Know how to interview abused children
When you suspect abuse, it’s imperative that you interview the child without making the situation worse, says Marti Monk, RN, CEN, a forensic interview specialist/emergency nurse at Children at Risk Evaluation Services (CARES) at St. Luke’s Regional Medical Center in Boise, ID. Here are some things to consider when interviewing children:
Be a nurse, not an investigator. "You are looking for answers to help them make a medical diagnosis, so ask appropriate questions, such as What happened to your arm?’" says Monk. "You need to know the mechanism of injury to know how to fix it. It’s the same with rape, in that it’s not up to the nurse to get a description of the rapist. It’s up to the nurse to figure out what he did to her, so we know how to treat it."
Nurses should not take on the role of investigator. "If you do that, you may get some misleading answers, which will throw everything off," says Monk. "Or the child may talk about it so much that by the time they get around to talking to the police, they won’t want to talk about it any more."
Stick to questions that pertain to medical care. "The purpose of asking questions is for the provision of medical care, but what you ask also has ramifications for an investigation, so you have to keep that in mind," says Cantlon.
Take the focus away from the child. "Instead of asking how did you hurt your arm?’ ask the child how did your arm get hurt?’" Monk advises. "It’s much better to take the onus away from the child. That way, you are making the child completely innocent, instead of it sounding like it was their fault."
Start with simple questions. "Begin with the simplest and easiest questions for a child to answer," says Monk. "If they tell you that their daddy hit their arm with a bat, that opens the door for you to ask more detailed questions, such as where were you when it happened?’ based on the information the child has already given you."
Talk to children alone. "This goes against everything we teach nurses, but it’s the one situation where it’s a good idea to separate the caregiver from the child," says Monk. "Otherwise, there is a tendency to talk to the caregiver over the child, but kids can talk very well about what happened, and most of time they want to."
Abused children separate very easily from caregivers, Monk notes. "Just tell them that mommy is going to go talk to my friend, and you and I get to go in this room and talk," she says. "If the parent balks at that and says, Don’t you take my daughter away,’ you don’t want to put yourself or child at risk so you stop at that point. But that should put some suspicions in your mind."
If the parent refuses to allow you to interview the child, don’t push the issue. "If it’s the only way you will be allowed to treat the child, then back off and don’t interview them," says Monk. "However, in my opinion, that would be sufficient enough to make the call to report suspicion of abuse."
Talk at child’s level. "Talk to them at a level they can understand," says Monk. "If you mention a CAT scan, the child may assume a big cat is going to be down there."
Consider ages of children when asking about abuse. "Children younger than [age] 4 will have a real difficult time telling you about abuse, so be very careful with the language you use," says Cantlon.
Don’t sound as if you are accusing the parent. "Who hurt you?’ is a pretty scary question. Instead, ask, How did your arm get hurt?’" says Monk. "Most children really love their abusers and will protect them, so you have to be careful of that."
Document the child’s responses. "You should quote the child word for word. You don’t have the luxury of video or audio tape, so you have to get it down on paper so you can defend it on the stand if called to court," says Monk.
Describe the child’s body language and demeanor with details. "Document if a child yelled something with tears running down their face. Or if the child refused to go to the parent and says, No, no, no!’ when the parent reaches for them. It is vitally important to include those things," says Monk. "Some states have the excited utterance hearsay’ law, which allows a statement to be admitted in court when it normally would not be."
Describe details of injuries. "Instead of just writing bruise,’ say there is a 2 cm circular bruised area on the left thigh’," says Monk. "You’re not saying what happened, just what it looks like. You should also draw where the injuries are on a picture of a child."
Don’t question children repeatedly. "If a child presents to the triage nurse and the parent comes out and says that the father may have sexually abused them, you know there are mandated investigators that will come in. So limit your history taking to get whatever information you need to make sure the patient is stable, because the wheels are already in motion," says Nicholson. "Other people will have to come after you, and questions will have to be asked again. It complicates things if you have asked them already."
Be aware of what you say in front of the child. "Sometimes if we are talking to a parent, we assume a 3-year old is playing with their toys. But in reality, they are listening to every word spoken," says Nicholson. "Don’t obtain a family history in front of the child. The whole case can be sabotaged at that point, if the child winds up repeating what they heard their parent say to a nurse."