What is the best approach to conduct a comprehensive child psychiatric interview for a pediatric patient?

Comprehensive Child Psychiatric Interview: A Structured Approach

Begin by conducting a family interview that includes both individual and joint sessions, systematically gathering history while simultaneously observing parent-child interactions, with the understanding that interviewing the child alone is optional for young children but essential for adolescents. 1

Interview Structure and Sequence

Initial Family Interview Setup

• Conduct the interview in a comfortable room large enough for all family members, removing potentially harmful furniture and providing games or activities for younger children to facilitate rapport and minimize behavioral disruption. 1

• Plan for 1-2 hours depending on the clinical situation, number of family members, and ages of children, recognizing that follow-up sessions may be needed for complex cases. 1

• Include not just immediate family but anyone who interacts with the child regularly in an influential manner—grandparents, extended family, or live-in partners. 1

Establishing Rapport and Beginning the Interview

• Start by addressing each family member informally at their developmental level, immediately identifying family strengths and resources through an informal interview style. 1

• Presume the positive by assuming the family cares about the child and has areas of competency, while remaining attentive to ways the family may be maintaining or exacerbating problems. 1

Core Assessment Components

History Gathering Goals

Systematically collect the following information while simultaneously observing family interactions: 1

• Onset and evolution of the presenting complaint, including what solutions have been tried and parents' perspectives on causes 1

• Family context and developmental antecedents related to the presenting complaint 1

• Family factors that determine, influence, or ameliorate the child's psychiatric disorder 1

• Relationships between intrafamilial interaction patterns and the child's psychiatric disorder 1

Observation of Parent-Child Interactions

While gathering history, actively observe and document: 1

• Parent's ability to set effective limits (particularly relevant for behavior disorders) 1

• Age-appropriate independence and anxiety regulation support (particularly for anxiety disorders) 1

• Family communication patterns, especially hostile or ambiguous communication that lacks clarity 1

• Congruence between expressed affect and behavior (e.g., anger should not be accompanied by a smile) 1

• Processes that contravene healthy child development: familial unavailability leading to poor attachment, inconsistent limit setting, or overinvolvement frustrating adolescent independence 1

Individual Interview Components

Interviewing Parents Alone

Conduct separate parent interviews to: 1

• Allow parents to freely discuss their relationship and provide differing views on their symptomatic child without the child present 1

• Gather information that parents may be reluctant to share with the child present 1

Interviewing the Child Alone

The importance of individual child interviews increases with age: 1

• For very young children: Individual interviews are optional 1

• For adolescents: Individual interviews are essential 1

Individual child interviews allow: 1

• The child to freely discuss conflicts not easily divulged with parents present, particularly true for adolescents 1

• Discrepant views of clinical problems to emerge more sharply, which may suggest family treatment as part of the treatment plan 1

• Children to report more illness about themselves than parents report about them, as parents tend to under-report psychiatric disorders 2

• Children to provide clinically relevant and valid information that is congruent with their presenting problems (84%) and eventual diagnosis (74%) 3

Critical Confidentiality Considerations

Navigate confidentiality based on developmental stage: 1

• For younger children: Parents should be made aware of issues of concern 1

• For adolescents: Respect the adolescent's desire for confidence unless dangerousness precludes maintaining confidentiality 1

• Maintain confidentiality wherever possible when interviewing individuals separately, as this helps them share their history more freely 1

Managing Common Challenges

Absent Family Members

When family members fail to attend despite requests: 1

• Interview all who actually attend but remain attentive to the absence and its meaning for the family 1

• Recognize that the absence of a member (most often a reluctant parent or adolescent) powerfully affects the session and provides opportunity to understand family difficulties 1

• Understand that the family interview with members missing, although less than optimal, can still provide important information 1

Unexpected Attendees

When families bring uninvited individuals: 1

• Despite social awkwardness, recognize that information from these individuals often enhances the completeness of the assessment 1

Managing Acute Issues During the Interview

Remain flexible when acute problems emerge: 1

• Acute problems such as suicidal ideation or intense disagreement can prevent systematic history gathering, effectively terminating content data gathering while providing powerful experiential process data 1

• When conflict emerges during history gathering, antecedents and consequences of behavioral problems are not merely reported but demonstrated 1

Interview Progression and Facilitation

Using Probing Questions

Facilitate the interactional stage by: 1

• Asking family members about their individual responses, behaviors, and feelings to understand how events have acquired specific meanings for each member and how these meanings differ 1

• Reviewing history of successful problem resolution as well as situations where problems remain unresolved 1

Organizing Clinical Data

Structure your observations around: 1

• Family structure 1
• Family communication 1
• Family beliefs 1
• Family regulation of child development 1

Summation Stage

Complete the family interview by: 1

• Formulating what you have observed and its relevance to the identified patient 1

• Emphasizing the influence of child on family and family on child 1

• Identifying family problems in the context of existing family strengths 1

Key Pitfalls to Avoid

• Do not focus solely on the identified patient; recognize that other family members may appear more symptomatic 1

• Do not rely exclusively on parent reports, as parents consistently under-report psychiatric disorders in their children compared to children's self-reports 2

• Do not dismiss children's accounts as unreliable; children provide clinically relevant and diagnostically valid information during interviews 3

• Do not maintain rigid interview structure when acute safety issues emerge; prioritize immediate safety assessment over systematic history gathering 1

• Do not judge families; collaborate with them by emphasizing their competencies and strengths 1