One of the most difficult aspects of dealing with cases of possible child maltreatment involves communicating with the caregivers of the child. Common questions that medical providers ask themselves when dealing with potential child abuse cases are, “Am I talking with a perpetrator?” “How do I take this history without getting angry?” “I’m not sure this is abuse—what do I do now?” “How do I ask these questions without making this parent angry or defensive?” Further complicating the issue are questions about the medical provider’s role in the interviewing process. What questions do medical providers need to ask? What questions are best left for police and child protection investigators? More has been written about the interview of children in suspected abuse cases than about interviewing caregivers. The purpose of this chapter is to attempt to answer the above questions and to provide some practical tips and suggestions for communicating with caregivers in suspected maltreatment cases. Figure 8-1 illustrates an approach to the child maltreatment caregiver interview and summarizes the information in this chapter.
The volume of research about the assessment and diagnosis of child maltreatment has increased dramatically over the past 4 decades. However, there remains little research or guidance about best practices for the medical provider who interviews caregivers. Consequently, the information in this chapter is more practical and experience-based, although supportive research is cited when available.
The Pediatric History before Concern for Maltreatment
The first stage of the caregiver interview occurs before the medical provider has become concerned about the possibility of child maltreatment. During this time, the provider is obtaining a routine history during a well checkup or illness visit. Most important during this stage is asking the right screening questions that optimize the likelihood of recognizing maltreatment when it has occurred. It is rare to have “child abuse” as the chief complaint. More common presenting complaints are “fussiness,” “vomiting,” “fell off couch,” “starting to wet the bed at night,” or “no concerns—here for school physical,” among others. These routine patient encounters are sometimes the only opportunity to recognize the warning signs of child maltreatment. The first and most important key to recognition is to keep child maltreatment (including physical abuse, sexual abuse, and neglect) in the differential diagnosis for every patient and every visit. As the common maxim goes, “You see what you look for, and you look for what you know.”
Recognizing Red Flags During the History and Examination
When a nonverbal patient has an obvious injury, regardless of whether the injury is the reason for the visit, medical providers need to obtain enough detail to determine if the history is concerning for maltreatment and to document the explanation in case it changes or is later questioned. It is most helpful to do this matter-of-factly. The tone for this type of questioning can vary based on the setting, the reason for the visit, and the depth of the relationship between the provider and the caregiver. For example, at times, a routine, “What happened here?” is the most direct and appropriate way to systematically assess skin findings. In other situations, particularly if the caregiver is defensive, a less formal tone can help with rapport. In this way, medical providers can gather basic information about the injury. They can quickly find out how, where, and when the injury occurred, and who the child was with at the time.
Oftentimes, the information is clearly consistent with the injury. It is particularly reassuring when caregivers report that other adults witnessed the injury. Sometimes, however, red flags begin to appear ( Table 8-1 ). The history may not be consistent with the developmental ability of the child (an 8-month-old who turned on the hot water), the injuries may be too severe or too numerous to be explained by the history (bilateral depressed skull fractures after a roll off a couch onto carpeted flooring), or there may be no history of trauma offered (“I don’t know … he just woke up one morning not using that arm.”) Sometimes a patient does not have a visible injury but with a chief complaint (will not stop crying), history (an apparent life-threatening event), pattern of behavior (precocious sexual behavior), or physical finding (limp) that can be consistent with occult injury or abuse. Although some behaviors may not be independently diagnostic of maltreatment, such symptoms should heighten awareness of that possibility and prompt further questioning and evaluation.
| Current History |
|
| Symptoms |
|
| Past Medical History |
|
| Social History |
|
| Physical Examination |
| Infants |
|
| Any Age Child |
|
Important Interactional Cues and Behavioral Observations
In addition to the history and physical examination, medical providers must also pay attention to the interaction, or lack thereof, between the caregiver and the child. Table 8-2 lists some common behavioral cues that can be indicators of abuse or neglect. Observation and documentation of these subtle findings is important supporting information if a case is being formally investigated.
|
Separation of Caregiver from the Child for the Interview
Interviewing the caregiver out of the child’s presence is necessary if the child is verbal, the subject matter seems inappropriate for the child to hear, or if the caregiver merely appears to be uncomfortable discussing the issue in front of the child. It is also preferable for the child and caretaker to be interviewed separately to prevent any real or perceived coercion or leading of the verbal child. If separation from the caregiver appears to be difficult for the child, then an alternative is to bring another adult into the room to attempt to distract the child while the history is being obtained. For example, after the history and physical for an adolescent or preadolescent, the provider could say, “Mrs. Jones, Sally is getting old enough now that I’d like to have a minute or two to speak with her privately. It gives her a chance to ask me any questions that she might be embarrassed to ask in front of you, and it helps start to prepare her for that day (too soon!) when she’ll be grown up and coming to the doctor on her own.”
For every well check, and as often as possible during illness visits, verbal children should be asked privately, “Do you feel safe at home?” This is a key screening question not only for child maltreatment, but also for identifying other issues such as domestic violence, a dangerous neighborhood, an out-of-control sibling, or a chaotic home environment.
Beware of Bias
While much has been written about risk factors associated with child abuse, the absence of risk factors does not imply the absence of risk. Similarly, the presence of risk factors does not necessarily mean that abuse has occurred. , Child maltreatment does not discriminate among socioeconomic level, education level, geography, or ethnicity. Research has shown that the most likely cases of abusive head injury to be missed by medical professionals involve Caucasian, middle-class, intact families, a profile that also describes most medical professionals in America. It is natural to have opinions and biases. The clinician that is unaware of these biases may have misconceptions and provide less-than-optimal care for patients. Therefore, medical providers must be self-aware and unwavering in their commitment to objectively evaluate every child and every family, regardless of where the family lives, what language they speak, or how many years of education they have.
The Detailed Interview Once There is Concern for Abuse
After the general history, the second stage of the interview occurs after the provider has developed concern for abuse ( Figure 8-1 ). During this stage, questions are asked that help determine the likelihood of abuse. The assessment for child maltreatment is similar to any other clinical assessment in that questions are asked and the physical examination is performed to establish a differential diagnosis. The following section addresses the process of gathering information sensitively from caregivers once child maltreatment is being seriously considered.
First Things First
Once child maltreatment has become a distinct possibility, it is often overwhelming for medical providers to decide how to proceed. Several factors should be considered to determine the next steps in the process. For example, is a potential perpetrator present, and if so, how is the safety of the child ensured while the workup proceeds? Does the medical provider ask more questions now, or send the child elsewhere for further evaluation? For many providers, it is necessary to step out of the room to gather thoughts and consider options. This is often an appropriate time to briefly consult with peers, supervisors, or local child protection experts. Some medical disciplines have published guidelines to address the specific role of the medical provider in forensic matters, , but the subtleties of these interactions remain challenging for the majority of providers.
Table 8-3 summarizes the major themes that need to be addressed during patient encounters once it is concerning that the patient might also be a victim. By systematically and deliberately addressing all of these themes, medical providers can feel confident that they have appropriately fulfilled their role in the assessment of suspected child maltreatment.
|
Rapport
While some patients may have clear-cut abuse, usually the evidence will be less clear and information from the caregiver will be essential to make an appropriate assessment of the case. Additionally, it might be unclear or unknown if the person who has brought the child for medical care is the abuser, a witness to the abuse, or is unaware or uninvolved. Sometimes it is impossible to determine this during the interview. An effective rapport with the child’s caretaker is essential to gathering information that can clarify specifics of an abusive event or situation. Medical providers are often in the unique position of being the first nonperpetrator to recognize that maltreatment has occurred. , This provides an opportunity to record spontaneous responses to questions before the interview becomes rehearsed, altered, or guarded.
Often the most difficult aspect of developing this rapport involves overcoming feelings of anger or suspicion toward the caregivers or the situation in general. It is helpful to remember that the caregiver coming with the child is not necessarily the perpetrator and might be completely unaware of the true history. No harm is ever done when a medical provider is kind to a potential perpetrator. In fact, building rapport can allow the opportunity to obtain crucial detail about an event. Irreparable harm is done, however, when nonperpetrators feel judged or criminalized by medical providers.
The degree of rapport that can be built or maintained is dependent on many factors. The length of the relationship between the medical provider and the family, the setting in which the encounter occurs, and the severity or urgency of the presenting complaint all play a role. Inevitably, regardless of the setting or the relationship between the medical provider and the family, cases of suspected child maltreatment are time-consuming and usually unexpected. Whenever possible, arrangements should be made as soon as possible to allow the medical provider to spend the necessary time to appropriately evaluate and care for the patient. This might involve rescheduling later patients, calling in assistance, or notifying office staff that there will be a significant delay for subsequent patient visits. If the provider is in a situation where there is a child abuse medical consultation service, this service can also be a resource to help obtain a complete and timely history and workup. ,
Separation of Caregivers from One Another for the Interview
Separation of caregivers from one another during the interview is often impossible in the medical setting if rapport is to be maintained. In many cases, this technique is best reserved for law enforcement or child protection investigators, or at times, child abuse medical specialists. However, if it is practical or easily achievable (for example, one caregiver accompanies the child to radiology while the other stays to talk with the medical provider), this is always preferred for obtaining a spontaneous history. This is also the only acceptable way to screen for domestic violence. Screening questions about feeling safe at home or physical violence in the home should not be asked in front of a potentially abusive partner or caregiver.
Key Details to Ask
Several key areas are important to address in the medical interview with caregivers. Table 8-4 summarizes the areas that should be covered during the history in most abuse or neglect cases. This information serves the purpose of establishing a timeline of events and list of people involved with the child. If the person providing the history is the perpetrator, gathering this information allows for clear documentation of the initial timeline and details provided, should those details change later. Subsequent sections of this chapter provide questions that relate more specifically to the characteristics of the injury or maltreatment.
