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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 a History from the Parent/Caregiver

The purpose of taking this history includes:
  • Obtaining a complete pediatric history
  • Obtaining as complete a picture of the sexual offense as the person can provide
  • Giving the parent/caregiver an opportunity to express his/her feelings about the abuse and address concerns
  • Assessing the level of support the parent/caregiver is able to provide the child/adolescent
  • Providing education about the abuse investigation and legal process
In order to do this, the parent/caregiver needs to feel free to talk with the medical provider privately.

The Social History
line spacer A social history should include the following:
  1. Information about the interview
    • List of all persons present
    • Name of the primary interviewer
    • Date, time, and location/site of interview
  2. Information about the child/adolescent
    • Name, including nicknames
    • Home address and telephone number(s)
    • Date of birth
    • Sex
    • Ethnicity
    • Place of birth/country of origin/date of arrival in USA
    • Language(s) spoken/comprehended
    • School attended and grade level
    • Work site(s) if an adolescent
  3. Information about the parent(s)/caretaker(s)
    • All names, including maiden, married, alternates
    • Home address and telephone number(s)
    • Work address and telephone number
    • Country of origin
    • 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 offense (informant)
      • 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 interview cannot be considered reliable.
        • Consider whether language difficulties or handicapping conditions are interfering with the ability to relay reliable information.
Much of the above information may be obtained by a social worker who works with the medical provider. Healthcare social workers are invaluable resources and are usually 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 of the patient and family.

The Medical History
line line The medical history should contain information about the following:
  1. 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.)
  2. Past medical history
    • Developmental history
    • Previous injuries or hospitalizations
    • Allergies
    • Other medical problems
  3. Family health history
    • History of bleeding disorders or bleeding in a family member
    • Other inherited illnesses (e.g., Osteogenesis imperfecta, collagen vascular disorders, copper deficiency, etc.)
    • Siblings who died of sudden infant death syndrome, or who have a serious illness
    • History of growth delay in siblings, parents, or relatives
    • Abuse in other family members
Suggested Questions to Ask Regarding Abuse
Does your child have any genital complaints?
  • Vaginal, rectal, penile pain
  • Staining of underwear, discharge, foul odor
Are there any new or changed behavioral problems?
Are there recurrent somatic complaints?
  • Abdominal pain, headaches

Have you noticed any bruising?

What kind of appetite does your child have?

Understanding the Uncooperative, Non-Offending Parent
line spacer 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 .

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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:
The Social History
The Medical History
Understanding the Uncooperative, Non-Offending Parent