THE ART OF THE INTERVIEW IN CHILD ABUSE CASES
Captain Barbara Craig, MC, USN
Medical Consultant for Child Abuse and Neglect
Department of Pediatrics
National Naval Medical Center
Bethesda, Maryland 20889-5600
1 -(301 )-295-5648

 Interviewing children about physical and sexual abuse is one of the most critical steps in the evaluation process. Unfortunately, it can be the most difficult and fmstrating portion of the investigation as well. The number of interviews should be kept to a minimum by having as many of the multi-disciplinary professionals present as possible. Ideally this should be done in a viewing room with a one way mirror, so as not to overwhelm the child. The interview may be conducted by a physician, nurse, nurse practitioner, social worker, psychologist, or criminal investigator. No matter who performs the interview, it should be someone with experience and patience. 

A. DEVELOPMENTAL STAGES AND CHILDREN'S ABILITY TO DISCLOSE ABUSE 1. Infancy (0-18 months): These children are of course unable to make any disclosures of physical or sexual abuse. Cases can only be substantiated if there is an eye witness, the perpetrator confesses, or the infants are found to have an STD, sperm or semen on their examination. They will probably exhibit no symptoms but may be fearful of the offender, be fussier than normal, reluctant to have diaper changed, or occasionally imitate sexual acts. Interviewing is universally unsuccessful.

 
2. Toddlers (18-36 months): This is a common age group to be molested. Because of their limited communication skills, toddlers are unlikely to report the abuse. They may mimic the sexual acts with their own bodies, other children, or dolls. They frequently show fear and anxiety around the perpetrator. Simple phrases may be the only clue that something has happened, such as, "Owie, pee-pee, Daddy" while pointing to their genital area. On rare occasion, the older toddler can verbalize their account of the assault. Toddlers cannot sequence time and place very well and will probably not be able to tell you how often something has happened, when it happened, or even where it happened. Most of the time their expressive language abilities are significantly less than their receptive language. Only some children of this age group know their body parts or understand right from wrong. Toddlers do masturbate but can be easily distracted from that activity, unusual obsession with their genitalia is rare in non-abused children. They show little embarrassment about genital or sexual discussions. They may be experiencing regressed behaviors, difficulty toilet training, sleep disturbances, and angry outbursts. Again, to substantiate the abuse, a witness, a confession, an STD, or sperm/semen are usually required.

An interview can be attempted with the 2 and a half to 3 year old, however the questions need to be more direct and specific. Avoid yes/no questions.

 
3. Preschool (3-5 year olds): Again, a common age for physical and sexual abuse, there children have limited vocabulary and ability to be reliable witnesses. They tend to be concrete thinkers, with an egocentric world. They cannot conceptualize or think abstractly. During an interview, they become easily distracted, and revert to physical activity, or phrases such as "I don't know" or "I can't remember". They tend to tell small excerpts of their abuse with minimal detail, disorganized thought processes, and give relevant and irrelevant details. Time and space relationships are poorly defined, however they can relate things to before and after such as birthdays holidays, dinner, bedtime, etc. They can on occasion be specific and give enough detail to be good witnesses in court. Demonstration is a better tool than verbalization for many children this age. They may confuse he-she-me and sex specific body parts. Sexual differences are usually known and of great curiosity and interest. Questions that start with who, what, and where tend to be more helpful than when and why. Preschoolers may exhibit sexualized play, somatic complaints (headaches, abdominal pain, painful urination, genital discomfort, etc) and may also have nightmares, regressed behavior, anger, aggression, withdrawal, mood lability and other psychosocial problems. Although substantiation may still rely on finding acute injuries, sperm or semen, or an STD, their history becomes increasingly important. Ask short and specific questions, but do not put words in their mouths. Asking them to draw or demonstrate what happened might be easier for them than verbal communication. Make the child feel at ease and safe. They may be fearful of what will happen to them if they tell. Preschool children and older children can lie, but they are not as sophisticated as adults in their ability to concoct details.
 

4. Elementary school aged children (6-9 years old): For the first time, the children are becoming more independent, having a life separate from their families through associations with their classmates, friends, teachers, and others. They are exposed to a wider variety of information resources than previously. Although still primarily concrete thinkers, as children advance through the latency age years, they become better able to understand concepts and symbolism. They still tend to want their emotional support to be family oriented, but socialization is with their peers, usually of the same sex. By the early school years, children are able to orient themselves in time and space, especially relating to events and holidays, and draw simplistic floor plans of the place where the abuse occurred. They are capable of deceiving in a more convincing way and are more capable of keeping a secret. As they become more aware of the unacceptable nature of sexual touching, and since they are too young to control their environment well, many children of this age feel they are responsible at least in part for the sexual abuse. They feel conflicted and confused, guilt ridden, embarrassed and may be fearful that they themselves will end up in jail. Behavioral symptoms may include withdrawal, depression, emotional lability, nightmares, poor school performance, aggression, lying, stealing, and other antisocial behaviors. Physical symptoms may include enuresis, encopresis, dysuria, headaches, abdominal pain, genital pain, and tics. Children of this age are reluctant and tentative in their disclosures and will withdraw if they perceive non-reassuring reactions from the interviewer. Role play may be an appropriate tool, as well as drawing and the use of dolls and doll houses. When interviewing elementary age children, building rapport is essential before the interview begins because they are frequently embarrassed and uncomfortable discussing the inappropriate touching. One way to ease their discomfort is to engage them in a simultaneous activity like drawing, coloring, or working a simple puzzle. Again nonverbal communication is helpful.
 

5. Puberty (9-13 year olds): Preadolescents are usually more at ease with an interviewer of the same sex. They not only feel uncomfortable about the sexual molestation, but are feeling awkward and self conscious about their bodies and discussions regarding sexual issues. Their hormones are blossoming and with that are seen moodiness, unprovoked tearful outbursts, and easy frustration. Because the need to "fit in" is so strong, being molested and therefore different from their peers may increase their reluctance to disclose. Now their friends may be a new source of emotional support and intimacy while the pre-adolescent may cause increased family tension and withdrawal. They may begin to challenge social acceptability by experimenting with shoplifting, substance abuse, or peer sexual contact. Preteens understand that the sexual behavior is wrong, but are even more likely than the younger children to feel that they are responsible for the abuse. Guilt and shame can be overwhelming, with frequent denial and recantation. They experience similar behavioral changes and physical symptoms as the latency age children. A more formal approach to the interview frequently minimizes the pre-adolescents discomfort with the discussion. Keep your questions brief and clinically oriented, yet let them know that their feelings and opinions are also important to the investigation. Reassure them that they are not at fault for what has happened.
 

6. Adolescents (13 years to adulthood): By this age, many have had peer sexual
encounters. They are less emotionally dependent upon their families, seeking solace with their peers. Independence is an important aspiration while the need to challenge authority makes interviewing difficult. Because of teenagers need to be in control, they may have great deal of difficulty in accepting the fact they need help, whether it be counseling, legal, medical, etc. Behavioral problems may include defiant, aggressive acts, truancy or school failure, criminal behavior, suicidal ideation or attempts, promiscuity, substance abuse, self mutilation and runaway behavior. They may present to the medical clinic with chronic aches and pains, vague complaints, and hysteria. To maximize the outcome of the interview, an open, direct approach is usually the best. Be serious about their concerns and supportive of their needs. Never criticize of judge their acts. By being honest with them, they will be more likely to be cooperative with you.
 

B. HOW CHILDREN DISCLOSE ABUSE:
  Disclosure of sexual abuse is a gradual process, not an isolated event. Most children go through a progression of stages which include denial--disclosure-recantation-reaffirmation. Studies have shown that 72% of sexually abused children will initially deny the abuse. Once they are willing to speak about what ha happened to them, only 7% of children will move directly to active, full disclosure. The most common way that children disclose their sexual abuse is tentatively, with 78% of children going to this stage first. They will ~ details, minimize or distance themselves from the event, dissociate, or discount the acts. Approximately 22% of children and teenagers who disclose sexual abuse will then go on to recant their stories, especially if the non-offending parent does not believe them. Ultimately, of those who recanted, 92% will later reaffirm that the abuse did occur. Younger children are more likely to disclose the abuse accidentally through inappropriate statements or actions. Older children and teenagers are more likely to disclose the abuse purposefully because they are angry at the perpetrator or are influenced by their peers.

 

C. THE INTERVIEW PROCESS:
1. For the best results, the interviewer should already have some knowledge of the case before they meet the child. This should include the child's name, age, developmental level, prior disclosures, method of disclosure, and results of previous interviews or examinations, past medical history, symptoms or signs related to sexual abuse. It is also helpful to inquire who the family members, babysitters, and friends are, as well as who else is called "Daddy11 and/or the name of the alleged perpetrator. You should also find out about exposure to pornographic magazines and videos in the home, and other ways the child may have learned about anatomy or sexually explicit behavior.

 
2. The basic format should include a short rapport building phase, an attempt to determine the child's developmental level, communication skills, and knowledge of truth/lie, pretend/real. Next one should go over the child's knowledge of body parts and ability to use words phrases such as on top of, under, in front, behind, in, and on, beside, before, after, first, last, never, always. I ask routine safety questions to assess the child's ability to give detail and relate learned knowledge.
 

3. Next, begin the main part of the interview by asking open ended questions like:

"Do you know why you are here?"

"Your Mommy told me you've been having a problem with.

"Has anyone ever talked to you about good touching or not so good touching before?" If they will talk to you, ask as many open ended or focused or direct questions as possible. Avoid leading questions or putting words in the child's mouth.

 
4. Avoid teaching the child about sexual activity, correcting the child's statements, or giving judgements regarding the alleged perpetrator being a bad person. Don't use words the child will not understand. Don't ask complicated sentences. Avoid questions to be answered by yes or no. Don't ask questions about something hurting, because many types of sexual abuse are not only not painful, but they may invoke pleasurable sensations. Ask about pornography, creams, lotions, toys used, etc. Some child molesters have the child touch the adult, not vice versa, so remember to ask about that as well.
 

5. Good ways to elicit information include questions or statements such as:

Tell me more

What makes you think so?

Then what happened?

Is there anything else you want to tell me?

What did he say when that happened?

What did he do with his hands?

Has anyone ever asked you to keep secrets?

Has anyone ever told you not to tell about private touching?

What would you do if someone touched you on a private place and then told you not to tell?

Have you ever told anyone before about touching on your privates?

I know sometimes it is hard to talk about things that have happened to you, but I talk to lots

of children about things that are bothering them. It's always okay to talk to doctors about

anything, even secrets are okay to tell to the doctor. You aren't going to get into any trouble

(or go to jail).

What were you wearing, What was he wearing/

How did your clothes come off?

What did it feel (taste, look) like?

Can you point to where that happened?

Did anything happen with your (or his) mouth?

Who else was there?

When was the first (last) time that happened to you?

Where were you when that happened?



Adapted for the web by  LT Gorman from an April '98 handout