This article reviews some of the challenges and pitfalls in communicating with families when abuse is part of the differential diagnosis and offers some suggestions for improving communication with parents and children in these challenging clinical settings.
Key points
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The physician’s role is medical, but medical concerns should always include the patient’s safety and, thus, may include forensics.
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Open-ended questions, structured interviews, and active listening skills help provide accurate information.
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Questions should be phrased as simply as possible and pitched to the developmental level of the person being interviewed, whether adult or child.
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It can be hard for doctors to consider maltreatment by a caregiver in the differential, because to do so appears to sacrifice the partnership between parent and clinician.
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Preconceptions and prejudices interfere with accurate information gathering but are almost universal. Taking a history should begin with self-awareness.
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Clear, accurate documentation of history taking and medical decision making is essential to patient care and allows effective transfer of vital information to other agencies involved in guaranteeing the patient’s safety.
Introduction
There is no such thing as a baby. If you set out to describe a baby, you will find you are describing a baby and someone.
The cooperative partnership of parent and physician in the interest of a child’s health is one of the strengths and joys of pediatric medicine. Interactions with the child’s caregivers, however, can become problematic when medical providers suspect a child may have been abused or neglected. When the doctor is forced to confront the possibility that the child patient may have come to harm through the actions or negligence of a trusted caregiver, trust in the family is shaken, and some difficult conversations lie ahead.
This article reviews some of the challenges and pitfalls in communicating with families when abuse is part of the differential diagnosis and offers some suggestions for improving communication with parents and children in these challenging clinical settings.
Introduction
There is no such thing as a baby. If you set out to describe a baby, you will find you are describing a baby and someone.
The cooperative partnership of parent and physician in the interest of a child’s health is one of the strengths and joys of pediatric medicine. Interactions with the child’s caregivers, however, can become problematic when medical providers suspect a child may have been abused or neglected. When the doctor is forced to confront the possibility that the child patient may have come to harm through the actions or negligence of a trusted caregiver, trust in the family is shaken, and some difficult conversations lie ahead.
This article reviews some of the challenges and pitfalls in communicating with families when abuse is part of the differential diagnosis and offers some suggestions for improving communication with parents and children in these challenging clinical settings.
Taking the history from parents and caregivers when abuse is suspected
When the initial history appears to be at odds with an observed injury, the first step should be to review the history with the caregivers. Beginning with the history of the presenting complaint (injury), the physician needs to know when the child last appeared to be at his or her normal baseline and when after that the child first appeared to be injured. It is useful to ask, “How did you know?” in obtaining this information, distinguishing between what the historian witnessed versus what was told them or deduced logically. It is useful to inquire as to the presence of other witnesses to the event and recording their names if known. To the extent that it is possible, a reliable timeline should be constructed with the caregivers, from the time of the injury event to the child’s arrival in the office or hospital.
It is useful to speak to multiple caregivers separately. This separation allows for a comparison of the histories provided and helps to minimize coercion by allowing shy or intimidated witnesses to speak freely.
A thorough review of systems and past medical history may prompt the family to recall other, earlier symptoms and can identify conditions that may prove pertinent to the diagnosis or to subsequent care. Finally, family and social history will help place the child’s history in proper context, identifying sources of support and sometimes areas of vulnerability.
When informing the family of the decision to report the case to Children’s Protective Services (CPS) or to law enforcement, it is important to be mindful of the effect of this decision on the family and to treat it as an important discussion. The decision to report should be disclosed respectfully but firmly, along with the reasons for the report. It may help to explain that medical providers are required by law to notify the authorities of any inadequately explained injury that occurs to a child. There is widespread confusion and misapprehension about the role and the workings of CPS, and this conversation is a good time to help the family understand what happens next, again, explaining that medical providers work with CPS and police agencies to gather information that may help in our diagnosis and treatment, for example, they can interview others outside of the hospital or visit the scene of the incident. This conversation is a good time to point out that the common goal of parents and professionals is to provide for the child’s safety and to prevent future injury.
The art of asking
Although knowing what to ask is obviously necessary, it is equally important to know how to ask the questions to best encourage the free exchange of accurate information. The conversations that ensue after a suspicious injury, especially when there is suspicion of abuse, can be highly emotional for both parties, but the information gathered may be essential to making an accurate diagnosis. It can be helpful to plan the sequence of the interview in advance.
One Recommended Sequence for Conducting the Interview
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Introduce yourself , and clarify your medical role in caring for the patient. Identify and acknowledge each person in the room, including each child. If possible, sit down and help put the others at ease.
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Establish rapport by showing concern for the family’s welfare and immediate needs. Take some time to gather an impression of their communication and coping skills and their emotional states. Useful questions on meeting a family for the first time might be, “What have you been told so far?” and “What do you know about the injuries?” Such questions begin a discussion of the injuries and establish the questioner in the appropriate role of a helpful expert. They also frame the discussion properly: as an attempt to provide the best possible health care for the child by obtaining all the available, accurate information.
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Gather information , beginning with the chief complaint or presenting injury, using open-ended questions whenever possible and avoiding judgments (see later discussion). In obtaining information about the presenting complaint, the clinician should always remember that each caregiver usually will have a different perspective on the events, and attempts should be made to speak to each separately to facilitate free conversation and to assess concordance in their accounts.
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Learn about the patient , including medical history; a review of systems; and educational, social, and family histories. Any information may prove valuable in evaluating possible abuse. Preexisting medical conditions may render a child more fragile and more susceptible to injury after accidental trauma. School or discipline problems may reflect a stressful environment. A social history may suggest other possible perpetrators of abuse or identify positive factors for recovery after trauma. To paraphrase Sir William Osler, it is as important to know which patient has been injured as it is to know which injury the patient has.
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Close with the family . It is at this stage that the examiner may need to respectfully explain that maltreatment is being considered, and why. Discrepant histories and inexplicable injuries can be reviewed in the context of difficulty in making a medical diagnosis. Parents can be reminded that law requires that medical providers consult with CPS whenever an injury is medically inexplicable. The decision to report should be explained in the light of the legal mandate and the necessity of gathering more information than is available in the medical setting. True closure also implies giving the family time and opportunity to react to the decision and helping them process the information. If appropriate, explain the next steps anticipated in medical care and when you expect to see them again. Provide a means to contact the appropriate medical provider if more information becomes available.
First Principles of Interviewing
In proceeding through a sequence like the one above, it is helpful to remember a few basic principles.
Listen before talking
An oft-cited axiom in the medical profession is that “They don’t care how much you know until they know how much you care.” Parents of injured children can be expected to experience anxiety, often extreme, as well as uncertainty, fear, and, in some cases, guilt. They may well find it difficult to organize their own thoughts, let alone understand and answer questions, until they have had time to give voice to their concerns. Opening with a sympathetic query (“A workup like this can be pretty overwhelming. I’d like to help. What’s going through your mind right now?”) can serve to open the door while offering comfort to stressed parents.
This invitation to share, coupled with a demonstration of sympathy, serves an additional purpose: by opening a conversation, the physician has an opportunity to assess important characteristics of the caregiver. These include emotional state and emotional relationship with the child, facility with language, and cognitive ability, all characteristics that are relevant to the evaluation.
It is useful, as information is obtained, to pause and reflect on what has been said. Pausing to verbally summarize and allow the others to affirm what has been said allows the interviewer to demonstrate mutual understanding.
Don’t answer your own questions
Interviewing necessitates asking questions, but not all questions are equally useful. Ideally, queries to caregivers will invite them to tell their historical narrative in their own words. Optimal questions that will elicit this narrative are termed open-ended questions, in that they do not limit the response options. Examples of open-ended questions include “What happened next?” or a request to “Tell me more about that.” Research shows that beginning an interview with open-ended questions leads to more information.
A more restrictive form, common in medical interviews, is the restrictive (yes-or-no) question. In a yes-or-no format, the question allows only 2 possible options. This form of questioning allows the interviewee to choose an answer but does not invite a narrative that could provide richer information. For example, a 6-year-old being interviewed about possible sexual abuse might be asked “Did he have his pants on or off?” and find herself unable to describe an assailant who left the trousers on, but unzipped. Similarly, “Has your husband ever hit you like this before?” will usually obtain less information than the similar “Have you and your husband been having problems?”
The most restrictive class of questions is known as leading questions, in which the interviewee is asked to endorse a proffered version of the events. Usually seen in legal cross-examination, it takes the form “X is true, isn’t it?” Interviewers who feel sure of an answer often tend to fall back on this mode (“That must have hurt, huh?” or “She’s had all her shots, hasn’t she?”), often to save time, but leading questions pose considerable danger of introducing bias. This bias can result from the interviewer’s closing the door to other possible scenarios and from suggestibility and a desire to please on the part of the interviewee.
It can be difficult, and sometimes impossible, to conduct an interview using only open-ended questions, and most interviewers will occasionally resort to more restrictive formats. In these instances, however, it is advisable to open the format as soon as possible for fear of restricting the quality of the information obtained. For instance, a directed question such as “Did she fall off the bed?” would be followed immediately by the more open “Tell me more about that.”
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