- Email: [email protected]
Introducing a Structured Interview Into a Clinical Setting
Associate Editor: Michael S. Jellinek, M.D.
CLINICAL PERSPECTIVES
Introducing a Structured Interview Into a Clinical Setting MARGO THIENEMANN, M.D.
A professor discussed options for interviewing new patients using a bloodhound metaphor. After picking up a scent at the door, would the hound methodically search from room to room to room? Or would the hound efficiently follow the thread of the scent directly to the meter reader? In the past, psychiatrists learned to interview by tracking emotional “scents” to find clues to conflicts and symptoms. When insight-oriented and supportive therapies were recommended for most psychiatric problems, open-ended interviews launched therapy effectively. Over time, new treatments have developed that specifically target particular symptoms and diagnoses. To test and use these medications and therapies appropriately, psychiatric subjects’ pathology should be classified reliably. Otherwise, different investigators’ subject populations could not be rightfully compared with each other and patients might receive treatments that were not indicated for their particular problems. A new diagnostic system evolved, changing from one of analysis of conflict and deviations in development to one using the medical mode in which diagnoses are determined by symptomatic phenomenology. Constellations of signs, symptoms, and illness course defined specific diagnostic entities. So that diagnoses can be reliably made, structured diagnostic interviews have been written. Structured diagnostic interviews are used primarily in psychiatry reAccepted March 8, 2004. From the Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA. Jacqueline Martin, Ph.D., is acknowledged for her help with data compilation. Correspondence to Dr. Thienemann, Division of Child and Adolescent Psychiatry and Child Development, Stanford University, 401 Quarry Road, Stanford, CA 94305-5719; e-mail: [email protected]. 0890-8567/04/4308–1057©2004 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000129221.12305.13
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004
search. These interviews vary in the degree of scripting and in the amount of interviewer interpretation of subjects’ responses. The interviewing “bloodhound” systematically examines each diagnostic “room” to determine the presence or absence of each diagnosis. Such a hound takes longer to be methodical and risks distraction by many, possibly irrelevant, scents, but he or she is less likely to overlook something. Skilled structured interviewers rely more on adherence to format rather than on the intuition, knowledge, and experience that aided the traditional clinical interviewer. Many clinicians feel constrained by this form of interviewing, but structured interviewing yields the reliable diagnoses necessary for making comprehensive treatment plans. Faced with growing evidence of many of diagnosis-driven treatments, how should today’s practicing clinician appropriately evaluate patients? Research does not support unstructured interviews as reliable means to DSM diagnoses. Even experienced clinical interviewers are not reliable diagnosticians when compared with each other, with structured interviews administered by humans, or with structured, computer-assisted interviews (Aronen et al., 1993; Ezpeleta et al., 1997; Miller, 2001; Miller et al., 2001). Anxiety diagnoses are often missed using an unstructured interview (Jensen and Weisz 2002; Komiti et al., 2001; Lewczyk et al., 2003; Zimmerman and Mattia, 1999). Using an unstructured interview may even delay delivery of appropriate treatment: One investigator’s evidence suggested that because the structured interview yields precise diagnostic data, appropriate treatments may be delivered earlier, leading to more rapid recovery and shorter hospital stays (Miller, 2001). Our clinic has taken steps to integrate more structured elements into our intake evaluations. The change was, at first, driven by obvious clinical necessity. The clinic began as a specialized pediatric obsessivecompulsive disorder clinic. To even begin to elicit a thorough history of symptoms from this population 1057
THIENEMANN
of historians who were often reluctant and whose parents were frequently unaware of internal, obsessive experiences, open-ended questions were insufficient. A detailed knowledge of specific symptoms was necessary to understand the severity of illness and its impact on the patient and family to do cognitive-behavioral treatment and follow its course. Using the semistructured interview instrument, the Yale-Brown Obsessive Compulsive Scale with the children and their parents led to a richer and far more accurate history (Goodman et al., 1989). To be able to treat the patients, the clinic incorporated this instrument into each assessment in which obsessive-compulsive disorder was suspected. The clinic grew and its mission also grew to include delivering, teaching, and developing accurate diagnostic evaluations and evidence-based treatments for all childhood anxiety disorders. Hoping to elicit useful symptom reports of internalizing from children who may not be forthcoming and reports of external behaviors from parents and to distinguish between the numerous anxiety diagnoses, we extrapolated from our experience with obsessive-compulsive patients and introduced a structured interview into our evaluation. This report recounts our experience. We chose the Anxiety Disorders Interview Schedule for DSM-IV Child/Parent Version (ADIS-C/P) to diagnose and distinguish between the anxiety disorders. The ADIS-C/P is a semistructured interview designed specifically for children and adolescents aged 7 to 16 years old (Albano and Silverman, 1996). In the interview, the patient and parent rate specific symptoms with the degree of fear they cause and rate the degree of interference symptom clusters cause in the patient’s life. The interview sets up work for cognitivebehavioral therapy by gathering details about the occurrence of anxiety-provoking situations and introducing the skill of distinguishing their different severities. The interview was designed for separate child and parent interviews, but each report has been shown to be reliable and valid (Silverman et al., 2001; Wood et al., 2002). The ADIS-C/P is used in virtually all published childhood anxiety clinical trials. We hoped that, for us, it would enhance clinical diagnostic abilities and serve as a training tool. When we added the ADIS-C/P, we added it at the end of the initial 2-hour evaluation slot when time allowed and finished it in the next session. Research 1058
studies have shown that interviewed alone, using a structured interview or not, parents and children rarely agree on diagnosis (DiBartolo et al., 1998; Jensen et al., 1999; Rapee et al., 1994). Therefore, we administered most of the interview with both the parent and child in the room, making sure to see each alone for a period of time to inquire about trauma or other sensitive topics. To train ourselves, we watched a postdoctoral psychologist, who had trained in the laboratory of one of the ADIS-C/P authors, perform an interview with a child and parent. Then we rated a tape of this interviewer doing a different interview and compared the results with those of our experienced interviewer. Finally, the trainee performed and received feedback on an interview under the observation of the experienced interviewer. Each trainee learned to administer the interview easily. To see what impact introducing the interview had on our diagnoses, we reviewed charts of the previous 6 months of consecutive patients evaluated using our routine psychiatric evaluation before we began using the ADIS-C/P (n = 37) and charts of the next 6 months’ patients evaluated adding the ADIS-C/P (n = 40). During the time reviewed, some of our trainee population turned over (n = 3), but attendings and another trainee remained the same (n = 3). We tabulated the number of anxiety diagnoses made per patient and the frequency of specific anxiety diagnoses recorded. We predicted that we would make a larger number of and more specific anxiety diagnoses using the ADIS-C/P. We did make more anxiety diagnoses using the ADIS-C/P. On average, patients had 2.1 diagnoses using the structured interview, and 1.5 anxiety diagnoses without. Using the ADIS, we no longer made the nonspecific diagnosis of anxiety disorder, not otherwise specified, nor the obsolete diagnosis overanxious disorder. We made diagnoses that we had missed before adding the structured interview. We began diagnosing generalized anxiety disorder (48% versus 0%). We diagnosed more social anxiety disorder (42% versus 16%), specific phobia (30% versus 0%), and separation anxiety disorder (28% versus 6%). Clinicians and staff reacted to the change. More time was required to officially complete the psychiatric evaluation, which sounded like an increased burden to busy staff. Those charged with clinic financial issues questioned the expenses incurred: to the clinic for the J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004
CLINICAL PERSPECTIVES
interview booklets and to the patients because of extending the evaluation’s duration. Clinicians feared that families would resent the added time, exhaustiveness, and redundancy of the structured interview. Although those with research experience welcomed the format’s completeness, some clinicians felt stilted and constrained using an unfamiliar structured interview. Specific concerns arose regarding some weaknesses of the interview, most notably that it lacks a bipolar affective disorder section. Senior clinicians in other specialty clinics questioned whether we intended to abandon dynamic formulations and become diagnostic automatons. Because we believed that both evidence of diagnostic reliability and clinical experience with our anxious patient population supported inclusion of structured interviews in our evaluations, we attempted to address these negative reactions. We did not agree that adding the instrument actually added time to the evaluation. Psychiatric evaluation is an ongoing process that always continues beyond the first encounter. Although insurance companies have designated evaluation as a unitary item occurring only at the first visit, a complete child psychiatric evaluation includes meetings with parents, patients, and possibly other family members as well as conversations with important informants such as pediatricians and teachers. Continuing the evaluation after the first session is consistent with usual practice. We continued to bill further sessions as before as psychotherapy sessions. The cost of the interview was not significant: The several-dollar interview booklet cost was minuscule when amortized over the duration of therapy. It was our experience that patients and their families felt satisfied that they were evaluated thoroughly and did not object to being interviewed using the ADISC/P. Often in the process, parents learned about fears that they had not known about, sometimes fears that caused unexplained oppositional behavior. Less experienced clinicians, the trainees, reported gaining increased familiarity with and skill in making anxiety disorder diagnoses. One commented that he had adapted the query language into his other clinical work, finding it useful in eliciting symptoms. Another trainee’s curiosity was stimulated about diagnostic distinctions, as when, for example, patients met criteria for both obsessive-compulsive disorder and generalized anxiety disorder. Although some experienced staff iniJ. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004
tially apologized to families for using the interview, this diminished after several tries using the interview because they believed that the degree of symptom detail gained helped set up cognitive-behavioral treatment and that the treatment alliance was not negatively affected. We have not abandoned our traditional psychiatric interview, in part because we are uncomfortable with deleting elements of the traditional interview and in part because the particular structured interview that we chose has areas of insufficiency. The intake is a medical document and, as such, we believe that we must include a detailed chief complaint, history of present illness, psychiatric history, developmental history, medical history, family and social histories, review of systems, and mental status examination. Although the structured interview that we chose contains many of these elements, familiarity with organizing the evaluation gained from medical training and use of the evaluation as a means of communication to other medical providers keeps us in the habit of using that traditional format. Our current model of adding the ADIS-C/P is our first step in the evolution of our evaluations. When clinical judgment suggests, we add portions of other interviews and instruments to supplement the ADIS, such as the Child Yale-Brown Obsessive Compulsive Scale and the bipolar mood disorder section of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kaufman et al., 1997). Because children with a psychiatric disorder most frequently suffer from psychiatric comorbidity, we anticipate continuing to integrate instruments to clarify other diagnoses, including depressive, autistic spectrum, and externalizing disorders. Will new psychiatrists only read questions, list symptoms, and write medication orders? Will training our students to use structured diagnostic interviews risk their neglecting to develop psychodynamic assessment and treatment skills? Although new interviews and therapies are structured and prescribed, clinical skill and dynamic formulations are required to engage the patient and family, to address social and emotional consequences of having a psychiatric illness, and, of course, to address treatment resistances. Having an anxiety disorder often interferes with social and emotional development. In families with anxious children, for example, parents are often divided on parenting issues, which sometimes leads to unhelpful alliances 1059
THIENEMANN
and splits. The dynamic problems coexisting with and possibly resulting from an anxiety disorder may improve as patients gain skills to deal with anxiety symptoms but may still need to be addressed after these skills have been learned. We cannot abandon making psychodynamic formulations as a result of using a structured interview or we risk being unable to deliver treatments effectively. We have not formally examined whether changing our diagnostic procedure has changed treatment. If Miller’s (2001) inpatient findings in adults apply to our setting, having accurate, complete diagnoses may lead to less expensive treatment overall. It is our impression that families feel more informed about their children’s specific symptoms and are more focused and motivated when beginning treatment. Ideally, using intuition and experience, the psychiatrist bloodhound will use clinical senses to sniff out clues to diagnosis at first encounter. On picking up a diagnostic scent, he or she will doggedly follow it into a specific diagnostic room to gather details, thereby determining a diagnosis’ presence and clarifying its severity. Integrating this reliable diagnostic information with clinical observations, the clinician will be better positioned to engage patients and their families with effective treatments. Disclosure: The author is currently on the speakers’ bureaus of Novartis and Pfizer pharmaceutical firms. REFERENCES Albano A, Silverman WK (1996), The Anxiety Disorders Interview Schedule for Children for DSM-IV: Clinician Manual (Child and Parent Versions). San Antonio, TX: Psychological Corporation
1060
Aronen E, Noam G, Weinstein S (1993), Structured diagnostic interviews and clinicians’ discharge diagnoses in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry 32:674–681 DiBartolo P, Albano A, Barlow D, Heimberg R (1998), Cross-informant agreement in the assessment of social phobia in youth. J Abnorm Child Psychol 26:213–220 Ezpeleta L, de la Osa N, Domenech J, Navarro J, Losill J, Judez J (1997), Diagnostic agreement between clinicians and the Diagnostic Interview for Children and Adolescents—DICA-R—in an outpatient sample. J Child Psychol Psychiatry 38:431–440 Goodman W, Price L, Rasmussen S et al. (1989), The Yale-Brown Obsessive-Compulsive Scale. I. Development, use and reliability. Arch Gen Psychiatry 46:1006–1011 Jensen P, Rubio-Stipee M, Canino G et al. (1999), Parent and child contributions to diagnosis of mental disorder: both informants always necessary? J Am Acad Child Adolesc Psychiatry 38:1569–1579 Jensen M, Weisz J (2002), Assessing match and mismatch between practitioner-generated standard interview-generated diagnoses for clinicreferred children and adolescents. J Consult Clin Psychol 70:158–168 Kaufman J, Birmaher B, Brent D et al. (1997), Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980–988 Komiti A, Jackson H, Judd F et al. (2001), A comparison of the Composite International Diagnostic Interview (CIDI-Auto) with clinical assessment in diagnosing mood and anxiety disorders. Aust N Z J Psychiatry 35:224–230 Lewczyk C, Garland A, Hurlburt M, Gearity J, Hough R (2003), Comparing DISC-IV and clinician diagnoses among youths receiving public mental health services. J Am Acad Child Adolesc Psychiatry 42:349–356 Miller P, Dasher R, Collins R, Griffiths P, Brown F (2001), Inpatient diagnostic assessments: 1. Accuracy of structured v. unstructured interviews. Psychiatry Res 105:255–264 Miller P (2001), Inpatient diagnostic assessments: 2. Interrater reliability and outcomes of structured vs. unstructured interviews. Psychiatry Res 105:265–271 Rapee R, Barrett P, Dadds M, Evans L (1994), Reliability of the DSM-III-R childhood anxiety disorders using structured interview: interrater and parent-child agreement. J Am Acad Child Adolesc Psychiatry 33:984–992 Silverman W, Saavedra L, Pina A (2001), Test-Retest Reliability of Anxiety Symptoms and Diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. J Am Acad Child Adolesc Psychiatry 40:937–944 Wood J, Piacentini J, Bergman R, McCracken J, Barrios V (2002), Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. J Clin Child Psychol 31:335–342 Zimmerman M, Mattia J (1999), Psychiatric diagnosis in clinical practice: is comorbidity being missed? Compr Psychiatry 40:182–191
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004
CLINICAL PERSPECTIVES
Introducing a Structured Interview Into a Clinical Setting MARGO THIENEMANN, M.D.
A professor discussed options for interviewing new patients using a bloodhound metaphor. After picking up a scent at the door, would the hound methodically search from room to room to room? Or would the hound efficiently follow the thread of the scent directly to the meter reader? In the past, psychiatrists learned to interview by tracking emotional “scents” to find clues to conflicts and symptoms. When insight-oriented and supportive therapies were recommended for most psychiatric problems, open-ended interviews launched therapy effectively. Over time, new treatments have developed that specifically target particular symptoms and diagnoses. To test and use these medications and therapies appropriately, psychiatric subjects’ pathology should be classified reliably. Otherwise, different investigators’ subject populations could not be rightfully compared with each other and patients might receive treatments that were not indicated for their particular problems. A new diagnostic system evolved, changing from one of analysis of conflict and deviations in development to one using the medical mode in which diagnoses are determined by symptomatic phenomenology. Constellations of signs, symptoms, and illness course defined specific diagnostic entities. So that diagnoses can be reliably made, structured diagnostic interviews have been written. Structured diagnostic interviews are used primarily in psychiatry reAccepted March 8, 2004. From the Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA. Jacqueline Martin, Ph.D., is acknowledged for her help with data compilation. Correspondence to Dr. Thienemann, Division of Child and Adolescent Psychiatry and Child Development, Stanford University, 401 Quarry Road, Stanford, CA 94305-5719; e-mail: [email protected]. 0890-8567/04/4308–1057©2004 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000129221.12305.13
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004
search. These interviews vary in the degree of scripting and in the amount of interviewer interpretation of subjects’ responses. The interviewing “bloodhound” systematically examines each diagnostic “room” to determine the presence or absence of each diagnosis. Such a hound takes longer to be methodical and risks distraction by many, possibly irrelevant, scents, but he or she is less likely to overlook something. Skilled structured interviewers rely more on adherence to format rather than on the intuition, knowledge, and experience that aided the traditional clinical interviewer. Many clinicians feel constrained by this form of interviewing, but structured interviewing yields the reliable diagnoses necessary for making comprehensive treatment plans. Faced with growing evidence of many of diagnosis-driven treatments, how should today’s practicing clinician appropriately evaluate patients? Research does not support unstructured interviews as reliable means to DSM diagnoses. Even experienced clinical interviewers are not reliable diagnosticians when compared with each other, with structured interviews administered by humans, or with structured, computer-assisted interviews (Aronen et al., 1993; Ezpeleta et al., 1997; Miller, 2001; Miller et al., 2001). Anxiety diagnoses are often missed using an unstructured interview (Jensen and Weisz 2002; Komiti et al., 2001; Lewczyk et al., 2003; Zimmerman and Mattia, 1999). Using an unstructured interview may even delay delivery of appropriate treatment: One investigator’s evidence suggested that because the structured interview yields precise diagnostic data, appropriate treatments may be delivered earlier, leading to more rapid recovery and shorter hospital stays (Miller, 2001). Our clinic has taken steps to integrate more structured elements into our intake evaluations. The change was, at first, driven by obvious clinical necessity. The clinic began as a specialized pediatric obsessivecompulsive disorder clinic. To even begin to elicit a thorough history of symptoms from this population 1057
THIENEMANN
of historians who were often reluctant and whose parents were frequently unaware of internal, obsessive experiences, open-ended questions were insufficient. A detailed knowledge of specific symptoms was necessary to understand the severity of illness and its impact on the patient and family to do cognitive-behavioral treatment and follow its course. Using the semistructured interview instrument, the Yale-Brown Obsessive Compulsive Scale with the children and their parents led to a richer and far more accurate history (Goodman et al., 1989). To be able to treat the patients, the clinic incorporated this instrument into each assessment in which obsessive-compulsive disorder was suspected. The clinic grew and its mission also grew to include delivering, teaching, and developing accurate diagnostic evaluations and evidence-based treatments for all childhood anxiety disorders. Hoping to elicit useful symptom reports of internalizing from children who may not be forthcoming and reports of external behaviors from parents and to distinguish between the numerous anxiety diagnoses, we extrapolated from our experience with obsessive-compulsive patients and introduced a structured interview into our evaluation. This report recounts our experience. We chose the Anxiety Disorders Interview Schedule for DSM-IV Child/Parent Version (ADIS-C/P) to diagnose and distinguish between the anxiety disorders. The ADIS-C/P is a semistructured interview designed specifically for children and adolescents aged 7 to 16 years old (Albano and Silverman, 1996). In the interview, the patient and parent rate specific symptoms with the degree of fear they cause and rate the degree of interference symptom clusters cause in the patient’s life. The interview sets up work for cognitivebehavioral therapy by gathering details about the occurrence of anxiety-provoking situations and introducing the skill of distinguishing their different severities. The interview was designed for separate child and parent interviews, but each report has been shown to be reliable and valid (Silverman et al., 2001; Wood et al., 2002). The ADIS-C/P is used in virtually all published childhood anxiety clinical trials. We hoped that, for us, it would enhance clinical diagnostic abilities and serve as a training tool. When we added the ADIS-C/P, we added it at the end of the initial 2-hour evaluation slot when time allowed and finished it in the next session. Research 1058
studies have shown that interviewed alone, using a structured interview or not, parents and children rarely agree on diagnosis (DiBartolo et al., 1998; Jensen et al., 1999; Rapee et al., 1994). Therefore, we administered most of the interview with both the parent and child in the room, making sure to see each alone for a period of time to inquire about trauma or other sensitive topics. To train ourselves, we watched a postdoctoral psychologist, who had trained in the laboratory of one of the ADIS-C/P authors, perform an interview with a child and parent. Then we rated a tape of this interviewer doing a different interview and compared the results with those of our experienced interviewer. Finally, the trainee performed and received feedback on an interview under the observation of the experienced interviewer. Each trainee learned to administer the interview easily. To see what impact introducing the interview had on our diagnoses, we reviewed charts of the previous 6 months of consecutive patients evaluated using our routine psychiatric evaluation before we began using the ADIS-C/P (n = 37) and charts of the next 6 months’ patients evaluated adding the ADIS-C/P (n = 40). During the time reviewed, some of our trainee population turned over (n = 3), but attendings and another trainee remained the same (n = 3). We tabulated the number of anxiety diagnoses made per patient and the frequency of specific anxiety diagnoses recorded. We predicted that we would make a larger number of and more specific anxiety diagnoses using the ADIS-C/P. We did make more anxiety diagnoses using the ADIS-C/P. On average, patients had 2.1 diagnoses using the structured interview, and 1.5 anxiety diagnoses without. Using the ADIS, we no longer made the nonspecific diagnosis of anxiety disorder, not otherwise specified, nor the obsolete diagnosis overanxious disorder. We made diagnoses that we had missed before adding the structured interview. We began diagnosing generalized anxiety disorder (48% versus 0%). We diagnosed more social anxiety disorder (42% versus 16%), specific phobia (30% versus 0%), and separation anxiety disorder (28% versus 6%). Clinicians and staff reacted to the change. More time was required to officially complete the psychiatric evaluation, which sounded like an increased burden to busy staff. Those charged with clinic financial issues questioned the expenses incurred: to the clinic for the J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004
CLINICAL PERSPECTIVES
interview booklets and to the patients because of extending the evaluation’s duration. Clinicians feared that families would resent the added time, exhaustiveness, and redundancy of the structured interview. Although those with research experience welcomed the format’s completeness, some clinicians felt stilted and constrained using an unfamiliar structured interview. Specific concerns arose regarding some weaknesses of the interview, most notably that it lacks a bipolar affective disorder section. Senior clinicians in other specialty clinics questioned whether we intended to abandon dynamic formulations and become diagnostic automatons. Because we believed that both evidence of diagnostic reliability and clinical experience with our anxious patient population supported inclusion of structured interviews in our evaluations, we attempted to address these negative reactions. We did not agree that adding the instrument actually added time to the evaluation. Psychiatric evaluation is an ongoing process that always continues beyond the first encounter. Although insurance companies have designated evaluation as a unitary item occurring only at the first visit, a complete child psychiatric evaluation includes meetings with parents, patients, and possibly other family members as well as conversations with important informants such as pediatricians and teachers. Continuing the evaluation after the first session is consistent with usual practice. We continued to bill further sessions as before as psychotherapy sessions. The cost of the interview was not significant: The several-dollar interview booklet cost was minuscule when amortized over the duration of therapy. It was our experience that patients and their families felt satisfied that they were evaluated thoroughly and did not object to being interviewed using the ADISC/P. Often in the process, parents learned about fears that they had not known about, sometimes fears that caused unexplained oppositional behavior. Less experienced clinicians, the trainees, reported gaining increased familiarity with and skill in making anxiety disorder diagnoses. One commented that he had adapted the query language into his other clinical work, finding it useful in eliciting symptoms. Another trainee’s curiosity was stimulated about diagnostic distinctions, as when, for example, patients met criteria for both obsessive-compulsive disorder and generalized anxiety disorder. Although some experienced staff iniJ. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004
tially apologized to families for using the interview, this diminished after several tries using the interview because they believed that the degree of symptom detail gained helped set up cognitive-behavioral treatment and that the treatment alliance was not negatively affected. We have not abandoned our traditional psychiatric interview, in part because we are uncomfortable with deleting elements of the traditional interview and in part because the particular structured interview that we chose has areas of insufficiency. The intake is a medical document and, as such, we believe that we must include a detailed chief complaint, history of present illness, psychiatric history, developmental history, medical history, family and social histories, review of systems, and mental status examination. Although the structured interview that we chose contains many of these elements, familiarity with organizing the evaluation gained from medical training and use of the evaluation as a means of communication to other medical providers keeps us in the habit of using that traditional format. Our current model of adding the ADIS-C/P is our first step in the evolution of our evaluations. When clinical judgment suggests, we add portions of other interviews and instruments to supplement the ADIS, such as the Child Yale-Brown Obsessive Compulsive Scale and the bipolar mood disorder section of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kaufman et al., 1997). Because children with a psychiatric disorder most frequently suffer from psychiatric comorbidity, we anticipate continuing to integrate instruments to clarify other diagnoses, including depressive, autistic spectrum, and externalizing disorders. Will new psychiatrists only read questions, list symptoms, and write medication orders? Will training our students to use structured diagnostic interviews risk their neglecting to develop psychodynamic assessment and treatment skills? Although new interviews and therapies are structured and prescribed, clinical skill and dynamic formulations are required to engage the patient and family, to address social and emotional consequences of having a psychiatric illness, and, of course, to address treatment resistances. Having an anxiety disorder often interferes with social and emotional development. In families with anxious children, for example, parents are often divided on parenting issues, which sometimes leads to unhelpful alliances 1059
THIENEMANN
and splits. The dynamic problems coexisting with and possibly resulting from an anxiety disorder may improve as patients gain skills to deal with anxiety symptoms but may still need to be addressed after these skills have been learned. We cannot abandon making psychodynamic formulations as a result of using a structured interview or we risk being unable to deliver treatments effectively. We have not formally examined whether changing our diagnostic procedure has changed treatment. If Miller’s (2001) inpatient findings in adults apply to our setting, having accurate, complete diagnoses may lead to less expensive treatment overall. It is our impression that families feel more informed about their children’s specific symptoms and are more focused and motivated when beginning treatment. Ideally, using intuition and experience, the psychiatrist bloodhound will use clinical senses to sniff out clues to diagnosis at first encounter. On picking up a diagnostic scent, he or she will doggedly follow it into a specific diagnostic room to gather details, thereby determining a diagnosis’ presence and clarifying its severity. Integrating this reliable diagnostic information with clinical observations, the clinician will be better positioned to engage patients and their families with effective treatments. Disclosure: The author is currently on the speakers’ bureaus of Novartis and Pfizer pharmaceutical firms. REFERENCES Albano A, Silverman WK (1996), The Anxiety Disorders Interview Schedule for Children for DSM-IV: Clinician Manual (Child and Parent Versions). San Antonio, TX: Psychological Corporation
1060
Aronen E, Noam G, Weinstein S (1993), Structured diagnostic interviews and clinicians’ discharge diagnoses in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry 32:674–681 DiBartolo P, Albano A, Barlow D, Heimberg R (1998), Cross-informant agreement in the assessment of social phobia in youth. J Abnorm Child Psychol 26:213–220 Ezpeleta L, de la Osa N, Domenech J, Navarro J, Losill J, Judez J (1997), Diagnostic agreement between clinicians and the Diagnostic Interview for Children and Adolescents—DICA-R—in an outpatient sample. J Child Psychol Psychiatry 38:431–440 Goodman W, Price L, Rasmussen S et al. (1989), The Yale-Brown Obsessive-Compulsive Scale. I. Development, use and reliability. Arch Gen Psychiatry 46:1006–1011 Jensen P, Rubio-Stipee M, Canino G et al. (1999), Parent and child contributions to diagnosis of mental disorder: both informants always necessary? J Am Acad Child Adolesc Psychiatry 38:1569–1579 Jensen M, Weisz J (2002), Assessing match and mismatch between practitioner-generated standard interview-generated diagnoses for clinicreferred children and adolescents. J Consult Clin Psychol 70:158–168 Kaufman J, Birmaher B, Brent D et al. (1997), Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980–988 Komiti A, Jackson H, Judd F et al. (2001), A comparison of the Composite International Diagnostic Interview (CIDI-Auto) with clinical assessment in diagnosing mood and anxiety disorders. Aust N Z J Psychiatry 35:224–230 Lewczyk C, Garland A, Hurlburt M, Gearity J, Hough R (2003), Comparing DISC-IV and clinician diagnoses among youths receiving public mental health services. J Am Acad Child Adolesc Psychiatry 42:349–356 Miller P, Dasher R, Collins R, Griffiths P, Brown F (2001), Inpatient diagnostic assessments: 1. Accuracy of structured v. unstructured interviews. Psychiatry Res 105:255–264 Miller P (2001), Inpatient diagnostic assessments: 2. Interrater reliability and outcomes of structured vs. unstructured interviews. Psychiatry Res 105:265–271 Rapee R, Barrett P, Dadds M, Evans L (1994), Reliability of the DSM-III-R childhood anxiety disorders using structured interview: interrater and parent-child agreement. J Am Acad Child Adolesc Psychiatry 33:984–992 Silverman W, Saavedra L, Pina A (2001), Test-Retest Reliability of Anxiety Symptoms and Diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. J Am Acad Child Adolesc Psychiatry 40:937–944 Wood J, Piacentini J, Bergman R, McCracken J, Barrios V (2002), Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. J Clin Child Psychol 31:335–342 Zimmerman M, Mattia J (1999), Psychiatric diagnosis in clinical practice: is comorbidity being missed? Compr Psychiatry 40:182–191
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:8, AUGUST 2004