The goal of any diagnostic interview is to help the child and adolescent psychiatrist or trainee tailor the treatment approaches that best suit the patient and ideally take a biological, psychological, and social integrated approach (McConville and Delgado 2006).

The child and adolescent psychiatrist traditionally asks the child, adolescent, and/or their parents to share the history of their present illness, with a timeline that establishes when they first noticed the symptoms, the frequency of symptoms, and variations in the intensity of symptoms over time, along with precipitating and perpetuating factors. Over the course of a traditional psychiatric evaluation, the child and adolescent psychiatrist or clinician may quickly become focused on elucidating risk factors, identifying predictors of treatment response, and determining which “symptoms ” meet threshold criteria for a disorder. Thus, with the standard use of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition ( DSM–5, APA 2013), the diagnosis is based on a collection of signs and symptoms that have been well defined. The child and adolescent psychiatrist or clinician is charged with incorporating the information obtained from the patient, his or her family, and also other multiple sources (e.g., prior medical or psychiatric treatment records) into the formulation of effective recommendations, whether psychotherapeutic or psychopharmacological.

It is agreed that an integrated biological, psychological, and social interview is valuable when assessing patients and developing well-thought-out treatment plans (Delgado and Strawn 2014). However, it is generally agreed that child and adolescent psychiatrists in training learn to switch interview and diagnostic approaches rather than integrate them, as Cardoso Zoppe et al. (2009) state, “There is still tension between biological and psychosocial tendencies.” They further highlight that current teaching methods for trainees routinely lack integration and are heavily influenced by the setting in which the patient is seen (e.g., academic, local hospital, community mental health center) and their supervisors’ school of thought (e.g., traditional one-person, psychopharmacologist, behaviorist).

From a biopsychosocial perspective, we propose that when an integrated developmental approach is used in developing a comprehensive diagnostic formulation , as in the case of the 12-year-old boy described above, it facilitates the complex decision making needed to outline the sequencing of the interventions to ensure successful outcomes. One might describe this approach as a grasp of the interplay between the forces of nature and nurture (Table 8.1).

We are aware that the skeptic child and adolescent psychiatrist trainee would ask whether a biopsychosocial developmental interview is useful or practical. Further, some feel that the child and adolescent psychiatrist should practice at the top of their license: the evaluation of a psychiatric DSM–5 diagnosis with pharmacological recommendations and a referral to an allied professional for psychosocial interventions if considered appropriate (Drell 2007). The authors are frequently asked, “Isn’t a detailed biopsychosocial evaluation needed only if we are going to recommend individual or family therapy?” This could not be farther from the truth, when considering that an integrated approach provides the critical information needed in designing treatment recommendations and gives insight about whether the patient and family is likely to comply.

In using a traditional DSM–5 type of interview, generally the child and adolescent psychiatrist’s diagnostic formulation is based on the assumption that the responses by the patient and parents or caregivers are factual and accurate, unless due to psychotic processes or developmental disabilities . Delgado and Strawn (2014) aptly capture the limitations of the DSM–5-style interview in child and adolescent psychiatry, namely, that it ignores the patient’s temperament, internal working models of attachment , learning abilities or weaknesses, and cognitive flexibilities within the backdrop of the family and of the social and cultural environment in which they have lived. Herein, the careful assessment of the patient’s innate and relational factors allows the child and adolescent psychiatrist or clinician to obtain in a succinct manner critical information as to whether the responses provided are actually factual and accurate and then use this information to tailor an effective treatment regimen (Delgado and Strawn 2014).

Although attending to temperament , internal working models of attachment, learning abilities or weaknesses, and cognitive flexibilities may initially seem like a daunting task for the child and adolescent psychiatrist or clinician, it avoids polypharmacy and reduces the likelihood of serious side effects. We are not minimizing the lifesaving experiences some children and adolescents can have with the appropriate use of medication; rather, we are cautioning about the tension between biological and psychosocial interventions that can be limiting to a child’s future (Kaplan and Delgado 2006).

Although we have identified some of the weaknesses of the traditional DSM–5 structured interview model, our primary goal is to add and enhance the techniques available to the child and adolescent psychiatrist or clinician’s toolbox to improve the diagnostic reliability needed. However, we would not expect many of the “tools” to initially fit neatly into current clinical practice. The contemporary diagnostic interview (CDI) is aimed at observing and interacting with patients and their parents or caregivers, and it is designed to capture a different spectrum of information that is inaccessible by the standard DSM–5-style interview. As with the adoption of any new useful and practical technique, the initial challenge will be overcome through careful study and frequent practice.

We have found that the CDI increases reliability, consistency, and accuracy in the description of the signs and symptoms endorsed by children and their parents or caregivers, allowing for the development of a comprehensive diagnostic formulation , as well as a two-person relational psychodynamic formulation. Herein, we will outline a “how to” guide to complete a detailed CDI for the reader to consider using in his or her day-to-day clinical work.

In certain medical situations such as a stroke or a dangerous arrhythmia, we would argue that all the evidence needed for an accurate diagnosis and assessment are plainly visible. However, we would argue that neuroscience has demonstrated that human behavior does not readily play by the same rules of the observable to the plain eye. Human behavior is exquisitely contextual and is influenced by numerous factors, including both internal and external cues. Thus, a traditional unilateral approach may, despite the best intentions of the clinician, result in obscuring the true nature of the psychological difficulties and thus prevent optimal treatment. In contrast, we suggest that engaging in the complex process of understanding our patients and their parents or associated caregivers requires the active participation by the child and adolescent psychiatrist or clinician to create an atmosphere of safety, curiosity, and exploratory inquiry of all participants’ subjective experiences, which will result in a more accurate representation of the patient’s lifestyle and concerns at hand.

To illustrate this point, we consider our colleagues in pediatric cardiology . The astute reader may claim that any form of a psychiatric diagnostic interview is not different than a pediatric cardiology evaluation, as they are both based on a collection of signs and symptoms that have been well defined. In fact, child and adolescent psychiatrists, like pediatric cardiologists, have begun to use neurological diagnostic tests, computerized testing, and laboratory tests with increasing frequency. We propose that the difference lies in the moment in which the pediatric cardiologist intently listens to the quiet perturbations of the heart with his stethoscope on the chest of the young patient. In these few seconds, the pediatric cardiologist integrates his or her own subjective sense of what the young patient needs to feel safe as the pediatric cardiologist reaches for the patient’s chest with exquisite sensitivity to the patient’s unique physiology, quietly responding to what he or she hears and rapidly adjusting his or her attention and exam based on this moment of cocreation. The pediatric cardiologist’s future actions are tempered by the observable and the implicit feedback provided by the young patient in the here-and-now moments during the examination. Here, we must stress that this is not a “mystical” moment but rather one informed through the unique clinical intuition about working with children that was acquired during the cardiologist’s early childhood experiences as implicit relational patterns stored in his or her implicit nondeclarative memory systems and also through his or her subsequent rigorous training grounded in an in-depth understanding of anatomy and physiology. Herein, in a recent study, pediatric cardiologists could identify a pathologic heart condition using only their physical exam nearly 92 % of the time (Mackie et al. 2009) even when they did not have access to an electrocardiogram (routinely performed at most visits). Thus, there is both an explicit and implicit comparison between the pediatric cardiologist’s and the child and adolescent psychiatrist’s exam. The moments during the time a stethoscope is on the chest, the awareness and interpretation of these “moments of meeting” (Chap.​ 5) shared by both parties are critical to any subsequent decision making. The child’s experience in the situation will influence their heart rate and their willingness to cooperate. Scientific advancements have broadened our understanding of the importance of nonverbal communication and implicit nondeclarative memory when people interact with each other. For the pediatric cardiologist, the lines are blurred between a verbal history and the telltale physical signs; both stories are provided by the young patient yet neither is sufficient. We hope to demonstrate through the findings of modern developmental research and neurosciences that the tried-and-true semistructured verbal interview is only a narrow slice of the raw spectrum of data available to the child and adolescent psychiatrist.

The goal of a contemporary diagnostic interview is to facilitate the expression of the patient’s and his or her parent’s temperament, cognition, cognitive flexibility, and the patterns of relating with each other and with others. The child and adolescent psychiatrist’s or clinician’s initial approach is best received when all parties are included in the interview. This allows for an initial in vivo subjective experience of how the patient and family have “danced together.” This is heightened by the fact that a request for a psychiatric evaluation of a family member places the system in a stressful situation.

The advancements in developmental research and neuroscience inform us that many more people are implicitly present during the encounter than what appears. In addition to the personality attributes of the child and/or adolescent and his or her family, the child and adolescent psychiatrist also brings, through his personality, his or her own set of early childhood implicit relational experiences. Thus, given our understanding of internal working models of attachment, the interview room is actually crammed by nonconscious neurological imprints of past and present from each individual.

We will now describe how the child and adolescent psychiatry trainees and experienced clinicians alike can effectively perform a contemporary diagnostic interview (CDI). Thus, to effectively perform a CDI, the child and adolescent psychiatrist or clinician will need to do the following simultaneously: (1) provide an atmosphere of safety in which the patient and his or her parents realize that they are more than a set of signs and symptoms to be fixed; (2) approach the patient and parents and/or caregivers with vitality ; (3) provide a genuine emotional alliance that allows for mutual curiosity about each other’s subjectivities, including temperament, cognition, cognitive flexibility, and internal working models of attachment (IWMA) from childhood experiences; and (4) begin the interview with an open frame of mind that allows for the psychiatrist or clinician to respond intersubjectively and in a meaningful way to the patient’s and his or her family’s subjectivities. As Buirski and Haglund say, “There is no subjectivity without intersubjectivity ” (2009).

Mental illness does not exist in a vacuum; it is a set of signs and symptoms that affects a person within the context of their personality and their environment. The treatment must be of the person and not only of their illness. The four pillars of a CDI are essential for understanding a patient from the inside out. The authors define the four pillars of a CDI as those that define a person’s unique personality within the context of others. The four pillars are the synergy of innate and environmental processes that become the blueprint of how a child learns to develop and maintain self-regulatory abilities and unique implicit relational patterns to successfully interact with others.

The first three pillars—temperament, cognition, and cognitive flexibility—form the foundation of the fourth pillar, internal working models of attachment (IWMA). By understanding the contribution from each of the pillars, the clinician will have a true biopsychosocial understanding of the patient and their parents or caregivers, as well as their needs.

Although many psychodynamic and attachment-theory-based texts pay limited attention to temperament and cognitive functioning in forming personality, contemporary developmental research has demonstrated that an individual’s genetic makeup is a determining factor in the formation of a personality, which some consider the basis of the psychodynamic self (Mancia 2006).

We now will review each of the four pillars obtained during a CDI. The pillars are outlined in the order in which they emerge in the psychological development of a person. We note that when using a CDI, the four pillars are simultaneously elucidated.

Temperament refers to the “stable moods and behavior profiles observed in infancy and early childhood” and came to the forefront in developmental psychology and child psychiatry in the 1960s and 1970s (Chess et al. 1960). Thomas and Chess (1999) are recognized for their landmark scientific contribution to the study of temperament. Their seminal work has achieved general consensus in that its expression has been consistent across situations and over time. In their study, Thomas and Chess longitudinally evaluated 141 children over 22 years, from early childhood until early adulthood (1982, 1986). Over the course of the evaluation, nine temperament traits became apparent.