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The effects of psychiatric and psychosocial interviews on children
The Effects of Psychiatric and Psychosocial Interviews on Children Wendy Reich and Laura Kaplan To test child and parent reactions to direct interviewing, a survey was administered to parents and children who had been directly interviewed as part of two family alcoholism studies. Subjects had been asked about possible psychopathology in the children and about psychosocial stressors that the children may have experienced. For this study, parents and children were asked if the children had been upset by the experience or affected in any negative way. The results
T
of chilHE DIRECT INTERVIEWING dren is now an accepted means of obtaining information from them about their own psychopathology. When this method of eliciting information from children was first used in the late 1960s and early 1970s some researchers were concerned that children might be upset by the kinds of questions usually found in a psychiatric interview. Today, few researchers or clinicians worry about this possibility, largely due to their experience in administering these instruments and noting the children’s reactions to them. Little formal research on this topic has been conducted. An exception is the pioneering study by Herjanic et al.’ at Washington University. In this study, parents and children were asked if the children, who had undergone a structured psychiatric interview, the Diagnostic Interview for Children and Adolescents (DICA), were in any way adversely affected by any of the questions asked of them. The study concluded that there are no real risks involved with the direct interviewing of children about their own psychopathology. Another study conducted at Yale on the Diagnostic Interview Schedule for ChildrenRevised asked children how they felt after they had been interviewed with this instrument.’
From the Division of Child Psychiatry, Washington University, St Louis, MO. Laura Kaplan is a graduate student in the Psychology Deparfment at Northwestern University in Evanston. Address reprint requests to Wendy Reich, Ph.D., Washington University School of Medicine, Department of Psychiatry, 4940 Children’s Place, St Louis, MO 63110. Copyright 0 1994 by WB. Saunders Company 0010-440x/9413501-0001$03.00i0
50
show a positive response from both parents and children to all aspects of the interview. There were no serious negative effects. Many parents and children enjoyed the interview, and none of the families indicated that they would not continue to participate in the study because of the questions asked of the children. Copyright 0 7994by W.B. Saunders Company
Eighty percent of the children found the interview experience to be enjoyable, and 90% said that they would encourage a friend to participate. This study did not ask about adverse effects. To our knowledge, these are the only studies devoted to the reactions of children and their families to the direct interviewing of children with structured or semistructured instruments. Given the usefulness of the direct interviewing of children about their psychiatric problems, it seems only natural that researchers and clinicians would want to question children about other areas of their lives. This would include questions about their home and social environments and any psychosocial stressors in their lives. There is little doubt that children know more about certain aspects of their lives than do their parents. In some cases, children may be the only source of information about their home environment. For example, the parents may not realize that a specific problem exists and therefore would be unable to report on it. In other cases, the parents may not be aware of the nature of the child’s reaction to a problem. For instance, alcoholic parents are sometimes unable to remember enough about their drinking episodes to report on their children’s reaction to them. Depressed parents may not realize how upset their children are about the parent’s illness, or what it is about their illness that is upsetting the children. Clearly there are compelling reasons for asking questions of this nature directly to children. However, concerns have been expressed as to whether personal questions like these might be too upsetting for children. There is also the
ComprehensivePsychiatr/,
Vol. 35, NO. 1 (January/February),
1994: pp 50-53
51
EFFECTS OF INTERVIEWING ON CHILDREN
issue of whether parents might object to questions like these being asked of their children, resulting in their refusal to participate in research projects. As we are currently conducting studies that involve asking children about their own psychopathology, as well as their home and social environments, we believe that we are in a position to address these concerns. METHOD The methods used in this study are similar to those used by Herjanic et al.’ We decided to ask parents and children about their reactions to both psychiatric and psychosocial questions to determine whether we could replicate the results of Herjanic et al.’ and to find out about the impact of psychosocial questions. Surveys were mailed to all of the families in two ongoing studies of the children of alcoholic and substance-abusing probands. Enough surveys were included for all adults and children who had participated in the study. In most cases only one adult. usually the mother, responded. Those families who did not return their surveys were telephoned and asked to do so. If the surveys were still not returned, the families were phoned again and asked if they would mind giving the information over the telephone. When information was obtained over the phone, we spoke with the children and their parents. Families returning only one interview by mail were also contacted by telephone and were asked either to send additional forms for the children or to give us the information over the telephone.
In these studies, parents and children are administered the DICA, which asks questions about psychiatric symptoms in the children, and the Home Environment Interview for Children (HEIC). The HEIC asks children and their parents questions that assess the strengths and weaknesses of the children’s home and social environment. The HEIC contains specific questions about their home life, for example, how the children get along with their parents, whether there is much quarreling in the family. and the kinds of supervision and discipline that the children receive. The HEIC also contains the Structured Assessment Record for Alcoholic Homes (SARAH), a module that asks about alcohol and substance abuse problems and the possible effects that these behaviors might have on the children. The survey, titled “Family Questionnaire,” contained the questions outlined in Table 1. The questionnaire was mailed to 54 previously interviewed families with a total of X0 children. Fifty families with a total of 72 children responded. Two families could not be located, and two families had alcoholic parents who had died during the course of our study. Of the 72 children, 30 were between the ages of 6 and 12. and 42 were 13 to 18 years old. Thirty-nine children were black. 32 were white, and one child was biracial. All of the children had at least one parent who had abused alcohol or other substances.
RESULTS
As can be seen from Table 2, the interview as a whole appears to have been well received. A majority of the subjects did not mind the inter-
Table 1. Family Questionnaire How many adults in your family participated in our study? How many children in yourfamily participated in our study? Did you mind being interviewed for our study? Did your children mind being interviewed? Did you learn more about yourself during the interview? Did your children learn more about themselves? Did any of the questions make you uncomfortable? If so, which ones? Did any of the questions make your children uncomfortable? If so, which ones? Did any of the questions offend you? If so, which ones? Did any of the questions offend your children? If so, which ones? We’d like to know how the children felt about different sections. Feelings:
Liked
Didn’t mind
Behaviors:
Liked
Didn’t mind
Disliked
School:
Liked
Didn’t mind
Disliked
Family life:
Liked
Didn’t mind
Disliked
Activities:
Liked
Didn’t mind
Disliked
Vocabulary:
Liked
Didn’t mind
Disliked
Would you change the interview in any way? If so, how? After the first interview, did your family mind being interviewed again? If so, why? Do you have any comments about the interview?
52
REICH AND KAPLAN
Table 2. The Interview in General Parents (N = 501 Children (N = 7.2) NO.
%
NO.
%
Didn’t mind interview
49
98
71
99
Enjoyed interview
45
90
68
94
Learned more about selves
45
90
67
93
Not made uncomfortable
46
92
70
97
Not offended
50
100
71
99
Didn’t mind being reinterviewed
50
100
72
100
Wouldn’t change interview
47
94
67
93
view, and a good percentage reported that they enjoyed it and learned more about themselves. Two children reported that some of the questions made them uncomfortable. One had been made uncomfortable by the vocabulary test, and one by the questions about his father’s drinking. None of the parents reported being offended by any of the questions. Only one child reported being offended; it was the same child who had felt uncomfortable answering questions about his father’s drinking. Four parents were made uncomfortable by the interview. Two said it was difficult to talk about their substance abuse, and two did not give any reason. None of the parents or children minded being interviewed again, including the child who had disliked the questions about his father’s alcoholism. Most of the parents would not change the interview in any way. Of the three families who said they would, two wrote that they would make it shorter and less repetitive, whereas one parent believed that we should pay more money for completing the interview. Five children said they would change the interview; three said they would make it shorter, one said that we should offer children help for their problems, and the fifth did not give any reason. Table 3 shows the short section of the survey in which children were asked to indicate how Table 3. Specific Sections of the Interview: Children Only (N = 72) Liked
Didn’t Mind
Disliked
NO.
%
NO.
%
NO.
%
Feelings
20
28
51
71
1
.Ol
Behaviors
14
19
57
79
1
.Ol
School
17
24
53
74
2
.03
Family life
18
25
53
74
1
.Ol
Activities
24
33
47
65
1
.Ol
Vocabulary
14
19
57
79
1
.Ol
they felt about different interview sections by circling a response. We thought it would be a rare child who would actually like any part of a 2-hour interview, and found it interesting that some reported that they did. Twenty families wrote or gave comments about the interview; of these, most were positive. Examples include “I enjoyed it,” “the interviewers were nice and easy to talk with,” “I enjoyed the interview, and learned a lot about myself and my daughter,” and “glad to see research being done.” Some comments were neutral, such as “overall, it was O.K.” and “brought to mind things I hadn’t thought about in a long time.” There were no negative comments. DISCUSSION
Almost all of the parents and children appeared to view their interview experience in a positive light. However, as might be expected, there were some negative replies. Of the two children who were made uncomfortable by questions in the interview, one was made uncomfortable by the vocabulary test. The second was the child who was upset over the questions about his father’s drinking. It was this response that gave us the most concern. However, this family also said that they would not change the interview in any way, and they have since been reinterviewed. That child agreed to answer all of the questions that he had been asked the first time. In both interviews, he expressed the same negative feelings about his father’s drinking. For this reason, it is difficult to evaluate the seriousness of the child’s objection to being asked questions about his father’s drinking. Clearly it was not a pleasant experience; however, it was not so unpleasant as to cause the family to leave the research project or to request that these questions not be asked of the child during subsequent interviews. It is worth noting that this is one child out of 72, and thus the risk ratio is not very high. It does seem that the risk of upsetting children or alienating families in research projects involving the direct interviewing of children about sensitive topics is reasonably low. Our findings indicate, as do those of Herjanic et al.’ and Zahner,2 that children do not seem to be adversely affected by
EFFECTS OF INTERVIEWING
ON CHILDREN
standard psychiatric questions, and in fact may enjoy their interview experience. Additionally, psychosocial questions are equally unlikely to upset or offend children. Since the direct administration of psychosocial questionnaires to children provides substantial primary information about the home life and interpersonal relationships, the exclusion of such questionnaires on the basis of risk factors seems unfounded. Further data on the quality of information provided
53
by parents versus children will be presented an upcoming report.
in
REFERENCES l. Herjanic B, Hudson R, Kotloff K. Does interviewing harm children? Res Commun Psycho1 Psychiatry Behav 1976;1:523-531. 2. Zahner GEP. The feasibility of conducting structured diagnostic interviews with preadolescents: a community field trial of the DISC. J Am Acad Child Adolesc Psychiatry 1991;30:659-668.
T
of chilHE DIRECT INTERVIEWING dren is now an accepted means of obtaining information from them about their own psychopathology. When this method of eliciting information from children was first used in the late 1960s and early 1970s some researchers were concerned that children might be upset by the kinds of questions usually found in a psychiatric interview. Today, few researchers or clinicians worry about this possibility, largely due to their experience in administering these instruments and noting the children’s reactions to them. Little formal research on this topic has been conducted. An exception is the pioneering study by Herjanic et al.’ at Washington University. In this study, parents and children were asked if the children, who had undergone a structured psychiatric interview, the Diagnostic Interview for Children and Adolescents (DICA), were in any way adversely affected by any of the questions asked of them. The study concluded that there are no real risks involved with the direct interviewing of children about their own psychopathology. Another study conducted at Yale on the Diagnostic Interview Schedule for ChildrenRevised asked children how they felt after they had been interviewed with this instrument.’
From the Division of Child Psychiatry, Washington University, St Louis, MO. Laura Kaplan is a graduate student in the Psychology Deparfment at Northwestern University in Evanston. Address reprint requests to Wendy Reich, Ph.D., Washington University School of Medicine, Department of Psychiatry, 4940 Children’s Place, St Louis, MO 63110. Copyright 0 1994 by WB. Saunders Company 0010-440x/9413501-0001$03.00i0
50
show a positive response from both parents and children to all aspects of the interview. There were no serious negative effects. Many parents and children enjoyed the interview, and none of the families indicated that they would not continue to participate in the study because of the questions asked of the children. Copyright 0 7994by W.B. Saunders Company
Eighty percent of the children found the interview experience to be enjoyable, and 90% said that they would encourage a friend to participate. This study did not ask about adverse effects. To our knowledge, these are the only studies devoted to the reactions of children and their families to the direct interviewing of children with structured or semistructured instruments. Given the usefulness of the direct interviewing of children about their psychiatric problems, it seems only natural that researchers and clinicians would want to question children about other areas of their lives. This would include questions about their home and social environments and any psychosocial stressors in their lives. There is little doubt that children know more about certain aspects of their lives than do their parents. In some cases, children may be the only source of information about their home environment. For example, the parents may not realize that a specific problem exists and therefore would be unable to report on it. In other cases, the parents may not be aware of the nature of the child’s reaction to a problem. For instance, alcoholic parents are sometimes unable to remember enough about their drinking episodes to report on their children’s reaction to them. Depressed parents may not realize how upset their children are about the parent’s illness, or what it is about their illness that is upsetting the children. Clearly there are compelling reasons for asking questions of this nature directly to children. However, concerns have been expressed as to whether personal questions like these might be too upsetting for children. There is also the
ComprehensivePsychiatr/,
Vol. 35, NO. 1 (January/February),
1994: pp 50-53
51
EFFECTS OF INTERVIEWING ON CHILDREN
issue of whether parents might object to questions like these being asked of their children, resulting in their refusal to participate in research projects. As we are currently conducting studies that involve asking children about their own psychopathology, as well as their home and social environments, we believe that we are in a position to address these concerns. METHOD The methods used in this study are similar to those used by Herjanic et al.’ We decided to ask parents and children about their reactions to both psychiatric and psychosocial questions to determine whether we could replicate the results of Herjanic et al.’ and to find out about the impact of psychosocial questions. Surveys were mailed to all of the families in two ongoing studies of the children of alcoholic and substance-abusing probands. Enough surveys were included for all adults and children who had participated in the study. In most cases only one adult. usually the mother, responded. Those families who did not return their surveys were telephoned and asked to do so. If the surveys were still not returned, the families were phoned again and asked if they would mind giving the information over the telephone. When information was obtained over the phone, we spoke with the children and their parents. Families returning only one interview by mail were also contacted by telephone and were asked either to send additional forms for the children or to give us the information over the telephone.
In these studies, parents and children are administered the DICA, which asks questions about psychiatric symptoms in the children, and the Home Environment Interview for Children (HEIC). The HEIC asks children and their parents questions that assess the strengths and weaknesses of the children’s home and social environment. The HEIC contains specific questions about their home life, for example, how the children get along with their parents, whether there is much quarreling in the family. and the kinds of supervision and discipline that the children receive. The HEIC also contains the Structured Assessment Record for Alcoholic Homes (SARAH), a module that asks about alcohol and substance abuse problems and the possible effects that these behaviors might have on the children. The survey, titled “Family Questionnaire,” contained the questions outlined in Table 1. The questionnaire was mailed to 54 previously interviewed families with a total of X0 children. Fifty families with a total of 72 children responded. Two families could not be located, and two families had alcoholic parents who had died during the course of our study. Of the 72 children, 30 were between the ages of 6 and 12. and 42 were 13 to 18 years old. Thirty-nine children were black. 32 were white, and one child was biracial. All of the children had at least one parent who had abused alcohol or other substances.
RESULTS
As can be seen from Table 2, the interview as a whole appears to have been well received. A majority of the subjects did not mind the inter-
Table 1. Family Questionnaire How many adults in your family participated in our study? How many children in yourfamily participated in our study? Did you mind being interviewed for our study? Did your children mind being interviewed? Did you learn more about yourself during the interview? Did your children learn more about themselves? Did any of the questions make you uncomfortable? If so, which ones? Did any of the questions make your children uncomfortable? If so, which ones? Did any of the questions offend you? If so, which ones? Did any of the questions offend your children? If so, which ones? We’d like to know how the children felt about different sections. Feelings:
Liked
Didn’t mind
Behaviors:
Liked
Didn’t mind
Disliked
School:
Liked
Didn’t mind
Disliked
Family life:
Liked
Didn’t mind
Disliked
Activities:
Liked
Didn’t mind
Disliked
Vocabulary:
Liked
Didn’t mind
Disliked
Would you change the interview in any way? If so, how? After the first interview, did your family mind being interviewed again? If so, why? Do you have any comments about the interview?
52
REICH AND KAPLAN
Table 2. The Interview in General Parents (N = 501 Children (N = 7.2) NO.
%
NO.
%
Didn’t mind interview
49
98
71
99
Enjoyed interview
45
90
68
94
Learned more about selves
45
90
67
93
Not made uncomfortable
46
92
70
97
Not offended
50
100
71
99
Didn’t mind being reinterviewed
50
100
72
100
Wouldn’t change interview
47
94
67
93
view, and a good percentage reported that they enjoyed it and learned more about themselves. Two children reported that some of the questions made them uncomfortable. One had been made uncomfortable by the vocabulary test, and one by the questions about his father’s drinking. None of the parents reported being offended by any of the questions. Only one child reported being offended; it was the same child who had felt uncomfortable answering questions about his father’s drinking. Four parents were made uncomfortable by the interview. Two said it was difficult to talk about their substance abuse, and two did not give any reason. None of the parents or children minded being interviewed again, including the child who had disliked the questions about his father’s alcoholism. Most of the parents would not change the interview in any way. Of the three families who said they would, two wrote that they would make it shorter and less repetitive, whereas one parent believed that we should pay more money for completing the interview. Five children said they would change the interview; three said they would make it shorter, one said that we should offer children help for their problems, and the fifth did not give any reason. Table 3 shows the short section of the survey in which children were asked to indicate how Table 3. Specific Sections of the Interview: Children Only (N = 72) Liked
Didn’t Mind
Disliked
NO.
%
NO.
%
NO.
%
Feelings
20
28
51
71
1
.Ol
Behaviors
14
19
57
79
1
.Ol
School
17
24
53
74
2
.03
Family life
18
25
53
74
1
.Ol
Activities
24
33
47
65
1
.Ol
Vocabulary
14
19
57
79
1
.Ol
they felt about different interview sections by circling a response. We thought it would be a rare child who would actually like any part of a 2-hour interview, and found it interesting that some reported that they did. Twenty families wrote or gave comments about the interview; of these, most were positive. Examples include “I enjoyed it,” “the interviewers were nice and easy to talk with,” “I enjoyed the interview, and learned a lot about myself and my daughter,” and “glad to see research being done.” Some comments were neutral, such as “overall, it was O.K.” and “brought to mind things I hadn’t thought about in a long time.” There were no negative comments. DISCUSSION
Almost all of the parents and children appeared to view their interview experience in a positive light. However, as might be expected, there were some negative replies. Of the two children who were made uncomfortable by questions in the interview, one was made uncomfortable by the vocabulary test. The second was the child who was upset over the questions about his father’s drinking. It was this response that gave us the most concern. However, this family also said that they would not change the interview in any way, and they have since been reinterviewed. That child agreed to answer all of the questions that he had been asked the first time. In both interviews, he expressed the same negative feelings about his father’s drinking. For this reason, it is difficult to evaluate the seriousness of the child’s objection to being asked questions about his father’s drinking. Clearly it was not a pleasant experience; however, it was not so unpleasant as to cause the family to leave the research project or to request that these questions not be asked of the child during subsequent interviews. It is worth noting that this is one child out of 72, and thus the risk ratio is not very high. It does seem that the risk of upsetting children or alienating families in research projects involving the direct interviewing of children about sensitive topics is reasonably low. Our findings indicate, as do those of Herjanic et al.’ and Zahner,2 that children do not seem to be adversely affected by
EFFECTS OF INTERVIEWING
ON CHILDREN
standard psychiatric questions, and in fact may enjoy their interview experience. Additionally, psychosocial questions are equally unlikely to upset or offend children. Since the direct administration of psychosocial questionnaires to children provides substantial primary information about the home life and interpersonal relationships, the exclusion of such questionnaires on the basis of risk factors seems unfounded. Further data on the quality of information provided
53
by parents versus children will be presented an upcoming report.
in
REFERENCES l. Herjanic B, Hudson R, Kotloff K. Does interviewing harm children? Res Commun Psycho1 Psychiatry Behav 1976;1:523-531. 2. Zahner GEP. The feasibility of conducting structured diagnostic interviews with preadolescents: a community field trial of the DISC. J Am Acad Child Adolesc Psychiatry 1991;30:659-668.