Forensic (Investigative) Interviews

In recent years, the focus of the criminal and civil justice systems on the forensic interview process has increased substantially, particularly for child sexual abuse investigations. In some states, child protective services are required by law to audiotape or videotape the investigative interviews conducted with children. In general, videotape has been preferred to audiotape so that the child’s facial expressions, body language, and demeanor are recorded along with their words. Ideally, the forensic interview is conducted in a neutral, child-friendly environment such as a children’s advocacy center where all professionals that require investigative information can watch and listen to the interview from a nearby observation room. This process prevents unnecessary multiple interviews while ensuring that the information needs of all the agencies involved are met.

Forensic interviewers are required to undergo specialized training. This individual may be a child protective services worker, a law enforcement professional, or an employee of a children’s advocacy center. Regardless of who conducts the interview, other investigative and sometimes prosecutorial professionals involved in the case are usually present in the observation room (and are usually seated behind a one-way mirror) during the interview. While children younger than 12 years old are usually videotaped or recorded, protocols and mandates vary when children are 12 years and older. Older children can provide written statements, verbal statements that are transcribed and signed, or can be videotaped.

Videotaped forensic interviews of children are frequently used as evidence in grand jury proceedings, and these interviews also can assist investigators during questioning of alleged perpetrators. In some circumstances, the videotape is introduced during civil and/or criminal court proceedings, although the availability of a videotaped interview does not preclude a child from being required to testify during the trial.

Investigative protocols have been developed to guide interviewers in “best practices.” One of these protocols, developed by the National Institute of Child Health and Human Development (NICHD) has been widely used for more than 10 years for investigative interviews of children who are suspected victims of either physical or sexual abuse. This protocol provides guidelines for consecutive phases of the interview: The introductory phase where ground rules and expectations are established; a rapport-building phase that includes the child’s description of a neutral event; and a substantive phase consisting of open-ended questions followed by focused or clarifying questions about the abuse. A study that evaluated the effectiveness of the NICHD protocol found that “open-ended invitations” yielded more details from children than focused questions and nonprotocol interviews, but the total number of details elicited did not differ significantly among these various approaches.

Investigative interviews may occur before or following the medical examination, depending on the circumstances of the specific case, including whether the child has already made a disclosure and where the child first presents with statements or symptoms of abuse. The history taken by a medical professional sometimes provides additional information the child might not have disclosed to the forensic interviewer, and might represent important corraborative evidence regarding the validity of the child’s history. From one jurisdiction to another, procedures vary in the types of professionals that interview children, and whether the forensic interviews precede, follow, or are a part of medical examinations. Regardless of the agreed-upon local protocols and procedures, the overarching goal common to all disciplines is to protect the child and preserve important information throughout the investigative process.

Importance of the Medical History

As with any medical assessment, a patient’s history, including physical and behavioral symptoms, descriptions of events that may have affected medical and mental health, and social, family, and past medical and surgical histories, are fundamental to the diagnosis and treatment of the patient. Such information should be gathered from the parent and child when possible. A primary difference from general pediatric/clinical practice is the need to interview the child and parent separately when abuse is suspected to minimize influences on the child’s history. Some children and adolescents may withhold hurtful, intimate details of abuse in the presence of their parents if they fear disapproval, distress, or disbelief.

The role of the child’s medical history in the diagnosis of abuse often varies by the type of abuse. For example, the diagnosis of sexual abuse is primarily based on the child’s history, and frequently there are no additional findings on physical examination. Examples of other medical diagnoses that are made based primarily on patient history are migraine headaches, seizures, and depression. In these cases, the idiosyncratic, experiential details provided by the patient establish the diagnosis. The diagnosis of physical abuse depends on the compatibility of the history (timing, mechanism of injury, symptoms of child, motor capabilities of child) with the characteristics of the child’s injury(s). Unlike other medical diagnoses, the child’s history is often discrepant from the parent’s history, particularly when the parent is the abuser. Alternatively, the child may provide a vague or evasive history regarding their injury (or injuries) if they are trying to protect the abuser or they fear the consequences of disclosing abuse.

Neglect in a medical setting usually involves preverbal children and observable compromises in the child’s health or safety, attributable to some extent to inadequate parental care. In cases of neglect, the parent might deny, minimize, or claim ignorance about the child’s condition. The diagnosis of neglect in young children and infants often depends upon an assessment of the parent’s understanding of the child’s medical condition and the extent to which the severity of the condition is attributable to parental causes. The medical history often focuses on the parent’s ability and willingness to assume appropriate responsibility for ensuring that the basic needs of their child are met.

Of the types of evidence and information that can be collected during the medical assessment for suspected abuse, the history is usually the most important evidence. In most cases of child sexual abuse or assault, other types of evidence—semen/sperm, anogenital or bodily injuries, and sexually transmitted diseases—will not be present. Not all clinicians have the training or the luxury of time to conduct extensive interviews of children, but that should not preclude the clinician obtaining a medical history from the patient and/or family, sufficient for the performance of the medical evaluation.

Advantages to clinician interviews include:

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  It helps establish rapport with the child, facilitating child relaxation and cooperation during the examination.

  
  
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  Children generally see the physician as someone who helps them. This perception may facilitate disclosure of additional information not obtained by child protective services or law enforcement officers, whose role may be unknown or threatening to the child.

  
  
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  A normal examination, taken in isolation from historical facts, can sometimes be misconstrued by the legal and lay community as meaning “nothing happened,” thus the inclusion of the clinician’s interview findings might improve the overall accuracy and effectiveness of the presentation of the medical assessment in court proceedings.

Disadvantages of extensive clinician interviews include time and inconvenience. Difficult interviews can take up to 1 hour. Most clinicians in private practice or in an emergency room setting are rarely able to set aside that much time on short notice. In addition, child abuse may provoke anger and even denial in some professionals. The medico-legal implications of diagnosing child abuse and the possibility of testimony and adversarial interactions in court are added disadvantages for some clinicians.

Decisions regarding how much and what type of information to gather from suspected victims of child abuse are clearly dependent upon each physician’s personal preferences, availability of time, and access to other resources of assistance.

Legal Considerations

There are specific circumstances under which a medical professional may testify about the medical history gathered from the child in abuse evaluations, including:

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  Outcry witness. If the professional is the first person over the age of 18 years that the child has disclosed abuse to, then that person is the “outcry witness” and may testify as to what the child told him or her.

  
  
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  Hearsay exception: medical diagnosis and treatment. If the medical professional is asking the child for information important for medical diagnosis and treatment, then the medical professional may testify as to what the child told him or her and the medical records are sometimes admitted into evidence and can be reviewed by the judge or jury.

  
  
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  Hearsay exception: excited utterance. If the child suddenly discloses new information to a person because of the unique nature of the circumstances (i.e., disclosing sexual abuse during a genital examination or while testing for genital infections), the child’s statements to the professional can be presented during testimony.

Factors that Impact Patterns of Disclosure

It is common for children to not disclose their abuse. In one study of more than 26,000 children investigated for abuse, disclosure rate for cases of sexual abuse was 71% and for cases of physical abuse was 61%. However, retrospective studies of adults who were sexually abused as children indicate that only 30% to 40% recall ever disclosing their abuse as a child. Adult survivors of child sexual abuse do report periods of time when the abuse is forgotten, and then independently recalled. Other reasons for nondisclosure include denial, reticence, and lack of conceptual understanding of the abuse. In one study, the self-reports of 10 children were compared with the videotapes of their sexual abuse by one perpetrator. The videotapes of 102 incidents of sexual abuse involving these children (mean age 5.6 years) were compared with their statements, which were taken 3 to 23 months after the last incident of abuse (mean age 6.9 years). Every incident of sexual abuse that each child described was corroborated by video. However, three children did not disclose abuse and denials were correlated with a greater number of abusive incidents. Even with the use of confrontational interview techniques, leading questions, and accusatory suggestions, the abused children in this study denied or minimized their experiences. Two children in this study indicated they tried to actively forget the abuse, and another was described as having “childhood amnesia.” As with many clinical situations, when the child indicates they “don’t remember” the abuse, it is difficult to determine whether the memory is truly not accessible or whether the child is offering a deterrent because they do not want to talk about the traumatic event.

When disclosure does occur, it is often delayed, with up to 75% of sexually abused children waiting at least 1 year before telling someone about their abuse. A national survey study of 288 women who experienced child sexual abuse revealed that 28% never disclosed and 47% waited more than 5 years to disclose. Another survey study found a 2.3 year average delay in child sexual abuse disclosures; median time to disclosure was 6 months, indicating a wide range of reported disclosure intervals. Reasons for nondisclosure and delay in disclosure are multifactorial, and include the child’s fear of consequences, interpretation of the abuse, and attribution of blame. These factors additionally are modulated by the child’s gender and age, the relationship between the child and abuser, threats made by the abuser, and the child’s perception of support for their disclosure.

A number of studies have examined the effects of gender and age on children’s disclosure of abuse. Boys are generally more reluctant to disclose abuse, especially sexual abuse, than girls, but gender differences are not consistent and vary by type of abuse as well. Boys are thought to have higher levels of shame and embarrassment due to fears of being stigmatized as victims or homosexuals. In addition, boys sexually abused by older women sometimes mistakenly view the abuse as desirable and minimize or deny their experience. Perpetrators often prey upon gender-specific vulnerabilities in children by suggesting that the abusive experiences are enjoyable and a privilege for the child.

Numerous studies have indicated a relationship between victim age and disclosure. Younger victims are generally less likely to disclose. This tendency holds for physical and sexual abuse, although one study found that older children delayed disclosures longer than younger children because they understood and feared the consequences. Low rates of disclosure in very young children can occur because interview protocols do not prompt the abuse statement or memory in a young child. Unfounded suspicions may be disproportionately higher in this age group compared with older children. Alternatively, younger children might be more easily coerced and deceived into silence by their abusers, especially because they are more likely to think they are responsible for, or have somehow caused, their own abuse. Alternatively, they may be more susceptible to perpetrator tactics for maintaining secrecy.

Developmental considerations, such as children’s relationships with family and peers, also impact their tendencies to disclose. For example, preschool and school-age children tend to become strongly attached to their mother and father, and the preservation of the family’s happiness and stability is a high priority. Once they reach adolescence, peer approval and intimacy may supersede close parental bonds, so that disclosure of parental abuse might be more likely; this developmental shift might explain why some disclosures occur during arguments between adolescents and their parents, and why older adolescents (ages 14-17) are more likely to tell peers about sexual abuse while younger children are more likely to tell adults.

Certainly, older children and adolescents are cognizant of the consequences of disclosure of abuse and often fear consequences for themselves, the perpetrator, and other family members. ^, Their fears often stem directly from the threats of the abuser. Such threats may include breaking up the family, placement in foster care, punishment, and being responsible for the abuser’s incarceration. Children victimized by family members living in the same house are more likely to be affected by these threats, supporting the finding that victims of parents or parental figures are more likely to delay or withhold disclosure, especially when the abuse is sexual. Hershkovitz et al found that victims of sexual abuse were more likely than victims of physical abuse to disclose and surmised that this difference was primarily attributable to the predominance of family member perpetrators of physical abuse when compared with sexual abuse. Children are explicitly entrusted with the integrity of the family when they are told their disclosure could destroy everything. Nondisclosure and longer delays in disclosure are more likely when the abuser is a family member rather than a nonfamily member. ^, Socioeconomic and cultural factors can also influence disclosure; among some Mexican-American cultures the girl’s quincenara , a celebration of impending womanhood on her fifteenth birthday, is provided only if the girl is chaste and a virgin. Girls in families that place high values on virginity and chastity until marriage are often reluctant to disclose abuse and risk the anticipated disappointment of their families. Isolation and lack of community security as seen in populations affected by discrimination, migration and poverty, are potential deterrents to disclose abuse. ^, Another study found that sexually abused children that never lived with both parents were less likely to disclose their abuse, and those that lived with family members that abused drugs were more likely to disclose promptly. While the latter finding appears counterintuitive, the author proposed that abused children in dysfunctional families may have stronger peer bonds, facilitating disclosure to their friends.

Children are also protective of their abusers, which affects the tendency and type of disclosure they are willing to provide. In a study of 47 children whose sexual abuse was corroborated by perpetrator confession, 14% indicated they had been in love with the perpetrator and to some degree enjoyed the abuse experiences. One third of these children voluntarily returned to the abuser or took the initiative in sexual activities. As might be anticipated, those children who were attracted to or protective of their abusers had a longer delay in disclosure (mean 40 months) compared with victims who were not attracted to their abuser (mean 8 months). Even when children are not attracted to their abuser, they may still value the nonabusive components of their relationship and be reluctant to jeopardize the loss of that component by disclosing.

Abusers who reside in the home and who are demonstrably violent with others can effectively silence their child and adult victims with threats of harm should they disclose abuse. Children with families characterized by intimate partner abuse, substance abuse, and ineffective parent-child bonding are less likely to perceive support for their disclosures and therefore less likely to disclose. Abusive corporal punishment of children often occurs in homes where intimate partner abuse occurs, but is often discovered when injuries are visible, not when the child discloses. In contrast to sexual abuse, victims of physical abuse tend to accommodate this practice, interpreting it as discipline rather than abuse. In general, children are more likely to disclose if they perceive their parents are supportive rather than skeptical of their disclosure; one study found that 63% of children with supportive parents disclosed sexual abuse during their initial interview compared with only 17% of children whose caretakers were skeptical. In another study of 41 adult survivors of child sexual abuse, most of the victims who disclosed to their mother perceived a hostile or indifferent reaction. While it is unknown whether the parents in these circumstances were actually supportive or believing of the children, it is the children’s perception of support that ultimately influences their tendency to disclose.

Custody issues present unique challenges when abuse allegations arise. The number of sexual abuse reports arising from families involved in custody disputes do not differ significantly from those reported in families without custody disputes. Children and adolescents do sometimes make false allegations of abuse. In a study of 576 child sexual abuse cases, 1.4% involved false allegations. In another review of 551 child sexual abuse cases, there were 14 (2.5%) false reports; eight were false allegations by the child, 3 were false reports made in collusion with a parent, and 3 involved confusion or misinterpretation by the child. It is important for the clinician to conduct unbiased and complete assessments of any child with a clear outcry of abuse, keeping in mind that while situations might be exaggerated or fabricated in particularly contentious child custody cases, separation of a child from their abuser can also prompt disclosure of valid abuse.

Given the various factors impacting the likelihood and timing of abuse disclosure by the child, it is not surprising that children may make partial (also referred to as “incremental”) disclosures or full disclosures of abuse, and may recant part or all of their history depending on the responses following disclosure. Recantation rates for child sexual abuse range from 4% to 22%. In one study, 92% of the cases involving recantation of child sexual abuse were reaffirmed over a period of time. The clinician might interview the child early in the investigation before consequences of disclosure have occurred, or might interview the child later in the investigation, after investigators and family members have responded to the child’s outcry. If the child perceives the responses as supportive, the medical history is more likely to reflect a full disclosure. Other times, the child victim can become alarmed by the response of their parent and become reluctant to provide further details. The clinician should have a sense of the factors that impact the child’s history. If the child recants or appears to provide a partial history, the clinician should document observations that support retraction and conduct an examination that addresses suspected types of abuse, even if the child is recanting or minimizing their initial statement. For example, the medical examination of an 8-year-old child who recants a statement of vaginal-penile contact by her stepfather and whose mother chooses to believe the child is lying should include testing for sexually transmitted infections.

Clinical Approach to the Medical History

Because the information gathered can be forensically significant and children experience considerable anxiety in discussing their abuse, the clinician’s medical history encompasses several priorities, including the need to ask questions in a developmentally appropriate and forensically sound manner, and the provision of a neutral but appropriately supportive setting that optimizes the child’s ability to share information about sensitive topics. As the interview progresses, the clinician sometimes needs to adjust his or her approach as the child’s developmental capabilities and barriers to disclosure become more evident. These skills require knowledge of child development and appropriate interview approaches.

Language Acquisition and Development in Children ( Table 7-2 )

Clinicians should be well informed on how to interview children and adolescents of various ages and stages of development. In general, preschool children often are not capable of consistently understanding and appropriately responding to the kinds of questions asked during a medical history for suspected abuse. While they do respond well to directive yes/no questions such as, “Did anyone touch your private parts?” or “Has anyone ever hit you in the face?,” their responses are difficult to verify. Younger children under the age of 6 years tend to provide less information spontaneously but do retain accurate memories. However, they are more susceptible to highly leading and suggestive questions than children older than 6 years, so it is particularly important to ask nonsuggestive questions such as, “How did you get that bruise?” rather than “Who hurt you there?” Young children have shorter attention spans, so medical histories should be generally no longer than 20 minutes. In general, children are able to understand and respond appropriately to questions between the ages of 4 and 5 years.

Table 7-2

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