B5. Medical History

These recommendations are for pediatric examiners related to the medical history.

Recognize the medical history is a critical component of medical forensic care, both acute and nonacute.^{^[1]} The pediatric examiner, prior to the examination, should seek information regarding the child’s health and symptoms, including the specific circumstances of sexual abuse. The process for taking a medical history as part of medical forensic care is similar to any other medical history taking: chief complaint/history of present illness; review of systems;^{^[2]} and medical, family, and psychosocial history. The sexual abuse is the presenting medical issue about which the examiner needs information to provide care. The history subsequently guides the examination, formulation of a diagnosis, treatment and other health care interventions, and discharge planning, and helps determine if and which forensic evidence collection procedures are necessary (Adams et al., 2015; Day & Pierce-Weeks, 2013; De Jong, 2011; Finkel & Alexander, 2011; Kaplan et al., 2011). The medical history may provide information useful to the investigation (Adams et al., 2015).

Recognize that a forensic interview is different from the medical history. The forensic interview is a component of a comprehensive child sexual abuse investigation (Newlin et al., 2015). Forensic interviewing of children who disclose sexual abuse or for whom sexual abuse is suspected is an impartial fact-finding process that guides decision making in criminal, family, and juvenile law cases (Swerdlow-Freed, 2015). A forensic interview is a semi-structured conversation that is designed to obtain information from the child about the reported abusive event(s) (adapted from Swerdlow-Freed, 2015). During the interview, a forensic interviewer designated by the investigative team (or if not available, a law enforcement or/and child protective services investigator as applicable to the case) seeks to obtain a statement from the child in an objective, developmentally appropriate, and legally defensible manner (Davies et al., 1997). The interview is typically video-recorded. To ensure that facts are gathered in a way that will stand up in court, forensic interviews are carefully controlled: the interviewer’s statements and body language must be neutral, alternative explanations for a child’s statements are thoroughly explored, and interview results are documented in such a way that they can bear judicial scrutiny (North Carolina Division of Social Services and Family and Children’s Resource Program, 2002).^[3]

See below for tips for pediatric examiners to keep the medical history and forensic interview separate but complementary.

*Tips to Keep the Medical History and Forensic Interview Separate but Complementary*
· Pediatric examiners should limit the medical history to information necessary to address the child’s health care needs and to guide the examination and collection of forensic samples (if applicable). It is not necessary for examiners to document detailed information that would normally be considered investigative in nature, as such information typically has less applicability to the components of the medical forensic examination, and would be routinely gathered by law enforcement personnel or through a forensic interview. · Multidisciplinary response team protocols for child sexual abuse cases should delineate the roles of each team member. All involved on the team should have knowledge about and appreciation of the value of each member’s contribution. (See A3. Coordinated Team Approach ) · Coordination should be encouraged among examiners and investigative agencies around sharing of case information. When relevant investigative information is available prior to medical forensic care and/or the forensic interview has already occurred, the pediatric examiner should be briefed on that information prior to the medical history and examination. Likewise, if medical forensic care is completed prior to the forensic interview, investigators and/or forensic interviewers should be briefed before the interview on the relevant information gathered during the medical history and examination.^{^[4]} · Multidisciplinary response team protocols vary widely from jurisdiction to jurisdiction as to whether to include the pediatric examiner among the professionals viewing the child’s forensic interview. If the examiner observes the forensic interview and is subsequently conducting the medical forensic examination, observance of that interview does not negate the need for the examiner to conduct a medical history with the child. As noted earlier, the medical history is part of the overall assessment that guides the examination and forensic evidence collection, and when conducted by the examiner, is performed for the purposes of diagnosis and treatment. In contrast, the purpose of the forensic interview generally is to assist with the investigation and possible prosecution. In most instances, the history obtained by the examiner is information allowable in testimony as a result of the medical exception to the hearsay rule. If the examiner were to obtain the medical history by observing the forensic interview versus gathering the history directly from the child, the hearsay exception likely would no longer apply. Documentation by the examiner, particularly as it relates to statements made by the child, should be limited to information obtained directly from the interaction between the examiner and the child. · Observing the forensic interview can assist the examiner in a variety of ways (e.g., in gaining more details of the abusive event; in assessing the child’s demeanor and development; in observing what strategies employed by forensic interviewers may have successfully engaged the child and which ones did not work; and in supporting education and anticipatory guidance to the caregiver as part of the post-exam process). · To maintain objectivity, jurisdictions should avoid having pediatric examiners assume the role of forensic interviewer. However, if a jurisdiction requires examiners to function in the role of forensic interviewer as well, it is important to consider the following: Because these roles are separate and distinct with different purposes, the examiner should be expected to adhere to all required initial education and ongoing training with regard to both roles. In addition, care should be taken to avoid role confusion that may result in impeding the examiner’s ability to testify under the medical exception to the hearsay rule. · Investigative agencies should be educated about what an acute and a non-acute medical forensic examination entails, the purpose of the medical history, and how the medical history differs from the forensic interview. They should understand that law enforcement or child protective service representatives should not be present during the medical history or the examination. In addition, they should be provided with opportunities to ask medical questions related to a case.

Tips to Keep the Medical History and Forensic Interview Separate but Complementary

· Pediatric examiners should limit the medical history to information necessary to address the child’s health care needs and to guide the examination and collection of forensic samples (if applicable). It is not necessary for examiners to document detailed information that would normally be considered investigative in nature, as such information typically has less applicability to the components of the medical forensic examination, and would be routinely gathered by law enforcement personnel or through a forensic interview.

· Multidisciplinary response team protocols for child sexual abuse cases should delineate the roles of each team member. All involved on the team should have knowledge about and appreciation of the value of each member’s contribution. (See A3. Coordinated Team Approach )

· Coordination should be encouraged among examiners and investigative agencies around sharing of case information. When relevant investigative information is available prior to medical forensic care and/or the forensic interview has already occurred, the pediatric examiner should be briefed on that information prior to the medical history and examination. Likewise, if medical forensic care is completed prior to the forensic interview, investigators and/or forensic interviewers should be briefed before the interview on the relevant information gathered during the medical history and examination.^{^[4]}

· Multidisciplinary response team protocols vary widely from jurisdiction to jurisdiction as to whether to include the pediatric examiner among the professionals viewing the child’s forensic interview. If the examiner observes the forensic interview and is subsequently conducting the medical forensic examination, observance of that interview does not negate the need for the examiner to conduct a medical history with the child. As noted earlier, the medical history is part of the overall assessment that guides the examination and forensic evidence collection, and when conducted by the examiner, is performed for the purposes of diagnosis and treatment. In contrast, the purpose of the forensic interview generally is to assist with the investigation and possible prosecution. In most instances, the history obtained by the examiner is information allowable in testimony as a result of the medical exception to the hearsay rule. If the examiner were to obtain the medical history by observing the forensic interview versus gathering the history directly from the child, the hearsay exception likely would no longer apply. Documentation by the examiner, particularly as it relates to statements made by the child, should be limited to information obtained directly from the interaction between the examiner and the child.

· Observing the forensic interview can assist the examiner in a variety of ways (e.g., in gaining more details of the abusive event; in assessing the child’s demeanor and development; in observing what strategies employed by forensic interviewers may have successfully engaged the child and which ones did not work; and in supporting education and anticipatory guidance to the caregiver as part of the post-exam process).

· To maintain objectivity, jurisdictions should avoid having pediatric examiners assume the role of forensic interviewer. However, if a jurisdiction requires examiners to function in the role of forensic interviewer as well, it is important to consider the following: Because these roles are separate and distinct with different purposes, the examiner should be expected to adhere to all required initial education and ongoing training with regard to both roles. In addition, care should be taken to avoid role confusion that may result in impeding the examiner’s ability to testify under the medical exception to the hearsay rule.

· Investigative agencies should be educated about what an acute and a non-acute medical forensic examination entails, the purpose of the medical history, and how the medical history differs from the forensic interview. They should understand that law enforcement or child protective service representatives should not be present during the medical history or the examination. In addition, they should be provided with opportunities to ask medical questions related to a case.

For more discussion of the implications of evolving law on hearsay exceptions, see Appendix 5. Impact of Crawford v. Washington and the Confrontation Clause.

Consider the following issues when preparing for and when starting the medical history:

What information on the child and case is already available? Examiners can check the child’s chart for details that are pertinent to medical forensic care, which health care providers have already documented. They can confer with investigative agencies if a forensic interview has been conducted to ascertain data already gathered.
Have any injuries been identified and treated? (See B3. Entry into the Health Care System)
Have the crisis intervention and support needs of the child and caregiver been met? Victim advocates typically are able to provide crisis intervention and support during the exam process, including the medical history. They also can support the child while the caregiver is providing information and support the caregiver while the child gives an event history. (See A3. Coordinated Team Approach) Also, note that the medical history provides examiners an opportunity to assess related fears or concerns of children and caregivers and stress the usefulness of mental health services to help deal with the ramifications of the sexual abuse (Adams et al., 2015).
Has a mandatory report been made? Examiners should not assume disclosures or suspicions have already been reported. Instead, they should confirm a report with child protective services and/or law enforcement as applicable to the case, as per jurisdictional and facility policies (See A5a. Reporting)
Is the child safe in the facility? To the extent possible, examiners should be cognizant of the relationship of the perpetrator to the child and the child’s living situation, as these facts may speak to safety issues at the health care facility and during discharge planning, and to the urgency of conveying safety concerns to child protective services and/or law enforcement. (See B3. Entry into the Health Care System) During history taking, examiners should document any reference to perpetrators and/or persons abusive to the child. The medical history can provide information about whether the caregiver has been supportive of the child through the disclosure process (Adams et al., 2015).
Is a private and comfortable setting available for history taking? Ideally, there should be no interruptions during history taking and no time constraints for the history or other use of the room while information is being gathered. History taking often takes place in the exam room prior to the examination. Regardless of the space, examiners can help the child feel safe, comfortable, and relaxed as possible. Avoid rushing the child through the history.
Are procedures in place to allow examiners to speak with the child and caregiver together and separately during the medical history, as appropriate in a case? The majority of the medical history in prepubescent child cases generally is sought from the caregiver presenting with the child, and may be supplemented by the child if she/he is developmentally able (see below). However, approaches vary to gathering information about the abusive event history: some jurisdictional protocols provide detailed instruction as to what information to obtain from the child versus the caregiver (e.g., see Washington State, 2012), while others are less specific; some do not seek the abusive event history from the children,^{^[5]} while others seek this information from the child, but not separately from the caregiver; and, lastly, some first gather information about the event history from the caregiver, without the child present, and subsequently obtain the event history from the child, without the caregiver present (De Jong, 2011; Kaplan et al., 2011). This last approach gives the child who is developmentally able the opportunity to express her/his own viewpoint on what has happened, without being inhibited by the caregiver (Day & Pierce-Weeks, 2013). Being able to independently give an account of the abuse is particularly important for a child whose caregiver may be the perpetrator, in collusion with the perpetrator, or otherwise abusive to the child (but is unsuspected by responders). Examiners are encouraged to assess what is the most appropriate approach in each case, giving the child who is developmentally able to provide the abusive event history as many options as possible. Some children are not developmentally able to provide this history or are uncomfortable being separated from the caregiver.
What is the child’s developmental level? Examiners should assess the child’s developmental level to tailor the history taking approach to the child. Because a child’s communication ability changes dramatically, depending on her/his development, the examiner’s knowledge about developmental stages can play an important role in rapport building, in communicating with the child in a developmentally appropriate way, and in the care provided. ( See A2. Adapting Care for Each Child) The child’s developmental level also directly affects whether the event history is sought from the child as opposed to only the caregiver or other sources. Consider (adapted from Day & Pierce-Weeks, 2013; IRC, 2012):

BIRTH – 4 YEARS OLD: Children in this age range have emerging communication skills (e.g., it is possible that 3- or 4-year-old children may be eloquent and descriptive in their communications). However, caregivers and other adults presenting with the child are usually the primary sources of information for the event history.
5-9 YEARS OLD: Children in this age range should provide an event history if possible, if they are developmentally able. Caregivers and other adults presenting with the child may provide supplemental information for the event history.
10 AND ABOVE: Children in this age range should provide an event history, if they are developmentally able. Again, caregivers and other adults presenting with the child may offer supplemental information.

Although growth stages are often correlated with chronological age, ages at which developmental milestones occur are not the same for all children (e.g., an older child with autism may have limited communication skills). A child’s development level should be assessed in multiple areas (e.g., fine motor, language, cognitive, and social skills), not merely chronological age.

· Are there other circumstances of the child that may impact history taking? (See A2. Adapting Care for Each Child) In particular, examiners need to evaluate the child for factors that may affect communication and cognition, and document skills, abilities, circumstances, and limitations. They should work with the child and/or caregiver to understand these factors and determine how best to communicate with the child. A few specific situations to consider (adapted from Day & Pierce-Weeks, 2013; IRC, 2012):D

o If A CHILD HAS DISABILITIES THAT AFFECT COMMUNICATION OR COGNITION, examiners should communicate with her/him during the history in the manner that is most effective for that child (e.g., using sign language, Braille, plain language/pictures, or audio aids). They should not assume, that due to a disability, a child is incapable of communication. However, it can be difficult to understand some children with disabilities, as well as for them to understand others, which can lead to misunderstandings that further impede comprehension. Examiners should respect that some children with disabilities may not wish to have the physical examination and expose their body to a stranger.

o IF A CHILD IS NONVERBAL (not due to a disability, but because of developmental capacity, discomfort, being scared, etc) and not otherwise communicating with the examiner (using body language, facial expression, etc.), the examiner should talk with the child to build rapport and explain exam procedures, but have no expectations that the child will provide an event history. It is not unusual for a child who initially will not verbally communicate (and has the capacity) to begin to communicate as the exam progresses as she/he feels more comfortable and less afraid. However, some children may not be willing to discuss the sexual abuse. Forcing them to communicate is traumatizing and should be avoided. (Note it is also possible that a child will not give an event history because the suspected sexual abuse did not actually occur)

· If a child or caregiver has a need for communication aids or language assistance during history taking, have those accommodations been arranged? Examiners should be familiar with facility policy for making such arrangements. ( See A2. Adapting Care for Each Child)

· Has there been a request for an examiner of a specific gender or culture? Examiners should accommodate such request to the extent possible.

Be mindful of the child’s capacity to answer questions during the information gathering process (Day & Pierce-Weeks, 2013; IRC, 2012). Examiners should take breaks as needed by the child. A child’s short attention span, due to developmental level or other circumstances, may limit the amount of time available for history taking.

Be familiar with the main areas of history taking (adapted from Day & Pierce-Weeks, 2013; Botash, n.d.). At the start of history taking, examiners should make clear to the child and caregiver that their role is to obtain a medical history for the purpose of diagnosis and treatment, and that the medical history is not an investigative interview. After building rapport and assessing the child’s circumstance and developmental level, examiners can explain that questions will focus on the sexual abuse event(s), the child’s medical condition, and the child’s family and psychosocial history (see below for the four main areas of medical history taking). Examiners should be careful to avoid the use of leading questions.

Note that the use of video and audio recording is not appropriate during the medical history.

*Main Areas of the Medical History* A general principle in any history taking is to tailor questions to the child’s developmental level.
1. Getting started: Some questions to ask the child
· My name is [ ]. I am a [doctor, forensic nurse, etc.]. My job is to make sure you are all right. · Can you tell me your name? · How old are you? · Do you know why you are here today? · Review the child’s knowledge of body parts. “What do you call this?” Point to the child’s ear. Continue in this fashion until the child has named most body parts, including genitalia. Use the child’s language when talking about body parts.^{^[6]}
2. Event history—chief complaint
· Write the event history in the child and/or caregiver’s exact words, using quotes. · Ask open-ended questions to gain information. For example, “Tell me what happened.” Do not pressure the child to speak. It is not necessary to obtain all the details of the event from the child. If a child is reluctant to speak, and answers only “yes” or “no” or “I don’t know,” consider discontinuing efforts to obtain the history from the child at that time. (Washington State, 2012) · Information about the timing and nature of the event o When and where did it occur? o Did it occur more than one time? o Type of penetration/contact (specifically what and where on child/perpetrator)? o Condom use, use of objects? o Were photographs/videos taken or shown? o Perpetrator a known person or stranger? o Perpetrator’s STD status, including HIV, if known? (Note the child likely will not know this information, but caregivers might if perpetrator is known to them) · Events since the event (e.g., to ascertain status—preservation of forensic evidence)
3. Past and current medical history
· Any current pain, bleeding, discharge, injuries, illnesses, or other physical symptoms · Sexual history with awareness of gender identity and sexual orientation^{^[7]} · Other medical history: for example— o Developmental history o Allergies o Immunization status o Current medications^{^[8]} o Past surgeries or hospitalizations o Active/past medical conditions, including normal bowel pattern o Approximate weight/height o Child’s primary care provider
4. Family and psychosocial history
Note family and social circumstances can affect responses during the medical history. · FAMILY: Illnesses, diseases, conditions in other family members; abuse in/by other family members · SOCIAL: Pertaining to the child, caregivers, others in the household, child care providers o Child: name, including preferred name and nicknames; contact information; date of birth, sex and gender identity, ethnicity of child; place of birth/country of origin/date of arrival in USA; language(s) spoken/comprehended; school attended; and grade level o Caregivers: Names; contact information; country of origin; language(s) spoken; name(s) of parent/guardian if other than caregiver; others involved in the child’s care o Others living in the home (siblings, relatives, friends, etc.) o Other children who may be at risk of abuse · PSYCHOLOGICAL: (Day & Pierce-Weeks, 2013; IRC, 2012; WHO, 2003): Any signs of emotional distress or behavioral changes the child may be experiencing as a result of the abusive event. for example— o Sadness, depression, anger, fearfulness, and anxiety o Symptoms associated with PTSD, such as avoidance, numbing, and hyper-arousal o Inappropriate sexual behavior o Loss of social competence o Cognitive impairment o Regressive behaviors (e.g., loss of bladder control, reversion to thumb-sucking) o Changes in eating and/or sleeping habits o Substance abuse o Suicidal/homicidal ideation

Main Areas of the Medical History

A general principle in any history taking is to tailor questions to the child’s developmental level.

1. Getting started: Some questions to ask the child

· My name is [ ]. I am a [doctor, forensic nurse, etc.]. My job is to make sure you are all right.

· Can you tell me your name?

· How old are you?

· Do you know why you are here today?

· Review the child’s knowledge of body parts. “What do you call this?” Point to the child’s ear. Continue in this fashion until the child has named most body parts, including genitalia. Use the child’s language when talking about body parts.^{^[6]}

2. Event history—chief complaint

· Write the event history in the child and/or caregiver’s exact words, using quotes.

· Ask open-ended questions to gain information. For example, “Tell me what happened.” Do not pressure the child to speak. It is not necessary to obtain all the details of the event from the child. If a child is reluctant to speak, and answers only “yes” or “no” or “I don’t know,” consider discontinuing efforts to obtain the history from the child at that time. (Washington State, 2012)

· Information about the timing and nature of the event

o When and where did it occur?

o Did it occur more than one time?

o Type of penetration/contact (specifically what and where on child/perpetrator)?

o Condom use, use of objects?

o Were photographs/videos taken or shown?

o Perpetrator a known person or stranger?

o Perpetrator’s STD status, including HIV, if known? (Note the child likely will not know this information, but caregivers might if perpetrator is known to them)

· Events since the event (e.g., to ascertain status—preservation of forensic evidence)

3. Past and current medical history

· Any current pain, bleeding, discharge, injuries, illnesses, or other physical symptoms

· Sexual history with awareness of gender identity and sexual orientation^{^[7]}

· Other medical history: for example—

o Developmental history

o Allergies

o Immunization status

o Current medications^{^[8]}

o Past surgeries or hospitalizations

o Active/past medical conditions, including normal bowel pattern

o Approximate weight/height

o Child’s primary care provider

4. Family and psychosocial history

Note family and social circumstances can affect responses during the medical history.

· FAMILY: Illnesses, diseases, conditions in other family members; abuse in/by other family members

· SOCIAL: Pertaining to the child, caregivers, others in the household, child care providers

o Child: name, including preferred name and nicknames; contact information; date of birth, sex and gender identity, ethnicity of child; place of birth/country of origin/date of arrival in USA; language(s) spoken/comprehended; school attended; and grade level

o Caregivers: Names; contact information; country of origin; language(s) spoken; name(s) of parent/guardian if other than caregiver; others involved in the child’s care

o Others living in the home (siblings, relatives, friends, etc.)

o Other children who may be at risk of abuse

· PSYCHOLOGICAL: (Day & Pierce-Weeks, 2013; IRC, 2012; WHO, 2003): Any signs of emotional distress or behavioral changes the child may be experiencing as a result of the abusive event. for example—

o Sadness, depression, anger, fearfulness, and anxiety

o Symptoms associated with PTSD, such as avoidance, numbing, and hyper-arousal

o Inappropriate sexual behavior

o Loss of social competence

o Cognitive impairment

o Regressive behaviors (e.g., loss of bladder control, reversion to thumb-sucking)

o Changes in eating and/or sleeping habits

o Substance abuse

o Suicidal/homicidal ideation

Table of Contents

B6. Photo-Documentation

[1] That said, circumstances may present where examiners will need to proceed with a medical forensic examination without a medical history (e.g., if a child is nonverbal/noncommunicative and a caregiver or family member is not available).

[2] The review of systems should include particular attention to gastrointestinal symptoms, constipation, genitourinary, and behavioral and emotional symptoms. Such symptoms could be associated with sexual abuse, although not diagnostic of it.

[3] In-depth discussion of forensic interviewing is beyond the scope of this protocol. See Newlin et al. (2015) for best practices in interviewing children in cases of alleged abuse. Coulborn Faller (2015) offers a history of the evolution of forensic interviewing in child sexual abuse cases. For additional resources related to investigative interviewing in child abuse cases, see the Child Welfare Information Gateway at www.childwelfare.gov/topics/responding/iia/investigation/interviewing/.

[4] Note that, although jurisdictional and agency protocols vary regarding the timing of the forensic interview in relation to the acute and nonacute examination in child sexual abuse cases, the forensic interview usually precedes nonacute medical forensic care. If medical forensic care precedes the forensic interview, it is usually in acute cases where the immediate need to evaluate the child’s medical status, provide care, and/or collect forensic evidence takes precedence over the forensic interview.

[5] Kaplan et al. (2011) noted that some communities discourage clinicians from obtaining a medical history from the child about the abuse so as to avoid traumatizing the child. However, children can find it therapeutic to disclose to and be validated by health professionals.

[6] Note that while anatomically neutral body maps should be used to document exam findings, with some children, gender-specific body maps can be useful to aid examiners when discussing body parts.

[7] Children may be reluctant to discuss certain issues or may wish to discuss them in private, such as sexual orientation or gender identity.

[8] Treatment or medication a child is receiving may have direct implications on the medical forensic examination and documentation. For example, examiners need to be aware if a prepubescent child is receiving hormone treatment for pubertal suppression and anticipated subsequent gender transition.