this diagnostic interview, strike a balance between becoming a psychiatric robot and practicing a formal version until it becomes a habit. The 30-minute diagnostic interview will seem forced at first, but gradually it provides the infrastructure for a conversational interview.
No matter how distracted or upset the patient, good interviewers always give a person a few minutes to speak her own mind. Then, they summarize and clarify the patient’s concerns and organize the examination as necessary, modulating the structure and language of the interview to fit the needs of the patient. They ask clear and succinct questions. If the patient is vague, they seek precision. If she remains vague, they explore why. They do not ask permission to change the subject but use transition statements, such as “I think I understand this, but how about that?” Developing a supply of stock questions is helpful, which is why we advise using this structured interview until it becomes a habit. Then you can use these questions to develop a conversational style for an interview in which a patient tells her story, you form an alliance with her, you gain insight into her thought process, and you gather the clinical data needed to make an accurate diagnosis. When you do so, you reduce the patient’s alienation by making the strange more familiar.
The interview outline in this section includes headings that indicate the time allotted for each portion of the interview (boldface type), instructions to the interviewer (roman type), and questions for the interviewer to ask (italic type).
Introduce yourself to the patient. Ask how she would like to be addressed. Set expectations for how long you will meet and what you will accomplish. Describe applicable limits of confidentiality with an adolescent, such as “What we talk about will remain confidential except if there is a risk for your 75safety—then we would talk together with your parent about how to best keep you safe.” Then ask, “Why are you here today?”
A patient’s uninterrupted speech indicates much of her mental status, guides your history taking, and builds the alliance. As she speaks, listen to the content and form of her statements. What is she saying or not saying? How is she saying it? How do her statements match her appearance? Although you may be tempted to interrupt or begin asking questions, with experience, you will find that allowing the person to talk initially without interruptions gives you more information about her than the answers to your questions will. When you do speak next, try to have your question be both responsive and open ended, along the lines of “You said ____; can you tell me more about that?” Depending on the nature of the illness, some people will be unable to fill this time; their inability to do so also provides valuable information about their mental status and distress. When the person does not speak spontaneously, you may have to use prompts and proceed to the history of the current illness.
Your questions should follow the DSM-5 criteria, as described in Chapter 6, “DSM-5 Pediatric Diagnostic Interview.” Additionally, you should focus on what has changed recently—the “why now?” of the presentation. As you do, seek understanding of precipitating events: When did the patient’s current distress begin? When was the last time she felt emotionally well? Can she identify any precipitating, perpetuating, or extenuating events? How have her thoughts and behaviors affected her psychosocial functioning? How does the patient view her current level of functioning, and how is it different from what it was days, weeks, or months ago?
“When did you first notice symptoms? When did you first seek treatment? Did you ever experience a full recovery? Have you ever 76been hospitalized? How many times? What was the reason for those hospitalizations, and how long were you hospitalized? Do you receive outpatient mental health treatment? Do you take medications for a mental illness? Which medicines have helped the most? Did you have any adverse effects from any medications? What was the reason for stopping prior medications? How long were you taking each medication, and how often did you take it? Do you know the name, strength, and number of doses per day of medicines you are currently taking?”
Students and trainees may feel uncomfortable asking these questions and may worry that they will upset patients or even give them ideas about ways to hurt themselves or others. These fears are largely unfounded, and with practice you will find that these questions become much easier to ask. It is important to remember that one of the biggest predictors of future behavior is past behavior, so asking about prior episodes of violence to self and others is required for an overall risk assessment. “Do you frequently think about hurting yourself? Have you ever hurt yourself, such as cutting or hitting? Have you ever attempted to kill yourself? How many attempts have you made? What did you do? What medical or psychiatric treatment did you receive after these attempts? Do you often become so upset that you make threats to hurt other people, animals, or property? Have you ever hurt people or animals, destroyed property, tricked other people, or stolen things?”
The psychiatric review of systems is an overview of common psychiatric symptoms that you may not have elicited in the history of the current illness. If a person answers affirmatively to these questions, you should explore further with the DSM-5 criteria, as modeled in Chapter 6.
Mood. “Have you been feeling sad, blue, down, depressed, or irritable? If so, does feeling this way make it hard to do things, to concentrate, or to sleep? Are you angry most of the time? Has there been a time when for many days straight your mood was super happy, you were more self-confident, and you had much more energy than usual? If so, can you describe what happened?” (See 77“Depressive Disorders” or “Bipolar and Related Disorders” in Chapter 6.)
Psychosis. “Have you seen visions or other things that other people did not see? Have you heard noises, sounds, or voices that other people did not hear? Do you ever feel like people are following you or trying to hurt you in some way? Have you ever felt that you had special powers or found special messages from the radio or TV seemingly meant just for you?” (See “Schizophrenia Spectrum and Other Psychotic Disorders” in Chapter 6.)
Anxiety. “Would you say that you worry a lot or more than other kids your age? Do people say that you worry too much or are too shy? Do you feel afraid when you’re alone or away from your family? Do you get scared about going to school? Is it hard for you to control or stop your worrying? Are there specific things, places, or situations that make you feel very anxious or fearful? Have you ever felt suddenly frightened, nervous, or anxious for no reason at all? If so, can you tell me about that?” (See “Anxiety Disorders” in Chapter 6.)
Obsessions and compulsions. “Do you ever get unwanted thoughts or pictures stuck in your mind and repeating that you cannot get rid of? Is there anything you feel you have to check, clean, or organize over and over again in order to feel OK?” (See “Obsessive-Compulsive and Related Disorders” in Chapter 6.)
Trauma. “What is the worst thing that has ever happened to you? Has someone ever touched you in a way you did not want? Have you ever felt that your life was in danger or thought that you were going to be seriously injured? Do you have unhappy memories that make it hard to sleep or to feel OK now?” (See “Trauma- and Stressor-Related Disorders” in Chapter 6.)
Dissociation. “Do people say that you daydream a lot or look spaced out? Do you lose track of time and feel unsure of what you did during that time? Do you ever feel as if you are standing outside your body or watching yourself?” (See “Dissociative Disorders” in Chapter 6.)
Eating and feeding. “Do you avoid particular foods so much that it affects your health or weight? Do you worry about losing control over how much you eat?” (See “Feeding and Eating Disorders” in Chapter 6.)
Elimination. “Have you had any problem with passing urine or feces onto your clothing or bed?” (See “Elimination Disorders” in Chapter 6.)
78Somatic concerns. “Do you worry about your health more than other kids do? Do you often miss school because you do not feel well? Do you get sick with aches and pains more often than most young people do?” (See “Somatic Symptom and Related Disorders” in Chapter 6.)
Sleeping. “Do you struggle to fall asleep, or do you wake up a lot at night? Do you often feel sleepy during the day? Has anyone said that you stop breathing or gasp for air while sleeping?” (See “Sleep-Wake Disorders” in Chapter 6.)
Substances and other addictions. “In the past year, have you drunk alcohol, smoked marijuana, or used anything else to get high? Have you ever ridden in a car with someone who was high or drinking alcohol? Do you ever use alcohol or drugs when you are alone? Do you ever use alcohol or drugs to relax?” (Knight et al. 2002). (See “Substance-Related and Addictive Disorders” in Chapter 6.)
“Do you have any chronic medical problems? Have these illnesses affected you emotionally? Have you ever undergone surgery? Have you ever experienced a seizure or hit your head so hard that you lost consciousness? Do you take any medications for medical illness? Do you take any supplements, vitamins, or over-the-counter or herbal medicines regularly?”
Allergies. “Are you allergic to any medications? Can you describe your allergy?”
Family history. “Have any of your relatives ever had mental or behavioral health problems, such as attention-deficit/hyperactivity disorder, anxiety, depression, bipolar disorder, psychosis, problems from drinking or drugs, suicide attempts, nervous breakdowns, or psychiatric hospitalizations?”
Developmental history. “Do you know if your mother had any difficulties during her pregnancy or delivery? What were you like as a young child? Did you ever receive developmental, speech, or special education services?” (See Chapter 12, “Developmental Milestones,” for early developmental milestones.) Look at the child’s current height and weight on a growth curve.
Social history. “Did you have any behavior or learning problems during your early childhood? When you started school, did 79you have trouble relating socially to your classmates or difficulty keeping up academically? How far have you made it in school? Who lived in your home during your early childhood? Who lives there now? Was a religious faith part of your upbringing? Currently? Have you ever held a job outside of the home? Have you ever been suspended? Expelled? Arrested? Jailed? What do you like to do? How do you spend your time online? What do you like about yourself? What do your friends like about you? Do you have any friends you can confide in? Are you sexually active? Are you really uncomfortable with your assigned gender?”
By this point of the interview, you should have already observed or obtained most of the pertinent mental status examination data. See Chapter 9, “The Mental Status Examination: A Psychiatric Glossary,” for a more detailed version of the mental status examination, which includes the following components:
• Appearance
• Behavior
• Speech
• Emotion
• Thought process
• Thought content
• Cognition and intellectual resources
• Insight and judgment: “What problems do you have? Are you sick in any way? What are your future plans?”
The Mini-Mental State Examination (MMSE) is a commonly used basic cognition ability assessment in adult and geriatric psychiatric care that has standardized questions and yields a numerical score. We find that the MMSE is less pertinent to administer to young persons than to older adults. When it is used, the MMSE is more challenging to interpret for the younger developmental ages. However, if a major mental illness (e.g., schizophrenia) or encephalopathy is suspected, a MMSE may add diagnostic value. When the MMSE is used, the lead-in could be along the lines of “Have you had any problems 80with your concentration or your memory? Can you help me understand the extent to which you might be having those types of difficulties?” The MMSE then includes the following items: name, date and time, place, immediate recall, attention (counting backward from 100 by 7s, spelling world backward), delayed recall, general information (president, governor, five large cities), abstractions, proverbs, naming, repetition, three-stage command, reading, copying, and writing (Folstein et al. 1975).
Ask any follow-up questions. Thank the patient for her time and, if appropriate, begin discussing diagnosis and treatment.
Consider asking the following: “Have the questions I asked addressed your major concerns? Is there anything important I missed or anything that I really should know about to better understand what you are going through?”