Pediatric Clinics of North America, Vol. 37, No.4, August 1990, 943-954.
Pediatric Interview Assessment of Child Abuse
Challenges and Opportunities
Eli H. Newberger, MD
Director, Family Development Program, The Children’s Hospital, Boston, Massachusetts
The increasing visibility of child abuse and family violence presents for child health professionals a novel and exciting set of challenges. These include parental requests to examine children for signs of sexual abuse, subpoenas from attorneys to testify in court in conflicts about children’s custody, invitations to consult to child care programs about how to protect children from victimization, and telephone calls from school teachers and administrators who have heard new disclosures of sexual abuse from their students. Central to the health professional’s role is the orderly and systematic assessment of allegations and reports of victimization. The task of this article is to describe the principles of practice as they have evolved into the last decade of the century, based on an understanding of the current context of family violence and a review of the techniques and ethics of communication with parents, children, and other members of the professional community.
CONTEXT OF CHILD ABUSE ASSESSMENT
The last decade has seen a transformation in the way we give care to children in the United States. With more than a million marriages ending in divorce each year, each including on average at least one child, and with dramatically increasing numbers of single-parent families, nearly all headed by women, a substantial decline has occurred in the economic and social status of women and children.16 This is because most fathers do not pay the child support that they are supposed to pay, and because of several converging impacts of governmental policy: State and federal welfare programs have not kept pace with inflation; housing costs have outstripped inflation (minimum wage employment is now insufficient to bring a family within federal poverty lines); and government support has been cut for programs that pay for child care.12 These harsh realities of family life, which, because of their particular impact on women have been characterized as the “feminization of poverty,” are associated with immense increases in the participation of mothers in the work force, so that now more than one half of women with children younger than 3 years of age are working. In the absence of affordable, quality child care, most women have no choice but to create patchwork child care arrangements, leaving children with relatives, boyfriends, and other day care providers, often for short periods in the course of the working day. Many of the most serious cases of physical and sexual abuse that now come to light are inflicted by partners in recently formed families and by teenaged friends of families where children are given day care.
Conflicts about children’s custody and visitation frequently now include allegations of neglect or sexual abuse, and the health professional’s diagnostic services are often sought as lawyers and courts try to make sense of allegations that are nearly always denied by the accused parties. Such is the nature of the adversarial court system that some of these allegations seem even to be inspired by aggressive counsel seeking more powerful weapons with which to damage the opposing side and to wrest a better property settlement.
Parallel to these changes in the way care is given to children is an increasing trend toward the criminalization of family violence. This trend toward a policy that favors punishment over help derives in part from the increasing visibility of battered women and victims of child sexual abuse.13 Such problems are now widely appreciated as crimes, and in most jurisdictions, these cases are processed through the criminal system. For professionals in the health service sector, this means that often a prosecutor is waiting in the wings to find out whether the medical data will support a criminal case against an alleged offender.
It is perhaps then not surprising that many child health professionals are reluctant to become involved in these complex and often litigious matters, for which they may not be sufficiently prepared, which may consume a substantial amount of time (in the office and at court), and for which they may not receive a sufficient reimbursement. We are also hesitant to draw value judgments about people, especially when they may lead to criminal convictions.
Newer knowledge on the prevalence of the various forms of family violence suggests that these are far more frequent phenomena than we could have imagined a decade ago, with estimates of sexual abuse ranging to 27% of girls and 16% of boys in a recent survey,4 with many cases in middle- and upper-class homes. Child physical abuse and the abuse of women are estimated to affect between 2% and 10% of children, and up to 37% of women seeking divorce.5, 6, 17 It is thus certain that we will see these children and parents in our work. Whether and how we respond to them also appears to have important implications for their subsequent health and development.3, 14 Both physical abuse and sexual abuse are now understood to carry with them substantial and continuing developmental and psychological risks. These have been summarized in recent reviews.1, 19 Children’s exposure to their mothers being beaten also appears to have important developmental consequences, not dissimilar to the experience of being victimized themselves.9 Indeed, a study of a national sample of representative American families suggested that men who beat their wives were more likely to have watched their own mothers being beaten in childhood than they were to have been physically abused themselves.17
PRINCIPLES OF DIAGNOSTIC ASSESSMENT
At a time of shortened social services and of increasing visibility of family violence, it is often the medical office or pediatric emergency department that serves as the portal of entry into the service system. Physicians and their colleagues are often the first professionals to whom mothers will turn—for example, when they become concerned about the possibility of sexual abuse. It is important to note that many families in which victimization occurs are isolated from kin and other supports, and a visit to a health provider may be a rare occasion of reaching out for help by a family that may have few other resources available.
Medical Interview as Bridge to Other Services
It is important then to see the initial interview as both an opportunity to gather data to inform the physical examination and subsequent laboratory studies and other treatments, and as a way of establishing a relationship with parent and child. This relationship can be an important bridge to other services to assure that the child will be protected and that the family is given helpful services and appropriate interventions to assure that the victimization will not recur.
Necessity of Understanding Child Abuse Reporting Obligations
Familiarity with the child abuse reporting statutes and with the relationships between the protective services agencies and the prosecutor are essential as one contemplates how one’s data may be used, and how one’s findings and conclusions may be employed by the agencies assigned the legal task of protecting children and assuring that the people who have offended against them will no longer do so. It is often helpful to have available a knowledgeable legal consultant and an expert on child abuse diagnosis and treatment; it should also be possible often to establish an informal consulting relationship with a local child protection agency director, for example, to review the complex data that these cases present in relation to one’s own responsibilities and ethics of practice. The health care professional is nearly always seen as an esteemed and respected source of information and guidance by the social welfare agencies and courts, although occasionally she or he may feel like a victim in the process. Ways to prevent this from happening are reviewed in the subsequent section on the ethics of practice.
Allegations in Divorce and Custody Conflicts
Maintenance of Focus on Child. In cases of victimization involving allegations that a separated or divorced parent may have abused the child, it is important to avoid, if at all possible, the appearance of being hired by one side to participate in an attack on the other. One can emphasize to a parent or to the parent’s lawyer one’s concern to orient the professional work toward the child, in support of the child’s health and welfare. It is perfectly appropriate to request that all parties agree to the evaluation and, if the case is active in court, to ask the lawyers to obtain the judge’s blessing for the evaluation in the form of a court order. In most cases in this author’s experience, this request will be granted. If the child is alleged recently to have been victimized, to have current medical or behavioral complaints, or to have just disclosed for the first time having been abused, it is important not to temporize. In these situations, the child can be seen promptly and the complexities of the legal involvements can be treated later. Priority should always be given to the meeting of the child’s health and developmental needs.
Separate Interview of Parents
Interviews of parents should be conducted separately from the interviews with the child or children. Children should always be protected from exposures to material that may be threatening and create a situation, in the medical office, where they are caught in the cross-fire between warring parents. As soon as it becomes obvious that the parent is raging or retributive, for example, it is appropriate to suggest that the parent be interviewed alone, and the child is excused from the room. If one has prepared the child and family at the outset for an interview in which first child and parent will be together with the interviewer, and then subsequently each will be seen separately, the separation will seem easy and natural.
Newer knowledge on the association between child abuse and women abuse suggests that many victimized children also have victimized mothers.11 Often part of the pattern of woman abuse is to attack the woman’s capacity to give care to her children and her custody of them; this can be understood as another artifact of controlling behavior by an abusive man. It is a good idea to interview women separately from their partners in situations in which child abuse has been alleged.
PARENTAL AND CHILD INTERVIEWING
Interview of Mother
The usual pediatric history provides an excellent structuring guide for the interview with the mother, but the intention is not only to gather specific data, which one may already have in the record from previous contacts with the child. This is also an excellent way to construct a historical time sequence of salient events that may be associated with the child’s risk of victimization and an opportunity to make a human connection with the informant.
At the outset, discuss the reason that the parent and child are in the office. It is best to do this with sympathetic, open-ended questions that focus on their understanding and expectations of your role. In general, it is appropriate to avoid questions that telegraph suspicion, pinpoint blame, or specify desired responses. Avoid questions framed in the negative (“He hasn’t had any bedwetting, has he?”).
Often it is helpful to defer a specific review of the abuse allegations until that portion of the history arrives that seems to fit in the time sequence.
If one begins the pediatric history with the pregnancy, it is important to begin with benign and neutral questions that have predictable and objective answers. For example, start with the birth date and birth weight. Ask where the child was born. Then ask: “How was the pregnancy?”
Often it is this question that prompts a woman to reflect on her expectations for her child, the nature of her relationship with the child’s father, and the points of stress and discomfort in her personal relationships. One can also ask: “What was this time like for you as a person?” or “Was this a happy time for you?” in a sympathetic and caring way and then to listen thoughtfully and attentively to the responses.
If a mother shows a particular emotional reaction, it is often valuable in an interview of this kind to affirm it by noting, for example, “That must have been difficult for you” or “I can see it makes you sad to talk about that.” Not infrequently, these affirmations of the emotions of the parent will demonstrate that you have the ability and desire to listen, and this will provide a much better opportunity to probe sensitive material that pertains to the protection and victimization of the child later in the interview.
It is appropriate to ask women about relationships with their partners during the pregnancy. In this connection, it is important to remember that recent surveys suggest a prevalence of 8% to 11% of woman abuse in pregnancy.7, 8 Before the usual questions about the use of cigarettes, alcohol, and drugs, questions can be posed simply to ask if anyone hurt the woman during pregnancy, whether she had any injuries during pregnancy, and if she had any problems in getting medical care during pregnancy.
If in the course of the initial portion of the interview material emerges suggesting that a mother may be a victim of violence, it is appropriate to request, if you are a male professional, that you be joined in the interview by a female colleague, noting that sometimes it is much easier to talk about these difficulties in the presence of a woman.
The response to the question “What was your child like when she or he first came home from the hospital?” is often quite informative in cases of child abuse. The parent’s attributions regarding the meaning of the child’s crying and her ability to tolerate the infant’s provocations may appear to augur importantly for the child’s subsequent treatment. Here, again, it is important to take the posture of active listening, with attention to and, when appropriate, response to the parent’s expressed feelings. One question that often stimulates an informative response is “Did you ever think that anything was unusual about your child?” or, in another version for a parent who tells you at the outset that something is wrong: “When was the first time you felt something was wrong with your child?” Be alert to persistently negative characterizations, conflicts between how the parent and her partner saw the child, estrangement from the child’s maternal or paternal grandparents, and conflicts between adults about how best to care for the child.
Often it is in the context of talking about the child’s early life that a parent may reflect on her or his own childhood, especially if problems existed that the parent was concerned to set right for this particular child. At some point in the interviewing, although generally not at the outset of the first interview, it is of substantial importance to establish whether the mother was herself a victim of physical or sexual abuse. This is important both regarding the risk of the particular child’s victimization (because of the well-defined frequency with which physically abused children have mothers who have been physically abused in childhood, and sexually abused children’s mothers were sexually abused in childhood), and because it provides an opportunity to listen sympathetically to the parent’s own experience and, it is hoped, to pave the way for this experience to be processed in the context of the subsequent treatment relationship with a social worker or mental health professional.
Because of the important association between the abuse of alcohol and psychoactive substances in child and sexual abuse, it is important not to neglect these items in the interview.
Inevitably as the history unfolds, the mother will mention other caregivers, who may include the child’s father, stepfather, or a boyfriend. In addition to asking about how much or how little responsibility for the care of the child these people may have, it is appropriate to ask in a sympathetic way what the mother’s relationship is like with this person. Once again, at this point in the interview, the question can be posed “Has anybody been hurting you in your life right now?” Health professionals who ask these questions are amazed and appalled at the frequency of positive responses. In this field, at this time, it is important to listen to the answers.
As one approaches the allegation of victimization, once again it is important to proceed with sympathetic, open-ended questions like “What happened then?” and “What did she say to you?” Here as well, be alert to the parent’s own emotional responses and indicate your capacity to listen to them and support their expression. Most important, avoid leading questions and the telegraphing of specific anticipated responses. Gather details of what the parent actually heard and saw. Ask if any other professionals have been consulted. Find out what interventions have been made—for example, by child protection agencies, the police, or a lawyer in a family court.
At the end of the interview, always leave time for questions. Sometimes it is in response to the query “Do you have any questions for me?” that the most important information emerges, ironically, in the form of a question to you. Also at this time, parents find it helpful to know that you will be available to them, so be sure to let them know that you do not want to lose touch, and that you will be responsive to any subsequent questions that they want to ask.
Interview of Child
Since the acquittal in the first trial of the two principals in the McMartin preschool in Manhattan Beach, California, the longest and most expensive criminal trial in U.S. history, attention has been drawn to the problematic technique of interviewing the children whom the day care center personnel were alleged to have victimized. Most child health workers will not have had the opportunity for specific training in the techniques of child interviewing to get good information on the child’s victimization.
This methodology has been discerningly reviewed in the literature, and it would be good to refer to a good current review for the rationale and technique.2, 18 In general, child health workers are comfortable with children, and the key issue in the assessment of child abuse is creating an atmosphere that is relaxed, unintimidating, and professional. It is important to have available play materials that are appropriate for the child’s level of development and to deport oneself in a way that is warm, gentle, and sympathetic to the child.
With younger children, it is often essential to have a parent’s presence and support, especially when the physical examination is performed, although in the actual interviewing, it is most often appropriate to see the child separately from the parent. First, get acquainted with the child. Sit, do not stand, and, if possible, join the child at the child’s level, perhaps at a play table.
In good interview technique, one establishes the child’s level of cognitive development, identifies the names that the child uses for body parts, and asks questions about their experiences in ways that are direct and open-ended, appropriate to the child’s cognitive development, and avoid the appearance of accusation of a particular caregiver or the constructions of leading the child to a particular answer.
It is important to write down the particular questions on victimization that have been posed, with as precise a notation of language as can be recorded, and to write the precise responses, using the child’s own language. For younger children, it is important to avoid questions that pinpoint the time of day or the frequency of the particular event, although one can ask if the child remembers where and when certain things may have happened.
The use of anatomically correct dolls in the evaluation of child sexual abuse is a helpful adjunct to the interview. These, too, have been a source of some controversy, but recent reviews suggest that they can be a valuable way of facilitating communication with a child without having to resort to abstruse or uncomfortable language.10, 15
If a consultant social worker, psychologist, or nurse is available who has specific interviewing experience in child abuse and neglect, this professional’s contributions can often be invaluable in the initial assessment. A referral, however, should supplement, not substitute for, the gathering of history in the pediatric office.
At the end of sessions with older children, it is appropriate to ask them if they have any questions. Here, as with the parental interview, one should be alert to new information posed in the form of a question to the examiner and to take the opportunity to pursue it thoughtfully.
Finally, the preparation for the physical examination should be done in the presence of the parent, who will assist and offer support to the child during this procedure. In general, in these cases it is important not to gather history in the course of completing the physical examination.
Interview of Father
It is useful to have a similar structuring guide for the paternal interview. In this situation, the pediatric child health history also can serve as a framework. Discrepant reports on certain important data and health events can be observed, and a similar set of observations can be gathered.
In interviews with fathers who have been accused of abusing their children, it is important to clarify at the outset one’s role and professional responsibility, which does not include drawing a judgment about who did what to whom. In this interview as well, a respectful and compassionate professional perspective will go a long way to stimulating honest, informative, and complete responses. It is important to remember that many men who victimize children are oriented particularly toward control in family relationships. (Indeed, sexual abuse is increasingly understood as much a problem of the power distribution in families as a form of sexual deviancy.) Therefore, it is important to be alert to the extent to which a man may attempt to dominate the interview, focus continually on the mother’s disappointing or inadequate care of the child or participation in the relationship, her psychopathology, or, for that matter, her personal vulnerability or disability associated with her having been a victim in childhood. It is important to be attentive to his own reflections on his own childhood experience, preferably taking note when he may bring up in the course of the interview personal experiences of physical or sexual abuse. These, as with mothers, may militate importantly for later vulnerabilities to victimization and, especially with men, to victimizing behaviors. The abuse of alcohol and psychoactive drugs, as previously noted, should also be treated in the course of this interview.
Often fathers who have victimized their children have narcissistic characters. They may report the experience of giving care to their children and of being a spouse in a marriage as having mainly to do with their needs and their satisfactions. Not infrequently, these men may represent tearfully how unfairly they have been maligned. They may try valiantly to portray themselves as men who have been shamefully accused of things that no person ever could possibly believe that they would do. It is important to be cautious and objective in one’s response to these reports and one’s approbation of these feelings, as many professionals want deeply to believe in the parents of their patients and are made quite uncomfortable by the allegations themselves. By all means avoid appearing to support a parent’s earnest efforts to exculpate himself by indicating in questions or responses that you agree with what he tells you. Rather, maintain an inward skepticism while outwardly indicating your concern and willingness to listen.
One of the most vexing aspects of this area of practice in the present day is the situation in which indeed the father is falsely accused of having victimized a child. It is often impossible to determine in the initial interviews whether this is the case; therefore, one must maintain an open mind, a professional and neutral demeanor, and a capacity to accommodate new and unexpected data. It is especially important to avoid being drawn to one or another side of the conflict. If one takes the opportunity to assemble all of the data after one’s initial work, preferably in consultation with other professional colleagues, a clearer sense of the issues will often emerge. Avoid at all costs the drawing of quick conclusions and the making of observations or implied promises from which it may be difficult to extricate oneself at later points in the development of the case.
It is important to have available all previous medical data including psychological and psychiatric assessments and reports. Attorneys often will attempt to persuade you or a court that your observations should be made “objective” by denying you access to previous medical examinations and psychosocial assessments. This can be a ploy to keep under wraps previous damning information, although it may be a well-intended if mistaken effort to preserve the neutrality of the process. The physician is nearly always respected as someone who can objectively interpret other professionals’ work, and it is quite appropriate to insist on seeing other records, always, to be sure, with signed releases from the parties involved.
Just as it is important to avoid the impression of being a hireling for one side in a divisive struggle in which a child is caught in the middle, it is also important to be paid for one’s work. Because most courts do not have the wherewithal to pay outside experts, it usually falls to one of the parties in the action to compensate the professional evaluators. Because third-party payers almost never can pay for elaborate interviewing, examinations, and conferences with parents and their lawyers, it is appropriate at the outset of an evaluation to ask how you and your colleagues will be compensated for their work. Not infrequently the parents will agree that your work is of great importance to the health of their child, and a suitable payment arrangement can be reached.
Similarly, in situations in which a custody action or criminal prosecution is brought by an agency of the state (for example, a child protection agency or a district attorney), it is appropriate to ask if the expectation is to qualify you as an expert witness. Because this is nearly always the case, the response will nearly always be yes. In this situation, it is appropriate to ask they you be paid accordingly, and it is usually a simple matter to find out what the prevailing compensation schedules are for specialists who are asked to give court testimony. If an agreement has been reached to provide compensation for expert witness services at a reasonable level, this will also provide an active incentive to keep low the number of hours you actually spend testifying in court.
Documentation of Findings and Writing Reports
Recording one’s findings should be done with attention to small and large detail. Reports should be clearly expressed in straightforward English. They should be typed on good paper, with no typographical errors or signs of careless technical preparation. Conclusions and recommendations should be expressed clearly and simply, and they should always be buttressed by the data in the report.
Brevity is to be valued highly in written reports that may come before the court. Judges rarely have interest in reading long clinical documents. They attach greater importance to coherent and straightforward expression of findings and conclusions than to assiduous and voluminous recounting of every item of dialogue and each nuance of interpretation.
When the work is done, it is important to debrief with all parties, including the child, if the child is at an age to be able to engage in such discourse. At this session, it is often helpful to ask parents if they would like to bring their counsel. (This is about the only time in the course of an assessment when it is helpful to have counsel present. More often than not, their participation in the course of the evaluation provides them with an opportunity to argue their case in front of you, thus limiting the data available to you and telegraphing to their client the way they would like to see the data and issues represented and framed.)
Deportment Toward the Parties in Court
If one is obliged to testify in court, particularly if the child has been victimized, the testimony will not please all parties. Notwithstanding, an effort should be made to greet all of the members of the family even if the testimony may fall against their interests. This preserves the impression of objectivity and professional neutrality, and it gives a sense of respect to the participants in the process on both sides. It also makes clear your ethical concern to focus on the welfare of the child.
Often in the course of these assessments, one will find that the pattern of victimization may involve more than one individual. This is particularly vivid in custody conflicts in which sexual abuse allegations are made; in many of these cases, the children’s mothers will have had victimizing experiences as well, both during childhood and at the hands of the person they allege has offended against a child. Here, the neutrality and objectivity of the professionals are really put to test. The mother’s disclosure of victimization in the medical office may be the first (and sometimes the only) opportunity to reach out to her and to offer her help. Experience suggests that this can be done by offering to provide liaison to battered women’s services or referrals for legal and social services. This obviously changes one’s posture as a neutral professional but it cannot be avoided.
Not infrequently, the interview will lead to a discovery of other victimizations involving other children. In these circumstances, the professional will be obliged to make case report(s) of child abuse to the agencies mandated by law to receive them. These reports will have to be explained to the members of the family as one’s obligation under law. Here, once again, it is important to maintain a respectful demeanor and to listen seriously to the parents’ personal responses, including their expression of angry feelings. It is useful to emphasize that the making of the report is not with an intent to damn any party, but with a view to assure that children are protected and that injuries will not recur.
Communication with Other Professionals
The interviewing of families in which children are alleged to have been abused also poses important challenges and opportunities regarding the quality of communication with colleagues and others. It is essential to treat them all with the seriousness and respect one would want of them. The establishment and maintenance of good communication with members of other disciplines is often vexingly difficult in highly charged and contentious clinical situations. A gracious and warm demeanor, an attitude of receptiveness and careful contemplation of all the data offered by other professionals, and a serious effort to appreciate their perspectives will go far to facilitate trust and open lines of communication.
In cases in which ambiguous data and conflicting input require reconciliation, nothing substitutes for a clinical case conference. Here, the authority of the health care professionals can provide a context for serious discourse and a reasoned and careful approach to the data.
Although it is helpful to have present at this conference the attorney or guardian ad litem for the child, the parents’ counsel, if invited, may occasionally use this forum as a setting in which to advance what they see as their clients’ interests. Time and again one sees that parents choose lawyers who mirror their own personal qualities. Some lawyers are aggressively mistrustful of professionals whose work might run counter to their client’s interests. For this reason, it is often valuable to defer communicating with parents’ counsel until the evaluation is complete, and it is always important to be cautious in these communications lest in a subsequent court hearing previous conversations and statements may be thrown back at you, often in distorted form, as examples of your inconsistency or professional inadequacy. When in doubt about what to communicate, and when and how to communicate it, consult your own lawyer.
The assessment of child abuse is a professionally and personally challenging task. Here as elsewhere in medicine success often is linked with the informed intelligence, mature attitude, and professional demeanor of the clinician. If one can maintain a thoughtful and skeptical approach to the data; display warmth, calm, and respect to everyone involved in the case; and express one’s views with care and parsimony, good information will be forthcoming and, it is hoped, excellent management will follow.
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