History : Taking a History from the Parent/Caregiver
The Social History
Consider population risk factors for the child and family and other social risks in the context of the situation. Other details that may be noted include social cues, such as the way a parent describes their child, the alleged perpetrator, or experiences with medical or investigative professionals in the past. Blame-shifting, parenting practices, a changing history, or a history of other trauma may help direct subsequent questions.
Medical providers will need to be aware of their own biases and recognize cultural and religious differences. While many children living in adverse conditions including poverty, drug abuse, mental illness, or other adverse childhood experiences (ACES), the collection of this information is not intended to bias the medical provider understanding of or response to the abuse. It is used to help assess needs for community resources and to determine how to best help the family.
Note that the text below may be cut-and-pasted and used to help organize the narrative as a dot-phrase in an electronic medical record.
- Information about the setting
- List of all persons present
- Name of the primary person taking the history
- Date, time, and location/site
- Information about the child/adolescent
- Name, including nicknames
- Home address and telephone number(s)
- Date of birth
- Assigned gender at birth and preferred pronouns
- Language(s) spoken/comprehended
- School(s) attended and current grade level
- Work site(s) if an adolescent
- Information about the parent(s)/caretaker(s)
- All names
- Home address and telephone number(s)
- Work address and telephone number
- Languages spoken; ability to comprehend; need for an interpreter
- Name(s) of child's legal guardian if other than parent(s)
- Name(s) of those who are involved in the child's care
- Source of referral
- Source of information about the abuse (informant)
- History of child protective services or law enforcement involvement related and unrelated to this incident
- History of domestic violence
- Drug use in the home
- An assessment and documentation of the parent/caregiver's reliability and credibility
- A parent/caregiver who knows little of the child's personal information and history or who gives confusing, conflicting, or contradictory information during the history cannot be considered reliable.
- Consider whether language difficulties or other communication challenges are interfering with the ability to relay reliable information.
The above information may be obtained by the medical provider or a healthcare social worker who works in the medical setting. Healthcare social workers are invaluable resources and are often called to assist as part of most hospital child abuse protocols. Using a team approach in the healthcare setting can greatly assist in the acquisition of needed information and in the further care and coordination of resources and next steps for the patient and family.
The Medical History
A brief outline of the medical history generally includes the details listed below. Some of the details will overlap with the social history and should not replace the social history. Note that the text below may be cut-and-pasted and used to help organize the narrative as a dot-phrase in an electronic medical record.
- Chief complaint
- Accurately record in the parent/caregiver's own words the reason for the evaluation
- Document the cause(s) or concern(s) that precipitated or prompted the necessity for an evaluation of abuse (e.g., obvious injury, disclosure on the part of the child, a witness to the event(s), suspicions based on behavior changes, etc.)
- Past medical history
- Birth history, if relevant
- Hospitalizations
- Surgeries
- Immunizations
- Well child care (name of Primary Care Physician)
- Developmental history
- Behavioral history
- Mental health history
- Previous injuries
- Allergies
- Other medical or mental health problems
- Medications
- Review of Systems
- Systemic symptoms: fever, lymphadenopathy, joint pain, increased work of breathing
- Specific symptoms: rash, headache, sore throat, abdominal pain, constipation, bloody stool, enuresis, dysuria or other urinary symptoms, discharge/blood in the underwear/toilet paper
- Family health history
- Developmental, medical, and child abuse history of siblings
- History of bleeding disorders or bleeding in a family member (if relevant)
- Other inherited illnesses (e.g., Osteogenesis imperfecta, collagen vascular disorders, copper deficiency, etc.)
- Siblings who died as infants, or who have a serious congenital or inherited illness
- History of growth delay in siblings, parents, or relatives (if relevant)
- Abuse in other family members, ask specifically about sexual abuse
- Recent sexually transmitted diseases in family members (if relevant)
- Mental illnesses; history of suicide in the family
- Other relevant questions as per social history
- Drug abuse in the home, history of interpersonal (domestic) violence and injuries, prior CPS involvement and outcomes.
Example Questions to Ask Regarding Abuse
- General
- Are there any new or changed behaviors?
- Are there recurrent somatic complaints such as abdominal pain, other GI complaints, or headaches?
- Does your child seem fearful of or act differently around anyone?
- How have they been sleeping?
- How would you describe your child’s current emotional state?
- Has your child ever expressed concerns about bullying?
- Sexual
Does your child have any genital complaints?- Vaginal, rectal, penile pain
- Staining of underwear, discharge, foul odor, previous genital bleeding?
- Physical
- Have you noticed any bruising in unusual body locations?
- Have you had concerns about other children in the care of the alleged abuser?
- Is your infant/child using all their extremities?
- Neglect
- What kind of appetite does your child have?
- How are they doing in school? What has attendance been like?
- When was the last time they took their medication(s)?
Understanding the Uncooperative, Non-Offending Parent
Situations in which the non-offending parent refuses to cooperate with investigative authorities or is resistant to suggestions and advice pose an uncomfortable challenge. A parent may be uncooperative for many reasons. The most common reason is denial regarding the possibility of abuse by a husband, relative, or friend. The non-offending parent may depend on the perpetrator for financial, emotional, or other significant needs. Sometimes the bond between the child and parent is less strong than that between the parent and perpetrator. Sometimes the abuse is so despicable that the non-offending parent is unable to tolerate the information, such as when a child is murdered by a parent.
Whatever the reason, it is important to recognize that the child's future mental health may depend on a continuing relationship with the non-offending parent. Therapeutic goals should recognize the limitations of the non-offending parent and be structured so that the steps are potentially achievable. Consider offering a follow-up appointment in your office and offering choices for counseling. Refer to a therapist located close to the parent's home or who is easily accessible. Sometimes school programs or other local services can be mobilized to provide interventions until the parent is better able to deal with the situation and to focus on the child's needs.
For more information on responding to parents' reactions, see TREATMENT AND FOLLOW-UP: Responding to Families. [NEEDLINK]
