Effective Child Interviewing: Developmental Considerations Alliance for Child Welfare Excellence Presents information regarding ages and stages of development that professionals should keep in mind when conducting interviews with children. The resource describes considerations for all ages as well as considerations for children 3 to 5 years old, for children 6 to 11 years old, and for adolescents.
Forensic interviewing is a means of gathering information from a victim or witness for use in a legal setting, such as a court hearing and is a key component of many child protective services investigations. Forensic Interviews: Specialized Training [Video] Center for Advanced Studies in Child Welfare Outlines established best practices in forensic interviewing and includes sample questions. The resource describes children's attention span, language skills, suggestibility, emotional regulation, developmental considerations, and more.
It also provides links to additional resources. Screening Children Stanford Medicine Provides sample questions for medical and related professionals to ask a child while investigating reports of child abuse and neglect. Oregon Interviewing Guidelines PDF - 1, KB Oregon Department of Justice Provides sample questions for professionals conducting interviews with children in child abuse assessment centers or in the field.
Skip to main content. The reader will note that the majority of tools are structured, in that the behaviors or items to be assessed are specified and are to be rated in a specific manner. The use of screening tools, structured diagnostic interviews or scales for particular disorders must be used based on the purpose of the assessment. For instance, if a child is diagnosed to have obsessive-compulsive disorder OCD , the Children's Yale-Brown Obsessive Compulsive Scale may be used to assess the severity of the condition or response to treatment, etc.
In the same child, an anxiety or depression screening tool may be used to ascertain anxiety and depression, apart from the clinical interview, to rule out the above-mentioned conditions as they are highly comorbid with OCD and not easily discernible in this population, unless enquired into specifically.
Thus, the use of these measures must be done with careful thought regarding the need that the particular measure is going to serve. No measure is a replacement for a good history, examination, and sound clinical judgment. While choosing these instruments, it is also important to consider the psychometric properties as well as other practical considerations including the impact of culture.
Another challenge in using these measures is that it may interfere with the rapport that the clinician is trying to develop with the child. The timing, need, and explanation regarding these measures, provided to the child and family, is vital in getting appropriate and useful information from them.
However, and this cannot be reiterated enough, that no measure can be a replacement for a comprehensive clinical evaluation and clinical expertise. Child and adolescent psychiatry straddles psychiatry, pediatric medicine, and neurology. A clinician needs to take a detailed medical history and conduct appropriate physical examination, and laboratory investigations where needed, to support or refute the provisional diagnosis from a biopsychosocial perspective.
If a child presents with psychological issues as part of a chronic medical condition such as juvenile onset diabetes or HIV, then the psychiatrist must be part of the multidisciplinary team involved in the care of the child and must be privy to the medical history, treatment provided, and investigations of the child. Generally, the physical examination begins with recording vital signs, and height and weight on a growth chart.
Head circumference must also be recorded on a growth chart. This helps track vital parameters over time as they are important measures of well-being and optimal development in children and adolescents. It is crucial to measure the height, and weight in children who are on stimulants or selective serotonin reuptake inhibitors SSRIs at every follow-up. Calculating the child's Body Mass Index BMI and measuring waist circumference has also become important given the extensive use of atypical antipsychotic drugs.
In child and adolescent psychiatry, apart from the presence of systemic illnesses and neurocutaneous disorders, the clinician must also look for signs of intentional self-injury, abuse scars, bruising, and petechiae , abrasions, skin picking that may be suggestive of compulsive behaviors; patterns of hair loss either on the scalp or other parts of the body may be suggestive of trichotillomania.
The presence of acne must also be noted — it may be due to adolescence itself or due to the use of Lithium or may be a sign of polycystic ovarian disease.
As acne causes considerable distress in young people measures must be taken to help the adolescent with this particular skin ailment. Signs of neglect and poor self-care must also be noted, such as unkempt general appearance, lice or other parasitic infections. This examination must begin with the recording of the head circumference. Signs of dysmorphic facial features characteristic of specific genetic disorders such as Fragile X, Prader-Willi, Angelman, Williams or Turner's Syndrome must be noted.
Examination of teeth, gums, and mouth is important to ascertain dental hygiene and signs of self-induced vomiting. This is of utmost importance in psychiatry and must include an examination of the cranial nerves, sensory and motor systems, balance, coordination, and reflexes. Mental status examinations must pay particular attention to changes in the emotional state and cognitive functions. Asking the child to copy a geometrical figure or to draw something of their choice not only gives an insight into their fine motor functions but also their cognition, attention, and emotional state.
A psychiatrist under most circumstances is not required to perform a genital examination. Otherwise, referral to a pediatrician for evaluation may be considered. Laboratory investigations must be guided by history and physical examination Box 6. There is no standard battery of investigations for psychiatric disorders. Under ideal circumstances, a child will have a pediatrician involved in their regular care.
All investigations must be done in the context of the child's global health care. The psychiatrist may do specific investigations pertaining to the child's mental health condition. For example, if a child is on lithium then serum lithium level, renal function tests, and thyroid function tests must be done. While a routine ECG is not required while starting stimulant medication it may be required if the child has symptoms suggestive of a cardiac illness or a family history of cardiac illness.
An electroencephalogram is not routinely required in psychiatric disorders but may be ordered if one suspects seizures or in high-risk groups such as children with intellectual disability and autism spectrum disorders.
Routine genetic evaluations must not be done. Conditions such as early-onset psychosis and autism spectrum disorders may have some differential diagnoses and the laboratory investigations must be guided by these possibilities.
Laboratory investigations relevant to a particular disorder will be dealt with in guidelines pertaining to those clinical conditions. Laboratory investigations in psychiatric assessment of children and adolescents - some examples guided by history and examination findings.
A history of similar or other behavioral concerns and history of medical issues must be asked for. In developmental disorders, therefore, there is no history. The history must flow in a continuous manner from early developmental period. However, in acting out behavior and in severe mental illnesses such as bipolar disorder and psychosis, episodic exacerbations can be made out.
Functioning of the child in the intervening period must be explored in different contexts - interaction with parents and significant others, self-care, academic performance, relationship with peers, and pursuance of hobbies and interests outside of academics.
Medical illnesses can have multi-pronged effects on clinical presentations [ Figure 3 ]. Several associations are seen between pregnancy, maternal health, early exposure related variables and developmental and behavioral outcomes during childhood and adulthood.
Systematic questionnaires such as the Pregnancy History Instrument-Revised[ 9 ] could be used for a comprehensive coverage of various pregnancy related and early developmental stressors. During clinical evaluation, the areas covered in Table 3 could be assessed.
For instance, a child with a developmental history of social and language delay, presenting with peer relationship issues and bullying in school, most probably has social skill deficits arising from autism spectrum disorder. Another child with declining academic performance with increasing school level, on exploration may have developmental delay in multiple domains, and the intellectual disability may be responsible for the academic difficulties.
A developmental profile of the child requires information on a age at acquisition of various milestones and b the current developmental level. Under-stimulation and malnutrition could present with a picture of early developmental delay, followed by rapid catch-up growth and development, with the correction of environmental and nutritional factors. Therefore, while assessing development in a child, environmental stimulation, and physical growth must be assessed alongside developmental milestones.
Children with developmental problems are also most sensitive to environmental and general health factors, i. A detailed coverage of developmental milestones and elicitation techniques is outside the scope of these guidelines. The developmental assessment must also proceed with attention to parental and child sensitivities. Parents are usually aware of even mild delays in their child's development, and there is a tendency to self-blame. In fact, some parents have a eureka moment when, say, the clinician points out how excessive screen time and insufficient contact with same age peers is playing a role in the child's speech and social delay.
Some questions to elicit information on different aspects of child development[ 11 ] are given in Table 4. In addition to developmental milestones, the temperamental characteristics of a child have to be elicited. Temperament refers to patterns of emotional and behavioral reactivity to environmental situations and capacity for self-regulation.
Temperamental traits described by Thomas and Chess[ 11 ] are useful to generate a comprehensive picture of a child's temperament. Table 5 gives the temperamental traits with questions on how to elicit them.
The parents may have to be reminded during interview to give information on the child's behavioral tendencies prior to the occurrence of current behavioral concerns.
This is important as sometimes parents judge a child's behavior based on their own personality characteristics. Parents who are passive and calm may over-report normative increases in a child's activity levels, for example, a child restless in the first few days of starting school, or a child quickly moving from one toy to the next at a friend's place before settling on one.
School is the primary occupational arena for children and adolescents. It is where elaboration of developmental abilities, especially cognitive and socio-emotional abilities, occurs. Information about school should be collected from the child, parents, and teachers at school. There is a large amount of information that could be collected about the schooling experience of a child.
Some important areas include — age at starting school, initial adjustment challenges, academic learning, peer group interactions, participation in extra-curricular activities, absenteeism, change of school if ever, including reasons for the change and troubles or challenges the child is currently experiencing in school, if any. Details about the school per se are also important in order to completely understand the adjustment between a child and the school.
These include — the academic board the school is affiliated to, if the school follows any particular education philosophy e. A lot of children and adolescents attend tuitions postschool hours. The duration, and nature of these tuitions including whether these tuitions are one-on-one or group should also be explored, in addition to the reasons for these extra tuitions, and the child's inclination for them. The child and the parents must be asked about the skills, and interests of the child Box 7.
It is important to frame specific questions to get an accurate understanding about the child. Enquiring about the child's interests, skills and talents, can be an ice-breaker or a communication starter with the child.
The clinician must make a conscious effort to separate the illness from the personhood of the child. Enquiry into various aspects of family history has to be sensitively carried forward as parents may not readily appreciate the need for details on this front.
They may even be defensive, or nondisclosive. Adequate understanding about family factors may happen over a period of time. Parents need to be comfortable talking about themselves, and sharing family details. Some questions for exploration about various aspects of the family are presented in Table 6. Responses to these questions can be supplemented by further clarifications.
Factors that may indirectly play a role include socioeconomic disadvantages and parental conflict associated with mental illness. Enquiry about mental illnesses in the family may have to be done separately with each parent, and in the absence of the child, as they may not have discussed this with each other at all.
At times parents may not even reveal the fact that they themselves are suffering from mental illness. Parental mental illness affects attachment dynamics, and cognitive, emotional, social, and behavioral development of children. It also puts the offspring at risk of developing a mental illness in childhood, adolescence and later in adult life.
Developmental disorders may be part of genetic syndromes that may be associated with a unique family history profile.
Family history could also impact treatment decisions. A family history of young onset cardiac illness or sudden death in young family members is especially relevant for those children with ADHD in whom stimulant drugs are being considered. A family history of diabetes mellitus, hypothyroidism or neurological disorders are relevant from a risk perspective, especially when psychotropics are being considered for management.
The parent-child relationship and the child's relationship with significant others in the family give further insights into how various behavioral patterns may have established over a period of time.
These become particularly relevant in the context of internalizing and externalizing disorders. Vulnerabilities to anxiety disorders are perpetuated where there is a combination of temperamental anxiety, behavioral inhibition, and an anxious, over-cautious parent. Disruptive behavior problems worsen with both over-authoritative, and over-permissive parenting, where limits and boundaries are unclear.
When a child is adopted into the family, it affects interpersonal dynamics at every level. Once the time-consuming legalities and practicalities of adoption are done with, parent-child adjustments take priority, and may take a long time to settle down, especially in the case of older children. We are consciously refraining from going into the details of enquiry in the context of adoption. This merits independent practice guidelines. Details about past assessments, evaluations, treatments, response to the treatment, and side effects must be collected.
This informs future direction of evaluation and management. History and examination Table 7 are not watertight compartments. Mental states in children and adolescents may have a higher intensity and frequency variation than adults.
For instance, depressive disorders in young people have preserved reactivity such that a depressed child may appear reasonably excited when given a toy to play with during examination. Serial examinations are more useful in getting a true picture about the mental state characteristics. Children and adolescents may also not be ready to immediately share their experiences, feelings, and thoughts.
This may happen because of unfamiliarity and intimidation by the clinical setting, or a developmental unreadiness. Children as young as 2—3 years old can answer simple questions about what they like, who they like, what makes them angry, etc. The clinician must make it a point address the child and ask questions in an age appropriate language.
Expressive channels evolve from play in very young children, to art and other creative methods, and finally to verbal dialogue in adolescents. The manner of exploration and engagement with children must follow this understanding. Therefore, waiting for preschool children to cooperate across an interview table may not be successful, whereas letting the child sift through toys, or be in a play area may reveal his activity levels, attention span, ability to tolerate frustration, and cognitive abilities.
Use of colors, pens, paper, puzzles, peg boards, can all be used in the office to facilitate interaction with young children. Direct questions to a child should be short, precise, in simple words, dealing with one concrete issue at a time. Talking to them using these familiar themes may facilitate disclosure about their emotions, and experiences. Children may be intimidated by the clinical setting, and uncomfortable with direct questions. Use of paper and line diagrams, with both the clinician and the child looking at the paper and talking may be better than direct eye to eye contact.
The development of formal operational thinking in adolescents puts them in a position to be able to not only report their experiences, but also draw interpretations and hypotheses.
It is important to interview the adolescent alone, since a developing self-awareness and self-consciousness may make them feel inhibited in front of family. Adolescents are also very concerned about not being believed, or being considered weak or different. The clinician must therefore make all attempts to make the adolescent feel comfortable and acknowledge their subjectivities. Confidentiality can be a big issue, especially in the context of substance use or sexuality. The clinician must avoid false promises of confidentiality just to get the adolescent to open up.
Adolescents appreciate logical arguments and find comfort in predictability. It is, therefore, advisable for the clinician to be honest about the limits of confidentiality.
Assessment of infants is especially challenging as the clinician has no direct linguistic access to the problems concerned. How the infant fits into the family? What does the infant mean to each family member? What do caregivers like about the infant?
What is a typical day like in the life of the infant? Parents may need reassurance about the multi-factorial influences on child development so that they feel confident enough to share more information. Observing infants and toddlers can uncover a range of behavioral and developmental facets.
Using play techniques, especially with toddlers, can clarify cognitive, linguistic, social, and motor developmental achievements. The child has to be in a calm, alert state for the best estimation of cognitive and socio-emotional development. Therefore, if the child is irritable, from hunger or some physical discomfort, the parents may be asked to attend to the immediate needs of the child and then resume assessment process.
Physical health status of the child could give important clues to possibility of underlying medical conditions as also under-stimulation and parent-child attachment. Sensory abilities — vision, hearing — mature rapidly during the 1 st year of life. In a quiet, alert state even neonates can turn their head to sound. The clinician should note if the child appears sensitive to sounds and visual stimulation.
Some children with premature birth, and developmental disorders could have very low or very high sensory thresholds. Sensory stimulation may need to be accordingly adjusted to effectively engage the child. Domains of growth and development to be observed during consultation are given in Table 8.
The child can be made to do these activities with encouragement from the parents. Variations could arise from developmental deviations. A combination of historical information from the parents and a series of observations are more informative. While attempting simple activities to observe above mentioned developmental abilities, the clinician could also gain an idea about the child's temperament Box 9.
In toddlerhood, with their increasing motor and cognitive capacities, children are quite exploratory. Some simple observations during consultation are listed in Box Children with developmental problems may not show these behaviors, and may stay engrossed in solitary activities. Child and adolescent psychiatry necessitates evaluations and interventions from a multidisciplinary team most often consisting of a clinical psychologist, pediatrician, psychiatric social worker, speech and language pathologist, occupational therapist, and other health-care professionals.
The psychiatrist needs to make appropriate referrals to these professionals to gain a holistic understanding of the child and family and plan interventions accordingly. Children, parents, and families who come in for a psychiatric consultation are often loaded with historical details, and are distressed by the referral and evaluation process. It is understandably tedious for them to have to repeat information over consultations. Reviewing clinical notes from previous consultations puts the clinician in a clearer frame of mind in terms of future course of enquiry and future planning.
It is good practice to have a recording format for recording history, examination, and clinical discussion details. The information gathered can be fed back to the family so that they have an understanding about the future course of action - one child may need to be scheduled for an IQ test, another child may need to come in for a more elaborate consultation with additional members of the family, and so on.
Evaluation in child and adolescent psychiatry is layered and complex. Clinical impressions may change from the first contact to the next. It is useful to go over in detail the clinical history at least a few times. As parents answer questions pertaining to different domains they too get clarity on the multi-factorial contributors to the child's difficulties. Child and adolescent mental health shares close links with other medical specialties such as neurology and pediatrics while being rooted in the child's psychosocial environment and experience.
Assessment of children and adolescents must evolve from a biopsychosocial perspective, taking into account these inextricably interlinked aspects.
Clinical history taking and interviewing are one of the most powerful tools available to the child and adolescent mental health professional to make a diagnosis and plan management. These guideline can be used as an aid in that endeavor.
Other measures such as rating scales, diagnostic interviews, and laboratory investigations must be used in conjunction with the information obtained during history taking and interviewing. The clinician must be sensitive to the child's lived experience and culture as well as their developmental and cognitive capabilities.
Clinical judgment and expertise is required to assimilate the information obtained from the child and other key informants. In child and adolescent mental health, multidisciplinary inputs are required for almost every child and family and efforts must be made to link the different arms of evaluation and treatment such that there is convergence.
Confidentiality and the limits thereof must be discussed with the child and family. Documentation is a very important aspect of assessment and must be strictly maintained. A comprehensive clinical assessment goes a long way in ensuring interventions in the best interest of the child and family.
The authors would like to acknowledge Dr. National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v.
Indian J Psychiatry. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: moc. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4. This article has been cited by other articles in PMC. Open in a separate window. Box 1. Aim of clinical practice guidelines on assessment of children and adolescents.
Figure 1. Objectives of clinical assessment in child and adolescent psychiatry. A child-friendly space for assessment of children and adolescents The clinical setting for the assessment of children and adolescents should engage the child for the requisite duration of time. Challenges in establishing rapport The silent child A major challenge in establishing rapport is when a child does not talk during the consultation.
Figure 2. Figure 3. Figure 4. Background and context of presentation Often, the first health-care contact for children and adolescents with behavioral concerns is not a mental health professional.
Box 2. Know the child and the family - the sociodemographics Clinicians are busy people. Ongoing concerns and Presenting complaints Parents and children may be unclear about the extent or nature of the problem. Box 3. Questions to elucidate ongoing concerns and presenting complaints. Table 1 Symptom dimensions in child psychiatry.
Table 2 Structured assessment tools in child and adolescent psychiatry. Medical history and physical examination Child and adolescent psychiatry straddles psychiatry, pediatric medicine, and neurology. Box 4. Box 5. Physical examination in psychiatric assessment of children and adolescents. Examination of skin, hair, nails In child and adolescent psychiatry, apart from the presence of systemic illnesses and neurocutaneous disorders, the clinician must also look for signs of intentional self-injury, abuse scars, bruising, and petechiae , abrasions, skin picking that may be suggestive of compulsive behaviors; patterns of hair loss either on the scalp or other parts of the body may be suggestive of trichotillomania.
Examination of the head, eyes, nose, and throat This examination must begin with the recording of the head circumference. Neurological examination This is of utmost importance in psychiatry and must include an examination of the cranial nerves, sensory and motor systems, balance, coordination, and reflexes. Genital examination A psychiatrist under most circumstances is not required to perform a genital examination. Laboratory investigations Laboratory investigations must be guided by history and physical examination Box 6.
Box 6. Pasthistory A history of similar or other behavioral concerns and history of medical issues must be asked for. Figure 5. Pregnancy, perinatal, early developmental history Several associations are seen between pregnancy, maternal health, early exposure related variables and developmental and behavioral outcomes during childhood and adulthood. Table 3 Pregnancy, perinatal and early developmental history.
Table 4 Questions to elicit information on developmental domains. Temperamental history In addition to developmental milestones, the temperamental characteristics of a child have to be elicited. Table 5 Questions to elicit temperamental traits in a child.
Schooling history School is the primary occupational arena for children and adolescents. Child's interests, skills and talents The child and the parents must be asked about the skills, and interests of the child Box 7. Box 7. Table 6 Questions to elucidate family factors in child mental health. Past evaluation and interventions Details about past assessments, evaluations, treatments, response to the treatment, and side effects must be collected.
Examination Interview of children and adolescents History and examination Table 7 are not watertight compartments. Table 7 Components of the mental status examination.
Box 8. General principles for mental status examinations of children and adolescents. Use of developmentally appropriate techniques Young children Expressive channels evolve from play in very young children, to art and other creative methods, and finally to verbal dialogue in adolescents.
Adolescents The development of formal operational thinking in adolescents puts them in a position to be able to not only report their experiences, but also draw interpretations and hypotheses.
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