Transcript Taking a Medical History

ICANHELP:
III. Taking a Medical History
January 23-24, 2016
Aaron J. Miller, MD, MPA & Melissa Jimenez, MD
Building Regional Alliances to Nurture Child Health branchpartners.org
Learning Objectives
• The participant will be able to:
• Discuss important logistical issues in speaking
with survivors.
• Integrate psychosocial history into medical
history when interviewing survivors.
• Incorporate evidence-based best practices
when asking survivors about maltreatment.
General Considerations
• Location:
• Survivor-friendly environment
• Quiet and distraction-free room
• Built in audio-video capabilities
• If interview cannot be conducted in a
specially designed room, make it
comfortable
• Be very patient, and don’t interrupt the survivor.
• Never assume that you know what a survivor means
by the use of a particular word. Clarify.
Speaking with family member first
• If the client is a child, speak with the family
member alone, first, to get more background
information to help you with the interview.
• Speak with them alone so that they will feel
more comfortable telling you things that they
might not want the child to hear.
Speaking with family members
first: Social History
• Who lives at home with the child?
• Who takes care of the child?
• Who has taken care of the child during the days or
hours in which this injury could have occurred?
• Do caregivers work in or outside the home?
• If someone is not working, when was the last time
he/she was working?
• Substance abuse or mental health issues?
Speaking with family members
first: history of the abuse
• Obtain background information from all sources
available
• Interview parent first
• How did parent learn about allegation? Where were
you, where was your child, what was going on?
• When you walked in the room, what did you see?
• Who has talked to the child about it?
• How did parent react to disclosure?
• Take full medical and developmental history
• Does the child know why they are here today?
• Form as many hypotheses as possible
Participants in the room
• No family members should be in the room:
• Children usually will not tell about the abuse in
front of parents, because the child knows that the
abuse will either make their parent mad or sad.
• Exception (rare): If a survivor is so scared they
will not let go of the parent, then have the parent
bring the survivor to the room and play for a few
minutes and then leave. If the survivor still won’t
stay, then the parent can stay, with instructions that
they sit away from the survivor and remain quiet.
The Survivor's Needs
• Be aware of the survivor's attention span
• Be aware of the survivor’s “personal space”
• You can sit close, but not too close.
• For children, sit down at their level, eye to eye
• Nutritional requirements
• Body functions
• Emotional needs
Confidentiality
• Know the laws
• Mandated reporters
• If you have mandated reporter laws, then you
can not tell the survivor “Don’t worry, I won’t
have to tell anyone.”
• Hospitals speaking with police
• Hospitals speaking to parents
• Do not make any promises about
confidentiality that you can not keep
Interviewing Children or Adults
in Cases of Suspected Abuse
• Introduction and building rapport
• Interview rules (optional)
• Establish the need to tell the truth
• Introducing the topic of concern
• Free narrative and open questioning
• Specific questions
• General health questions
• Conclusion of interview
• Documenting the interview
Introduction
• Give information about your professional role
• If recording, provide date, time and location of the
interview and the full names of everyone present,
and discuss recording method with survivor.
Building Rapport
Purpose:
•
•
•
•
•
Puts the survivor at ease and establishes a baseline
of survivor's body language and how verbal they are
when discussing easy topics.
Ask information about general topics to determine
understanding of certain concepts (over, under,
before, after)
Assess language and memory skills
Assess body language, eye contact, affect
Reframing Questions
Question inviting 1 word
Open-ended invitation
Do you like school?
Tell me about school.
What do you do at
school?
Do you like math or reading What subjects do you
better? (forces them to choose) like?
Who is your best friend?
Tell me about your
friends.
Interview Rules
• Use for children age 10 and under:
“When I talk with kids I have 3 rules:
• 1. I am a doctor, so you can tell me anything, and I
won’t get mad, and you won’t be in trouble with
me.
• 2. If I ask you something, and you don’t know the
answer – that’s o.k., just say ‘I don’t know.’” If
you do know the answer, please tell me.
Interview Rules (continued)
• Use for survivors 10 and under:
• 3. We only tell the truth. Do you know the difference
between truth and lies?”
• If the survivor is unable to tell differences give
examples. Many 4-year-olds can tell the difference
• If survivor does not have the concepts of truth
and lies, you can still continue forward, but with
much more caution.
Interview Rules (continued)
• Use for survivors 10 and under:
• 3. We only tell the truth. (continued)
• Give reassurance: “Sometimes it’s scary to tell the
truth – like if someone did something bad to you, it
can be scary to tell the truth about it - but it’s
important for you to tell me the truth so that I can
how to help you. I promise to tell you the truth, do
you promise to tell me the truth?”
Introducing the topic of concern
• Approach in an open-ended manner
• One question that is always fine:
• “Do you know why you are here today?”
• Young survivors may need more directive questions
• The best question depends on:
• How old is the survivor?
• Has the survivor already disclosed abuse to someone?
Introducing the topic of concern
• For young survivors who already disclosed
the abuse to someone else:
• “Your mother told me that something happened to
you, and my job is to help you. Tell me what
happened to you?”
• survivor: “He did something” <puts head down>
• Best response: “Tell me about it.”
• survivor keeps her head down.
Introducing the topic of concern
• For young survivors who already disclosed the abuse
to someone else:
• Ask other questions: “OK, you don’t have to tell me
right now what he did, but I just need to ask you a few
questions so I know what I need to do to help you. Tell
me - when did it happen?... How did it feel?... Did any
part of your body hurt?”
• Younger survivors (under age 7) will have harder
time answering when the abuse occurred, so
spend more time with parent, before or
afterward, trying to establish the time frame.
Introducing the topic of concern
• For young survivors who have not yet disclosed
abuse:
• “Like I said, I am a _____ and my job is to help you,
so I want to talk about each of your body parts to see
how I can help. Let’s start with your head. Has
anything happened to your head or has anyone done
anything to your head?”
• Then ears, mouth, arms, legs, feet, trunk, genitalia
• “Has anyone ever done anything to you that made you
sad, or scared or confused?”
• If yes, “Tell me about it.”
Introducing the topic of concern
• Tell teenagers/adults survivors: “I tell all teenagers two
things:
• “Number 1, part of my job is to take care of kids who
had bad things happen to them… so don’t worry that
you will say something that will surprise me – I won’t
be surprised. I have heard it all.
• And number 2, don’t worry that you will say something
that will make me think bad of you or judge you - I
know life is difficult and that bad things happen, so I am
just here to help you.
• So tell me, has anyone ever done anything to you that
made you uncomfortable, or scared or sad?”
Free Narrative
• “Tell me everything that happened, starting from the
beginning” (if one episode)
• DO NOT INTERRUPT.
• If survivor stops, say “What happened next,” “You
were saying that…and then what happened?”
• If the survivor stays silent, you stay silent – even up
to 1-2 minutes.
Free Narrative
• If allegation is of repeated episodes obtain an
outline of the usual pattern
“Tell me what would usually happen?”
• Ask if it ever happened in a different way or place,
first and last times
• Allow survivor to stop if needed
Reframing Questions
Question inviting 1 word
Open-ended invitation
Were his clothes on or off ?
(forces them to choose)
Where were his clothes?
Did uncle Jimmy do stuff to you Did something happen that
that you didn’t like?
you didn’t like?
Did white stuff come out of his
penis?
Then what happened?
Tell me everything that
happened with his penis.
Tell me everything you felt.
Specific, Focused Questions
• Clarify and expand upon previous answers (utilizing
What, where, when (and if appropriate, why & how)
• For young survivors, try to avoid multiple choice
questions and yes/no questions
• If giving multiple choices, always end with “or
something else?”
• If using a yes/no question, always follow up with an
open-ended question (Where you clothes off ? Yes.
Tell me all about your clothes being off)
• If inconsistencies arise, clarify
• If language is inappropriate for age, determine where
survivor learned it from
Specific, Focused Questions
• “Did he want you to tell anyone about what he did?”
• survivor: “No.”
• “How do you know?” (source monitoring)
• survivor: “He told me.”
• “What did he tell you?”
• survivor: “He said don’t tell my mommy. He told
me it was a secret.”
• “What made you tell?”
• survivor: “I was feeling bad and wanted to.”
When you sense fear
• Acknowledge their fear
• Explore their fears
• Clarify any misunderstandings
When you sense fear
• Acknowledge their fear:
• “Do you have some worries?” or, “Is your mom
worried about you? Tell me what she is worried
about.” or
• “Are you afraid to tell me what really happened?”
• Many survivors will answer yes, so then:
• Explore their fears:
• “What are you afraid will happen if you tell me?”
• “How do you know that….?” or “Who told you
that…?”
When you sense fear
• Clarify any misunderstandings.
• Often center around consequences to the survivor or
other parent or the family
• Sometimes these fears are accurate, but we can let them
know that these feared outcomes do not always happen
and that it is important to tell the truth so we can help
them.
• But do not make promises you can not keep
Case Example for Acknowledge Fears,
Explore, Clarify
• 7-year-old girl told a friend that mom’s
boyfriend touched her private parts.
The friend told parents who reported it
to social services.
• When the child is interviewed by social
services, the child denies abuse.
Case Example for Acknowledge Fears,
Explore, Clarify
• During my interview of child:
• Built rapport – child was very talkative
• Established rules of the interview
• I asked if someone did something bad
recently, and she put her head down.
• I remained silent, but she did not
answer.
Case Example for Acknowledge Fears,
Explore, Clarify
• 1. Acknowledge her fear
• What should I say to acknowledge her fear?
• “Are you afraid to tell me what happened?
• Child nodded yes.
• 2. Explore her fears
• What should I ask to explore her fears?
• “What are you afraid will happen if you tell
me?”
Case Example for Acknowledge Fears,
Explore, Clarify
• 1. Acknowledge her fear
• What should I say to acknowledge her fear?
• “Are you afraid to tell me what happened?
• Child nodded yes.
• 2. Explore her fears
• What should I ask to explore her fears?
• “What are you afraid will happen if you tell me?”
• Girl: “Mom told me not to break up the family.”
Case Example for Acknowledge Fears,
Explore, Clarify
• 3. Clarify
• Is this child’s fear realistic?
• Will the child have to get separated from the mom?
• Thus, is there anything we can say to help calm the
child’s fears?
• “If your mom’s boyfriend did something bad to you,
it doesn’t always mean you have to get removed from
your mom – maybe just he can get and trouble and he
could leave the home.”
• Child paused, thought, then said “Just he could get in
trouble?”
General Health Questions
• Can be asked at any point in the interview
• Can also ask the family before the interview, but
also ask the survivor
• Health issues, medications, past injuries
• Developmental issues, problems in school or work
• Past mental health issues
• Adolescents
• Sexual health: sex partners – number/gender, age
at first sex, birth control, condom use
General Health Questions
• Can be asked at any point in the interview
• Adolescents: After asking general health questions,
can explore additional types of abuse
• Ask about the sex partners: how did they meet?
• “What do you like about him – what does he do
for you?
• “Has anyone ever offered to give you anything or
to do anything for you?” or ask with the name of
their boyfriend: “Has John ever offered to give
you anything or….?”
Mental Health Screen:
A) Signs and Symptoms of Emotional Trauma
• Problems sleeping?
Nightmares about the
abuse?
• Having intrusive
thoughts? Meaning,
thoughts about the abuse
keep coming into their
mind frequently.
• Problems concentrating
at school or with work?
Easily distracted?
• Episodes of heart beating
fast? Trouble catching
their breath?
• Hyper alert? Startle easily
with any small sound?
• Socially withdrawn? Not
spending time with friend
(or playing) like they used
to do?
• Thoughts of hurting self ?
• Hearing voices?
Mental Health Screen:
A) Signs and Symptoms of Emotional Trauma
• Asking sensitive questions – normalize it:
• “Anytime a person gets defiled, it is
normal to have a wide range of feelings –
sadness, anger, feeling numb – are you
having any of these feelings?”
• If they tell one, ask more about it, and then
ask whether they have the other feelings,
too.
Mental Health Screen:
B) Psychosomatic Symptoms
• Screen for psychosomatic symptoms - how
emotional trauma puts stress on the body:
• Headaches: How often? How many months ago
did they start becoming this bad? What type of
headache? How many minutes or hours do they
last?
• Stomach aches: How often? How long do they
last? How many months ago did they start
becoming this bad?
• Increased or decreased appetite: How many
months ago did they start becoming this bad?
Mental Health Screen:
B) Psychosomatic Symptoms
• Screen for psychosomatic symptoms (continued):
• For children: urinating in the bed or on oneself
during the day, or defacating on oneself. How
long has this been a problem?
• Constipation: How long has this been a problem?
Human Trafficking
Screening Questions
• Can you leave your job or situation if you want?
• Can you come and go as you please?
• Have you been threatened if you try to leave?
• Have you been physically harmed in any way?
• What are your working or living conditions like?
• Where do you sleep and eat?
• Do you sleep in a bed, on a cot or on the floor?
• Have you ever been deprived of food, water, sleep
or medical care?
Human Trafficking
Screening Questions
• Do you have to ask permission to eat, sleep or go to
the bathroom?
• Are there locks on your doors and windows so you
cannot get out?
• Has anyone threatened your family?
• Has your identification or documentation been
taken from you?
• Is anyone forcing you to do anything that you do
not want to do?
• Do you owe a debt to anyone?
Concluding the Interview
• If the survivor disclosed abuse, make sure
you asked “Has anyone else ever done
anything bad to you?”
• Thank the survivor for participating
• Ask the survivor if he/she has any questions
for the investigators or interviewer
• Explain what will happen next
Healing statements that can come at
the beginning and the end
• “I believe you.” Builds trust
• “I am glad that you told me.” Builds a relationship
with the survivor
• “I am sorry this happened to you.” Expresses
empathy
• “This is not your fault.” Non -blaming
• “You are very brave to talk with me, and we will
try to help you.” Reassuring and empowering
(IRC 2012)
Documenting the Interview
• Document to whom the survivor made the disclosure –
to you or to your colleague?
• Write at least one statement in quotes and write the
questions you asked that elicited the answers:
• “When patient was asked how she got the ouchy, she
said ‘uncle Johnny touched me there (pointing to her
genitalia).’”
• Summarize other pertinent positives in your own words
• Include many details of what parents say
• DO NOT write “patient denied oral sex” because they
might be open about it later, and lawyers will make the
survivor look inconsistent.
References
• Finkel M.A., Alexander R.A. (2011). Conducting the
medical history. Journal of survivor Sexual Abuse.
20(5):486-504.
• Lamb M.E. et al. (2007). A structured forensic
interview protocol improves the quality and
informativeness of investigative interviews with
survivors: A review of research using the NICHD
Investigative Interview Protocol. survivor Abuse &
Neglect. 31(11-12):1201–1231.
References
• United Kingdom Ministry of Justice (2011). Achieving
Best Evidence in Criminal Proceedings: Guidance on
interviewing victims and witnesses, and guidance on
using special measures. Available at:
www.cps.gov.uk/publications/docs/best_evidence_in_
criminal_proceedings.pdf
• Yuille, J (1997). The step-wise interview: A protocol
for interviewing survivors. Resource paper in Ministry
for survivors and Families, Investigative Interviewing:
Instructor’s Manual (pp.175-184). Victoria, BC: Author.
References
 Poole, D.A., Lamb, M.E. (2003). Investigative
Interviews of Children: A Guide for Helping
Professionals. Washington, D.C.: American
Psychological Association.
 Smith, D., Letourneau, E. J., Saunders, B. E.,
Kilpatrick, D. G., Resnick, H. S., & Best, C. L. (2000).
Delay in disclosure of childhood rape: Results from a
national survey. survivor Abuse & Neglect, 24, 273–287.