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HomeChaptersTriageHistoryHistory: OverviewHistory: History Taking Stepscommunication challengesHistory: Taking a History from the Parent/CaregiverHistory: Taking a History from the Child/AdolescentResponding to the Disclosure of AbuseHistory: Additional ResourcesPhysical ExaminationLaboratoryRadiologyDiagnosisTreatment and Follow-UpDocumentationReportingFoster CareChildren and Adolescents with DisabilitiesJuvenile Sexualized BehaviorMultidisciplinary TeamsLegal IssuesAppendicesAbout UsContactAcknowledgementsSupport and Endorsements  

HISTORY: Taking the History from the Child/Adolescent

If the Parent/Caregiver Must Be Present
line spacer If at all possible, obtain a direct history from the child/adolescent without an accompanying parent/caregiver. This may not be possible in the following instances:
  • A very young child (less than four years old) who does not separate well from adults
  • An older child who refuses to be separated from adults
  • A child who does not speak English and an interpreter cannot be provided in the medical setting
  • A parent/caregiver who refuses to allow an interview unless he/she is present
When a parent/caregiver is present during the interview, document the reason for his/her presence. The adult should be seated behind the child so that the child cannot see facial expressions or other nonverbal cues. The adult must understand that the child may not be able to answer all the questions or may answer questions differently from his/her expectations. Instruct the adult that any expressions of shock, disbelief, or disapproval and/or any verbal or physical signals could upset the child and impede the interview. Also instruct the adult not to ask or respond to questions.

Questioning the Child/Adolescent
line line Resume building rapport with the child/adolescent by asking non-threatening questions about a neutral subject. Use the answers to assess the child/adolescent's cognitive, developmental, and social levels and language ability. Then move on to ask non-leading, non-suggestive questions. Avoid complex questions that may be confusing. When asking yes/no questions, follow-up to ensure the child/adolescent understood the question and you understood the response. Be sure to use terminology the child/adolescent understands. For a confidence continuum related to the types of interview questions, see A Sample Continuum of Medical History Questions and Confidence in the Responses, Appendix B.

Questions that May Trigger Disclosure of Abuse
  • Do you know why you are here?
  • Does anything on your body hurt?
  • Do you know about good touch and bad touch?
  • Has anyone ever touched you in a way that made you feel uncomfortable?
  • Do you have any secrets?

Although it is important to maintain confidentiality, special situations may arise when talking to adolescents or older children regarding their abuse. It may be helpful to explain that some confidential issues may need to be shared. For example, such a statement could be: "If you tell me something that is a threat to you or your health, I have a duty to tell someone. I will include you in the process and make sure you are involved in the process."

Keys to Good Rapport with the Child/Adolescent
  • Have the child sit at eye level
  • Begin the conversation with neutral subjects
  • Draw on information previously obtained about the child
  • Prepare the child for the exam through education regarding the procedure, that is, it will be a head-to-toe exam, like a routine check up

Ending the History Taking
line spacer Before proceeding with the physical examination explain that the purpose of the head-to-toe examination is to ensure his/her well-being. In addition, describe the steps of the exam and how the colposcope works. This will help the child/adolescent prepare for the physical examination. For further information on preparing the child/adolescent, see PHYSICAL EXAMINATION: Preparing the Child/Adolescent for the Examination.

If No History Is Given
line line Attempt to obtain as much information about the suspected abuse from the parent/caregiver, other appropriate adults, and from previous interviews when the child is unwilling or too young to talk, when a report of abuse has already been investigated and substantiated, or when the child has been interviewed more than once in a complex case. Then determine how best to proceed with respect to clinical evaluation and treatment.

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History: Overview   History: Taking Steps  History: Communication Challenges  History: Taking a History from the Parent/Caregiver  History: Taking the History from the Child/Adolescent  History: Responding to the Disclosure of Abuse  History: Additional Resources 

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On this page:
If the Parent/Caregiver Must Be Present
Questioning the Child/Adolescent
Ending the History Taking
If No History Is Given