SOCW 6446
Jodas1
E M P I R I C A L R E S E A R C H
How Mental Health Interviews Conducted Alone, in the Presence of an Adult, a Child or Both Affects Adolescents’ Reporting of Psychological Symptoms and Risky Behaviors
Aubrey V. Herrera1 • Corina Benjet1 • Enrique Méndez1 • Leticia Casanova1 •
Maria Elena Medina-Mora1
Received: 26 November 2015 / Accepted: 6 January 2016 / Published online: 20 January 2016
� Springer Science+Business Media New York 2016
Abstract The normative process of autonomy develop-
ment in adolescence involves changes in adolescents’
information management typically characterized by
decreasing disclosure and increasing concealment. These
changes may have an important impact on the early detection
and timely treatment of mental health conditions and risky
behavior. Therefore, the objective was to extend our under-
standing of how these developmental changes in adolescent
disclosure might impact adolescent mental health interviews.
Specifically, we estimated the effects of third party presence
and type of third party presence (adult, child, or both) on
adolescents’ reports of psychiatric symptoms, substance use,
suicidal behavior, and childhood adversity. In this represen-
tative sample of 3005 adolescents from Mexico City (52.1 %
female), administered the World Mental Health Composite
International Diagnostic Interview (WMH-CIDI-A), adult
presence influenced reporting the most; in their presence,
adolescents reported more ADHD, parental mental illness
and economic adversity, but less panic disorder, PTSD, drug
use and disorder, and suicidal behavior. The presence of
children was associated with increased odds of reporting
conduct disorder, opportunity for drug use, parental criminal
behavior, neglect, and the death of a parent. While adolescent
information management strategies are normative and even
desirable as a means of gaining emotional autonomy, they
may also interfere with timely detection and treatment or
intervention for mental health conditions and risky behaviors.
Research and practical implications of these findings are
discussed.
Keywords Adolescence � Privacy � Information management � Social desirability � Mental health � Mexico
Introduction
The increasing autonomy of adolescence has important
implications for adolescents’ information management; in
other words, how much, what, to whom and under what
conditions adolescents disclose or conceal information
(Campione-Barr et al. 2015; Tilton-Weaver 2014). Auton-
omy development through the realignment of parent–child
relationships in adolescence is achieved through a process of
lessening parental control, and reduced parental knowledge
and adolescent willingness to disclose (Keijsers and Poulin
2013). This is important because the developmental decrease
in disclosure and increase in concealment specifically rela-
ted to risky behaviors and psychological distress might limit
timely detection and treatment of mental disorders during a
stage of development with high risk for the onset of psy-
chiatric disorder.
Disclosure by adolescents is mediated by adolescents’
attitudes regarding what parents have a right to know (Chan
et al. 2015). U.S. adolescents have been found to feel more
obligated to disclose to parents prudential information (de-
fined as information that pertains to one’s comfort, safety
and health such as risky behaviors) than personal (defined as
that pertaining to privacy, preferences, and control over
one’s body) or conventional information (that pertaining to
social norms) (Smetana et al. 2006). However, adolescents
who engage in risky behavior tend to disclose less about
prudential behaviors than personal or multifaceted ones.
& Corina Benjet [email protected]
1 Dirección de Investigaciones Epidemiológicas y
Psicosociales, Instituto Nacional de Psiquiatrı́a Ramón de la
Fuente, Calzada México-Xochimilco 101, San Lorenzo
Huipulco, 14400 México, D.F., Mexico
123
J Youth Adolescence (2017) 46:417–428
DOI 10.1007/s10964-016-0418-1
Adolescents fail to disclose prudential behaviors for fear of
disapproval or punishment (Smetana et al. 2009) whereas
they fail to disclosure personal information because they
consider such information legitimately under their personal
control and they do not feel obliged to share this domain of
information with parents (Smetana and Asquith 1994).
Additionally prior research has found that U.S. adolescents
disclose more to mothers than to fathers (Smetana et al.
2006) and more to mothers than to siblings (at least in early
adolescence, although this gap between mothers and siblings
narrows toward emerging adulthood; Campione-Barr et al.
2015). Both depressive symptomatology and risky behaviors
have been negatively associated to disclosure with both
parents and siblings (Campione-Barr et al. 2015; Kerr and
Stattin 2000; Laird et al. 2013).
Because adolescents do not seek treatment for them-
selves, detection and treatment of mental disorders and
risky health behaviors in adolescents requires detection by
an adult third party such as parent or teacher and thus
largely depends on adolescent disclosure and information
management. To evaluate sensitive topics with adolescents
in clinical settings and in research, including health risk
behavior, mental disorders, and adverse experiences, self-
reporting is commonly used to gather this information.
However, questions regarding adolescent self-report
stem from numerous findings of commonly discrepant
reports between adolescents and their parents (e.g., Jensen
et al. 1999; Rescorla et al. 2013; Salbach-Andrae et al.
2009; Seiffge-Krenke and Kollmar 1998). Most of these
aforementioned studies find that parents report more
externalizing symptoms, that adolescents report more
internalizing symptoms and that there are greater discrep-
ancies for externalizing than internalizing symptoms.
Conclusions from this research have suggested that neither
adolescent nor parent report should be considered true or
untrue, but rather that both informants likely contribute
useful albeit discrepant information related to clinically
meaningful conditions and associated impairment. The
possible exceptions are ADHD and oppositional defiant
disorder for which adolescents’ reports alone are found to
have less clinical validity (Jensen et al. 1999).
Why might adolescents or persons of any age use infor-
mation management strategies involving incomplete dis-
closure or concealment? When asked sensitive questions,
people might misreport information because they view the
questions as intrusive, worry that disclosure of the infor-
mation might bring negative consequences, or want to pre-
sent themselves in a more favorable light by responding in a
socially desirable manner (Holtgraves 2004; Johnson and
Van de Vijver 2002; Krumpal 2013; Tourangeau and Yan
2007). This misreporting or concealing of information for
sensitive topics is a notable source of error attributed to bias
in survey estimates, may also be relevant in clinical settings,
and is largely dependent on the situation (Krumpal 2013;
Tourangeau and Yan 2007). When filtering responses to be
more desirable or acceptable, respondents aim to avoid
embarrassment when speaking with either the interviewer or
a third party bystander who may be present (Holtgraves
2004; Krumpal 2013; Mneimneh 2012; Tourangeau and Yan
2007). If the bystander is already aware of the information
being asked and can serve as a ‘‘truth control,’’ the
respondent will be less inclined to report dishonestly
(Mneimneh 2012; Tourangeau and Yan 2007). Anonymous
reporting is an option in some cases, and several studies
suggest that anonymity increases truthful responses for
sensitive information (Krumpal 2013; Ong and Weiss 2000;
Tourangeau and Yan 2007). Contrasting this, anonymity
cannot be assumed to automatically increase the quality of
reporting, because confidential questionnaires may give the
same results as anonymous questionnaires (van de Looij-
Jansen et al. 2006). Additionally, a 2002 study by Newman
et al. reports that taking the human interviewer out of the
picture may reduce the chance that respondents will report
psychological symptoms due to the impersonal nature.
Another influence on self-reports is the respondent’s
culture. It dictates both what is deemed a desirable
response and the privacy, or lack thereof, of the interview
setting (Diop et al. 2015; Hofstede et al. 2010; Mneimneh
2012; Pollner and Adams 1994). For example, it is more
common in a collectivist culture for a family member or
friend to invade privacy, compared to an individualistic
culture, where privacy is more prioritized (Hofstede et al.
2010). Cultural norms may dictate how easy or difficult it
is for an interviewer to ask for privacy during the interview
(Mneimneh 2012). While Tilton-Weaver (2014) found that
relationship dynamics and adolescent delinquent behaviors
play a role in adolescents’ information management, she
suggested that future research should sample more diver-
gent cultures where strong expectations to conform to the
rules and expectations of parents and other adults might
affect this relationship. In one study with Japanese ado-
lescents, levels of adolescent disclosure to parents, and
perceptions of the obligation to disclose to parents were
less than typically found in U.S. adolescents (Nucci et al.
2014). These authors interpreted these results to reflect a
cultural tendency in Japan to view adolescents’ actions as
matters of personal responsibility. One of the few studies of
a Latino population, Puerto Rican adolescents in the U.S.,
showed that greater adherence to Latino family values was
associated with more disclosure and less lying to mothers
(not so with fathers) regarding prudential issues, but not
peer-multifaceted issues (Villalobos and Smetana 2012). A
comparison of U.S. adolescents from Mexican, Chinese
and European backgrounds found Mexican–American
youth to disclose risky prudential behaviors less to mothers
than European American teens (Yau et al. 2009). The
418 J Youth Adolescence (2017) 46:417–428
123
authors concluded that, since Mexican culture emphasizes
more conformity to external standards, that these adoles-
cents may have felt that they had more at stake than other
adolescents when violating parental rules.
Interview settings with the presence of a third party have
shown an association with how interviewees respond to
sensitive topics, especially underreporting or over reporting
of sensitive information (Diop et al. 2015; Krumpal 2013;
Taietz 1962; Tourangeau and Yan 2007). Information man-
agement in adolescence is likely to be more pronounced than
in other stages of life given the developmental process
toward autonomy on the one hand and the power of adults
over adolescents to punish on the other. Adolescents inter-
viewed at home, at school, or in a clinical setting, may have
varying willingness to disclose sensitive information
depending on the context. At home, typically in the presence
of third parties who may have the power to punish the ado-
lescent or disprove of certain behaviors, typically a parent,
adolescents tend to underreport risky health behaviors, such
as alcohol and substance use (Aquilino et al. 2000; Brener
et al. 2006; Hoyt and Chaloupka 1994; Kann et al. 2002;
Krumpal 2013). In Aquilino et al.’s 2000 study, the presence
of a sibling showed fewer effects on reporting. In these
general population household surveys, interviewing the par-
ticipants privately is often not possible. This problem may be
even more pronounced in developing countries where the
number of family members in the household may be larger,
including extended family members, while at the same time
the size of the home smaller with fewer private spaces
(Aquilino 1997; Mneimneh 2012). While reporting infor-
mation at school, in the presence of peers or friends, the
literature shows an over reporting of these risky health
behaviors, in order to gain acceptance or seem ‘‘cool’’
(Brener et al. 2006; Gfroerer et al. 1997; Hoyt and Chaloupka
1994; Kann et al. 2002). However, Davis et al.’s 2010 study
reports the opposite and finds that adolescents understate
alcohol consumption, in order to present themselves more
favorably. In clinical settings, it is usually possible to inter-
view the adolescent in private, where more confidentiality is
reassured, and thus, they may report more openly (Gans and
Brindis 1995).
Like risky health behaviors, mental disorders are a sen-
sitive, and often stigmatized, issue. For mental disorders,
there are no reliable biomarkers to diagnose disorders and,
thus, the use of standardized diagnostic interviews is the
main form of diagnosis (Kessler and Ustun 2004). With such
interviews, respondents may not want to report symptoms or
feel embarrassed to report them in the presence of a third
party (Epstein et al. 2001). However, Pollner and Adams
(1994) reported that the presence of a third party was not
related to reporting symptoms of possible mental disorders,
and responses likely reflected methodological, situational,
and cultural influences. Overall, there is scant literature
available concerning the impact of a third party presence,
such as a parent, a sibling or other family member, during
adolescent mental health interviews and none to our
knowledge in the adolescent population of Mexico City.
The Current Study
The objective of this article is to build on research in the area
of adolescent information management, extending our
understanding of how these developmental changes in ado-
lescent disclosure might impact adolescent mental health
interviews. More specifically, we estimate the effects of third
party presence on adolescents’ reports of psychiatric symp-
toms meeting diagnostic criteria, substance use, suicidal
behavior, and childhood adversity. Additionally, the effect is
examined by type of third party present (adult, child, or both).
Because the literature shows that adolescents often fail
to disclosure prudential information that they fear will get
them in trouble, we hypothesize that rates of psychiatric
disorders, substance use, and suicidality will be lower in
the presence of an adult, that rates of conduct problems and
substance use, will be higher when only children are pre-
sent, due to adolescents’ desire to show off in front of
peers, and that childhood adversities will be higher when
an adult is present, as parents are likely to already possess
this information and thus may serve as a ‘‘truth control’’.
Methods
Participants
Data were collected as part of the 2005 Mexican Adoles-
cent Mental Health survey, with 3005 adolescent partici-
pants, aged 12–17 years old, representative of the almost
two million adolescents living in Mexico City. They were
chosen from a stratified multistage area probability sample.
Census count areas, cartographically defined and updated
for the XII Population and Housing Census, were the pri-
mary sampling units for all strata. City blocks with prob-
ability proportional to size were chosen as the secondary
sampling units. The Kish method of random number charts
was used to randomly select one eligible adolescents from
each household, and the response rate was 71 %. As
described previously, the sociodemographic distribution
was similar to the distribution of the adolescent population
in Mexico City: one half female, nearly 80 % students,
two-thirds residing with both parents, and the socioeco-
nomic level of the parents typically being low (Benjet et al.
2009).
J Youth Adolescence (2017) 46:417–428 419
123
Procedures
Adolescents and their parents were given both a verbal and
written explanation of the study, followed by the parent or
guardian providing signed informed consent and the ado-
lescent providing assent. Adolescent interviews were con-
ducted in their home by extensively trained lay
interviewers and each participant and their family were
offered information on local mental health services. The
Internal Review Board of the National Institute of Psy-
chiatry Ramon de la Fuente approved this project.
Measures
The computer-assisted, fully structured adolescent version of
the World Mental Health Composite International Diag-
nostic Interview (WMH-CIDI-A; Kessler et al. 2009;
Merikangas et al. 2009) was administered to participants.
This research tool collects sociodemographic and other
information to generate diagnoses of DSM-IV disorders
(anxiety, mood, substance and disruptive behavioral disor-
ders), other risk behaviors such as substance use and suicidal
behavior, and risk factors such as childhood adversity. The
interviewer read each question aloud to the participant and
input responses directly into the computer. This computer-
assisted version includes complex logical skip patterns such
that each particular question posed was chosen by the
computer based on the previous responses of the participant.
Consistency check systems were in place to ensure that
inconsistent responses were probed and corrected.
Socio-Demographic Variables
The socio-demographic variables examined in this study were
asked about in the WMH-CIDI-A. This includes the sex of the
participants, age, family constellation, student status, parental
education and parental income. Family constellation was cat-
egorized as living with both biological parents or not living
with both biological parents (as reported by the adolescent).
Participants were considered students if currently enrolled as a
student. The adolescents were asked about the educational
attainment of each of their parents which was then categorized
as none/primary (six or less years of education), secondary
(7–9 years of education), high school (10–12 years of educa-
tion) or college (thirteen or more years of education); the score
of the parent with the highest level of education was used.
Parents reported family income was categorized into tertiles.
Psychiatric Disorder
The WMH-CIDI-A begins with a screening section which
includes a few screening questions for each disorder. Ado-
lescents who respond having ever experienced the symptoms
in the screening section then are asked more in depth ques-
tions for each disorder for which they screened positive. This
article reports the psychiatric disorders for which participants
met diagnostic criteria according to the diagnostic and sta-
tistical manual of mental disorders, fourth edition (DSM-IV;
American Psychiatric Association 1994) in the prior
12 months. All disorders used organic exclusion rules as well
as hierarchy definitions in order to avoid double counting of
disorders in the same person. The disorders are grouped as
follows: anxiety disorders (panic disorder, generalized anx-
iety disorder, agoraphobia, social phobia, specific phobia,
separation anxiety disorder and posttraumatic stress disorder
(PTSD)), mood disorders (major depressive disorder and
bipolar disorder (I and II)), disruptive behavior disorders
(intermittent explosive disorder, oppositional-defiant disor-
der, conduct disorder and attention-deficit/hyperactivity dis-
order) and substance use disorders (alcohol abuse or
dependence and drug abuse or dependence). A comparison of
diagnosis based on the adolescent CIDI with blinded clinical
interviews using the K-SADS showed generally good diag-
nostic concordance (Kessler et al. 2009).
Substance Use
The substance use section of the WMH-CIDI-A asks ado-
lescents about their lifetime use (defined as consumption of
the substance at least once at any time in one’s life) of
alcohol and illicit drugs, opportunity to use alcohol and
drugs, and substance abuse and dependence. The illicit drugs
included marijuana, cocaine in any of its forms, tranquilizers
or stimulants used without a medical prescription such as
methamphetamine, and other substances (e.g., heroin, inha-
lants, LSD, etc.) that were grouped as ‘‘other drugs.’’ Par-
ticipants were asked about each category of drugs openly and
then presented with a list of numerous different street names
for these drugs. The questions regarding opportunity to use
alcohol and drugs were posed after the questions about
alcohol and drug use such that opportunities to use alcohol
and drugs referred to all the alcohol and drugs previously
presented to the respondents. All participants were asked
about opportunities regardless of whether they had previ-
ously endorsed consuming any substance. Opportunity to use
alcohol and opportunity to use drugs were asked about sep-
arately and defined as having the opportunity to use any
substance regardless of whether or not the respondent did so.
They were given as an example that someone offered them
drugs or that they were present when others were using and
could have done so if he or she chose to.
Suidicial Behavior
The suicidal behavior section had a somewhat different
format than the other sections of the WMH-CIDI-A such
420 J Youth Adolescence (2017) 46:417–428
123
that the interviewer did not read the questions aloud to the
adolescent, but rather asked the respondent to report
whether they had experienced any of three experiences
which were printed in a booklet and referred to by letter.
These experiences were ‘‘Have you ever seriously thought
about committing suicide?,’’ ‘‘Have you ever made a plan
for committing suicide?,’’ and ‘‘Have you ever attempted
suicide?’’
Childhood Adversity
Twelve different types of childhood adversity were evalu-
ated and classified as present or not present using the same
criteria as the World Mental Health Survey Initiative (Green
et al. 2010). These included parental mental illness, parental
substance problems, parental criminal behavior, witnessing
family violence, physical abuse, sexual abuse, neglect, death
of a parent, parental divorce, other parent loss, life-threat-
ening physical illness, and economic adversity. Parental
pathology used questions from the family history research
diagnostic criteria interview and included parental mental
illness, substance problems, and criminal behavior (Endicott
et al. 1978). Physical abuse and witnessing family violence
were evaluated with a modified version of the Conflict
Tactics Scale (Strauss 1979). Neglect was assessed with
questions often used in child welfare studies (Courtney et al.
1998). Sexual abuse was determined by reading a definition
of rape and a definition of other forms of abuse or
molestation. To be consistent with the other World Mental
Health Surveys, chronic sexual abuse was defined as
reporting at least three episodes of sexual abuse thus rep-
resenting chronic sexual abuse as opposed to acute one time
trauma (Kessler et al. 2010). To assess parental loss, the
adolescents were asked whether they lived with both of their
parents all of their lives. Those who did not were asked
whether this was because their parents had separated or
divorced, a parent had died or some other reason. Those
endorsing separations of 6 months or more from either
parent for some other reason were classified as other par-
ental loss, with reasons ranging from having gone to
boarding school, having left home, or that their parent was in
prison. Physical illness is based on the adolescent’s report of
having experienced a life-threatening physical illness.
Family economic adversity was determined by the family
ever receiving money from a government assistance pro-
gram for poor families or by lack of parental employment
most or all of the time during the participant’s childhood.
Third Party Presence
An interviewer observation section at the end of the WMH-
CIDI-A, required the interviewer to register if anyone was
present during the interview aside from the adolescent, and
if so who. Those responses were categorized as follows: (1)
no one, (2) only children, (3) children and adults, or (4)
adults only.
Statistical Analysis
Data were weighted to adjust for non-response, differential
probabilities of selection, and post-stratification to the
adolescent population of Mexico City according to the year
2000 Census in the target sex and age range. The preva-
lence of reported DSM-IV diagnoses, substance use, sui-
cidal behavior and childhood adversity were calculated by
privacy category. Then, age- and sex-adjusted odds ratios
were calculated in SUDAAN software (Research Triangle
Institute 2009) for the association of privacy with the DSM-
IV diagnoses, substance use, suicidal behavior and child-
hood adversity.
Results
Only 42.7 % of interviews were conducted with the adoles-
cent alone, whereas children only were present in 3.4 % of
interviews, both children and adults were present in 4.8 %,
and at least one adult was present in 49.1 % of interviews. Of
the adults that were present 84.6 % was a parent. Sociode-
mographic characteristics are depicted in Table 1. Third
party presence varied by sex, age, and parental education. A
greater proportion of interviews with females, versus males,
had only children present; families with lower parental
education tended to have children present, as well. More
interviews were conducted alone when the interviewee was
an older adolescent versus a younger adolescent.
The association of third party presence with DSM-IV
diagnosis adjusted by age and sex is shown in Table 2.
Having only children present increases the probability of
reporting any disruptive behavior disorder (OR 1.74; 95 %
CI 1.21–2.51), which is explained primarily by the threefold
odds of reporting a conduct disorder in particular (CI
1.17–7.65). The presence of both children and adults also
increases the probability of reporting any disruptive behav-
ior disorder (OR 1.80; 95 % CI 1.05–3.10), but is explained
by the increased odds of reporting intermittent explosive
disorder (OR 2.35; 95 % CI 1.30–4.22). Having only adults
present increases the odds of reporting attention-deficit/hy-
peractivity disorder (ADHD) by 83 % (95 % CI 1.08–3.10)
but reduces the odds of reporting panic disorder (OR 0.62;
95 % CI 0.40–0.95), PTSD (OR 0.55; 95 % CI 0.35–0.86),
and a drug use disorder (OR 0.17; 95 % CI 0.07–0.38).
Table 3 presents the association of substance use and
third party presence, adjusted by age and sex. With only
children present, there are increased odds of reporting a
drug opportunity (OR 1.73; 95 % CI 1.10–2.70). Having
J Youth Adolescence (2017) 46:417–428 421
123
both children and adults present is unrelated to reporting of
substance use. However, when only adults are present,
odds are reduced by roughly half for reporting drug use
(OR 0.47; 95 % CI 0.31–0.73).
The association between suicidal behavior and third
party presence is shown in Table 4. Having children only
or children and adults present was unrelated to reporting of
suicidal behavior. However, having only adults present
reduces the odds of reporting suicidal behavior with ORs
ranging from 0.48 for suicide attempts to 0.68 for suicidal
ideation.
Table 5 depicts the association between childhood
adversity and third party presence. With only children
present, there is a greater probability of reporting the fol-
lowing: parental criminal behavior, neglect, and parent
death with ORs ranging from 1.88 for death of a parent to
2.44 for parental criminal behavior. When children and
adults are present, there is a greater probability of reporting
parental mental illness (OR 2.14; 95 % CI 1.34–3.41).
With only adults present, there is a greater probability of
reporting both parental mental illness (OR 1.39; 95 % CI
1.13–1.71) and economic adversity (OR 1.22; 95 % CI
1.01–1.46).
Discussion
The normative process of autonomy development in ado-
lescence involves changes in adolescents’ information
management typically characterized by decreasing disclo-
sure and increasing concealment of information (Campi-
one-Barr et al. 2015; Tilton-Weaver 2014). These changes
may have an important impact on the early detection and
timely treatment of mental health conditions and risky
behavior. These developmental changes in information
management depend on various factors including the
domain of the information managed and the person to
whom one discloses (mother, father, sibling, peer, other
adult) (Smetana et al. 2006; Campione-Barr et al. 2015).
While previous studies have found that less disclosure and
increased concealment is related to delinquent behavior
(Campione-Barr et al. 2015; Kerr and Stattin 2000; Laird
et al. 2013) and that there are important discrepancies
between children’s and parental reports of psychological
distress and risky behavior (Jensen et al. 1999; Rescorla
et al. 2013; Salbach-Andrae et al. 2009: Seiffge-Krenke
and Kollmar 1998), the purpose of this investigation was to
understand how the presence of third parties during
Table 1 Sociodemographic characteristics by third party presence in adolescent mental health interviews
Sociodemographic
characteristics
Third party presence df v2 p
No one present Children only Children and adults Adults only
n % se n % se n % se n % se
Sex 3 6.5 0.00
Male 631 51.96 2.06 40 40.98 4.26 55 38.62 3.38 697 49.83 1.06
Female 638 48.04 2.06 61 59.02 4.26 88 61.38 3.38 762 50.17 1.06
Age (years) 3 6.0 0.00
12–14 695 44.77 1.55 60 53.16 4.09 93 58.51 3.67 895 52.09 1.63
15–17 574 55.23 1.55 41 46.84 4.09 50 41.49 3.67 564 47.91 1.63
Living with parents 3 0.4 0.77
No (one/none) 428 33.86 1.15 37 39.17 6.51 50 36.13 5.20 499 34.51 1.07
Yes (both) 841 66.14 1.15 64 60.83 6.51 93 63.87 5.20 960 65.49 1.07
Current student 3 2.2 0.11
No 225 20.72 0.98 18 18.58 4.75 20 16.64 4.12 214 17.57 1.34
Yes 1044 79.28 0.98 83 81.42 4.75 123 83.36 4.12 1245 82.43 1.34
Parents’ education 9 3.3 0.01
None/primary 333 26.67 0.98 31 30.80 3.58 41 28.11 3.54 362 25.01 0.89
Secondary (7–9 years) 478 37.31 1.83 42 43.98 5.02 53 35.54 5.38 548 38.46 1.69
High school (10–12 years) 284 22.32 1.14 19 17.09 3.03 26 19.02 3.61 359 23.67 1.38
College (13? years) 173 13.71 1.00 9 8.12 1.88 23 17.33 3.32 190 12.86 0.85
Parents’ income 6 2.3 0.06
Low 459 35.58 1.95 43 44.77 4.36 50 35.41 3.51 545 37.60 1.46
Average 400 31.42 1.51 38 36.79 4.35 45 29.89 4.34 440 30.20 1.37
High 410 33.00 1.45 20 18.44 4.10 48 34.70 4.05 474 32.20 1.18
%s are weighted by sample design and non-response
422 J Youth Adolescence (2017) 46:417–428
123
adolescent mental health interviews influences the report-
ing of symptoms used to diagnosis disorders and other risk
behavior. We found that the presence of third parties
influences the responses provided by adolescents, but this
reporting varies according to whom is present and the type
of symptom or behavior asked about.
Adults present during the interview influence adolescent
disclosure the most; in the presence of only adults, adoles-
cents were more likely to report ADHD, parental mental
illness and economic adversity. Most adults present were the
parent, as such, they likely have better insight into their own
mental health and their family’s economic status compared to
adolescents, and thus may have stepped in to provide infor-
mation. Parents may also have observational insight regard-
ing their adolescent’s ADHD that the adolescent lacks or is
ashamed to mention. In fact, prior research has found ADHD
(as well as oppositional defiant disorder) to be the only dis-
orders for which adolescent report alone of symptoms is
unrelated to impairment (Jensen et al. 1999). Inattentive,
impulsive and hyperactive adolescents are likely to have little
insight into their condition due to the cognitive and atten-
tional characteristics of the disorder. While the presence of
adults was associated with greater odds of reporting the three
abovementioned conditions, it was also associated with
reduced odds of reporting the following seven conditions:
panic disorder, post traumatic stress disorder, drug abuse or
dependence, drug use, suicide ideation, suicide plan, and
suicide attempt. Our findings corroborate those of previous
studies (Aquilino et al. 2000; Brener et al. 2006; Kann et al.
2002; Krumpal 2013) indicating that adolescents are less
inclined to report risky behavior in the presence of third
parties who would disapprove and who have the authority to
punish them. The reduced odds of PTSD may be due to
adolescents’ not wanting to disclose to their parents or other
adult the traumatic event that led to the PTSD (such as a
sexual abuse). Prior research on the disclosure of sexual
Table 2 Association of third party presence with psychiatric diagnosis in adolescent mental health interviews
Psychiatric disorder Third party presence df v2 p
No one present
(reference group)
Children only Children and adults Adults only
OR OR 95 % CI OR 95 % CI OR 95 % CI
I. Anxiety disorders
Panic disorder 1.00 1.21 (0.32–4.52) 1.16 (0.39–3.39) 0.62 (0.40–0.95) 3 5.44 0.14
Generalized anxietv disorder 1.00 1.20 (0.16–8.94) 0.93 (0.08–10.41) 1.43 (0.53–3.86) 3 2.04 0.56
Agoraphobia 1.00 1.50 (0.64–3.50) 0.77 (0.28–2.16) 1.24 (0.84–1.83) 3 2.14 0.54
Social phobia 1.00 0.64 (0.31–1.32) 1.23 (0.60–2.53) 0.91 (0.68–1.20) 3 3.64 0.30
Specific phobia 1.00 1.18 (0.65–2.14) 1.20 (0.88–1.65) 1.02 (0.85–1.24) 3 1.42 0.70
Separation anxietv 1.00 0.98 (0.44–2.19) 1.19 (0.63–2.23) 0.97 (0.72–1.31) 3 0.52 0.92
Posttraumatic stress disorder 1.00 0.36 (0.04–2.93) 0.73 (0.22–2.44) 0.55 (0.35–0.86) 3 8.27 0.04
Any anxiety disorder 1.00 1.20 (0.69–2.09) 1.32 (0.96–1.82) 1.04 (0.88–1.22) 3 3.32 0.35
II. Mood disorders
Major depressive disorder 1.00 0.99 (0.48–2.02) 0.66 (0.31–1.40) 0.78 (0.54–1.13) 3 4.46 0.22
Bipolar disorder (broad) 1.00 1.37 (0.80–2.33) 1.22 (0.39–3.84) 1.07 (0.70–1.64) 3 1.70 0.64
Any mood disorder 1.00 1.09 (0.60–1.98) 0.78 (0.44–1.40) 0.85 (0.64–1.12) 3 3.88 0.27
III. Disruptive behavior disorders
Intermittent explosive disorder 1.00 1.16 (0.63–2.12) 2.35 (1.30–4.22) 1.05 (0.74–1.50) 3 8.96 0.03
Oppositional-defiant disorder 1.00 1.78 (0.94–3.39) 1.36 (0.64–2.87) 1.05 (0.82–1.36) 3 3.80 0.28
Conduct disorder 1.00 3.00 (1.17–7.65) 2.07 (0.81–5.24) 1.09 (0.60–1.99) 3 11.86 0.01
Attention-deficit/hvperactivitv disorder 1.00 0.50 (0.06–4.12) 2.75 (0.85–8.84) 1.83 (1.08–3.10) 3 11.39 0.01
Any disruptive behavior disorder 1.00 1.74 (1.21–2.51) 1.80 (1.05–3.10) 1.16 (0.91–1.46) 3 19.53 0.00
IV. Substance use disorders
Alcohol use disorder 1.00 0.66 (0.13–3.19) 1.40 (0.51–3.86) 1.08 (0.72–1.62) 3 0.99 0.80
Drug use disorder 1.00 0.90 (0.25–3.24) 0.74 (0.11–4.97) 0.17 (0.07–0.38) 3 21.24 0.00
Any substance use disorder 1.00 0.66 (0.21–2.10) 0.89 (0.34–2.33) 0.76 (0.54–1.06) 3 4.36 0.23
V. Any disorder 1.00 1.39 (0.82–2.34) 1.31 (0.94–1.82) 0.99 (0.84–1.17) 3 5.37 0.15
Regression models adjusted by sex and age
OR Odds ratio, 95 % CI 95 % confidence interval, italic shows significant ORs at p \ 0.05 Psychiatric disorders (the dependent variable) and privacy levels (the independent variable) are displayed as such for visual ease
J Youth Adolescence (2017) 46:417–428 423
123
abuse has shown many reasons why young people do not
disclose, including fear of not being believed, shame or self-
blame about the abuse, or fear of the consequences to
themselves or others of disclosure (McElvaney et al. 2014).
Why there might be reduced reporting of panic disorder is
unclear.
The presence of only children led to increased odds of
reporting conduct disorder, any disruptive behavior disorder,
opportunity for drug use, parental criminal behavior, child-
hood neglect, and the death of a parent. The threefold
increased reporting of conduct disorder might be due to the
adolescent ‘‘showing off’’ in front of their peers (Brener
et al. 2006). Impulse control disorders are marked by the
inability to resist a temptation or impulse to act in a way that
is harmful to the person or others. If the children present
during the interview have witnessed instances of the dis-
ruptive behavior, the affected adolescent might feel less
pressure to conceal what is already known and may even
feel compelled to disclose as not to appear to lie in front of
this person. Importantly, the symptoms of disruptive
behavior disorders can be observed and do not require the
adolescent to have disclosed these symptoms to the sibling
for the sibling to know them to be true. Finally, if the child
is a sibling, they have likely experienced the same
upbringing and can attest to childhood adversities, including
parental criminal behavior, childhood neglect, or death of a
parent. The adolescent may feel more compelled to disclose
these events knowing that the sibling knows this to be true.
When adults and children were present, there were
greater odds of reporting intermittent explosive disorder,
any disruptive behavior disorder, and parental mental ill-
ness. Again, if these third party members have witnessed
intermittent explosive bouts or disruptive behaviors, and
parental mental illness, there would be no need for the
adolescent to conceal it and he or she may even feel more
compelled to disclosure in order to not appear to be lying
in front of the third parties. Also, the parent may assist in
the reporting of this topic, even if the children were not
aware, in order to provide the most accurate assessment.
Interestingly, the presence of another person, either
adult or child, did not seem to influence reports of most
anxiety disorders (except panic and PTSD) or any mood
disorder, suggesting that overall symptoms of anxiety and
mood disorders may be considered less shameful or
embarrassing than those of other disorders. The presence
of a third party also did not influence reports of alcohol use
or disorder. This may be due to the cultural acceptance or
tolerance of adolescent drinking in Mexico City such that
adolescents do not feel the need to hide this from their
parents (Benjet et al. 2014).
Some limitations of the study must be acknowledged.
Directionality or causality cannot be ascertained for the
associations under question. It might be that a parent is lessT a
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424 J Youth Adolescence (2017) 46:417–428
123
likely to leave home alone or to allow a teenage son or
daughter with ADHD to be interviewed alone, and perhaps
an adolescent with a drug use disorder is more likely to be
found at home without a parent as parental neglect is
considered a risk factor for substance disorders (Snyder and
Merritt 2015). Or similarly, a parental death, parental
neglect and parental criminal behavior may lead to ado-
lescents’ being home with other children in the absence of
parental supervision. While these alternate explanations are
possible, it is important to keep in mind that, in all cases,
parents gave parental consent for the interview and an adult
was present somewhere in the household even if the
interview was conducted in a private room, thus mini-
mizing this explanation. Further studies should look at third
party presence and disclosure in an experimental design in
order to gain a fuller understanding of directionality and
causality. Despite these limitations, this study has
strengths, including sampling the general adolescent pop-
ulation of this area. This is notable, because nearly one-
third (31.8 %) of 15-17 year olds in Mexico are no longer
in school (Instituto Mexicano de la Juventud 2005), and
thus cannot be traced through studies that use only school
populations. Additionally, these data come from a devel-
oping country and a cultural context different from where
prior studies on the effect of third party presence have been
conducted, extending our knowledge of how privacy may
affect response bias in different cultural contexts.
The findings of this study have both research and
practice implications. While it is often not possible in
research to determine the privacy of an interview, espe-
cially in community studies, data such as these can provide
information for weighting prevalence estimates according
to if and who was present during the interview to obtain
more accurate estimates. In both research and clinical
Table 4 Association of third party presence with reports of suicidal behavior in adolescent mental health interviews
Lifetime suicidal ideation Lifetime suicidal plan Lifetime suicidal attempt
OR 95 % CI OR 95 % CI OR 95 % CI
Adult(s) only present 0.66 (0.54–0.81) 0.55 (0.36–0.83) 0.48 (0.30–0.76)
Adult(s) and child(ren)
present
0.49 (0.23–1.03) 0.60 (0.24–1.48) 0.47 (0.16–1.42)
Child(ren) only present 1.09 (0.63–1.86) 0.61 (0.22–1.68) 0.98 (0.42–2.26)
No one present 1.00 1.00 1.00
v2 = 34.14, p \ 0.001 v2 = 11.84, p \ 0.01 v2 = 12.55, p \ 0.01
Regression models adjusted for sex and age
OR Odds ratio, 95 % CI 95 % confidence interval, italic shows significant ORs at p \ 0.05
Table 5 Association of third party presence with reports of childhood adversity in adolescent mental health interviews
Third party presence df v2 p
No one present
(Reference group)
Children only Children and adults Adults only
OR OR 95 % CI OR 95 % CI OR 95 % CI
Parental mental illness 1.00 1.39 (0.82–2.37) 2.14 (1.34–3.41) 1.39 (1.13–1.71) 3 21.82 0.00
Parental substance problems 1.00 1.25 (0.56–2.76) 1.75 (0.83–3.67) 1.08 (0.76–1.53) 3 2.55 0.47
Parental criminal behavior 1.00 2.44 (1.31–4.56) 1.38 (0.64–2.98) 0.95 (0.68–1.33) 3 10.92 0.01
Witnessing family violence 1.00 1.10 (0.71–1.72) 1.05 (0.72–1.53) 0.75 (0.62–0.91) 3 12.23 0.01
Physical abuse 1.00 1.29 (0.78–2.13) 1.32 (0.84–2.07) 0.74 (0.59–0.91) 3 12.33 0.01
Sexual abuse 1.00 1.72 (0.69–4.26) 0.52 (0.14–1.94) 0.69 (0.38–1.27) 3 7.85 0.05
Neglect 1.00 2.23 (1.15–4.31) 0.49 (0.16–1.51) 0.98 (0.74–1.31) 3 14.44 0.00
Parent died 1.00 1.88 (1.05–3.35) 0.69 (0.24–1.96) 0.99 (0.62–1.60) 3 6.31 0.10
Parent divorce 1.00 0.82 (0.50–1.34) 0.93 (0.47–1.85) 0.90 (0.74–1.10) 3 1.37 0.71
Other parent loss 1.00 1.45 (0.74–2.82) 1.11 (0.73–1.70) 0.92 (0.75–1.13) 3 1.95 0.58
Physical illness 1.00 1.33 (0.68–2.58) 1.37 (0.71–2.62) 0.91 (0.63–1.33) 3 4.76 0.19
Economic adversity 1.00 1.24 (0.84–1.83) 1.04 (0.66–1.66) 1.22 (1.01–1.46) 3 6.62 0.09
Regression models adjusted by sex and age
OR Odds ratio, 95 % CI 95 % confidence interval, italic shows significant ORs at p \ 0.05 Childhood adversity (the dependent variable) and privacy levels (the independent variable) are displayed as such for visual ease
J Youth Adolescence (2017) 46:417–428 425
123
settings, these findings can orient the researcher or clinician
interviewing adolescents on whether or not to have a third
party present depending on the type of information one is
assessing in order to obtain less biased information. For
example, it might be beneficial to have a parent present
when assessing ADHD or family financial difficulties, but
if one is assessing PTSD or suicidal behavior one should
attempt a private interview. These findings also suggest
what types of disorders, behaviors and experiences are
more embarrassing or stigmatized in the Mexican adoles-
cent population. Interestingly, mood, most anxiety disor-
ders and alcohol use do not appear to be embarrassing to
these adolescents whereas panic disorder, PTSD, drug use
disorders and suicidal behavior may be. Such information
may be useful in order to target and reduce stigma asso-
ciated to these particular disorders. Finally, adolescents are
at a stage when they have more insight into their internal
feelings and have more information regarding their expe-
riences than other informants, yet may not be motivated to
disclose sensitive information in a clinical setting if they
did not choose to seek services, but rather were brought by
their parents or obliged by their schools, such that this is a
population that may be more affected by third party pres-
ence than those in other stages of life. Therefore, whether
to conduct adolescent mental health interviews alone or in
the presence of others, and the type of third party presence,
should be considered by both researchers and clinicians.
Conclusion
As adolescents develop, they have an increasing sense of
privacy and emotional autonomy (Smetana and Asquith
1994). Adolescents may disclose, partially disclose or even
conceal information that they consider either subject to
punishment or disapproval or not obliged to share (Smetana
et al. 2009). Expanding on prior knowledge of adolescents’
information management with parents and siblings (Cam-
pione-Barr et al. 2015; Chan et al. 2015; Laird et al. 2013;
Tilton-Weaver 2014) and findings regarding adolescent and
parental discrepancies on reports of adolescent risk behav-
iors and mental health (Jensen et al. 1999; Rescorla et al.
2013; Salbach-Andrae et al. 2009; Seiffge-Krenke and
Kollmar 1998), this study finds that, when interviewed by a
stranger, having an adult, child or both present impacts on
adolescents’ disclosure of prudential information. Disclo-
sure depended on the type of third party presence and type
of information solicited. Adolescent disclosure in this study
was most affected by adult presence, increasing disclosure
for a few topics (ADHD, parental mental illness and eco-
nomic adversity) and decreasing disclosure for many topics
(panic disorder, PTSD, drug use and disorder, and suicidal
behavior). Culture may also play a role in adolescents’
information management and this study is unique in pro-
viding insights into the information management of a rep-
resentative sample of adolescent from Mexico City. While a
previous study with Mexican–American adolescents found
that they disclose prudential information to mothers less
than European American adolescents (Yau et al. 2009),
disclosure for particular themes are likely dependent on the
cultural tolerance or acceptance of the behavior or condition
as well as the adolescent’s cultural belief on parent’s rights
to certain domains of information. While adolescent infor-
mation management strategies are normative and even
desirable as a means of gaining emotional autonomy, they
may also interfere with timely detection and treatment or
intervention for mental health conditions and risky behav-
iors. This study contributes an original understanding of
how adolescents manage information regarding sensitive
topics of mental health and health behaviors to a stranger
depending on the presence of third parties, the type of third
party present, and the type of solicited information.
Acknowledgments We thank the WMH staff for assistance with instrumentation and fieldwork.
Authors’ Contributions A.H. participated in the interpretation of the data and drafted the manuscript; C.B. conceived of the study,
coordinated the study, and participated in the drafting of the manu-
script; E.M. participated in the design and performed the statistical
analysis; L.C. coordinated quality control and the acquisition of data.
She received her masters of public mental health from the National
Autonomous University of Mexico; M.E.M.M. participated in the
design and coordination of the study.
Funding The Mexican Adolescent Mental Health Survey was supported by the National Council on Science and Technology and
Ministry of Education grant CONACYT-SEP-SSEDF-2003-CO1-22
and National Council on Science and Technology grant CB-2010-01-
155221 with supplementary support from Fundación Azteca. Writing
of this paper was possible through a U.S. Student Fulbright-Garcı́a
Robles research grant and the Mexico-U.S. Commission for Educa-
tional and Cultural Exchange (COMEXUS).
Conflicts of Interest The authors report no conflict of interests.
Ethical Approval This study was approved by the internal review committee of the National Institute of Psychiatry Ramón de la Fuente
Muñiz.
Human and Animals Rights All procedures performed in studies involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and
with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.
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Aubrey V. Herrera B.S. works at the healthcare technology company Athenahealth in Austin, Texas. She received her Bachelor’s
in Public Health from the University of Texas at Austin following
which she was a recipient of the 2014–2015 Fulbright-Garcı́a Robles
research grant to study adolescent mental health in Mexico City.
Corina Benjet Ph.D. is a researcher at the National Institute of Psychiatry Ramón de la Fuente Muñiz and a professor at the National
Autonomous University of Mexico. She received her doctorate in
psychology from the National Autonomous University of Mexico.
Her research interests include adolescent mental health, psychiatric
epidemiology and the impact of trauma exposure upon mental health.
Enrique Méndez M.S. performs statistical analyses at the National Institute of Psychiatry Ramón de la Fuente. He received his masters of
science in statistics.
Leticia Casanova M.A. is a researcher at the National Institute of Psychiatry Ramón de la Fuente Muñiz. Her research interests include
alcohol abuse and its consequences, psychosocial functioning,
schizophrenia and psychoeducation.
Marı́a Elena Medina-Mora Ph.D. is the director of the National Institute of Psychiatry Ramón de la Fuente Muñiz. She received her
doctorate in psychology from the National Autonomous University of
Mexico. Her research interests include substance use, addiction,
mental health and public policy implications.
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Journal of Youth & Adolescence is a copyright of Springer, 2017. All Rights Reserved.
- How Mental Health Interviews Conducted Alone, in the Presence of an Adult, a Child or Both Affects Adolescents’ Reporting of Psychological Symptoms and Risky Behaviors
- Abstract
- Introduction
- The Current Study
- Methods
- Participants
- Procedures
- Measures
- Socio-Demographic Variables
- Psychiatric Disorder
- Substance Use
- Suidicial Behavior
- Childhood Adversity
- Third Party Presence
- Statistical Analysis
- Results
- Discussion
- Conclusion
- Acknowledgments
- References