Paediatrics: Asking the difficult questions

Asking the difficult questions

About sexual abuse

Sexual and other forms of abuse are common specific and non-specific vulnerability factors fors poor mental health and must be excluded as aetiological factors. The clinician’s task is to find an approach to asking about abuse that they are comfortable with and appear to the child to be comfortable with. One approach is a hierarchical set of questions.

·  Introductory comment: ‘I ask these questions to all children I see.’

·  Ask child to respond to a broad, non-leading statement: ‘Some children tell me something has happened to them that they wish had never happened.’ Child’s response may be verbal or non-verbal affirmation, denial, or looking perplexed; they may not understand the question at all.

·  Ask more specific questions: ‘Some things are done by other people . . .’ or ‘. . . are touched in places they wished they had not been touched.’

·  Ask very specific questions: ‘Some people are touched in places like their private parts/vagina/penis (language depends on age, may also point or draw picture), has this happened to you?’

Partial affirmation or non-verbal cues that suggest possible abuse should be followed up during later appointments. One caveat is there are differ-ences between a purely forensic and a clinical interview. In both settings open, non-leading questions are preferable. Local protocols will also guide assessments.

About suicidal ideation and intent

Clinicians must ask about suicidal thinking, especially in adolescents with any depressive features. Asking does not create or promote suicidal think-ing. Again, a hierarchical approach is used effectively by many clinicians.

·  Introductory comment: ‘I ask these questions to everyone I see.’

·  Ask adolescent to respond to a broad statement: ‘Some young people tell me that they feel life is not worth living anymore.’ Again look for responses that may be verbal or non-verbal affirmation or denial.

·  Ask more specific questions: ‘Have you considered what it would be like to not be alive’ or ‘Some people think it would be better to be dead.’

·  Ask very specifically to clarify risk and extent of planning: ‘Have you thought of killing yourself?’; ‘Have you ever made a plan to kill yourself? ‘Have you ever lost control and started your plan?’

As above, partial affirmation or non-verbal cues that suggest possible abuse should be followed up during later appointments.