One of the joys and privileges for mental health professionals working with children is meeting a new person/family for the first time and having them share their “story” with us.
However, there are also significant challenges for us in this first meeting (or assessment/session). We need to:
- Undertake an appropriately thorough informed consent process (ensuring families know what we and our services do/don’t do, understand records, confidentiality, rights and responsibilities, including complexities with permissions/confidentiality with separated families). This can be a complex process so this will be covered in another article.
- Help children and their families to feel cared for, that they can trust us and collaborated with.
- Work out what (and how) to ask children and families so that we can effectively plan treatment for them.
We have to do all of while managing a range of challenges which include (but are not limited to):
- Having only limited time frames to conduct an assessment
- Differing and sometimes restrictive funding bodies structures and requirements
- Children differing or low motivation for attendance
- Children’s developmental differences in introspection skill (not aware of/can’t remember details of their own and others emotional and cognitive experiences),
- Children’s developmental and individual differences in communication skills (not able to provide us with information in the same way as adults),
- Children/teens and parents/caregivers difficulties with emotional regulation
- Children/teens and parents/caregivers difficulties with attention/concentration skills
- Individual and cultural differences in family expectations, understanding and communication
Hence the initial meeting or interview with a family is both a joy – and a challenge!
In this article I would like to cover 1) a few guidelines which might be helpful in managing these challenges and 2) what topics mental health professionals might want to assess in this first clinical interview to effectively design clinical treatments.
Guidelines for conducting a clinical interview
- Assume all children have important information to give
Children/teens challenges with introspection, communication, attention and concentration and emotional regulation as outlined above mean that some children/teens might:
-Provide only minimal information in answer to our questions (don’t know/don’t care answers)
-Provide information which is verifiably false
-Display anxiety/annoyance/distress at being asked questions
It is vital this does not lull us into assuming this child does not or cannot provide us with vital information.
Instead, as therapists we should hold firmly to the assumption that all children/teens have important and valuable perspectives on themselves, their lives and their experiences.
Doing this is likely to mean children will slowly trust us with providing more information over time, and for us to be “on the lookout for it” even if it is not provided to us immediately or easily.
I’m fine, there is really nothing wrong with my mood. I don’t know what to tell you – I can’t think of anything. I haven’t cut myself, that was the cat scratching my arm when she sat on my lap.
I hear you. I want you to know your perspective really matters to me. Perhaps we can see whether your view changes over the next session or two – and if it does, that’s fine, and if it doesn’t – that is fine too. We will work out what to do next as we go, but I will always listen to what you are telling me.
I don’t know! (what makes me mad). Can I play with that toy?
That’s quite okay. It’s really hard to figure out what makes us mad. Sure, let’s play. Would you like to do this puzzle or hold the dolls? Is it okay if I talk about what makes some other kids mad while we play?
- Assume parents/caregivers have important information to give
In my experience, mental health professionals who work with children are almost always appropriately interested in and aware of the importance of the perspectives of parents/caregivers.
Unfortunately, there are a very small number of situations in which we might have a tendency to be a little dismissive or under-estimate these perspectives.
For instance, if a parents/caregiver uses particularly negative/critical language about their child, therapists will sometimes have an instinctive emotional reaction (often protectiveness towards a child) which may lead them to dismiss some of the information provided by this parent/caregiver.
Alternatively, if a parent/caregiver describes behaviour which – at first glance at least – appears developmentally “normal” to a therapist, the therapist may under-estimate the implications of this behaviour for the family, or fail to appropriately probe the complaint to see if there are further important details to discover.
I know there have been a few occasions over the last two decades (to my shame) where I have dismissed a parent perspective, and has always often “come back to bite me” and led to less than desirable outcomes.
It is vital that we do not equate a parent/caregivers low ability to constructively articulate their concerns with these concerns being of low importance. Instead, we need to continue to hold the assumption all parent/caregivers have important information to give us.
My (7yo) child is a bratty kid compared to his sister. For example, he gets angry at me when I yell at him, he needs to just listen and do what he is told!
I can hear your frustration, I imagine his behaviour makes life pretty tough at times. I’m interested in hearing more about this – some people might say that is a normal behaviour for 7 year old’s to get angry when they are yelled at but it sounds like you think your son does this more than the average child? What do you think?
- Be flexible in what and how assessment is conducted
Although we will have our own agenda about what needs to happen in the clinical interview, it is vital to be alert to the impact the assessment is having on the people present and to flexibly shift topics or goals when appropriate or needed.
We have been talking about some tricky stuff today Tommy, and I can see you are feeling a bit mad about it all. Is that right? Shall we talk about some things that have been going well for you and we can talk more about that other stuff later?
I have a lot of other questions for you which I am really interested in, but I think we have run out of time – I am wondering if I send you some questions via email/write some of these down for you whether you can do this later.
I know you are keen to tell me more about that. Because we don’t have a lot of time today, how would you feel if I came back to that later, and just focused on this other area for now? Would that be okay with you or would you feel disappointed about that?
- Be aware of our own biases, emotional reactions and assumptions
Clinical interviewing is a vital source of information for treatment planning, but there is no doubt it can be deeply flawed and lead us to making unhelpful decisions, or people feeling distressed.
For instance, research suggests that (especially experienced) clinicians often make diagnostic assumptions within the first few minutes of an interview, and that often they get these wrong. Studies also find that people from culturally diverse, neurodiverse and minority communities often feel misunderstood by health professionals.
In part, this is because as mental health clinicians we enter the interview with a set of cultural assumptions, emotional biases and societally driven expectations which can mean we miss important information.
There are many strategies we can use to try to overcome these problems, but a good start is to be aware of the vast number of cultural, spiritual, gender differences and diversity in our community, leading to an equally vast number of valid ways of understanding and experiencing the world.
We should be collaborative, humble, gently curious and assume families to be the experts on their lives in order to ensure assessments are accurate and helpful for families.
Here are some questions which can be helpful in doing this.
Have I asked about everything which is important/is there anything I am missing/have I focused on the right problems or questions today?
Have professionals in the past misunderstood something about your family/culture/beliefs which have made you feel uncomfortable?
Do you feel comfortable to tell me about how your culture/belief system impacts on what we have talked about today?
Is there a way I can make you/your child feel more comfortable or find it easier to work with me?
Can you please let me know if I use words which don’t make sense or fit with you?
- Use strategies to increase motivation, communication and emotional regulation skills
As described above, children’s challenges with motivation, attention/concentration, introspection and emotional regulation can get in the way of them providing important information to us.
The most important way to overcome these challenges is via a strong, connected therapeutic alliance – in which children feel cared for, respected and in which we work collaboratively and alongside them.
However, there are also specific techniques which can increase children and teen’s motivation, attention, concentration, a sense of calm/co-operation and their ability to reflect on and communicate information to us in an assessment session.
There are many individual strategies/techniques which are used by different therapists, depending on their style and approach, but the following broad categories of techniques can be helpful.
- The use of closed/choice questions rather than open questions (yes/no, visual scales or preprepared options to choose from)
- Providing visual or movement representations for questions and answers (child doesn’t just need to “say” or “hear” questions and answers, but instead can look at/see or move in order to answer a question).
- Using rewards, interest, games in the question/answer process
Examples of these will be provided throughout the rest of the article.
- What to assess – topics to cover in an initial clinical interview
A thorough assessment of all of the potential mental health challenges as well as history and backgrounds can take many hours to cover. Using a structured differential diagnostic interviews (such as the DISC-IV) for example can take up to 2-3 hours.
Often clinicians in community settings don’t have this length of time for an initial assessment. This means we need to prioritise the information which is most important to our goals.
If, as is the case for many clinicians, the goal is to effectively design a treatment/support package which will be helpful, we can instead prioritise the assessment of topics which tell us about the underlying processes (both helpful and unhelpful) contributing to the presenting problem which are modifiable – as well as the environment the child lives in.
With this approach in mind, here is an example model to guide potentially important topics of assessment.
- Presenting problem
One of the key areas of assessment is the “Presenting Problem”. In other words, what are the problems, symptoms and concerns which has brought the family to see us. This is the area of assessment which often takes up the most time in an interview and one in which parents/caregivers are keen to tell us most about. We might want to know the “W”s:
- What exactly does the “problem” look like? (with examples)
- When did it start?
- When/in what situations does it occur?
- What happens after (antecedent) or as a result of (impact) the problem?
- Why is it happening (child and parents/caregiver theories and opinions)?
- What helps/doesn’t help (including previous treatment)?
- What is the impact of the problem?
When assessing the presenting problem, eliciting the specific details, triggers and examples of the problem is essential to effective treatment planning. Having the information that a child shouts “I hate you” to Mum when they are asked to put their iPad away before bed gives us many more ideas about possible effective treatment kernels than the less helpful information that a child “gets angry when they don’t get their way”.
Unfortunately, parents/caregivers often find it hard to provide the level of detail or examples we need. Instead, they provide very general info and or “complaints” about the presenting problem.
This may be due to many factors including a fear of any one example trivialising the problem, feeling the pressure of time constraints, not being able to remember information. To overcome this, it is often important to “dig” for details, for example we might ask:
- Can you give me an example of when that happens/arises/is a problem?
- What does that look like when you notice he/she is…..?
- What is he/she doing?
- What does he/she actually say when this happens?
- When/what situations does that happen?
- How do you know that he/she is experiencing/feeling…
- What would it look like if this was not a problem?
- How is that different from other children/other situations?
If parents/caregivers continue to find it hard to provide details/examples, we may need to provide psycho-education to parents/caregivers about why we are doing this and then support for them to do this more easily.
- I absolutely know that just one or two examples of this problem doesn’t really capture the whole issue, but it helps me to know what is going on.
- I know it is hard to think of the specifics sometimes, feel free to take your time. I will keep doing this as we are working together.
- Will it help to write some of these examples down as they happen during the week?
- If I provided a “tick chart” which could make it easier to record details, would that be helpful?
Here are some activity ideas/questions to elicit children’s perspective of the presenting problem (these are designed to assist in overcoming developmental or individual challenges with introspection/communication/attention and motivation):
- Drawing pictures/putting ticks in different columns (worried/sad/angry) labelled with drawings or different colours (chosen/drawn by child)
- Drawing cartoons/pictures of a sad/worried/angry house/school day
- Using closed questions about the problem (is it more X or more Y? It seems like mum/dad think….what do you think right/not right?)
- Using visual scales drawn on board/paper (with the ends labelled with pictures) about how “bad” or “unhelpful” various identified problems are in the eyes of parents/child/teen – child can tick a scale, or move along a line/places in the room
- Using pre-prepared lists (even just writing a few short words on the whiteboard) of sample problems for kids/teens to circle/highlight or using sets or cards for children to pick items from
- Drawings of thought bubbles/hearts/bodies to identify thoughts/beliefs/bodily symptoms
- Asking children to place counters/objects/stickers –in categories (draw boxes on paper/whiteboard, or in real boxes/areas in the room) to identify “big problems”, “little problems” or “sad” things or “unhelpful” or “helpful”
- Using Playdough – what would you squish, what would you make bigger
- Using Toys/figurines – who is doing what that is helpful/unhelpful/sad/happy?
One final note about assessing the presenting problem: this topic out of all the areas of assessment may be the one likely to increase distress in families. If we suspect or note certain questions or topics may/do seem to be impacting negatively/distressing children, we may need to start with another topic, or assess it briefly and come back to it later in the interview.
- Relationships or “People”
A second important area of assessment for child mental health professionals is the child’s relationships. In other words, we want to know who is important in their lives, who influences them and who do they think and care about. This includes knowing about:
- Parent/caregiver or other adult family relationships
- Sibling relationships
- Peer relationships and friendships
- Relationships with teachers
- A child’s social functioning and challenges
- Parenting styles and approaches
- Relationship ruptures – abandonment, rejection, bullying, significant periods of separation away from significant others etc.
- Cultural, community or religious affiliations/groups
Here are some activity ideas/questions to elicit children’s perspective of relationships in their lives (designed to assist in overcoming developmental or individual challenges with introspection/communication/attention and motivation):
- Asking children to help us draw family tree diagrams
- Having children draw locations (classroom/home/playground)– and then “stick figures” (friends/teachers) which “belong” in these locations
- (Before session) create a stack of cut out people (paper dolls) – asking child/teen to stick these on paper/whiteboard (and label each “paper doll” for characteristics – closeness/worried about/like being with etc.)
- Draw up columns (People who “Make me laugh”, “Help me”, “I would Send to Mars in a spaceship”, “Makes the rules in our house) or create containers – and ask child to put names/draw stick figures to be in these columns/containers
- Using different colours to “fill in” or draw stick figures in different ways (blue= feel MORE anxious with this person, red= feel LESS anxious with this person)
- Don’t forget to assess online friendships/relationships (Who do you talk to/what apps do you use/do you talk/chat when gaming)
- Using puppets/toys/figurines – who is saying what/where are they in the house?
- General cognitive, emotional and behavioural information (“Psychological” aspects)
A third important area of assessment is about a child’s cognitive, emotional and behavioural functioning. In other words, we want to know how a child is learning, communicating, feeling and what they spend their time doing.
This allows us to understand the personal context (and environment) in which the presenting problem/s exists which assists with our search for underlying, modifiable processes which can guide our treatment planning.
Some examples of topic areas we might be asking about which relate to psychological functioning include:
- Thinking and learning skills (e.g., school performance/abilities).
- Communication and talking skills (at home and with others)
- Emotions and emotional management generally (e.g., general mood, emotion management, temperament).
- Behaviours/routines generally (what spend time on, do during the day – school/hobbies/technology use).
Here are some activity ideas/questions to elicit children’s perspective of their psychological functioning (again all of these designed to assist in overcoming developmental or individual challenges with introspection/communication/attention and motivation):
- Creating columns/circles with labels (words or “icons” – e.g., sun/moon) about different times of day (sun/moon) or different types of days (school/evening/weekends) – and write/draw activities in these columns/circles
- Creating columns/circles/places in the room with labels (words or icons) about feelings about different parts of their life (fun/boring/happy) and child moves to/writes/draws activities in these
- Create “All about me” letters/drawings/templates/card sorting packs
- Tell a story about “A day in the life of (child name)” – telling a story of a typical day (“Once upon a time….”)
- Inquire about enjoyable games/social media apps/what do you do online – for how long and with who
- Would they like to show you photos on phone/tablets of key events or people?
- Physiological Aspects (health/physical aspects of a child)
A fourth important area of assessment is a child’s physical health and any physiological aspects which might be or have impacted on their psychological well-being.
For example, we might be asking parents/caregivers about the following:
- Anything about child’s (or family’s) physical health history (may include pregnancy/birth info) which might impact on the presenting problem
- Exercise and sport involvement
- Sleep patterns
- Nutrition/eating patterns
- Medication (including substance use if older)
Here are some activity ideas/questions to elicit children’s perspective of physiological factors (again designed to assist in overcoming developmental or individual challenges with introspection/communication/attention and motivation):
- Drawing body diagrams on paper/whiteboard – which parts feel good/feel bad
- Using visual (written/in the room) scales of 1-10, how well does your body/parts of your body work?
- Creating visual life timeline – when healthy, when not healthy on visual points during the board
- Bedtime/sleep using labels (sun/moon) – what time/how long/how rested?
5.Risks and Safety
A fifth and important area of assessment is a child’s safety and risks – both any risk/safety issues in the past, any current or potential future risk/safety issues.
Although a thorough risk assessment is outside the scope of this article, here are a few of the kinds of topics we might be asking parents/caregivers about when we are doing these assessments.
- Has there been any times the child has been hurt/at risk/experienced trauma?
- Do they have any current concerns about their well-being or safety?
- Is there anyone in the house who is at risk of being hurt in some way?
We will also need to be assessing risk and safety with children themselves. This often (although not always) means we want to spend time on own without parents/caregivers if appropriate/possible. Again, although how to do a thorough risk and safety assessment is outside the scope of this article, the general kinds of topics and strategies we might be using with children include (although are not limited to):
- Any/what secrets/hard to talk about topics?
- Suicidal ideation/violent/aggressive behaviours assessment
- Body safety/privacy assessment (using body diagrams and books)
An important area of assessment which can be overlooked is what families expect from or are hoping will happen as a result of coming to therapy.
This area (like others above) can be explored in an ongoing way throughout therapy but it is helpful in an initial interview, to at least briefly get a sense of the kinds of expectations a family might have come with. For example, we might ask questions of parents/caregivers such as:
- What do they feel they feel are the biggest problems?
- Most want from therapy?
- Think would be most helpful for them?
- Think would be most helpful for the child?
- Think about the idea of therapy/intervention?
- Think they have already tried?
Here are some activity ideas/questions to elicit children’s expectations and hopes (again designed to assist in overcoming developmental or individual challenges with introspection/communication/attention and motivation):
- Using a craft/drawn magic wand to hold/draw around while asking “what would be good if different/what would you like to change/have happen”
- Using a “happy life box” – putting drawings/child given counters and talks about/draws what would fill it
- Motivation scales – how much did you want to come – scale (with emoticon labels) 1-3?
- Pre-prepared lists – here are some goals/hopes some kids/teens have (categories – feelings, people, behaviours )– any sound like they might matter to you?
- Good bits about coming here/not so good bits
- Swapping chairs – if you were me, what would you do/say you should help me with?
- Strengths (internal and external)
A final important area of assessment is strengths. Mental health professionals in the past have been guilty of focusing entirely on problematic processes and symptoms – and not assessing a person’s strengths, and this is true for child mental health professionals too.
For example, we might ask parents/caregivers:
- What a child/teen is “good” at /their strengths/what most enjoy about them
- What the parents/caregiver believes are the strengths in their relationship with the child/relationships with others
- What are the positive experiences (hobbies) child/teen has
- What are the coping skills and strategies child/teen has used to cope with problems
Here are some activity ideas/questions to elicit children’s perspective of their strengths (designed to assist in overcoming developmental or individual challenges with introspection/communication/attention and motivation):
- Holding toy/drawing super hero and then drawing “super child’s name”/wearing/holding cape – what are your super powers
- I have met lots of amazing children like you – all kinds of coping skills like (write down/draw)….circle the ones you use/have these?
- Pre-prepared strength /value cards – rate thumbs up/thumbs down
- Reading picture books about strengths/making own “strengths” book
- Visualising strengths/”my best self” and sharing
- Listing/drawing activities/people make you happy and confident?
If reading through all the potential areas of assessment and the challenges in doing this well feels somewhat overwhelming, please remember the introduction to this article – you are not alone – most clinicians in my experience find initial assessments both satisfying AND very challenging.
It can be helpful to reassure ourselves by reminding ourselves of the need for patience, and flexibility. It takes time to meet, understand and get to know a family and it is acceptable – and important – to do this flexibly, in ways which work for different families and different clinical styles. In the meantime, here is an acronym you can use to remember the topic areas of assessment listed above – if you think it would be helpful: “PPPRES”
PROBLEM (the “Ws”/prev tried/help)
PSYCHOLOGY (general learning/doing/feeling)
RISK (others/self – previous/current/future)
EXPECTATIONS (Most want/expect/hope)
STRENGTHS (happy/good at/coping/rel strengths)
All the best in your “getting to know” the families you work with.