Morrison, J & Flegel, K. (2016).

Interviewing Children and Adolescents: Skills and Strategies

for Effective DSM-Five Diagnosis. (Second edition). New York: Guilford, xiv + 493 pp. $55.00

(hardcover).

James Morrison, Affiliate Professor of Psychiatry at Oregon Health and Science University

(OHSU) in Portland Oregon, has authored many practical books focusing on interviewing and

the use of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM).

Morrison is joined by Kathryn Flegal, Assistant Professor of Child and Adolescent Psychiatry

also at OHSU. They start their book by providing a list of abbreviations and then organize the

book into two parts plus appendices and an index. Part I contains three chapters providing a

background for evaluating children and adolescents followed by seven chapters providing

developmentally informed interviews and also touching upon conducting the parent-child initial

interview and provision of reports. Part II contains 16 chapters reviewing DSM-5 diagnoses most

applicable to children and adolescents.

Evaluating any patient involves information gathering and the provision of a diagnosis. Morrison

and Flegal see interview techniques as integral to and inseparable from the process of diagnosing

children. They believe that interviewing and diagnosing children deserve special consideration

due to many factors such as children’s reduced vocabulary, lack of abstract conceptualization,

the age-appropriate tendency towards concreteness and the reality that children often do not

realize the importance of forthright communication. Even if children do understand that it is wise

to be open and direct, younger children may not have the wisdom to know what information is

necessary to present. Sensitivity towards the development of both knowledge and cognitive

capacity as children grow is one component of effective child and adolescent interviewing and

therefore, diagnosis. Morrison and Flegel wisely note that often children are brought in for
diagnosis when in fact, the child’s symptoms are a function of parental conflict or a parental

mental disorder. When dealing with children, this point needs to be doubly emphasized. Often,

when children present management issues, some parents have a tendency to pathologize their

children rather than to recognize their own management challenges, believing that if their child

gets a diagnosis it’s “not their fault”. This is one compelling reason to ensure that information

comes from multiple sources. Such sources can include parents, teachers, other healthcare

providers and sometimes, grandparents and other relatives. The positives and occasional caveats

of using multiple sources are detail.

Morrison and Flegel note that some estimate about one in five children have a diagnosable

mental disorder, also believing that there are too few well trained mental health professionals to

come even close to seeing this many children. This is one motivating factor for the second

edition of this book.

All successful interviewing has several identifiable basics such as; listening with an open mind,

the skill to both follow and direct conversation, the ability to establish rapport and the ability to

focus not only on problems but on strengths while at the same time paying attention to the

particular values of the family in question and critical, impacting cultural beliefs. Morrison and

Flegal state that this book is not intended to be a textbook on interviewing; however, in order to

demonstrate the principles of interviewing they believe important, they provide edited transcripts

of several interviews including what they term “an infant-toddler interview” where the clinician

interviews the mother while interacting with the child. Throughout the book Morrison and Flegal

provide modified transcriptions of actual interviews with annotations, where the interviewer’s

goals, and methods are highlighted together with critical commentary regarding the effectiveness

of the interview and what material might also have been sought. Since this book is about use of
DSM-5 criteria in diagnosis, each vignette presented discusses those criteria as well as “Essential

Features” of the disorder. Interviewing techniques for specific diagnoses are presented along

with age-specific interviewing skills to produce developmentally relevant diagnostic information.

Essential Features are similar to but not identical with DSM current criteria and are often called

prototypes as they reflect the way clinicians actually make diagnoses. These Essential Features

are often taken from Morrison’s DSM- 5 Made Easy (2014) book. In addition to the DSM criteria

and Essential Features, Morrison and Flegal also include code numbers from the current ICD 10

CM. These authors also recommend that, either actually or mentally, clinicians rank how closely

the individual in need of diagnosis fits the ideal of any category with 1 equaling little or no

match, 2 equaling some overlap with a few features of the disorder, 3 meaning moderate

matching with significant important features of the disorder, 4 meaning good match, indicating

that the individual meets the standard for the diagnosis and 5, being an excellent match which

would represent a “classic case”. “4 D” questions are outlined, such as asking questions about

duration, demographics, level of distress and differential diagnoses. The current DSM has

abandoned the Global Assessment of Functioning Scale (GAF). Morrison and Flegel indicate

that even though subjective, this can be a valuable part of any evaluation. They explain that

diagnosis should include a good history of the present illness, personal and family information as

well as information regarding socioeconomic status, medical history, items from physical

examinations that may be relevant, family history, a mental status examination, any

psychometric testing that may have been completed and the exploration of sensitive subjects

such as suicidal ideation, violence, delinquency, physical or sexual abuse and substance use and

abuse. Morrison and Flegel then consider the factor of age, breaking down diagnoses are more

likely in younger children and those that tend to emerge in older children and adolescents. They
also note that it is very possible for a child or adolescent to have no diagnosable mental disorder

(!) in which case the code Z 03.89, indicating no mental disorder should be considered.

Caveats are also given noting that some currently diagnosable disorders such as Disruptive Mood

Dysregulation Disorder are in their infancy and do not have a great deal of research or validating

data behind this current DSM inclusion. We are also reminded that psychopathology in very

young children is rarely fixed and is highly contextual, changing with parent management and

age.

Comorbidity is common among young people especially those with intellectual disabilities,

anxiety disorders, learning disorders and disorders of conduct and attentiveness. Practitioners

should always keep in mind that adult symptomatology is often not representative of the

symptom profile in children. As one example, repetitive play rather than flashbacks may be

present in children who might be diagnosed with PTSD.

While many child clinicians may not frequently encounter bipolar disorder or schizophrenia, we

are warned that unused or atypical diagnoses may be missed. Morrison and Flegel additionally

note that while the DSM -5 is used worldwide, it is “uniquely American”, reflecting experiences

and issues involved predominantly in this country. They note that the prevalence of ADHD or

anorexia nervosa differs by country, which is more a reflection of diagnostic tendencies of the

country rather than of the disorder itself.

Morrison and Flegel review directive verses nondirective styles of interviewing, noting that

nondirective interviewing allows the individual answering questions more control over their

involvement in the interview. By not asking yes or no questions or even multiple-choice

questions and by providing open ended discussion, individuals can bring up information that

would typically be left out with more focused questioning. Directive interviewing certainly has
its place as the interview process progresses. Closed-end questioning can focus upon and narrow

down options elicited due to open-ended questioning. At all times, we are directed to listen

carefully and respectfully and convey acceptance and understanding, especially with body

language which can include leaning towards the individual, smiling, timely nodding assent and

issuing praise when appropriate. Comments on transitioning from topic to topic, probing for

information and other interviewing tips or detailed. An outline of an initial mental health

interview for a child or adolescent is presented in great detail. Also included is a comprehensive

section dealing with sensitive subjects. Today, diagnostic psychiatric interviewing would best

also include use of leisure time use of technology, especially given the fact that children and

particularly adolescents often retreat into gaming as a source of solace and avoidance from

dealing with real-world issues. This can often indicate another area of addiction.

Morrison and Flegal are quite comprehensive, taking us through setting up the first interview,

making the first contact, establishing rapport, discussing confidentiality and safety and then

commenting on interview styles. Play interviews are discussed together with interactional,

engagement strategies. Special issues are detailed, such as dealing with strong negative emotion

and dealing with the often encountered “I don’t know”. Sensitive issues, such as whether it is or

is not permissible to touch a young patient are covered together with dealing with lying and

engaging a child who neither talks nor plays. Use of structured interviews is also discussed.

A very comprehensive table is presented, detailing developmental milestones across the

dimensions of gross motor development, fine motor development, affect and mood, language and

speech, the ability to form relationships and intellectual/symbolic capacity. This chart details

monthly development up to 15 months, development in three month intervals up to two years,

yearly development up to six years, bi-yearly development up to 12 years and then jumps to 15
years of age. Morrison and Flegel then include an interesting section on birth order, noting that

80% of families have more than one child. Firstborns tend to be more conforming and aligned

with parental values and expectations and tend to be more strongly motivated toward school

achievement. Firstborns tend to be more prone to guilt feelings and display less aggressiveness

than later born children. They speculate that this may be one basis behind the fact that many

eminent scientists and scholars are firstborn children.

In diagnosing very young children from birth to three years of age, the most prevalent diagnoses

tend to be PTSD, reactive attachment disorder, autism spectrum disorder and intellectual

disability. They explained that the symptoms to look for in this age group tend to be aphasia,

excessive crying or other sleep-related problems, extreme misbehavior and temper tantrums,

extreme shyness, inadequate social interaction and poor eye contact, inflexible adherence to

routine, motor hyperactivity, language delay, acute separation reactions, stereotyped movements,

excessive limit testing and struggles over toilet training or the introduction of new foods. Within

the 3 to 6 year range, prototypical and common diagnoses tend to be communication disorders,

stereotypic movement disorders, oppositional and defiant disorders, attention deficit

hyperactivity disorders, pica, specific phobias, non-REM sleep arousal disorders, nightmares,

and physical abuse of a child. Examiners need to focus on symptoms of anxiety, especially

around separation problems, extreme reactivity or jealousy to the birth of a new sibling,

inattentiveness, impulsivity, mood dysregulation, excessive shyness, multiple fears, refusal to

follow directions, speech that is difficult to understand and temper tantrums to name but a few of

those covered.

The description of early adolescence is similarly thorough, noting that in the 15 to 21 year age

more significant anxiety and mood symptoms can become prevalent, symptoms suggesting
trauma can become more complex, appetite symptoms, substance use problems and the

emergence of psychotic disorders can be seen. Also, at this age, gender orientation issues

become more prevalent.

Morrison and Flegal stated early on their intention that this book is not a substitute for a good

course on interviewing. That said, the chapters which present the infant toddler interview, the

play interview with a six-year-old girl and a seven-year-old boy, the parent-child initial interview

and especially the adolescent interview are exceptionally well done and could be included in any

course on interviewing. As an example, the adolescent interview presents a very challenging

interview with an inpatient, resistant adolescent who presented a real challenge regarding the

creation of rapport. The dialogue between the adolescent and the interviewer is benefits from

annotated comments, helping the reader understand the reasons behind shifts of focus, transitions

from open-ended to closed-end questioning, siding with the interviewee and strategies used to

create a sense of understanding.

In describing the provision of a comprehensive report, Morrison and Flegel present a format

which includes identifying data, a statement of the chief complaint, presentation of the history of

the present illness, inclusion of personal and social background information, family history,

medical history and a mental status examination. This is followed by a formulation which

includes a brief restatement of identifying data, discussion of differential diagnoses, presentation

of the best diagnosis, highlighting of contributing factors, and a statement detailing any

additional information that would be helpful to obtain to confirm the diagnosis. The report

format is concluded by prognosis and treatment recommendations. The formulation should also

identify the “4 P’s” which include predisposing conditions, precipitating variables, perpetuating

conditions and protective factors.

developmental issues, intellectual disability, autism, ADHD, learning disabilities and tic

disorders as well as relevant others. Even though Asperger’s is no longer included in the DSM-5,

a section detailing its current assessment is included. In detailing ADHD, Morrison and Flegel

believe that it can be found in approximately 7% of school-age children. They also believe that

the genetic basis of ADHD is now generally accepted with heritability being about 75%.

Environmental factors such as maternal smoking and alcohol consumption as well as children’s

exposure to toxins have also received research support as contributing factors. Excessive TV

viewing, a carbohydrate laden diet or use of artificial coloring have not been substantiated as

having any impact on ADHD.

Throughout the book, information boxes are presented where particularly informative facts or

opinions or important points are detailed. As it pertains to ADHD, Morrison and Flegel note that

this disorder is more and more seen as resulting from delayed development of brain mechanisms

involved in the process of self-control and impulse control. Both of these tend to be focused in

left prefrontal cortical development. Effective medications used to treat ADHD tend to not only

stimulate the reticular activating (arousal) system of the brain but also target prefrontal cortical

activity.

As the chapters unfold detailing DSM conditions, they typically begin with a “quick guide” to

the particular disorders under discussion. In dealing with the schizophrenic spectrum and other

psychotic disorders, schizophrenia and schizophrenia like disorders, which include

schizophreniform disorder schizoaffective disorder, brief psychotic disorder and catatonia are

cryptically described. This is followed by other psychotic disorders such as delusional disorders,

psychotic disorders due to medical conditions, substance and medication -induced psychotic
disorders and other specified or unspecified psychotic disorders. Disorders that may masquerade

as psychosis such as specific phobia, intellectual disability, somatic symptom disorder, and

factitious disorder are highlighted. Differential diagnosis of psychotic disorders in young patients

is covered. As in the interview chapter, challenging and complex cases are utilized. Assessing

psychotic disorders by exploring hallucinations, both auditory and visual, delusions, thought

disorder, disruptive behavior and affect as well as developmental factors are discussed.

Disorders often not frequently seen by practitioners involve dissociative disorders such as

dissociative amnesia and dissociative identity disorder. Depersonalization disorders, or a sense of

derealization are more frequently seen. General suggestions in assessing dissociative disorders

are presented. The warning is given that younger children can become preoccupied with an

activity so that they appear oblivious and unresponsive to their surroundings, especially during

imaginative play. Symptoms of dissociation in adolescence more closely resemble those of

adults.

Somatic symptom disorders in children can be a challenge to diagnose. Functional neurological

symptom disorder, often referred to as conversion disorder, is seen less and less these days.

Somatic symptom disorders, especially those with pain as a main focus, are more frequently

encountered. Morrison and Flegel express their concern that the criteria for somatic symptom

disorder have been potentially oversimplified and made to general such that many more people

will now qualify for this diagnosis. Those rendering diagnosis are cautioned to be very careful

when making this diagnosis as it can often obscure more treatable conditions. As I am often

referred pain patients, it has often proven true that while initial attempts to diagnose a medical

basis for pain a medical reason for pain ultimately emerged in some cases. These individuals

tended to be easily misdiagnosed initially as having a somatoform disorder in need of psychiatric

seems to be worse than seems reasonable and is coupled with the presence of secondary gain,

due consideration of somatization disorder is appropriate.

Sleep-wake disorders are included in the DSM-5. Nightmare disorders, non-rapid eye movement

(non-REM) sleep arousal disorders, sleep terrors and sleepwalking are all coded psychiatric

disorders. Substance or medication induced sleep disorder as well as obstructive sleep apnea are

included in the DSM. Sleepwalking and sleep terror disorders are now termed nonrapid eye

movement sleep arousal disorders. Sleep terrors are discriminated from nightmares as sleep

terrors tend to occur during the first few hours of non-REM sleep while nightmares occur in the

last third of sleep where REM is more prevalent. Individuals are difficult to arouse from sleep

terrors and report no dream imagery. They tend to not recall the episodes in the morning whereas

individuals experiencing nightmares tend to be easily aroused, typically report dream imagery

and do often report recollection of imagery in the morning. It is understandable why obstructive

sleep apnea is included in the ICD coding but less understandable why it is included as a

psychiatric disorder in the DSM.

In discussing gender dysphoria, Morrison and Flegel stayed that children as young as 3 to 4 years

of age can be dissatisfied with their genetic gender. This is different from a transvestic disorder

where people do not wish to be of the other gender but have sexual urges related to cross-

dressing. The management of gender dysphoria is becoming more and more common and

treatment for this disorder now is seen as predominantly supportive and meant to assist

individuals with the decision of whether to go through the medical procedures needed to change

gender.
This book, as often noted above, is very comprehensive and takes a thorough walk through the

many diagnostic categories that apply to children and adolescents. The very structure of the

DSM, to a large extent, determines the structure of Part II, detailing these many diagnostic

categories and subcategories. Key features are explained, differential diagnoses are examined

and helpful suggestions and insights are offered throughout. This book can be a useful addition

to any child and adolescent psychology or social work graduate program. Cancer be used in any

psychiatric residency program with a specialty or fellowship in child and adolescent psychiatric

medicine. In hardcover, $55.00 seems to be a reasonable price given the thoroughness and

comprehensiveness of the text and expertise of the authors.

References:

Morrison J. (2014). DSM – 5 Made Easy. New York: Guilford.

Howard A Paul Ph.D., A.B.P.P.

Book Review Editor

[email protected]