The DAWBA is designed so that it doesn’t need to be administered by clinical child psychologists or psychiatrists. Researchers or survey interviewers who don’t have much (or any) prior experience of child mental health interviews can rapidly master the interviews. Experienced interviewers generally require around a day’s additional training before first administering the DAWBA, initially under close supervision. The interviewers’ instructions were written to help familiarize interviewers with the DAWBA and to answer commonly asked questions.
In this section:
- The basic structure of each section
- Why do we always want to know about impact as well as about symptoms?
- Interviewing young people
- Section A: Separation anxiety
- Section B: Specific phobias
- Section C: Social phobia
- Section D: Panic attacks and Agoraphobia
- Section E: Post Traumatic Stress Disorder (PTSD)
- Section F: Compulsions and obsessions
- Section G: Generalized anxiety
- Section H: Depression
- Section I: Deliberate self-harm (questions H22-H24)
- Section J: Attention and activity
- Section K: Awkward and troublesome behavior
- Section L: Less common disorders
- Section M: Significant problems section
- Interviewers’ observations
Interviewers’ notes about the basic structure of each section
Nearly all of the DAWBA sections cover one type of mental health problem and have a similar structure:
- There is a brief introduction to give the respondent a mental picture of what the section is about.
- There are usually one or two screening questions to see if it is worth going any further. If the screening questions are positive, or if the respondent reported related problems in the Strengths and Difficulties Questionnaire (SDQ), then the interview continues. If not, the rest of the section in skipped.
- The respondent is asked in detail about the presence and severity of symptoms in that domain. When symptoms are definitely present, the interview continues. When they are not, then the rest of the section is omitted.
- Respondents may be asked about how long symptoms have been present, and when they started.
- Each section ends by asking about the impact of symptoms on the child and the family.
Why do we always want to know about impact as well as about symptoms?
Practically all children have some symptoms. It is unusual to find children who are free of all fears and worries, who are never sad or irritable, and who always behave and concentrate well. Most children are only 100% angelic when they are asleep! And since most children have some symptoms, that makes it harder to draw a line between children who have a “normal” level of symptoms, and children who have “real” problems. Asking about the number and severity of symptoms helps, but the best guide is whether or not the symptoms have a serious impact. Are the symptoms really upsetting the child? Are they seriously interfering with the child’s everyday life? Are they a real nuisance as far as other people are concerned? That is why you will be asking about impact every time the respondent has told you about definite symptoms.
Interviewers’ notes about interviewing young people
You will only be interviewing children about mental health problems when they are aged at least eleven. Although some young people will be reluctant to talk with you, you will probably be surprised by how well they respond to your interest and attention. It is not often that most children get 1-to-1 attention from an adult who is interested in them and how they feel. Even if they tell you about distressing symptoms or problems in their life, they are very likely to feel better for having told you. Just being listened to may have been helpful to them, and if they do need professional help, they are more likely to seek it after they have had the experience of telling you without being criticized, ridiculed or ignored.
Interviewers’ notes about section A: Separation anxiety
Most children have strong attachment bonds to key adults in their lives – parents, grandparents, nannies and so on. Technically, these adults are described as ‘attachment figures’. The bonds between children and their attachment figures provide the children with security and comfort particularly in times of stress. Some children don’t form these bonds, and nor are these bonds always obvious in older teenagers either. Close friendships with other young people are obviously important but we are primarily interested in attachments to adults as far as this interview is concerned. It is only if the parent says that the child isn’t specially attached to any adult that you will ask about attachment to other children or young people.
Some children experience a lot of distress as a result of worries that something bad will happen to their attachment figures or that they will be separated from their attachment figures. This is what the section on separation anxiety is about.
It is clearly not possible to ask whether a child is anxious about separation from his or her attachment figures if the child doesn’t have any attachment figures. So the first stage is obviously to find out about attachment figures. That is what we are trying to do with the first question that we ask of parents, ‘Is [child’s name] specially attached to the following adults?’ This isn’t meant to be a list of everyone that the child is a little attached to – it is specifically about the child’s main attachment figures. So if the parent says ‘Yes’ to all or nearly all of the options, you need to tell them that we want to know about the main attachment figures, and suggest they say ‘Yes’ to no more than 4 or 5 categories. The procedure for interviewing adolescents is similar. To avoid repetition, these notes generally use the parent interview to illustrate the general principles that also apply to the adolescent interview.
Once you have identified the attachment figures, the questions about separation anxiety begin with question A2. ‘Overall, in the last 4 weeks, has s/he been particularly worried about being separated from his/her attachment figures?’ Note that the reference period is the last 4 weeks. In subsequent questions, your also need to emphasize that we are interested in how the child is usually and not in how she or he is on the occasional ‘off day’. This should be stressed every two or three questions until you are sure that the respondent knows.
Interviewers’ notes about section B: Specific phobias
This section is about intense and disabling fears of specific objects and situations. Most children have some fears, but what we mainly want to find out is whether they have a phobia that may need treatment. To decide that a fear is a phobia, what we are looking for is evidence that a fear is so strong that it is either causing considerable distress or that it is interfering with the child’s life because he or she is going to great lengths to avoid the feared stimulus. So we wouldn’t be particularly interested in a fear of snakes if this did not cause a lot of distress and only led to the child avoiding the reptile house when going to the zoo. We would, however, take seriously a fear of thunder that was so intense that the child often refused to leave the house just in case a storm suddenly brewed up and thunder began whilst they were away from home.
The section on specific phobias begins by asking about the situations or objects that children are most often scared of. We want to know about all the child’s fears. Again, as in the previous section, we are interested in how the child is usually and not just on the occasional ‘off day’.
Some fears are seasonal and if you just asked about the last few months, you might miss them. For example, some children are truly phobic of wasps or daddy-long-legs but if you asked in March whether they are scared of them every day, the answer would probably be ‘No’. For these seasonal phobias, it is important to ask about the children’s fears and behaviours in the relevant season.
‘Do [child’s name]’s fears lead to his/her avoiding the things s/he is afraid of?’ Sometimes, interviewers are reluctant to ask this question because they can’t see how a child could avoid the situation or object that they are afraid of – loud noises, for example. But the truth is that children can be very inventive in finding (or trying to find) ways to avoid things they are afraid of. For example, a child who is afraid of loud noises may try to avoid fireworks parties or may refuse to go to school on days when they are due to test the fire alarms.
Interviewers’ notes about section C: Social phobia
The aim of this section is to find out whether the child is particularly afraid of any social situations. As for specific phobias, we are trying to get the information we need to distinguish between mild fears (which are common) and a true phobia. Social fears and phobias are related to being with a lot of people, meeting new people etc. We are trying to identify children who have far more than ‘ordinary’ shyness, though social phobia might look like extreme shyness.
Again, please emphasize to the respondent that we are interested in how the child is compared to other children of his/her age and we are not interested in the occasional ‘off day’. Parents are asked about whether their child is afraid of particular social situations. Sometimes the parents won’t know or the situation won’t apply. For example, some parents don’t know if their child is anxious about reading out loud in front of others at school – and in some cases, the child is not attending school.
Interviewers’ notes about section D: Panic attacks and Agoraphobia
Please emphasise what is said in the introduction to this section: we are only interested in severe panic attacks that seem to come out of the blue and don’t seem to be triggered by anything.
Interviewers’ notes about section E: Post Traumatic Stress Disorder (PTSD)
PTSD involves flashbacks, nightmares and various other symptoms following an exceptionally stressful or traumatic event. It is not always easy for the clinical raters to decide what constitutes an exceptional stressful or traumatic event. That is why it is important, where possible, for you to record enough open-ended informtion about the traumatic event to allow the clinical raters to decide. It is obviously not appropriate to probe for details of the trauma if this is clearly too distressing for the respondent. However, if at all possible, it will be a great help to the clinical rater if you can record enough details of the trauma to allow the rater to judge whether the relevant trauma was so unusual or extreme that it would be subsequently become deeply engraved on a child’s memory and liable to cause flashbacks and vivid nightmares. Being chased by muggers or having to escape from a burning house are clear but unusual examples. Many other events could be relevant provided that they are of the sort of event that would tend to become engraved in the memory. Being abused is one possibility.
It is important to stress that this section does not cover all the events and occurrences that might have upset a child. For example, a child may well be extremely upset by a grandparent’s death or by his or her parents separating, but we will pick this up elsewhere in the interview, e.g. when asking about symptoms such as depression. The same applies to the death of a pet or to breaking up with a close friend. This is relevant to you because some parents or children will mention these ‘ordinary stresses’ when asked about other traumas. It is vey helpful to the clinical rater if you to provide a detailed enough description of this for the rater to judge whether or not it is an exceptionally stressful or traumatic event that might justify a diagosis of PTSD. Even if it is not, the description may still help the clinical rater in deciding about other possible diagnoses.
However, even an ‘ordinary’ stress that wouldn’t normally qualify a child for PTSD may be relevant when the stress occurs in a particularly vivid or intense way. For example, although losing a pet would not normally qualify a child for a PTSD, imagine that a boy was walking his dog in the park, and that the dog was mauled and killed in a bloody attack by a Rottweiler. It’s not hard to imagine that he would develop vivid flashbacks or nightmares of the dog bleeding to death, marked fear in the presence of dogs, and avoidance of parks and anything else that reminds him of the attack.
Here’s another example, this time of something even worse. The death of a father is obviously going to be a stressful event for any child. But if the death is peaceful or happens when the child is not there, it is not going to trigger PTSD. But in some circumstances, a father’s death can trigger PTSD. Imagine, for example, that a father and daughter are alone at home when the father develops a severe asthma attack. His daughter calls the ambulance and goes with her father in the ambulance because she can’t stay alone at home with no one to look after her. In the ambulance, the father’s asthma deteriorates and he dies in front of his daughter despite the efforts of the ambulance crew try to resuscitate him. This would certainly be the sort of trauma that could trigger off a PTSD.
What you can see is that the key factor is not the category of stressful event (death of pet, death of parent) but the circumstances in which it occurs. If the respondent says there has been a stressful event, you need to find out enough about it for the clinical rater to judge whether it might have been capable of triggering off a PTSD. As long as you describe the trauma clearly, the clinical rater will be able to decide whether it ‘counts’ or not.
It is unusual for children to have experienced even one trauma of the sort needed to trigger off PTSD. Consequently, it is unlikely that the same child will have experienced several different traumas – but this does happen at times. When a child has had several severe traumas, treat them together when asking the remaining questions about symptoms and their impact. For example, you would ask about flashbacks or numbing related to any or all of the traumas they have experienced.
Interviewers’ notes about section F: Compulsions and obsessions
Compulsions and obsessions are rather different than most of the other things you’ll be asking about because they’re not like ordinary experiences. Everyone has been worried or miserable but most people have no idea what a true obsession or compulsion is like. The important thing here is that it is not the same thing as an ordinary bedtime ritual or a ‘not stepping on the cracks in the pavement’ ritual. It is not the same as being much neater or more perfectionist than average. It is not the same as feeling that you’ve just got to eat that chocolate bar or buy that record. A child with true obsessive-compulsive symptoms may need to check plugs or gas taps twenty times, or may need to shower or wash their hands dozens of times each day, or may need to wear gloves before being willing to touch door knobs. The preamble to the section is long and mostly you will feel that you are wasting your time – it will ring no bells with most parents or children. But for the 1% of children who do have obsessions and compulsions, they or their family will recognize what you mean and they are often very surprised and pleased to know that there are other person in the world who experience this.
Interviewers’ notes about section G: Generalized anxiety
In this section, you are trying to find out whether the child worries so much, and about so many things, that this really interferes with his or her life and leads to physical symptoms such as being tense or not being able to get to sleep. Children with generalized anxiety have many different worries about many different things. Some worries are about the past, some about the future, some about schoolwork, some about their appearance, some about illness, and so on. The worries are present across different situations. So they may have one set of worries at home and a different set of worries at school.
What the clinical raters will need to know is whether the child has multiple worries after setting aside any worries or fears that have already been covered by the previous sections on separation anxiety, phobias and obsessions. So if the child has many worries but they are all related to separation anxiety, he or she won’t also be diagnosed as having generalized anxiety. Similarly, the clinical raters won’t give a child the diagnosis of generalized anxiety if he or she has several different worries that all have the same general theme, e.g. if the child has worries about exams, about getting homework done, about being late for school and about being told off by the teacher, but has no other worries relating to home life, friendships, bad luck, the future and so on.
So you can see why it isn’t easy for the clinical raters to make a diagnosis of generalized anxiety unless you have provided them with a good description of the child’s worries – exactly what they worry about, and how severe those worries are. A good description makes all the difference when the raters have to decide if the child has multiple worries, and if these are different from the worries and fears that were covered by the preceding sections of the interview.
Interviewers’ notes about section H: Depression
Just as in adults, depression in children and teenagers usually shows itself as severe and prolonged misery. Sometimes, though, the most obvious change in mood is not misery but increased irritability. This can be very tricky to judge since plenty of teenagers are irritable with their family! You need to focus on whether they have recently changed to being a lot more grumpy or irritable than in the past. In some cases, the most obvious clue to depression is neither misery nor irritability but a loss of interest in the things that the child used to enjoy doing. Perhaps the child has kept his or her misery secret, but the family may still have noticed that the child suddenly no longer wants to visit friends, go on outings, listen to music, or whatever.
There are three initial parts to section H:
- Feeling sad or miserable
- Feeling irritable
- Loss of interest
If there are real problems in any of these areas, you will need to ask question H18 to H21. Because question H18 covers deliberate self-harm, you won’t need to ask the separate questions on the same topic in questions H22 to H24.
Interviewers’ notes about section I: Deliberate self-harm (Questions H22-H24)
You will only ask these questions if you haven’t already asked about similar things in question H18. This means that you only get to ask questions H22 to H24 when the child has not recently been very miserable or irritable, and when the child has not recently lost interest in favourite activities.
Parents and young people are generally very willing to answer questions on deliberate self-harm, even though, in some cases, they are initially taken aback by the questions. It is important to take your time over this section, to thank informants for answering the questions and to help them to orientate themselves back into the rest of the interview by explaining what the next few questions are about. The preamble to the next section will help you to do this.
Interviewers’ notes about section J: Attention and activity
The trickiest thing in the section on attention and activity is to make sure that parents remember that you are asking about their child compared with other children of the same age. For example, the first detailed question asks whether the child often fidgets. If the mother of a five-year-old replies that her son definitely fidgets, we need to be sure this is by comparison with other five-year-olds. Most young children fidget. That’s not what we want to know. We are interested in whether this particular child fidgets a lot more than other five-year-olds. Each time a parent responds “definitely” to one of the symptoms of inattention or over-activity, it is worth checking the response until you are sure that they are comparing their child with other children of the same age. Obviously enough, once you are sure they have grasped this point, don’t drive them (and yourself) mad by repeating the checks unnecessarily. As with other sections, please emphasize that we are interested in how the child is usually – any child is allowed the occasional ‘off day’.
Interviewers’ notes about section K: Awkward and troublesome behavior
This section consists of two parts:
- Awkward behavior
- Behavior that sometimes get children into trouble
Many of the issues mentioned for section J also apply to the section on awkward behavior. It’s common for five-year-olds, for example, to refuse to do what they are told. So once again, you need to make sure that the respondent is comparing their child with an average child of the same age.
The section on ‘behaviors which sometimes gets children into trouble’ is mostly fairly straightforward to ask about, although you may be embarrassed to ask parents whether their children have done such dreadful things. In fact, it normally works fine, particularly if you mention that you have to ask parents all questions even if they are unlikely to apply. Instead of upsetting parents, this section sometimes cheers parents up as they realize all the bad things their child is not doing! So even though these questions are quite sensitive, most parents are willing to answer them and understand why they are being asked. But do keep a careful eye on how respondents are reacting – if they are getting irritated, make a note and stop.
Questions about ‘behaviors which sometimes gets children into trouble’ have a reference period of the past year. If any of these behaviors have occurred in the past year, you then need to ask if they have occurred in the last six months.
Interviewers’ notes about section L: Less common disorders
This set of questions is about a variety of different aspects of a child’s behavior and development and have a different format to the other sections. As the title of the section suggests, we are trying to pick up less common disorders, some of which affect fewer than one child or teenager per thousand.
Interviewers’ notes about section M: Significant problems section
In some respects this is the most important part of the assessment. With many mental health interviews, once you have collected the answers to the fixed questions, the answers are fed into a computer that decides whether the child has a diagnosis. That’s not what happens with this interview – it’s experienced clinicians who make the final diagnosis, not the computer. These clinical raters review all the data (from parents, teachers and older children), and it is very helpful for them to hear about any problem areas in the child’s or parent’s own words. Since they can’t meet the child or parent, they depend on you to type in as much verbatim information as you can. This is important for three main reasons:
|1)||It helps the raters decide whether the respondents really understood the questions. As you know, respondents may say ‘Yes’ or ‘No’ without having understood what it is that a question is getting at. Or they may exaggerate the problem, making a mountain out of molehill. Or they may go to the opposite extreme and minimise the problem – making a molehill out of a mountain! The only way the clinical raters can get round this is by reading your transcript of the problem described in the respondent’s own words. This makes it much clearer whether respondents have understood or not, and whether they are exaggerating or minimising the problem|
|2)||The clinical raters also depend a lot on the transcript when different people say different things about the same child, e.g. when the parent says one thing and the teacher or child say just the opposite. That makes it very difficult for the clinical raters to know whose account to believe. If the parent says that the child worries a great deal and gets very depressed and the child denies any worries or misery, who’s right? You might think that the child is bound to be right – if they don’t know if they are worried or sad, who does? But as you can easily imagine, there are times when children say ‘No’ to every question because they’re being macho and don’t like admitting to any problems, or because they are fed up and want to get the interview over with as soon as possible. When the clinical raters can read a detailed and convincing description of the problem in the parent’s own words, that often makes it clear that they can believe the parent’s account. In other cases, the reverse is true. Parents may claim that there are loads of problems, but when you ask them to describe them in their own words, they can’t come up with any examples. This may make it clear that the parents are very critical of their child without much reason.|
|3)||For less common disorders, the interview doesn’t ask many questions, but the pattern of symptoms may be so distinctive that a clinical rater won’t have any problem making a diagnosis as long as you have provided a detailed description.|
For all these reasons, it is vital that you record detailed descriptions of relevant problems. Whenever you have checked a box for one of the sections in M1, you should make sure that you get answers to the corresponding open-ended questions in M2 about that section. The exact wording of the open-ended questions in M2 are only suggestions – you can use your initiative to add extra questions or explain the existing questions more clearly.
You have a choice – you can ask the open-ended questions as you go along, or you can ask them after you have finished all the sections. For example, if you tick the box for section A, then you could ask the extra questions before going on to the next section, or you could wait until you have finished all the last section. If you are asking all the open-ended questions at the end, then it is often a good idea to let the parents choose which order to take the different topics in, starting with the area that concerns them most.
Whatever you decide to do – to ask the open-ended questions as you go along, or to ask all the open-ended questions all at the end – it is usually a good idea to note down the respondents’ spontaneous comments when they make them. That way, you will have less need to ask them to repeat themselves in this section. But do check before the end of the interview to make sure all questions have been covered for each area of difficulty.
When respondents provide a vague or generalized answer, then ask them for specific examples. For example, if a parent says, “he worries about everything,” then ask “What sorts of worries?” Or if a teenager says, “I’m always getting into trouble,” then ask “Can you tell me about a recent occasion when you got into trouble?”
Don’t feel that you need to keep the answers short – extra details help the clinical raters.
The exact questions vary by section, but there are some common themes:
|1.||Description of the problem.|
|2.||How often does the problem occur? – is it still a problem?|
|3.||How severe is the problem at its worst?|
|4.||How long has it been going on for?|
|5.||Is the problem interfering with the child’s quality of life? If so, how?|
|6.||Where appropriate, also record what the family think the problem is due to, and what they have done about it.|
If you are interviewing with a computer, you can decide whether you prefer to type the parent’s or child’s comments directly into the computer or to write the comments by hand in your notebook and type them in later. You can also use the notebook for recording spontaneous comments made earlier in the interview – respondents will often describe the problem in detail at the time when they are first asked about it. By the time you are ready to enter the details, they may not want to repeat themselves all over again. However, before finishing the interview, please do remember to check that you have covered all the key questions about each area of difficulty.
The clinical raters who make the diagnoses do not meet the parents or children. Whether they get the diagnoses right depends on the quality of the information they receive. You can obviously help them by providing detailed transcripts of respondents’ accounts of the problems in their own words. Another important way you can help them is by adding any relevant observations of your own to the end of the transcript. Naturally enough, what’s needed is objective information rather than value judgements (“He’s a nice kid”, “I didn’t like the parents”). Examples of really helpful observations include:
- These parents didn’t seem to understand the questions well because English is not their first language – I really don’t think they understood the questions about obsessions and compulsions.
- Although this child is 11, he has learning difficulties and his mother didn’t think he would understand the questions. I did administer the interview, but I think his mother was right – he often seemed to be answering at random or saying whatever it was he thought I wanted to hear.
- This child was one of the most restless individuals I have ever interviewed. She spent the whole time fidgeting and wriggling, and often got up and wandered around the room. On a few occasions she briefly left the room, but came back by herself. Though she enjoyed being interviewed, it was hard work keeping her attention on what I was asking – she was very distractible.
- When I got to section E and asked about possible traumas, he mentioned that he had been involved in a horrible car accident but added that he didn’t want to say anything about it. He looked very upset and was clearly unwilling to answer further questions on the topic.
- Part of the way through the interview, she said that she was fed up and that her favourite TV program was starting soon. I offered to take a break and finish the interview another day, but she said she just wanted to get it over with. From that point on, she said ‘No’ to all screening questions – that may have been true but it is also possible that she was denying problems to speed the interview up.
There is an opportunity for you to record your observations at the end of the interview.