Acceptance of a structured diagnostic interview in children, parents, and interviewers

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1 Received: 21 August 2016 Revised: 23 April 2017 Accepted: 28 April 2017 DOI: /mpr.1573 ORIGINAL ARTICLE Acceptance of a structured diagnostic interview in children, parents, and interviewers Murielle Neuschwander 1 Tina In Albon 2 Andrea H. Meyer 3 Silvia Schneider 1 1 Clinical Child and Adolescent Psychology, Ruhr Universität Bochum, Bochum, Germany 2 Clinical Child and Adolescent Psychology and Psychotherapy, University Koblenz Landau, Landau, Germany 3 Department of Psychology, University of Basel, Basel, Switzerland Correspondence Silvia Schneider, Fakultät für Psychologie, Klinische Kinder und Jugendpsychologie, Ruhr Universität Bochum, Universitätsstr. 150, 44789, Bochum, Germany silvia.schneider@rub.de Funding information Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung, Grant/ Award Number: PP ; Abstract The objective of this study was to investigate the satisfaction and acceptance of a structured diagnostic interview in clinical practice and in a research setting. Using the Structured Diagnostic Interview for Mental Disorders in Children and Adolescents (Kinder DIPS), 28 certified interviewers conducted 202 interviews (115 with parents, 87 with children). After each interview, children, parents, and interviewers completed a questionnaire assessing the overall satisfaction (0 = not at all satisfied to 100 = totally satisfied) and acceptance (0 = completely disagree to 3 = completely agree) with the interview. Satisfaction ratings were highly positive, all means >82. The mean of the overall acceptance for children was 2.43 (standard deviation [SD] = 0.41), 2.54 (SD = 0.33) of the parents, 2.30 (SD = 0.43) of the children's interviewers, and 2.46 (SD = 0.32) of the parents' interviewers. Using separate univariate regression models, significant predictors for higher satisfaction and acceptance with the interview are higher children's Global Assessment of Functioning, fewer number of children's diagnoses, shorter duration of the interview, a research setting, female sex of the interviewer, and older age of the interviewer. Results indicate that structured diagnostic interviews are highly accepted by children, parents, and interviewers. Importantly, this is true for different treatment settings. KEYWORDS acceptance, assessment, diagnostic, Kinder DIPS, structured interview for children and adolescents 1 INTRODUCTION A solid diagnostic assessment is an important precondition to ensure adequate research results and treatment of patients with mental disorders (Jensen Doss, 2015). From an evidence based perspective, structured interviews are regarded as the gold standard in the diagnostic procedure (Costello, Egger, & Angold, 2005; Silverman & Ollendick, 2005) and are widely recognized to be useful in getting a complete picture of a patient's symptomatology. Unlike in the diagnostic procedure with adults, both the child and parents should be involved in the diagnostic procedure in children (Silverman & Ollendick, 2005). According to interviewers, structured interviews are more accurate than clinical judgment. Nevertheless, diagnostic interviews are insufficiently used in the clinical setting because of concerns about their acceptance and feasibility (Jensen Doss, 2015; Joiner, Pettit, Walker, Perez, & Cukrowicz, 2005; Silverman & Ollendick, 2005). Therapists often rely more on their clinical judgment and experience, although this may lead to unreliable diagnoses (Beck, Ward, Erbaugh, Mendelson, & Mock, 1962; Jensen & Weisz, 2002; Merten, Cwick, Margraf, & Schneider, 2017; Pinninti, Madison, Musser, & Rissmiller, 2003; Shear et al., 2000; Sørensen, Thomsen, & Bilenberg, 2007). In addition, therapists show low acceptance of structured interviews and assume that patients do not estimate their use (Bruchmüller, Margraf, Suppiger, & Schneider, 2011). Therefore, in order to guarantee reliability and validity of structured interviews, they must fulfill the criteria of feasibility and acceptability by both patients (children and parents) and interviewers (Pinninti et al., 2003; Thienemann, 2004). Definitions of acceptance include subjective appraisal, expectancy of a subjective gain, reasonability, satisfaction, and minimizing of expenses (Hausknecht, Day, & Thomas, 2004; Kubinger, 2006). However, in order to increase the use of structured interviews in clinical practice, these often neglected aspects of acceptance have to be investigated. Studies investigating acceptance of a standardized feedback questionnaire in adult samples found that a computer assisted standardized diagnostic interview (DIA X/M CIDI, Wittchen & Pfister, 1997) was highly accepted by patients (Hoyer, Ruhl, Scholz, & Wittchen, 2006). Similarly, results indicated high acceptance of using Int J Methods Psychiatr Res. 2017;e wileyonlinelibrary.com/journal/mpr Copyright 2017 John Wiley & Sons, Ltd. 1of9

2 2of9 NEUSCHWANDER ET AL. a structured diagnostic interview (DIPS, Schneider & Margraf, 2006) by both interviewers and patients in a variety of treatment settings (Suppiger et al., 2009). Studies on satisfaction and acceptance of structured diagnostic interviews in children, parents, and interviewers showed generally high parental acceptance and good acceptance by children or adolescents, respectively (Matuschek et al., 2015; Shaffer, Fisher, Lucas, Dulcan, & Schwab Stone, 2000; Sørensen et al., 2007). Shaffer et al. (2000) investigated in 84 parents and 82 children (aged 9 17 years) their reaction to the computerized structured interview DISC IV (National Institute of Mental Health Diagnostic Interview Schedule for Children Version IV [NIMH DISC IV] 1997, Shaffer et al., 2000) with four questions. Results indicated that the majority of the youths would recommend a friend to participate (60%) but that the interview was too long (55%), however only a minority indicated that the interview was boring (17%), and only 3.6% reported being more upset after the interview than before. Sørensen et al. (2007) investigated the acceptance of the K SADS PL (Danish interview version) in 80 parents and children (aged 6 13 years). The parents found the interview pleasant (95%), relevant (85%), and not too time consuming (99%). Most of the children evaluated the interview as a good or fairly good way of talking about how they were doing (76%), and that they felt better (39%) or the same (43%) after the interview. However, 40% of the children found the interview a little and 21% very boring. Furthermore, the fact that the same interviewer performed all interviews is a major weakness of the study and restricts the extent to which the results can be generalized. Matuschek et al. (2015) evaluated the K SADS PL (German interview version) both in a clinical and in a research setting. A total of 227 parents of children aged 8 to 14 years were interviewed with the parent version of the K SADS PL. Further, 222 interviewer questionnaires from 17 interviewers were analyzed. The overall satisfaction was evaluated as highly positive with significant higher interviewee (parents) and interviewer ratings in the research compared to the clinical recruitment setting. An individual bias of the interviewer on his or her own acceptance of the time used for the interview was found, but not on the evaluation of the corresponding interviewee (parents). Neither the professional background nor the gender of the interviewer significantly predicted these differences. Significant predictors of interviewer overall satisfaction were the interview duration and the interviewee acceptance. Results further indicated significant correlations between the overall satisfaction of interviewers and the number of interviews conducted, interview duration, and the Global Assessment of Functioning (GAF) value. Furthermore, they found a significant correlation between the overall satisfaction of the interviewee (parents) with the GAF. A limitation was that they used only the parent interview version of the K SADS PL. Therefore, no conclusions on the satisfaction and acceptance of the child interview version are available. The authors concluded that only factors that can be improved by professional training had an effect on the interviewee (parents) and on interviewer acceptance. In comparison to the questionnaires used in the present study, Sørensen et al. (2007) and Shaffer et al. (2000) applied shorter questionnaires asking for a general appraisal of the structured interview with a focus on negative aspects (boredom, distress) only. The study of putative predictors of satisfaction and acceptance and a more elaborated investigation of potential negative aspects of structured interviews is lacking. Therefore, the aim of the present study was to expand the current literature on child, parent, and interviewer satisfaction and acceptance of structured interviews in clinical practice and in research setting using the Kinder DIPS (Diagnostisches Interview bei psychischen Störungen im Kindes und Jugendalter [Diagnostic Interview for Mental Disorders in Children and Adolescents]; Schneider, Unnewehr, & Margraf, 2009b): (1) to replicate the already existing results on parent and interviewer satisfaction and acceptance, (2) to complement these results with data on children and (3) to investigate explorative putative predictors of satisfaction and acceptance, such as the institution, sex of child, sex of interviewer, age of interviewed child, age of interviewer, interview duration, number of diagnosis, GAF value for the children interview, sex of parent, sex of interviewer, age of interviewed parent, age of interviewer, interview duration, number of diagnoses, GAF value for the parent interview. The selection of the putative predictors is based on the investigated possible putative predictors of previous studies and added further putative predictors. 2 METHODS 2.1 Participants Twenty eight certified interviewers implemented a total of 202 Kinder DIPS interviews (children: n = 87, parents: n = 115). Table 1 shows the sample characteristics of the participating children and parents. Seventy two interviews took place only with the mother (63.16%), seven interviews were conducted only with the father (6.14%), and 35 interviews took place with both mother and father (30.70%). Those interviewed by a female interviewer were 82.35% (n = 70) of the children and 91.07% (n = 102) of the parents. On average, the children's interviewers were years old (standard deviation [SD] = 3.42, n = 85) and the mean age of parents' interviewers was years (SD = 4.85, n = 110). TABLE 1 Characteristics Demographic characteristics of children and parents Children (n = 87) Parents (n = 115) Age in years Mean (SD) (2.17) (5.55) Range Sex Female n (%) 50 (57.47%) 58 (50.43%) Male n (%) 37 (42.53%) 57 (49.57%) Setting Research study n (%) 57 (65.52%) 78 (67.83%) Outpatient clinics 1 n (%) 30 (34.48%) 37 (32.17%) Interview duration Mean (SD) 52 (30.12) 61 (32.30) in minutes GAF value Mean (SD) (14.11) (12.25) Note: SD, standard deviation; GAF, Global Assessment of Functioning. 1 Total interviews from the four outpatient clinics.

3 NEUSCHWANDER ET AL. 3of9 On average, interviewers assigned 0.47 (SD = 0.85; range 0 3) diagnoses per child based on the child's report. Based on the information of the parents, interviewers assigned on average 0.62 (SD = 0.87; range 0 3) diagnoses per child. Table 2 shows current DSM IV TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) diagnoses based on the interviews with children and parents. 2.2 Interviewers and training The interviewers consisted of 28 clinical psychologists (20 Bachelor's level, 8 Master's level), aged years (mean age 29.2 years; SD = 6.12). Twenty four (85.7%) interviewers were female (mean age years; SD = 5.59) and four (14.3%) were male (mean age years; SD = 8.76). All diagnosticians were required to successfully complete a systematic training and to meet strict certification criteria for the administration of the Kinder DIPS. The standardized training (Schneider, Suppiger, Adornetto, Unnewehr, & Margraf, 2009a) included the following steps: 1. Introduction period: Reading the manual and conducting at least one interview with a friend as the patient (child or parent). TABLE 2 Current diagnoses based on parent interviews (n = 115) and child interviews (n = 87) Parents Children Diagnoses Frequency (%) Frequency (%) No diagnoses 66 (48.53) 56 (58.95) Disruptive behavior disorder 14 (10.29) 2 (2.11) Attention deficit hyperactivity disorder 5 (3.68) 0 (0.0) (ADHD) Oppositional defiant disorder 9 (6.61) 2 (2.11) Tic disorders 5 (3.68) 3 (3.16) Temporary tic disorder 2 (1.47) 1 (1.05) Chronic motor or vocal tic disorder 2 (1.47) 2 (2.11) Tourette syndrome 1 (0.74) 0 (0.0) Anxiety disorders 37 (27.21) 25 (26.32) Separation anxiety disorder 10 (7.35) 6 (6.32) Specific phobia 9 (6.62) 5 (5.26) Social phobia 15 (11.03) 7 (7.37) Generalized anxiety disorder 1 (0.74) 4 (4.21) Selective Mutism 1 (0.74) 2 (2.11) Panic disorder with agoraphobia 1 (0.74) 1 (1.05) Elimination disorders 7 (5.15) 3 (3.16) Enuresis 5 (3.68) 1 (1.05) Encopresis 2 (1.47) 2 (2.11) Sleep disorders 2 (1.47) 1 (1.05) Primary insomnia 2 (1.47) 0 (0.0) Sleep disorder with nightmares 0 (0.0) 1 (1.05) Depressive disorders 4 (2.94) 5 (5.26) Major depression 4 (2.94) 5 (5.74) Eating disorders 1 (0.74) 0 (0.0) Binge eating disorder 1 (0.74) 0 (0.0) 2. Practical training: A. Observation period: Trainees observed at least two live Kinder DIPS interviews conducted by a certified interviewer. Each of them gave ratings and diagnoses. Afterwards they compared and discussed diagnoses, dimensional ratings and interview behavior. B. Practice period: Trainees conducted at least three collaborative interviews in the presence of a certified interviewer. During these interviews, the certified interviewer asked additional questions if necessary (e.g. asked additional diagnostic questions the trainee had forgotten or indicated if a diagnostic section could be skipped). The priority objective of this part is to practice the correct administration of the Kinder DIPS. C. Certification period: Trainees conducted a minimum of five interviews under the observation of a certified interviewer. For the Kinder DIPS certification, trainees' diagnoses needed to match all the certified interviewers' diagnoses and severity ratings of the diagnoses in at least three of the five serial interviews and trainees were not to commit administrative errors. All children and parents in the outpatient clinics and in the research setting were interviewed by certified interviewers after successful training. 2.3 Participant recruitment The children and parents were recruited at four outpatient clinics in Switzerland (children: n=30, 34.48%, parents: n=37, 32.17%) and within a research study for separation anxiety disorder at the University of Basel, Switzerland (children: n = 57, 65.52%, parents: n = 78, 67.83%). The research study for separation anxiety disorder was reviewed and approved by the local ethics committee for medical research. The four outpatient clinics are responsible for primary health care in their region and for the recruitment of the clinical participants. Therefore, we have no access to the demographic and clinical characteristics of patients excluded by the clinics. Insufficient German language ability was the only predefined exclusion criterion in reference to the feasibility of the Kinder DIPS. 2.4 Measures Kinder DIPS for DSM IV TR The Kinder DIPS (Schneider et al., 2009b) is a structured diagnostic interview, which has alternate forms for the child and parent. It is applicable for parents of youths aged 6 to 18 years and for youth aged 8 to 18 years. Using the Kinder DIPS, the children's lifetime diagnoses, current and past according to DSM IV TR (American Psychiatric Association, 2000) and ICD 10 (International Classification of Diseases, 10th revision; World Health Organization, 2000) can be assessed. The Kinder DIPS assesses the most frequent mental disorders in childhood and adolescence (attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, tic disorders, all anxiety disorders, elimination disorders, sleep disorders, depressive disorders, and eating disorders). The Kinder DIPS has good validity and reliability for Axis I disorders (Neuschwander, In Albon, Adornetto, Roth, & Schneider,

4 4of9 NEUSCHWANDER ET AL. 2013; Schneider et al., 2009a). The Kappa values of the Kinder DIPS lifetime diagnoses are high to very high (parent report: ; child report: ; Neuschwander et al., 2013) Participants acceptance questionnaire The current study used a Child and Parents Acceptance Questionnaire (see Supporting Information) based on the Patient Acceptance Questionnaire of Suppiger et al. (2009). Similar to Suppiger et al. (2009), the overall satisfaction of being interviewed with a structured interview was measured using a scale ranging from 0 (not at all satisfied) to 100 (totally satisfied). For a child friendly presentation, crying (not at all satisfied) and laughing (totally satisfied) smilies were added to the endpoints of the scale. The questionnaires consist of a total of 16 items, four items from existing scales measuring reactions to therapeutic interventions (Grawe & Braun, 1994; Schindler, 1991), six items developed for the study of Suppiger et al. (2009), and six child specific items. Eight items were positively formulated (Items 1, 7, 9, 10, 12, 13, 14, 16) and eight negatively formulated (Items 2 6, 8, 11, 15). The participants responded on a 4 point Likert type scale ranging from 0 to 3 (0 = completely disagree,1 = slightly disagree,2 = almost completely agree, and 3 = completely agree). The Child and Parents Acceptance Questionnaires are identical, except for Items 14 and 16. Items 14 and 16 dealt with child related problems (e.g. Item 14: The interviewer took my problems/the problems of my child seriously). Cronbach's alpha for the Parents Acceptance Questionnaire was α = 0.84 and Cronbach's alpha for the Child Acceptance Questionnaire was α = Interviewer acceptance questionnaire In the current study we used the Interviewer Acceptance Questionnaire (see Supporting Information) from Suppiger et al. (2009). Similar to the Participant Acceptance Questionnaire, a scale ranging from 0 (not at all satisfied) to 100 (totally satisfied) measured the overall satisfaction about conducting the interview. The questionnaire included 10 items, one item from an existing scale measuring reactions to therapeutic interventions (Schindler, 1991) and nine items developed by Suppiger et al. (2009). Six items were positively formulated (Items 1, 3, 5, 6, 9, 10) and four negatively formulated (Items 2, 4, 7, 8). Interviewers responded on a 4 point Likert type scale ranging from 0 to 3 (0 = completely disagree,1 = slightly disagree,2 = almost completely agree, and 3 = completely agree). Cronbach's alpha for the Parents Interviewer Acceptance Questionnaire was α = 0.67 and Cronbach's alpha for the Child Interviewer Acceptance Questionnaire was α = Procedure After receiving information about the study, all participants signed a consent form for study participation. Participants received no monetary honorarium for their participation. After the Kinder DIPS interview, all participants (children and parents) and interviewers filled out a selfreport questionnaire about their satisfaction with the interview. Participants answered the questionnaire anonymously, except when help was needed. Afterwards, participants sealed the questionnaire in a coded envelope. The interviewer questionnaire was the same as in the study of Suppiger et al. (2009). The procedure with the interviewer questionnaires was identical with the procedure of participant questionnaires. 2.6 Statistical analysis Outcome variables were overall satisfaction of being interviewed (range: 0 100) and overall acceptance of the interview (mean of the 16 or 10 items of the acceptance questionnaire, respectively). To meet model assumptions (normality, homoscedasticity), both outcomes were square root transformed prior to the analyses. To test whether outcomes differed between children and their parents, and between children's interviewers and parents' interviewers, we used a covariance pattern model, a type of linear mixed model (Fitzmaurice, Laird, & Ware, 2004), where the variance covariance matrix of the residuals is explicitly modeled. Here, we used an unstructured variance covariance matrix allowing for unique variances and covariances of residuals. Model fit was based on parsimony by looking at Akaike's information index. A separate mixed model was set up for each of the two outcomes (satisfaction, acceptance), and also for each pair of raters (children and their parents, children's interviewers and parents' interviewers) since questionnaires assessing acceptance somewhat differ between these two pairs. To assess putative predictors of satisfaction and acceptance with the interview, we included the following characteristics in our analyses: institution, sex of child, sex of interviewer, age of interviewed child, age of interviewer, interview duration, number of diagnosis, GAF value for the children interview, sex of parent, sex of interviewer, age of interviewed parent, age of interviewer, interview duration, number of diagnoses, GAF value for the parent interview. For this purpose, we ran separate regression analyses for each combination of predictor, outcome, and rater type. These analyses were of exploratory nature. All analyses were performed using SPSS (version 20), an alpha level < 0.05 indicated a significant result. 3 RESULTS Table 3 shows the number of diagnoses, interview duration, and GAF value separately for the two settings (research study and outpatient clinics). We found significant differences when comparing the number of diagnoses, interview duration, and GAF value in the research and clinical settings. Interview duration in the clinical setting was significantly longer than in the research setting, children: U = , z = 3.03, p = 0.002, r = 0.36; parents: U = , z = 3.21, p = 0.001, r = The number of diagnoses in the clinical setting was significantly higher than in the research setting, children: U = , z = 2.93, p = 0.003, r = 0.32; parents: U = , z = 2.19, p = 0.029, r = Further, GAF values in the clinical setting were significantly lower than in the research setting, children: U = , z = 4.35, p < 0.001, r = 0.50; parents: U = , z = 4.10, p < 0.001, r = Overall satisfaction On the scale measuring overall satisfaction with the interview (0 = not at all satisfied, 100 = totally satisfied), children, parents, children's and parents' interviewers were markedly satisfied with the interview

5 NEUSCHWANDER ET AL. 5of9 TABLE 3 Means (standard deviations [SD values]) and range for the number of diagnosis, interview duration and Global assessment of Functioning (GAF) value of children, parents, children's interviewers, and parents' interviewers separately for the two settings Characteristics Research study (n = 57) Children (n = 87) Parents (n = 115) Outpatient clinics (n = 30) Research study (n = 78) Outpatient clinics (n = 37) Number of diagnosis Mean (SD) 0.23 (0.43) 1.00 (1.23) 0.49 (0.78) 0.94 (1.01) Range Interview duration in minutes Mean (SD) (24.43) (35.58) (32.12) (27.89) Range GAF value Mean (SD) (9.35) (16.06) (10.26) (12.97) Range (see Table 4). Overall satisfaction with the interview was significantly higher in parents compared to their children, F(1, 87) = 5.05, p = Similarly, higher overall satisfaction was shown in parents' interviewers compared to children's interviewers, F(1, 101) = 6.58, p = Overall acceptance Overall acceptance (mean of the individual items of the acceptance questionnaire) with the interview (0 = disagree, 1 = slightly agree, 2 = almost completely agree, 3 = completely agree) by children, parents, children's and parents' interviewers was also markedly high (see Table 4). Overall acceptance values were higher in parents' interviewers than in children's interviewers, F(1,93) = 8.74, p < 0.01, whereas parents' acceptance was not significantly higher than acceptance in children, F(1,105) = 2.92, p = The correlation between satisfaction and acceptance was 0.60 for children (p < 0.001, n = 77), 0.60 for parents (p < 0.001, n = 99), 0.70 for children's interviewers (p < 0.001, n = 81), and 0.62 for parents' interviewers (p < 0.001, n = 100). 3.3 Item analysis of the child and parents acceptance questionnaire Means and SD values for individual items are shown in the Supporting Information (Table S1 for children and parents and in Table S2 for children's interviewers and parents' interviewers). Further analysis showed that 77% (n = 67) of the children and 96.5% (n = 111) of the parents completely or almost completely agreed that they would do the interview again. Furthermore, 96.5% (n = 84) of the children and 100% (n = 115) of the parents almost or completely agreed that the interviewer was nice, 31% (n = 27) of the children and 41.2% (n = 47) of the parents, respectively, almost or completely agreed that the interviewer's actions helped them. In addition, 90.6% (n = 77) of the children, 96.5% (n = 111) of the parents, respectively, almost or completely agreed that they felt understood by the interviewer and 94.2% (n = 81) of the children, 99.2% (n = 114) of the parents, respectively, almost or completely agreed that the interviewer took their problems seriously. The majority of the children and the parents agreed almost or completely that the interviewer asked for enough detail to get an appropriate understanding of the situation (children: 89.6%, n = 78; parents: 98.2%, n = 113) and that they understood the questions (children: 93%, n = 80; parents: 98.2%, n = 113). A minority of the children (37.2%, n = 32) and half of the parents (50.8%, n = 58) had a better understanding of their own problems and of problems of the child, respectively, after the interview. The majority of the children and the parents did not feel confused (children: 75.9%, n = 66; parents: 81.7%, n = 94) or questioned (children: 65.5%, n = 57; parents: 67.7%, n = 88). A minority of the children and the parents completely agreed that there were too many questions (children: 4.6%, n = 4; parents: 1.8%, n = 2), the interview was exhausting (children: 6.9%, n = 6; parents: 2.6%, n = 3) and that important parts of the problem were not talked about (children: 2.3%, n = 2; parents: 2.6%, n = 3). None of the children and none of the parents completely agreed to discontinue the interview. However, 7% (n = 6) of the children and 1.7% (n = 2) of the parents almost or completely agreed that the interview was unpleasant and a minority of the children and the parents reported that they did not report everything that bothered them (children: 14.9%, n = 13; parents: 5.2%, n = 6). TABLE 4 Means (standard deviations [SD values]), median, and range for the overall satisfaction and acceptance questionnaire of children, parents, children's interviewers, and parents' interviewers Children Children's interviewers Parents Parents' interviewers Overall satisfaction (0 100) Mean (SD) (20.39) (11.52) (11.96) (10.71) Median Range n =77 n =81 n =99 n = 100 Acceptance Mean (SD) 2.43 (.41) 2.30 (.43) 2.54 (.33) 2.46 (.32) (0 3) Median Range n =87 n =86 n = 115 n = 106 Note: Overall satisfaction rated on scale of 0 to 100 (0 = not at all satisfied, 100 = totally satisfied; items of the questionnaire were rated on a scale of 0 to 3 (0 = disagree, 1 = slightly agree, 2 = almost completely agree, 3 = completely agree).

6 6of9 NEUSCHWANDER ET AL. 3.4 Putative predictors For the explorative analysis of the putative predictors of overall satisfaction and acceptance with the interview, we ran a total of 64 analyses (four raters eight potential predictors two outcomes) of which 21 turned out to be significant (see Tables 5 and 6). Thus, children's GAF is a predictor for overall satisfaction and overall acceptance of children, children's interviewers, and parents' interviewers, indicating that a higher GAF leads to higher overall satisfaction and overall acceptance. The number of diagnoses predicted the overall satisfaction of children as well as the overall acceptance of children, children's interviewers, and parents' interviewers, indicating that fewer diagnoses lead to higher overall satisfaction and overall acceptance. The duration of the interview predicted the overall satisfaction of children, children's interviewers, and parents' interviewers and also the overall acceptance of children, children's interviewers, parents, and parents' interviewers, indicating that a longer interview leads to lower overall satisfaction and overall acceptance. The institution, research or clinical setting, predicted the overall satisfaction and the overall acceptance of children's interviewers, indicating that the overall satisfaction and the overall acceptance in a research setting is higher than in a clinical setting. The sex of the interviewer is a predictor of the overall acceptance in children, indicating that having a female interviewer leads to higher overall acceptance. Furthermore, interviewer's age predicted the overall acceptance of parents, indicating that having older interviewers result in a higher overall acceptance. 4 DISCUSSION The aim of the present study was to (1) replicate the already existing results on parent and interviewer satisfaction and acceptance, (2) to complement these results with data on children, and (3) to investigate exploratory putative predictors of satisfaction and acceptance. Recently, the science of psychology has come under criticism because a number of research findings could not be replicated (Diener & Biswas Diener, 2016). Thus, it is important to replicate and complement previous findings showing that children, parents, and interviewers participating in a diagnostic procedure using a structured interview reported high satisfaction and acceptance with the interview (Matuschek et al., 2015; Shaffer et al., 2000; Sørensen et al., 2007). The mean of the overall satisfaction for children, parents, and interviewers, and the mean of the overall acceptance from the various informants were high. Such high satisfaction and acceptance values indicate that the Kinder DIPS (Schneider et al., 2009b) is well accepted for diagnostic purposes and can be used in clinical practice in the diagnostic process with children and parents. We found significant correlations between overall satisfaction and overall acceptance for children, parents, and for children's and parents' interviewers, indicating a construct overlap between satisfaction and acceptance. Therefore, prospectively it would be adequate to assess overall satisfaction after the interview. Importantly, positively formulated items of the questionnaires (e.g. I would do the interview again or I felt understood by the interviewer ) were mostly accepted by children and parents, whereas negatively formulated items of the questionnaires (e.g. I feel confused TABLE 5 Summary of predictors of the overall satisfaction with the interview by children, parents, children's interviewers and parents' interviewers Children Parents Children's interviewer Parents' interviewer Predictors B (se) t p B (se) t p B (se) t p B (se) t p Setting 0.27 (0.70) t(1,75) = (0.48) t(1,97) = (0.36) t(1,79) = (0.41) t(1,98) = Sex child/parent 0.25 (0.68) t(1,75) = (0.23) t(1,96) = (0.35) t(1,79) = (0.20) t(1,98) = Sex interviewer 0.60 (0.91) t(1,73) = (0.75) t(1,94) = (0.49) t(1,78) = (0.61) t(1,98) = Age child/parent 0.09 (0.16) t(1,72) = (0.04) t(1,88) = (0.09) t(1,78) = (0.03) t(1,91) = Age interviewer 0.06 (0.10) t(1,73) = (0.04) t(1,92) = (0.05) t(1,78) = (0.04) t(1,96) = Interview duration (0.01) t(1,58) = (0.01) t(1,79) = (0.01) t(1,65) = (0.01) t(1,78) = Number of diagnosis 1.15 (0.34) t(1,71) = (0.26) t(1,95) = (0.23) t(1,76) = (0.21) t(1,98) = GAF value 0.07 (0.02) t(1,66) = (0.02) t(1,85) = 0.371, (0.02) t(1,69) = (0.02) t(1,88) = Note: SE, standard error; GAF, Global Assessment of Functioning.

7 NEUSCHWANDER ET AL. 7of9 TABLE 6 Summary of predictors of the acceptance with the interview by children and parents, children's interviewers and parents' interviewers Children Parents Children's interviewer Parents' interviewer Predictors B (se) t p B (se) t p B (se) t p B (se) t p Setting 0.05 (0.07) t(1,85) = (0.05) t(1,113) = (0.06) t(1,84) = (0.05) t(1,104) = Sex child/parent 0.01 (0.07) t(1,85) = (0.03) t(1,112) = (0.06) t(1,84) = (0.03) t(1,104) = Sex interviewer 0.23 (0.09) t(1,83) = (0.08) t(1,110) = (0.08) t(1,82) = (0.08) t(1,104) = Age child/parent 0.02 (0.01) t(1,82) = (0.00) t(1,103) = (0.01) t(1,82) = (0.00) t(1,97) = Age interviewer 0.01 (0.01) t(1,83) = (0.01) t(1,108) = (0.01) t(1,82) = (0.01) t(1,102) = Interview duration 0.00 (0.00) t(1,67) = (0.00) t(1,91) = (0.00) t(1,66) = (0.00) t(1,84) = Number of diagnosis 0.11 (0.04) t(1,81) = (0.03) t(1,111) = (0.04) t(1,80) = (0.03) t(1,104) = GAF value 0.01 (0.00) t(1,74) = (0.00) t(1,101) = (0.00) t(1,73) = (0.00) t(1,93) = Note: SE, standard error; GAF, Global Assessment of Functioning. after the interview or From time to time I wanted to break off the interview ) were mostly denied by both children and parents, confirming the high acceptance of the structured interview. As 28 different interviewers conducted the interviews, the positive reactions to the structured interview are unlikely to be attributable to an individual diagnostician's style or personality. The high number of different interviewers varies from the study of Sørensen et al. (2007) where one and the same interviewer performed all interviews. We found one significant gender effect for the acceptance of children with the interview. Female interviewers were better accepted by children than male interviewers. However, the majority of the interviewers in our study were female. There was no other significant gender effect for acceptance or overall satisfaction. Only the age of the interviewer was associated with the overall acceptance of the parents, indicating that the parents accepted the interview better when the interviewer was older. There were no other significant associations with age and overall acceptance or overall satisfaction. The results indicate that age and sex of the interviewed children were not significantly associated with the overall satisfaction and the overall acceptance of children and children's interviewers. This is in line with the study of Sørensen et al. (2007) who also found no significant correlation with the gender of the child. However, Sørensen et al. (2007) indicated that a semi structured interview might be difficult for young children (8 9 years). Our results do not support this conclusion. Sex of the interviewed parent (mother, father or both parents) was also not significantly associated with overall satisfaction and overall acceptance. We found one significant effect in respect to the age of the parents. The age of the interviewed parent was significantly associated with the overall acceptance of parents. The other results in regard to the age of parents were not significant. To summarize, the results indicate that the Kinder DIPS can be used independently of the age and gender in the diagnostic process. Three putative predictors that illustrate the impairment of children, such as the GAF value, number of diagnoses, and duration of the interviews were significantly associated with overall satisfaction and overall acceptance of children, parents, and interviewers. The general pattern of results indicate that these predictors influenced overall satisfaction and overall acceptance of children, and both interviewers, but not of the parents: the higher the impairment of the child, the lower is the overall satisfaction and overall acceptance of the child as well as of both interviewers. In particular, the GAF value was positively associated with the satisfaction and acceptance of children, children's interviewers, and parents' interviewers. A higher GAF value indicated higher overall satisfaction and higher overall acceptance. This result was not found for parents. The positive association between the GAF value and satisfaction was also found in the investigation of Suppiger et al. (2009). Also Matuschek et al. (2015) found a positive association between the GAF value and overall satisfaction for interviewees (parents) and interviewers. In line with acceptance studies in adults (Suppiger et al., 2009), children and adolescents who are more affected by their symptomatology are less satisfied with the interview. Furthermore, a more pronounced impairment is also associated with a longer interview duration, which can add to a negative evaluation of the interview. However, at a high level of satisfaction and acceptance with the

8 8of9 NEUSCHWANDER ET AL. interview, the impairment of the child and the duration of the interview only lead to a slight decline in satisfaction and acceptance. Considering that the interviews in the present research setting had to be conducted in one session it can be assumed that the satisfaction and the acceptance with the interview would be higher if the interview is conducted under clinical routine conditions where the interview can be divided into several sessions depending on the child's age and attention span. In the present study, we found significantly higher overall satisfaction and overall acceptance in the research setting compared to the clinical setting, however, only for children's interviewers. There were no significant differences in overall satisfaction and overall acceptance for children, parents, and parents' interviewers. This finding is of special interest since further analyses (see Table 3) showed that there were significant differences between the two settings with respect to the number of diagnoses per child, duration of interview, and GAF, indicating that in the research setting the interview duration was shorter and the GAF value was higher. Our results indicate that the setting has only a marginal influence on the satisfaction and acceptance of diagnostic interviews in children and parents. These results are only partially in line with the results of Matuschek et al. (2015), who reported significantly higher overall satisfaction of interviewee (parents) and interviewers in the research setting compared to the clinical setting. There are some limitations that have to be considered when interpreting these results. The interviewers in the present study were thoroughly trained in the assessment of the Kinder DIPS, therefore the results cannot be generalized to untrained clinicians. Also Matuschek et al. (2015) indicated that intensive training in conducting the interview is an important requirement for achieving the high level of interviewer and interviewee (parents) satisfaction. We asked children and parents about their own impression (satisfaction and acceptance) after the structured interview. However, we did not assess parents' impression about the reaction of the child after the interview, like Sørensen et al. (2007) did. Parents might be able to report some changes in a child's behavior a while after the interview, which are not noticeable immediately after the interview. Even though we tried to guarantee anonymity, it might be that both children and parents were influenced by social desirability when answering the questions. However, this is a common issue in such investigations and therefore our findings are comparable with other present research studies. Structured interviews are used less in clinical practice than in a research setting (Bruchmüller et al., 2011). One reason could be therapists' concern that structured interviews might be inefficient or could impair the therapeutic relationship (Joiner et al., 2005). However, previous studies with adults, children, adolescents and their parents on the acceptance of structured interviews do not support these considerations (Matuschek et al., 2015; Shaffer et al., 2000; Sørensen et al., 2007; Suppiger et al., 2009). Results of the present study further support the use of structured interviews in clinical practice. The results of Dolle, Schulte Körne, von Hofacker, Izat, and Allgaier (2012) on the low agreement between clinical diagnoses and diagnoses based on structured interviews also emphasize the application of structured interviews in the diagnostic process in clinical practice. In summary, together with the existing evidence of the reliability and validity of structured interviews, there is clear empirical evidence to encourage the use of structured interviews in the diagnostic process in both clinical and research settings. ACKNOWLEDGEMENTS The authors are grateful to the participants in this study, the interviewers, the research assistants, and graduate students working on the project. Especially, the authors would like to acknowledge Dr Carmen Adornetto for her assistance in the project. Further, the authors would like to acknowledge the Psychotherapy Center, University of Basel; Child and Adolescent Psychiatry, University of Basel; Child and Adolescent Psychiatry, Basel Land; and Child and Adolescent Psychiatry, University of Zurich. FUNDING INFORMATION This study was supported by grant PP ; , Etiology and Psychological Treatment of Separation Anxiety Disorder in Childhood, awarded to Prof. Dr Silvia Schneider by the Swiss National Science Foundation. 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