Fases Estereotípicas del Mobbing

The medical provider will need to know about chronic health problems, ongoing medications, medication allergies, immunization status, major illnesses, injuries, accidents, or surgeries and whether the child is currently displaying signs of illness. These questions can help focus the evaluation, provide explanations for marks and scars, index risk status (as with multiple injuries, especially those that are unexplained) and permit appropriate follow-up recommendations. The examiner also can use this information to begin developing a differential diagnosis.

5. Names of child’s primary caretakers and contacts

In acute evaluations, the names of the biological parents and disclosure of where and with whom the child resides should suffice. In screening and assessment center evaluations, it is helpful to obtain a list of parents, stepparents, mother’s and father’s partners, siblings, regular baby sitters and others with whom the child spends significant time. This information provides for a

comprehensive, neutral evaluation by broadening the focus from the acts of a single alleged perpetrator to consideration of the child’s whole range of contacts. Knowing the

names/nicknames of significant people in the child’s life can help evaluators to understand a child’s statements. This is particularly contributory with young children who may use first names but may not be able to articulate the person’s role in their life. Gathering this data also

frequently provides an opportunity for the caretakers to reveal family problems, such as drug and alcohol abuse or custody disputes, which may impact the evaluation.

6. Permission to contact the primary medical provider

It is helpful to get the caretaker’s verbal and written permission to contact the primary medical provider for consultation. The primary healthcare provider may contribute aspects of the medical and social history not reported by the child’s caretakers. Moreover, because this individual may be responsible for medical follow-up with the child, it is recommended that he/she be informed about the results of the evaluation.

INFORMATION USEFUL TO OBTAIN DURING EXTENDED EVALUATIONS

• Medical

1) Prenatal History 2) Birth History

3) More comprehensive past medical history

• Social

1) Child behavior problems 2) Discipline and caretaking 3) Sources of sexual knowledge 4) Family risk factors

Oregon Medical Guidelines Chapter 7 pg 6

Medical History Useful For Extended Evaluations 1. Prenatal history

A history of the pregnancy is most relevant with young children and special needs children or when there is concern regarding transmission of a sexually transmitted disease. Some medical practitioners obtain a prenatal history on all children, while others gather the information only when it appears pertinent. Standard questions regarding the history of the pregnancy include prenatal care, complications, infections and sexually transmitted diseases, abnormal pap smears, use of prescription and non-prescription medications, and substance abuse. Questions

regarding prenatal care, pregnancy complications and drug use are helpful in determining risk status and may explain ongoing developmental difficulties, such as learning disabilities, cognitive impairments and hyperactivity. With many sexually transmitted diseases, such as anogenital warts or chlamydia, perinatal transmission is a possibility. The examiner will need to know about possible prenatal or perinatal transmission in determining possible sources for a current infection.

2. Birth history

The birth history is another important source of information regarding risk status and sources of developmental difficulty. Like the pregnancy history, it is most relevant with young children, special needs children and in children presenting with a sexually transmitted disease. It is helpful to find out where the child was born, in case it will be necessary to request medical records, and because the current evaluator’s records may be the most complete medical history recorded for this child. It is very important to learn if the child was born pre-term, at term or late, if the delivery was complicated and whether it was vaginal or Caesarean. The child’s birth weight and history of any post-natal complications may also be contributory.

3. More comprehensive past medical history

Some child sexual abuse medical evaluators find it helpful to develop a checklist to inquire about the patient’s past medical history. The clinician may wish to become aware of any

developmental difficulties (e.g., motor or cognitive delays or disorders; vision, speech, hearing deficits), chronic illnesses (e.g., asthma, diabetes, allergies, seizures, heart problems), serious medical events (e.g., loss of consciousness, anaphylaxis, major accidents or injuries), mental health diagnoses, learning disorders or ADHD, and common medical problems (e.g., ear infections, childhood illnesses, broken bones or stitches, skin problems) that the child has experienced. It is also routine to take history regarding emergency department visits,

hospitalizations and surgeries. This information may be helpful in predicting the child’s response to the examination and in providing explanations for physical findings (e.g., scars, marks).

If the patient has developmental limitations, the examiner may need to make adaptations in terms of language and physical accommodations. In children with a history of having undergone

Oregon Medical Guidelines Chapter 7 pg 7

painful medical procedures, it may be most reassuring for the examiner to tell the child repeatedly and clearly that this evaluation will not involve such procedures.

Social History Useful For Extended Evaluations

Extended evaluations for sexual abuse in children and teens are commonly conducted by a team consisting of the medical provider and a mental health professional such as a social worker or other child interview specialist. The child interviewer/mental health professional typically takes a comprehensive social history from the parents. Healthcare professionals conducting extended evaluations alone may also gather a thorough social history.

1. Child behavior problems

Identifying a history of child behavior problems can provide clues to the onset of abuse and may help the clinician to determine the need for mental health follow-up for the child and family. A description of problem onset, frequency, effect on the family and child, and how/whether it has been resolved may be useful in exploring possible associations with abuse. Use of a checklist format can be most effective in screening for behavioral concerns. The medical evaluator can create his/her own simple checklist to identify and document problem behaviors or may utilize a standardized checklist. Many behavioral questionnaires and checklists have been developed, usually intended originally for other purposes, but which may be applied to the extensive child sexual abuse evaluation setting. (Examples include Friedrich’s Child Sexual Behavior Inventory, the Achenbach Child Behavior Check List and several others.) Medical evaluators are

reminded that such instruments may require specific training in interpretation of responses.

Mental health professionals may provide useful consultation regarding the application of behavior checklists.

2. Discipline and care -taking in the home

A discussion about who bathes the child, who assists him with toileting, who puts the child to bed, with whom she sleeps, who disciplines and how the child is disciplined may be valuable in determining opportunities and risk for abuse. This information may establish perpetrator access and may provide important insights into how well the child is nurtured in the home. Particularly for young children and developmentally disabled children, the clinician can use this knowledge as a frame of reference for interpretation of statements the child might make.

3. Sources of sexual knowledge

Understanding the exposures that the child has had to sexual materials and matters can provide a foundation for considering various possible explanations for what the child has reported or for sexualized behaviors the child has displayed. The evaluator should ask about the child’s exposure to nudity in the home or other living environments, screen nudity (e.g., on television,

Oregon Medical Guidelines Chapter 7 pg 8

movies and computer screens to which the child has access), and pornographic materials. Most skilled clinicians ask the caretakers if the child has ever witnessed sexual activity (e.g., by observing or walking in on adults engaged in sexual activity). This information can assist the medical provider in considering the basis for the child’s statements or behaviors, other than or in addition to, the current abuse allegation.

4. Family risk factors

The medical evaluator should inquire about the child’s experiences with caretaker’s separation and divorce and any exposure to domestic violence, drug and alcohol abuse and criminal activity. Information about the parents’ mental health history and any prior involvement of the family or child with child protective agencies is important to consider. Contributory insights may also be gained from questioning the caretakers about major stressors in the family, health challenges, deaths or absences of significant figures, changes in residence or other life events impacting the child and family.

SPECIAL CONSIDERATION FOR OLDER CHILDREN AND ADOLESCENTS