Amended June 14, 2016 in the Interest of J.C., Minor Child J.C., Minor Child ( 2016 )


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  •                  IN THE SUPREME COURT OF IOWA
    No. 14–0357
    Filed April 1, 2016
    Amended June 14, 2016
    IN THE INTEREST OF J.C., Minor Child
    J.C.,
    Minor Child,
    Appellant.
    On review from the Iowa Court of Appeals.
    Appeal from the Iowa District Court for Scott County, Christine
    Dalton, Judge.
    A youth adjudicated as a delinquent seeks further review of a court
    of appeals decision affirming the adjudication.   DECISION OF COURT
    OF APPEALS AND JUVENILE COURT JUDGMENT AFFIRMED.
    Timothy J. Tupper, Davenport, for appellant.
    Thomas J. Miller, Attorney General, Bruce L. Kempkes, Assistant
    Attorney General, Michael J. Walton, County Attorney, and Elizabeth J.
    Cervantes, Assistant County Attorney, for appellee.
    2
    MANSFIELD, Justice.
    This appeal from an adjudication of delinquency requires us to
    determine whether a violation of the Confrontation Clause occurred when
    the juvenile court admitted out-of-court statements of a four-year-old
    child victim. The child made some of the statements during a medical
    assessment performed by a physician; others were made in the course of
    a recorded interview conducted by a forensic interviewer.       Both the
    physician and the interviewer testified at the hearing.
    Applying recent authority of the United States Supreme Court, we
    find that admission of the physician’s testimony and report did not
    violate the Confrontation Clause.    We also conclude that any error in
    admission of the forensic interviewer’s testimony was harmless beyond a
    reasonable doubt in light of other overwhelming evidence that the
    respondent committed the charged conduct.          For these reasons, we
    affirm the judgment of the juvenile court and the decision of the court of
    appeals.
    I. Facts and Procedural Background.
    On July 2, 2013, twelve-year-old J.C. visited the home of his friend
    K.W. An extended family lived in the home, including K.W.’s sister E.W.,
    K.W.’s brother I.W., and their four-year-old niece A.W.
    That afternoon a number of the children were playing outside.
    J.C. tried to take pictures with a cellphone of E.W.’s chest and tried to
    touch her. J.C. also attempted to show photos of his penis to E.W. On a
    previous occasion, J.C. had written a note to E.W. asking to have sex.
    After dinner, I.W. walked into an upstairs bedroom unannounced.
    He saw J.C. pulling down A.W.’s underwear and saying, “It’s time to go to
    sleep.” A.W. was lying on her back; J.C. was on his knees over her. The
    underwear was halfway pulled down when I.W. arrived. I.W. yelled at
    3
    J.C. and pulled him off of A.W. J.C. denied that anything was going on,
    turned red, and ran out of the house.
    Meanwhile, E.W. and her friend M.M. had been downstairs. M.M.
    heard A.W. scream.       She and E.W. ran upstairs and entered the
    bedroom. I.W. was already in the room. According to M.M., J.C. had
    A.W. pinned on the bed and was on top of her. J.C. was taking off A.W.’s
    clothing, and A.W.’s shirt was already on the floor.     J.C. soon left the
    house.
    E.W. also recalled hearing commotion and going upstairs with
    M.M. She arrived to see J.C. on the bed with A.W. and his arm on her.
    To E.W.’s recollection, A.W. was still dressed.
    The two older girls—E.W. and M.M.—grabbed A.W. and brought
    her downstairs to her mother who was doing chores at the time. The
    mother called the police and filed a report.      The police later directed
    A.W.’s parents to the Child Protection Response Center for interviewing.
    The police also obtained K.W.’s cellphone, which J.C. had been
    using that day.    The cellphone was found to contain photos of J.C.’s
    penis, a video of J.C. masturbating, and a video taken by J.C. of K.W.
    with J.C.’s voiceover stating that K.W. was going to suck his penis that
    evening.
    A.W. does not speak very clearly. A.W. is in speech therapy and,
    according to A.W.’s mother, talking to her is like talking to a two-year-
    old.
    On July 10, A.W. was brought to the Child Protection Response
    Center by her parents.    At that time A.W. was interviewed by Michele
    Mattox—a forensic interviewer with the Child Protection Response Center
    and a former twenty-five-year employee of the Iowa Department of
    Human Services. Mattox had a referral sheet that said, “Rule out sex
    4
    abuse by older child . . . .”     The interview was recorded on DVD, and
    Mattox also prepared a report. Mattox recalled that A.W. “had a definite
    speech and language problem and delay.”             In the interview, A.W. said
    that J.C. had touched her “pee” and that her clothes were off and J.C.’s
    were on. Law enforcement observed the interview. 1
    Additionally, Dr. Barbara Harre, a physician and the medical
    director of the Child Protection Response Center, saw A.W. on July 31.
    Her meeting was not recorded, but she dictated a report.                Dr. Harre’s
    report explained, “I was asked to complete a medical assessment for
    [A.W.]”      A.W.’s father brought her to the appointment, but Dr. Harre
    spoke to A.W. alone.         No one from law enforcement was present.
    Dr. Harre took notes and then prepared a report addressed to the
    assistant county attorney who later prosecuted the case.
    Dr. Harre initially reviewed truth–lie concepts and conducted a
    medical review of A.W.’s systems for any areas of discomfort or signs of
    illness.     Dr. Harre then asked A.W. if she could remember what had
    happened with her brother’s friend when he was at her place.                   A.W.
    stated, “Me upstairs.      Pulled underpants off.”       Dr. Harre asked if her
    underpants came all the way off or down to her knees or something else.
    A.W. stated, “To knees.” In response to a question whether she had been
    touched, A.W. said, “Touched me boob. One. Two.” While saying this,
    A.W. pointed to both sides of her chest.
    Dr. Harre asked if the brother’s friend touched her anywhere else.
    A.W. stated, “Touched back bottom,” while pointing to her rear.                  Dr.
    Harre asked again if he touched anywhere else. A.W. stated, “Touched
    1At one point, law enforcement sent in questions requesting more detail in one
    subject area, and those questions were put to A.W. by Mattox and answered.
    5
    front bottom.” Dr. Harre asked A.W. what he touched her body with, and
    A.W. said “Wawa,” apparently a reference to a dinosaur toy she used to
    have.    Dr. Harre asked if the touching hurt or felt good or tickled or
    something else. A.W. said, “Hurt.” Dr. Harre asked A.W. if anybody else
    had ever touched her in a way that made her uncomfortable or hurt or
    something else. A.W. said, “No one else.”
    After Dr. Harre finished asking these questions, she conducted a
    full medical exam of A.W., with her father now present at A.W.’s request.
    Dr. Harre found nothing abnormal in the physical exam. When asked
    during the medical exam to indicate where she had been touched, A.W.
    pointed to her front bottom area and her anal area.             According to Dr.
    Harre, it was “moderately” difficult to understand A.W. throughout the
    interview and exam.         Dr. Harre had not received any information
    concerning Mattox’s interview before she saw A.W.
    The State filed a delinquency petition and the case proceeded to
    hearing.      A.W.’s mother testified that A.W. would be traumatized by
    testifying and might not even be able to speak. A psychologist, Catherine
    Jackson, also testified that the trauma to a child of this age would
    outweigh any benefit from the testimony. The State did not call A.W. to
    testify. However, other witnesses for the State included I.W., E.W., M.M.,
    Mattox, and Dr. Harre.        J.C. testified on his own behalf and denied
    assaulting A.W.
    J.C. objected to testimony from Mattox and Dr. Harre describing
    A.W.’s statements on the basis of hearsay and the Confrontation Clause. 2
    2J.C.’scounsel did not specify whether he was referring to the Confrontation
    Clause of the United States Constitution or that of the Iowa Constitution.
    6
    J.C. also objected to the admission of their written reports and the DVD
    of Mattox’s interview with J.C.
    The juvenile court sustained the objections to Mattox’s written
    report and the DVD. The court admitted Dr. Harre’s written report. The
    court also permitted both Dr. Harre and Mattox to testify regarding their
    interviews of A.W. The court found beyond a reasonable doubt that J.C.
    committed assault with intent to commit sexual abuse in violation of
    Iowa Code section 709.11 (2013) and adjudicated J.C. a delinquent child
    as defined by section 232.2(12).
    The court noted that J.C.’s testimony “is inconsistent with A.W.[’s]
    statements to Dr. Harre, and eyewitness accounts by I.W., E.W., M.M.,
    and K.W. who saw A.W. and [J.C.] together. The eyewitness accounts
    alone are quite persuasive in this case and appear credible due to the
    differences which are explained by the order they entered the room.”
    J.C. appealed. He argued that the court erred in admitting certain
    testimony due to insufficient notice of the witness. He also urged that
    the court should have excluded any evidence of A.W.’s statements to Dr.
    Harre and Mattox as violating the Confrontation Clause.         Lastly, he
    argued that evidence of A.W.’s out-of-court statements to Dr. Harre and
    Mattox should not have been admitted because A.W. was incompetent to
    testify.
    We transferred the case to the court of appeals.      The court of
    appeals affirmed, with one judge on the panel dissenting. J.C. filed an
    application for further review, which we granted.
    II. Standard of Review.
    “We review constitutional questions de novo.”          Clarke Cty.
    Reservoir Comm’n v. Robins, 
    862 N.W.2d 166
    , 171 (Iowa 2015).           Our
    7
    review of evidentiary claims is for abuse of discretion.          State v.
    Harrington, 
    800 N.W.2d 46
    , 48 (Iowa 2011).
    III. Analysis.
    On further review, we have discretion to let the court of appeals
    decision stand as the final decision on an issue. See State v. Walker, 
    856 N.W.2d 179
    , 184 (Iowa 2014).        We do so here with respect to the
    inadequate notice argument and turn to the remaining issues.
    A. Confrontation Clause—Dr. Harre. Both the Sixth Amendment
    of the United States Constitution and article I, section 10 of the Iowa
    Constitution preserve an accused’s right “to be confronted with the
    witnesses against him.”     This right of confrontation applies to juvenile
    delinquency proceedings. In re Gault, 
    387 U.S. 1
    , 56, 
    87 S. Ct. 1428
    ,
    1459, 
    18 L. Ed. 2d 527
    , 562 (1967). Even though J.C.’s appellate brief
    refers to both the Sixth Amendment and article I, section 10 of the Iowa
    Constitution, he has not argued for a particular test or standard under
    the Iowa Constitution. In fact, he has only cited caselaw decided under
    the United States Constitution. We will therefore follow the approach we
    took in State v. Kennedy:
    “[W]e jealously protect this court’s authority to follow an
    independent approach under our state constitution” for
    provisions of the Iowa Constitution that are the same or
    nearly identical to provisions in the United States
    Constitution. However, in his appellate brief, [the appellant]
    does not propose a specific test we should apply under
    article I, section 10 of the Iowa Constitution. Rather he only
    cites caselaw analyzing the Confrontation Clause under the
    United States Constitution. Thus, under the facts of this
    case, we choose not to interpret the Iowa Constitution any
    differently from the United States Constitution.
    
    846 N.W.2d 517
    , 522 (Iowa 2014) (first alteration in original) (citation
    omitted) (quoting State v. Pals, 
    805 N.W.2d 767
    , 771 (Iowa 2011)).
    8
    Under the Sixth Amendment, the fundamental question we must
    answer is whether the out-of-court statements were testimonial in
    nature. See State v. Bentley, 
    739 N.W.2d 296
    , 298 (Iowa 2007). “If the
    statements are testimonial, they are inadmissible against [the defendant]
    at trial; but if they are nontestimonial, the Confrontation Clause does not
    prevent their admission.” 
    Id.
     The burden is on the State to prove by a
    preponderance    of   the   evidence   that   a   challenged   statement   is
    nontestimonial. State v. Schaer, 
    757 N.W.2d 630
    , 635 (Iowa 2008).
    In our determination of what constitutes testimonial evidence, the
    United States Supreme Court’s decision in Crawford v. Washington
    provides direction.   
    541 U.S. 36
    , 
    124 S. Ct. 1354
    , 
    158 L. Ed. 2d 177
    (2004). As we have said concerning that decision,
    [T]he Court indicated that, at a minimum, there were four
    types of evidence that met the definition of testimonial:
    grand jury testimony, preliminary hearing testimony, former
    trial testimony, and statements resulting from police
    interrogations. These are the types of evidence with the
    “closest kinship” to historical “abuses at which the
    Confrontation Clause was directed.”
    In addition to these four categories of evidence, the
    Supreme Court provided three “formulations” to aid courts in
    determining whether other types of statements are
    testimonial. The first formulation involved ex parte in-court
    testimony or its functional equivalent where the declarant
    would reasonably expect the statements to be used at trial
    and where the defendant was unable to cross-examine the
    declarant.    The second formulation involved formalized
    testimonial materials such as confessions and depositions.
    The third and most open-ended formulation included
    statements made under circumstances that would lead
    witnesses to objectively believe the statements might be used
    at trial.
    State v. Shipley, 
    757 N.W.2d 228
    , 235 (Iowa 2008) (citations omitted)
    (quoting Crawford, 
    541 U.S. at
    51–52, 68, 
    124 S. Ct. at 1364, 1374
    , 
    158 L. Ed. 2d at 193, 203
    ).
    9
    Our decision in Bentley involved the admissibility of an interview
    with a ten-year-old girl.         
    739 N.W.2d at 297
    .             The interview was
    conducted by a counselor at a child protection center but was arranged
    by police and DHS personnel and monitored by them through an
    observation window. 
    Id.
     During the interview, the girl made numerous
    statements alleging the defendant had sexually abused her. 
    Id.
    We determined in Bentley that use of the interview violated the
    defendant’s Confrontation Clause rights under the Sixth Amendment.
    
    Id.
     at 302–03. After carefully reviewing the facts and circumstances, we
    found that “[t]he extensive involvement of a police officer in the interview
    leads us to conclude [the girl’s] statements were in effect ‘taken by [a]
    police officer[] in the course of [an] interrogation[].’ ” 
    Id. at 299
     (last four
    alterations in original) (quoting Crawford, 541 N.W.2d U.S. at 52, 
    124 S. Ct. at 1364
    , 
    158 L. Ed. 2d at 193
    ).                  Among other things, we
    emphasized     the    “close,    ongoing       relationship”   between    local   law
    enforcement     and    the      child   protection     center;    the   participants’
    acknowledgment that the interview “served an investigative function for
    the State”; the disclosure to the girl at the beginning of the interview that
    police and DHS were listening through the observation window
    accompanied by the interviewer’s explanation that “it’s just really
    important the police know about everything that happened”; and the
    interviewer’s mid-interview consultation with the police and DHS
    representatives to obtain more questions. 
    Id.
     at 299–300.
    Since Bentley, we have determined in two cases that statements to
    medical personnel were not testimonial. In Schaer, the victim spoke to
    treating medical personnel in an emergency room before police arrived,
    identifying the defendant as her attacker. 757 N.W.2d at 632. We noted
    that the statements “were not solemn declarations made for the purpose
    10
    of proving some fact” or “made under circumstances that would lead an
    objective person to reasonably believe the statements would be available
    for use at a later trial.” Id. at 636. The interview “lack[ed] the indicia of
    formality” evident in Bentley, and there was “no indication in the record
    of any relationship between the emergency room personnel and law
    enforcement authorities that would support a finding the medical
    providers’ questioning of [the victim] as to the cause of her injuries was ‘a
    substitute for police interrogation at the station house.’ ” Id. at 637
    (quoting Bentley, 
    739 N.W.2d at 299
    ).
    Likewise, in State v. Harper, we held that a victim’s statements to
    hospital staff that the defendant had raped her, tied her, and set her
    house on fire were nontestimonial. 
    770 N.W.2d 316
    , 322 (Iowa 2009). A
    doctor had asked the badly burned victim what had happened to her and
    the victim responded.           
    Id. at 323
    .       “The primary purpose of the
    statements was to assist the physicians in treating her.” 
    Id.
    The question we confront today is whether the statements of a
    four-year-old to (1) the medical director of the Child Protection Response
    Center and (2) a forensic interviewer employed by the same organization
    were testimonial.       The statements were made on different visits that
    occurred on different dates.          Law enforcement observed the forensic
    interview but not the interview conducted by the medical director. It is
    clear that the police arranged the forensic interview, but less clear how
    the subsequent meeting with the medical director came about. 3
    3Dr. Harre testified that A.W. “was referred from the . . . emergency room where
    she was seen on July 3.” Her report, however, indicates that Mattox made the referral
    following the forensic interview. A police officer, meanwhile, testified that he directed
    A.W.’s parents to Dr. Harre’s office so A.W. could be examined. However, A.W.’s mother
    testified that “the hospital told me to make an appointment with the doctor lady to talk
    to her and find out if there was anything else going on, and that’s what I did.”
    11
    For additional guidance we turn to the United States Supreme
    Court’s recent decision in Ohio v. Clark, 576 U.S. ___, 
    135 S. Ct. 2173
    ,
    
    192 L. Ed. 2d 306
     (2015). Because of its recent vintage, we have not
    previously considered or discussed this case. In addition, the court of
    appeals did not have the benefit of Clark when it rendered its decision in
    this case.
    In Clark, the defendant was alleged to have physically abused his
    girlfriend’s two young children, one of whom was a three-year-old boy,
    L.P. 
    Id.
     at ___, 
    135 S. Ct. at
    2177–78, 
    192 L. Ed. 2d at 312
    . The boy was
    found not competent to testify, but his statements to two teachers
    identifying the defendant as the person who had caused his injuries were
    admitted by the trial court. 
    Id.
     at ___, 
    135 S. Ct. at 2178
    , 
    192 L. Ed. 2d at
    312–13.
    On appeal, both the Ohio Court of Appeals and the Ohio Supreme
    Court found that the admission of the young boy’s statements to his
    teachers violated the Confrontation Clause.              
    Id.
     at ___, 
    135 S. Ct. at 2178
    , 
    192 L. Ed. 2d at 313
    . Noting that the teachers were under a legal
    obligation to report child abuse to government authorities, the Ohio
    Supreme Court found that the statements qualified as testimonial
    because the primary purpose of the teachers’ questioning “was not to
    deal with an existing emergency but rather to gather evidence potentially
    relevant to a subsequent criminal prosecution.” 
    Id.
     The United States
    Supreme Court reversed and found no violation. 
    Id.
     at ___, 
    135 S. Ct. at 2179, 2181
    , 
    192 L. Ed. 2d at 313, 315
    . 4
    4The   reversal was unanimous. Clark, 576 U.S. at ___, 
    135 S. Ct. at 2177
    , 
    192 L. Ed. 2d at 311
    . Justice Alito wrote the opinion for the Court, which a total of six
    justices joined. 
    Id.
     Justice Scalia wrote a separate opinion concurring in the judgment.
    Justice Thomas also wrote a separate opinion concurring in the judgment. 
    Id.
     Justice
    Ginsburg joined Justice Scalia’s separate opinion. 
    Id.
    12
    The Court’s opinion first summarized the Court’s Confrontation
    Clause   precedents,   including   Crawford,    which    announced     and
    expounded on the primary-purpose test. 
    Id.
     at ___, 
    135 S. Ct. at
    2179–
    81, 
    192 L. Ed. 2d at
    313–15. The Court then went on,
    Thus, under our precedents, a statement cannot fall
    within the Confrontation Clause unless its primary purpose
    was testimonial. “Where no such primary purpose exists,
    the admissibility of a statement is the concern of state and
    federal rules of evidence, not the Confrontation Clause.” But
    that does not mean that the Confrontation Clause bars every
    statement that satisfies the “primary purpose” test. We have
    recognized that the Confrontation Clause does not prohibit
    the introduction of out-of-court statements that would have
    been admissible in a criminal case at the time of the
    founding. Thus, the primary purpose test is a necessary,
    but not always sufficient, condition for the exclusion of out-
    of-court statements under the Confrontation Clause.
    
    Id.
     at ___, 
    135 S. Ct. at
    2180–81, 
    192 L. Ed. 2d at 315
     (citations omitted)
    (quoting Michigan v. Bryant, 
    562 U.S. 344
    , 359, 
    131 S. Ct. 1143
    , 1155,
    
    179 L. Ed. 2d 93
    , 107–08 (2011)). In short, the Court made clear that
    out-of-court statements could fail the primary-purpose test and still be
    admissible notwithstanding the Confrontation Clause.
    Applying these principles to Clark’s prosecution, the Supreme
    Court majority first examined the primary-purpose test.      It found that
    the boy’s statements “clearly were not made with the primary purpose of
    creating evidence for Clark’s prosecution.” 
    Id.
     at ___, 
    135 S. Ct. at 2181
    ,
    
    192 L. Ed. 2d at 315
    . Rather, as the Court explained,
    L.P. statements occurred in the context of an ongoing
    emergency involving suspected child abuse. When L.P’s
    teachers noticed his injuries, they rightly became worried
    that the 3-year-old was the victim of serious violence.
    Because the teachers needed to know whether it was safe to
    release L.P. to his guardian at the end of the day, they
    needed to determine who might be abusing the child. Thus,
    the immediate concern was to protect a vulnerable child who
    needed help.
    13
    
    Id.
     at ___, 
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at
    315–16 (footnote omitted).
    The Court went on,
    There is no indication that the primary purpose of the
    conversation was to gather evidence for Clark’s prosecution.
    On the contrary, it is clear that the first objective was to
    protect L.P.. At no point did the teachers inform L.P. that
    his answers would be used to arrest or punish his abuser.
    L.P. never hinted that he intended his statements to be used
    by the police or prosecutors. And the conversation between
    L.P. and his teachers was informal and spontaneous. The
    teachers asked L.P. about his injuries immediately upon
    discovering them, in the informal setting of a preschool
    lunchroom and classroom, and they did so precisely as any
    concerned citizen would talk to a child who might be the
    victim of abuse.
    
    Id.
     at ___, 
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at 316
    .
    Yet the Court did not leave the analysis there. The Court stated
    that “L.P.’s age fortifies our conclusion that the statements in question
    were not testimonial. Statements by very young children will rarely, if
    ever, implicate the Confrontation Clause.” 
    Id.
     at ___, 
    135 S. Ct. at
    2181–
    82, 
    192 L. Ed. 2d at 316
    . The Court commented that “it is extremely
    unlikely that a 3-year-old child in L.P.’s position would intend his
    statements to be a substitute for trial testimony.” 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at 316
    . Additionally, the Court emphasized that in
    the eighteenth century, out-of-court statements by children who were
    incompetent to testify due to their youth were regularly admitted in
    criminal cases. 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at
    316–17.
    Therefore, in the Court’s view, “It is . . . highly doubtful that statements
    like L.P.’s ever would have been understood to raise Confrontation
    Clause concerns.” 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at 317
    .
    Also, the Court reiterated that the statements were made to teachers, not
    law enforcement officials:
    14
    Statements made to someone who is not principally charged
    with uncovering and prosecuting criminal behavior are
    significantly less likely to be testimonial than statements
    given to law enforcement officers. It is common sense that
    the relationship between a student and his teacher is very
    different from that between a citizen and the police.
    
    Id.
     (citation omitted).         The Court concluded, “In light of these
    circumstances, the Sixth Amendment did not prohibit the State from
    introducing L.P.’s statements at trial.” 
    Id.
    Based on the Supreme Court’s opinion in Clark, we do not believe
    admission of Dr. Harre’s testimony and report violated J.C.’s rights of
    confrontation under the Sixth Amendment.                  Several points must be
    noted. A.W. is a very young child, and the Supreme Court said in Clark
    that “[s]tatements by very young children will rarely, if ever, implicate the
    Confrontation Clause.” 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at 316
    .    The Court supported this statement with historical evidence
    including an approving citation to a law review article. 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at
    316–17 (citing Thomas D. Lyon &
    Raymond LaMagna, The History of Children’s Hearsay: From Old Bailey to
    Post-Davis, 
    82 Ind. L.J. 1029
     (2007) [hereinafter Lyon]).                 The article
    makes clear that in eighteenth century Britain, “the hearsay of
    unavailable child witnesses was routinely admitted.” Lyon, 82 Ind. L.J.
    at 1030.      Thus, A.W.’s age alone may settle the Sixth Amendment
    inquiry. 5
    5In his separate opinion concurring in the judgment, Justice Scalia gave primacy
    to the primary-purpose test. Clark, 576 U.S. at ___, 
    135 S. Ct. at
    2184–85, 
    192 L. Ed. 2d at
    319–20 (Scalia, J., concurring in the judgment). He explained,
    The Confrontation Clause categorically entitles a defendant to be
    confronted with the witnesses against him; and the primary-purpose test
    sorts out, among the many people who interact with the police
    informally, who is acting as a witness and who is not. Those who fall into
    the former category bear testimony, and are therefore acting as
    “witnesses,” subject to the right of confrontation.
    15
    Also, A.W.’s statements were made to a physician, with no law
    enforcement representative in the room or even observing the encounter
    remotely. In Clark, the Supreme Court stressed “that the relationship
    between a student and teacher is very different from that between a
    citizen and the police.” 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at 317
    .    The same is true of the relationship between a small child and
    physician.
    Under a pure primary-purpose test, the issue would undoubtedly
    be closer—certainly closer than Clark. 6              Yet even here a number of
    ___________________________________
    
    Id.
     at ___, 
    135 S. Ct. at 2185
    , 
    192 L. Ed. 2d at 320
    . Justice Scalia concurred in the
    result because, in his view, the primary-purpose test had not been met. 
    Id.
     at ___, 
    135 S. Ct. at 2184
    , 
    192 L. Ed. 2d at
    318–19. He also criticized parts of the majority opinion
    going beyond the primary-purpose test as “dicta” that in his view were “not binding.”
    
    Id.
     at ___, 
    135 S. Ct. at 2184
    , 
    192 L. Ed. 2d at 319
    .
    The academic community is only just starting to weigh in on Clark. The only
    published law review article we have been able to find by a law professor—as opposed to
    a blog or a law student note—reviewed the Court’s entire opinion and then concluded,
    “Which of these points was essential to the Court’s conclusion that the Confrontation
    Clause did not apply was not obvious.” David L. Noll, Constitutional Evasion and the
    Confrontation Puzzle, 
    56 B.C. L. Rev. 1899
    , 1917 n.158 (2015).
    Furthermore, “[c]arefully considered language of the Supreme Court, even if
    technically dictum, generally must be treated as authoritative.” United States v. Oakar,
    
    111 F.3d 146
    , 153 (D.C. Cir. 1997) (alteration in original) (quoting Doughty v.
    Underwriters at Lloyd’s, London, 
    6 F.3d 856
    , 861 n.3 (1st Cir. 1993)).
    It is also noteworthy that Justice Scalia—widely known as an originalist—did not
    reject the possibility that out-of-court statements by small children would be admissible
    today based on their admissibility at common law, even if they were deemed testimonial
    under the primary-purpose test. All he said was that once evidence is “testimonial,”
    i.e., as determined under the primary-purpose test, the burden rests with the
    prosecutor “to prove a long-established practice” of introducing this category of evidence
    “for which cross-examination was not typically necessary.” Clark, 576 U.S. at ___, 
    135 S. Ct. at 2185
    , 
    192 L. Ed. 2d at 320
    . Justice Scalia also cited the Lyon and LaMagna
    article with approval. 
    Id.
     at ___, 
    135 S. Ct. at 2184
    , 
    192 L. Ed. 2d at 319
    . So it is
    entirely plausible that Justice Scalia would have agreed: Out-of-court statements by
    very young children who are not competent to testify do not raise Confrontation Clause
    concerns today because they did not raise admissibility concerns in the eighteenth
    century.
    6For  one thing, A.W.’s statements were not made “in the context of an ongoing
    emergency,” but well after law enforcement had commenced their investigation. Cf.
    Clark, ___, U.S. at 
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at 315
    .
    16
    factors weigh against a Confrontation Clause violation.     The primary-
    purpose test asks whether the main purpose of the conversation was to
    “creat[e] an out-of-court substitute for trial testimony.” 
    Id.
     at ___, 
    135 S. Ct. at 2180
    , 
    192 L. Ed. 2d at 315
     (alteration in original) (quoting
    Bryant, 
    562 U.S. at 358
    , 
    131 S. Ct. at 1155
    , 
    179 L. Ed. 2d at 107
    . At the
    outset, we need to ask, “Whose primary purpose?” A.W.’s or Dr. Harre’s?
    The Court applied the primary-purpose test by considering the matter
    from the perspective of both interviewer and interviewee. See 
    id.
     at ___,
    
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at 316
     (noting that “the first objective
    was to protect L.P.” and L.P. “never hinted that he intended his
    statements to be used by the police or prosecutors”).     The Court also
    stressed that the conversation was “informal and spontaneous.” 
    Id.
    Weighing all the circumstances here, and considering the role of
    both participants in the conversation, the following factors support a
    determination that the Confrontation Clause was not violated under the
    primary-purpose test: First, it is obvious that A.W.’s purpose was not to
    make a statement to Dr. Harre that could be used to prosecute J.C.
    Second, the setting was informal. Dr. Harre and A.W. met by themselves
    at Dr. Harre’s office. Dr. Harre first asked A.W. to make letters on an
    easel board, and went over truth–lie differences. She then conducted a
    “medical review of systems,” asking A.W. about areas of discomfort or
    signs of illness. After doing so, she asked A.W. if she could remember
    what happened with her brother’s friend. Dr. Harre then conducted a
    full physical exam, at that point with A.W.’s father present. Dr. Harre
    took notes throughout the entire process, but no recording took place.
    Dr. Harre later dictated from her notes. The discussion of the incident
    with J.C. represented a single paragraph in the five-page report.
    17
    Third, while it appears that law enforcement made the original
    referral that led to Mattox’s forensic interview in early July, any law
    enforcement role in arranging Dr. Harre’s session with A.W. in late July
    would have been more attenuated. The two encounters took place three
    weeks apart, and Dr. Harre did not have access to the forensic interview
    when she examined and spoke with A.W. Furthermore, according to Dr.
    Harre, she receives referrals from “police department[s], [DHS], other
    physicians, therapists, [and] emergency rooms,” and she performed the
    standard evaluation with A.W. that she would perform with “any other
    child.”
    To be fair, when we view the matter from Dr. Harre’s perspective
    alone, the session likely served “two purposes”—analyzing A.W.’s medical
    condition and memorializing her story.      See State ex rel. Juv. Dep’t of
    Multnomah Cty. v. S.P., 
    215 P.3d 847
    , 865 (Or. 2009) (en banc) (finding,
    pre-Clark,   a   Sixth   Amendment    violation   when   a   three-year-old’s
    statements during an interview with a child abuse response center were
    admitted at trial). Dr. Harre was providing medical assessment, but her
    report was addressed to the assistant county attorney who later
    prosecuted the case.
    However, when we consider the totality of circumstances under the
    primary-purpose test, as well as the additional points emphasized by the
    Supreme Court in Clark, we find no Sixth Amendment violation. Several
    things distinguish this case from Bentley and the Oregon Supreme
    Court’s decision in S.P.     No law enforcement personnel attended or
    monitored Dr. Harre’s session with A.W. Cf. Bentley, 
    739 N.W.2d at 297
    ;
    S.P., 215 P.3d at 860.     In fact, a recorded forensic interview with law
    enforcement on site had already occurred when Dr. Harre met with A.W.
    without law enforcement. Moreover, A.W. was considerably younger than
    18
    the   ten-year-old     victim    in   Bentley 7—an       important     consideration
    according to the Clark Court.
    Finally, and crucially, we cannot ignore the Supreme Court’s
    pronouncement that “[s]tatements by very young children will rarely, if
    ever, implicate the Confrontation Clause,” as well as the Court’s reliance
    on the historical record, which indicates that hearsay statements of child
    witnesses who were incompetent to testify were admitted at common law.
    Clark, 576 U.S. at ___, 
    135 S. Ct. at
    2181–82, 
    192 L. Ed. 2d at
    316–17.
    Since J.C. does not urge us to apply a different approach under
    article I, section 10 of the Iowa Constitution, we decline to do so in this
    case. Thus, we find that admission of Dr. Harre’s testimony and written
    report did not violate J.C.’s confrontation rights under either the Sixth
    Amendment or article I, section 10 of the Iowa Constitution.
    Still, we close our discussion of Dr. Harre’s interview with a few
    words of caution. Under a primary-purpose test, we do not believe an
    interview whose primary purpose is testimonial generally can be salvaged
    just because it is wedged inside a medical exam. The primary-purpose
    test applies to “the interrogation” that is at issue. 
    Id.
     at ___, 
    135 S. Ct. at 2180
    , 
    192 L. Ed. 2d at 314
    . In addition, we do not believe that arranging
    a prior recorded forensic interview necessarily insulates a subsequent
    less-formal interview from attack under the Confrontation Clause.
    Lastly, as stated already, we jealously guard our authority to interpret
    the Iowa Constitution independently in a future case, particularly if a
    litigant argues such an interpretation in her or his briefing.
    7We    noted in Bentley that the victim functioned at a seven-year-old level, see
    
    739 N.W.2d at 300
    , but this is still much older than A.W.’s chronological age or the
    level of her communication skills.
    19
    B. Confrontation Clause—Mattox. We now turn to whether the
    admission of Mattox’s testimony violated J.C.’s Confrontation Clause
    rights. Despite A.W.’s very young age, we will assume without deciding
    that a violation occurred. Mattox’s job title is “forensic interviewer.” See
    Bentley, 
    739 N.W.2d at 299
     (noting that the interview was described by a
    police officer as a “forensic interview”). Law enforcement made a referral
    call for Mattox’s interview of A.W., and law enforcement was present
    when it occurred.     The interview was recorded, and the recording was
    provided to the county attorney’s office.      See 
    id. at 300
     (noting that a
    copy of the tape was provided to police and marked as evidence).
    Having said this, we agree with the court of appeals that any error
    was harmless.        See Kennedy, 846 N.W.2d at 527 (“The erroneous
    admission of evidence in violation of the Confrontation Clause is a
    constitutional error subject to a harmless-error analysis.”).       To find a
    constitutional error harmless, “[w]e are required to ask whether the force
    of the evidence ‘is so overwhelming as to leave it beyond a reasonable
    doubt that the verdict resting on that evidence would have been the
    same’ without the erroneously admitted evidence.” Id. at 528 (quoting
    Yates v. Evatt, 
    500 U.S. 391
    , 405, 
    111 S. Ct. 1884
    , 1893, 
    114 L. Ed. 2d 432
    , 449 (1991)). In this context, harmless error means “no reasonable
    possibility   that   [the   erroneously    admitted]   evidence   might   have
    contributed to the [adjudication].”       
    Id.
     (quoting State v. Hensley, 
    534 N.W.2d 379
    , 383 (Iowa 1995)).              The State bears the burden of
    establishing harmless error. 
    Id. at 527
    .
    Here, the other evidence against J.C. was quite strong. Unlike in
    many child abuse cases, there were other eyewitnesses to the act of
    abuse besides the victim—namely M.M., I.W., and E.W. As the juvenile
    court put it, “The eyewitness accounts alone are quite persuasive in this
    20
    case and appear credible due to the differences which are explained by
    the order they entered the room.” Furthermore, as noted by the juvenile
    court, there was recorded evidence of J.C.’s “heightened interest in
    sexual activity on the date in question.”     J.C.’s testimony that he was
    trying to get A.W. out of the room was contradicted by the eyewitnesses;
    furthermore, J.C. had no explanation for the cell phone recording. And
    Dr. Harre’s testimony and report provided further confirmation that an
    assault with intent to commit sexual abuse had occurred. In short, the
    remaining evidence was so strong that we see no reasonable possibility
    Mattox’s testimony might have contributed to the adjudication. See 
    id. at 528
    .
    C. Competency of A.W.       J.C. also challenges the admission of
    A.W.’s out-of-court statements to Dr. Harre on the basis that A.W. was
    incompetent to testify herself and, thus, Dr. Harre should not have been
    allowed to testify regarding A.W.’s statements. We will assume for the
    purposes of this analysis that A.W. was incompetent to testify. We have
    not previously addressed whether out-of-court statements made by
    incompetent witnesses may be admissible under exceptions to the
    hearsay rule.
    Dr. Harre’s testimony and her report of her interview with A.W.
    were admitted under Iowa Rule of Evidence 5.803(4) as statements made
    for   the   purpose   of   obtaining    medical   diagnosis   or   treatment.
    Significantly, J.C. does not appeal that ruling. Also, in Clark, the United
    States Supreme Court implicitly rejected the argument that a child’s
    incompetence to appear as a trial witness foreclosed the admission of
    that same child’s out-of-court statements:
    Clark is also wrong to suggest that admitting L.P.’s
    statements would be fundamentally unfair given that Ohio
    law does not allow incompetent children to testify. In any
    21
    Confrontation Clause case, the individual who provided the
    out-of-court statement is not available as an in-court
    witness, but the testimony is admissible under an exception
    to the hearsay rules and is probative of the defendant’s guilt.
    The fact that the witness is unavailable because of a different
    rule of evidence does not change our analysis.
    Clark, 576 U.S. at ___, 
    135 S. Ct. at 2183
    , 
    192 L. Ed. 2d at 318
    .        In
    addition, the Supreme Court has rejected the argument that an
    incompetent declarant’s out-of-court statements are “presumptively
    unreliable.” Idaho v. Wright, 
    497 U.S. 805
    , 824, 
    110 S. Ct. 3139
    , 3151,
    
    111 L. Ed. 2d 638
    , 658 (1990).
    Other courts have reached similar conclusions.        See Morgan v.
    Foretich, 
    846 F.2d 941
    , 949 (4th Cir. 1988) (“The fact that a young child
    may be incompetent to testify at trial affects neither prong of the two-part
    test for admitting evidence under 803(4).”); Borchgrevink v. State, 
    239 P.3d 410
    , 423 (Alaska Ct. App. 2010) (“[C]ourts have admitted hearsay
    under this exception even when the person who made the out-of-court
    statement was incompetent to testify.”), overruled on other grounds by
    Moreno v. State, 
    341 P.3d 1134
     (Alaska 2015); State v. Waddell, 
    504 S.E.2d 84
    , 90 (N.C. Ct. App. 1998) (rejecting the argument that the
    child’s incompetence rendered his out-of-court statements for purposes
    of medical diagnosis or treatment inadmissible); State v. Muttart, 
    875 N.E.2d 944
    , 954 (Ohio 2007) (“[R]egardless of whether a child less than
    ten years old has been determined to be competent to testify . . . , the
    child’s statements may be admitted at trial as an exception to the
    hearsay rule pursuant to [rule] 803(4) if they were made for purposes of
    medical diagnosis or treatment.”). But see B.B. v. Commonwealth, 
    226 S.W.3d 47
    , 51 (Ky. 2007) (holding that a child victim’s out-of-court
    statements should have been excluded because “the immaturity that
    22
    rendered her incompetent at trial would have existed at the time of the
    interview as well”). As one treatise has said,
    Out-of-court statements for purposes of medical
    diagnosis or treatment may in some instances be admissible
    despite lack of testimonial competence when the statement
    was made.       Statements for purposes of diagnosis or
    treatment are considered reliable because the patient has an
    incentive to be truthful with the physician. A child who
    lacks one or more elements of testimonial competence may
    nevertheless possess the incentive required by the diagnosis
    or treatment exception.
    John E.B. Myers, Myers on Evidence of Interpersonal Violence, Child
    Maltreatment, Intimate Partner Violence, Rape, Stalking, and Elder Abuse
    § 7.20 (2016) (footnote omitted).
    We affirm the juvenile court’s ruling that A.W.’s incompetence to
    testify at trial did not render Dr. Harre’s testimony and report per se
    inadmissible.
    IV. Conclusion.
    For the foregoing reasons, we affirm J.C.’s adjudication.
    DECISION OF COURT OF APPEALS AFFIRMED AND JUVENILE
    COURT JUDGMENT AFFIRMED.
    All justices concur except Cady, C.J., who concurs specially, and
    Wiggins, J., and Hecht and Appel, JJ., who dissent.
    23
    #14–0357, In re J.C.
    CADY, Chief Justice (concurring specially).
    I join in the opinion of the majority, but would not place weight on
    the eighteenth century practice of admitting statements of very young
    children. I otherwise agree the totality of the circumstances supports the
    conclusion that the primary purpose of the interview by Dr. Harre was
    not testimonial.
    24
    #14–0357, In re J.C.
    WIGGINS, Justice (dissenting).
    I dissent.     I disagree with the majority opinion’s analysis
    concerning the significance of A.W.’s age in determining whether the
    introduction   of   her   statements    violated   J.C.’s   rights   under   the
    Confrontation Clause contained in the Sixth Amendment to the United
    States Constitution. Additionally, I disagree with the conclusion reached
    in the majority opinion and the special concurrence as to the primary
    purpose of A.W.’s statements.          Because the primary-purpose test
    requires a court to consider the purposes of all participants involved in
    eliciting a statement as part of the totality of the circumstances, it is
    evident that A.W.’s statements were testimonial.
    Ohio v. Clark is the only case in which the United States Supreme
    Court has addressed whether statements a victim made to someone
    other than a law enforcement officer may violate the Confrontation
    Clause. 576 U.S. ___, ___, 
    135 S. Ct. 2173
    , 2180, 
    192 L. Ed. 2d 306
    ,
    314–15 (2015). In Clark, the Court recognized “at least some statements
    to individuals who are not law enforcement officers could conceivably
    raise confrontation concerns.” 
    Id.
     at ___, 
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at 315
    . The Court also affirmed that determinations as to whether
    such statements are testimonial turn on the primary-purpose test. 
    Id.
    The primary-purpose test requires a court to determine “whether,
    in light of all the circumstances, viewed objectively, the ‘primary purpose’
    of the conversation was to ‘creat[e] an out-of-court substitute for trial
    testimony.’ ” 
    Id.
     at ___, 
    135 S. Ct. at 2180
    , 
    192 L. Ed. 2d at 315
     (quoting
    Michigan v. Bryant, 
    562 U.S. 344
    , 358, 
    131 S. Ct. 1143
    , 1155, 
    179 L. Ed. 2d 93
    , 107 (2011)). As the Court has previously explained,
    25
    [T]he relevant inquiry is not the subjective or actual purpose
    of the individuals involved in a particular encounter, but
    rather the purpose that reasonable participants would have
    had, as ascertained from the individuals’ statements and
    actions and the circumstances in which the encounter
    occurred.
    Bryant, 
    562 U.S. at 360
    , 
    131 S. Ct. at 1156
    , 
    179 L. Ed. 2d at
    108–09.
    The primary-purpose determination demands objective analysis of
    the circumstances of the encounter and the statements and actions of
    both interviewer and interviewee. See 
    id. at 360
    , 
    131 S. Ct. at 1156
    , 
    179 L. Ed. 2d at 108
    . In other words, a court must look to the totality of the
    circumstances and consider the purposes of all participants involved in
    obtaining a statement when deciding whether a statement’s primary
    purpose was testimonial.
    The Clark Court made two additional observations concerning
    application of the primary-purpose test.               First, statements made to
    persons     who    are    “not   principally     charged     with    uncovering        and
    prosecuting     criminal     behavior     are   significantly     less   likely   to    be
    testimonial than statements given to law enforcement officers.”                   Clark,
    576 U.S. at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at 317
    . Second, a very
    young child who is being abused is “extremely unlikely . . . [to] intend his
    statements to be a substitute for trial testimony.” 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at 316
    .
    I agree with most of the majority opinion’s analysis of Clark.
    However, the majority opinion essentially reads Clark as holding
    statements by very young children never implicate the Confrontation
    Clause, unless (perhaps) such statements were made to or in the
    presence of a law enforcement officer. 8             The Clark Court stopped far
    8When  no single rationale explaining the result enjoys the assent of a majority of
    the Justices sitting, the holding of a fragmented court is the position taken by the
    26
    short of adopting such a rule. The age of the three-year-old child, L.P.,
    who made the statements at issue in Clark merely “fortified” the Court’s
    conclusion that the statements he made were nontestimonial insofar as
    his youth made it “extremely unlikely” he intended those statements to
    serve as a substitute for trial testimony. 
    Id.
     at ___, 
    135 S. Ct. at
    2181–
    82, 
    192 L. Ed. 2d at 316
    .        Although the Court acknowledged it was
    doubtful statements a three-year-old child made to his teachers would
    have been understood to raise confrontation concerns at the time of the
    founding,    the   Court   concluded       the   statements   at   issue   were
    nontestimonial by relying on the primary-purpose test. 
    Id.
     at ___, 
    135 S. Ct. at
    2181–82, 
    192 L. Ed. 2d at
    315–16; see 
    id.
     at ___, 
    135 S. Ct. at
    2184–85, 
    192 L. Ed. 2d at
    319–20 (Scalia, J., concurring in the
    judgment) (discussing the majority holding and pointing out that the
    burden is upon the prosecutor who seeks to introduce testimonial
    evidence despite the Confrontation Clause “to prove a long-established
    practice of introducing specific kinds of evidence, such as dying
    declarations, for which cross-examination was not typically necessary”
    (citation omitted)).
    The Clark Court acknowledged the existence of “strong evidence
    that statements made in circumstances similar to those facing L.P. and his
    teachers were admissible at common law” and indicated it is “thus highly
    doubtful that statements like L.P.’s ever would have been understood to
    raise Confrontation Clause concerns.” 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at
    316–17 (majority opinion) (emphasis added). However, the
    ___________________________________
    Justices who concurred in the decision on the narrowest grounds. Marks v. United
    States, 
    430 U.S. 188
    , 193, 
    97 S. Ct. 990
    , 993, 
    51 L. Ed. 2d 260
    , 266 (1977).
    27
    Court in no way suggested historical evidence was critical to its holding,
    let alone adopted a categorical rule that statements made by very young
    children do not raise confrontation concerns.
    For this reason, most legal scholars to consider Clark thus far have
    recognized as dictum the language in Clark suggesting the fact that an
    out-of-court statement’s primary purpose was testimonial as “necessary,
    but not always sufficient” for its exclusion under the Confrontation
    Clause. See Richard D. Friedman, Ohio v. Clark: Some Initial Thoughts,
    The     Confrontation      Blog     (June       19,   2015,       1:09      AM),
    http://confrontationright.blogspot.com/2015/06/ohio-v-clark-some-
    initial-thoughts.html (acknowledging the “necessary but not always
    sufficient”   language   as   “potentially   dangerous”      dictum);    Paul   F.
    Rothstein, A Comment on the Supreme Court’s Decision in Ohio v. Clark:
    The   Court’s    Confrontation    Clause     Jurisprudence     Evolves    (2015),
    http://ssrn.com/abstract=2627748 (noting Clark provides an “escape
    hatch for future cases—one that is clearly dictum”); see also Chad
    Squitieri, Note, Confronting Big Data: Applying the Confrontation Clause to
    Government Data Collection, 
    101 Va. L. Rev. 2011
    , 2022 n.71 (2015)
    (describing the “necessary, but not always sufficient” language as
    dictum).      Justice Scalia, joined by Justice Ginsburg in an opinion
    concurring in the result, agreed. Clark, 576 U.S. at ___, 
    135 S. Ct. at
    2184–85, 
    192 L. Ed. 2d at
    318–20 (Scalia, J., concurring in the
    judgment).
    In my view, the majority opinion rests on an expansive reading of
    dictum in Clark to adopt the very rule the Clark majority refused to
    adopt. Simply put, the Clark majority declined to hold that statements
    made by very young children or statements made to individuals other
    than law enforcement officers never implicate the Confrontation Clause.
    28
    Rather, as the Clark majority explained, “Courts must evaluate
    challenged statements in context, and part of that context is the
    questioner’s identity.” 
    Id.
     at ___, 
    135 S. Ct. at 2182
    , 
    192 L. Ed. 2d at 317
     (majority opinion).
    Of course, the analysis in Clark concerning whether the statements
    at issue in that case were testimonial is instructive. Because the three-
    year-old child who made those statements was so young, in applying the
    primary-purpose test the Court focused on the objective circumstances
    indicating the purpose his teachers had in eliciting them. 
    Id.
     at ___, 
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at
    315–16.        The Court concluded the
    statements were nontestimonial because his teachers were responding to
    an “ongoing emergency involving suspected child abuse” and sought to
    “protect the victim from future attacks.” 
    Id.
     In short, there was simply
    “no indication that the primary purpose of the conversation was to gather
    evidence for Clark’s prosecution” given that the conversation between the
    child and his teachers was “informal and spontaneous.” 
    Id.
     at ___, 
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at 316
    .
    In applying the primary-purpose test, it is important to consider
    objectively all the circumstances surrounding the statements at issue,
    not just those suggesting the statements were nontestimonial. Here, two
    objective circumstances weigh in favor of the conclusion that A.W.’s
    statements were nontestimonial. First, Dr. Harre is not a police officer.
    Second, A.W. was only four-and-a-half-years old when she made the
    statements to Dr. Harre.
    On the other side of the scale are several circumstances suggesting
    “in light of all the circumstances, viewed objectively, the ‘primary
    purpose’ of the conversation was to ‘creat[e] an out-of-court substitute
    for trial testimony.’ ” 
    Id.
     at ___, 
    135 S. Ct. at 2180
    , 
    192 L. Ed. 2d at
    315
    29
    (quoting Bryant, 
    562 U.S. at 358
    , 
    131 S. Ct. at 1155
    , 
    179 L. Ed. 2d at 107
    ). In contrast to Clark, there was ample circumstantial evidence to
    suggest the purpose of the individuals who elicited the statement at issue
    was to create an out-of-court substitute for trial testimony and virtually
    no evidence to suggest they had any other purpose.
    First, it is clear law enforcement instructed A.W.’s parents to take
    her to Dr. Harre’s office. Detective Robinson testified as follows:
    Q. When did you first become involved with the [J.C.]
    case? A. I don’t remember the exact date, but it was
    assigned to me at a certain time. That’s when and how I
    became involved in it.
    Q. Do you know if the family of [the victim] made
    initial contact with you or did they make initial contact with
    another officer? A. They made initial contact with the front
    desk of our police department and filed a report there.
    Q. And when was it assigned to you?           A. I do not
    know off the top of my head.
    Q. But would it have been shortly after they made
    contact? A. Yes. Yes, within a couple days.
    Q. And what’s sort of the standard procedure for
    investigating this type of case? A. Usually, after I receive
    the initial case, I’ll read the report and find out who I have
    involved in that investigation, and we’ll call each one in as a
    witness.
    With this particular case having a victim, especially a
    young victim, I got ahold of her mother and father and had
    them take her down to the Child Protection Center where
    Dr. Harre’s office is to be examined by her, and also
    specifically interviewed by Michele Mattox, who is a child
    forensic interviewer through that same department as well.
    Q. And did you interview the other children involved
    in this situation? A. I did.
    Thus, Detective Robinson testified he sought to have Dr. Harre’s office
    perform the investigative task of interviewing A.W. because she was so
    30
    young.   In contrast, Detective Robinson interviewed the older children
    present at the time of the alleged delinquent act himself. Moreover, as
    his testimony makes clear, Detective Robinson instructed A.W.’s parents
    to take her to Dr. Harre because doing so was part of the Davenport
    Police Department’s “standard operating procedure for investigating this
    type of case.”
    The fact that the Davenport Police Department regularly utilizes
    Dr. Harre’s office to interview young children who are suspected victims
    of abuse suggests Dr. Harre’s office acts on behalf of the police in
    conducting such interviews. The Code actively encourages the police and
    others   involved   in   prosecuting    suspected   child   abuse   to   work
    cooperatively with medical and mental health professionals such as
    Dr. Harre to conduct child abuse investigations and make child abuse
    assessments. The Code provides,
    4. a. A child protection assistance team involving the
    county attorney, law enforcement personnel, and personnel
    of the department of human services shall be established for
    each county by the county attorney. However, by mutual
    agreement, two or more county attorneys may establish a
    single child protection assistance team to cover a
    multicounty area. A child protection assistance team, to the
    greatest extent possible, may be consulted in cases involving
    a forcible felony against a child who is less than age fourteen
    in which the suspected offender is the person responsible for
    the care of a child, as defined in section 232.68. A child
    protection assistance team may also be utilized in cases
    involving a violation of chapter 709 or 726 or other crime
    committed upon a victim as defined in subsection 1.
    b. A child protection assistance team may also consult
    with or include juvenile court officers, medical and mental
    health professionals, physicians or other hospital-based
    health professionals, court-appointed special advocates,
    guardians ad litem, and members of a multidisciplinary team
    created by the department of human services for child abuse
    investigations. A child protection assistance team may work
    cooperatively with the early childhood Iowa area board
    31
    established under chapter 256I.          The child protection
    assistance team shall work with the department of human
    services in accordance with section 232.71B, subsection 3,
    in developing the protocols for prioritizing the actions taken
    in response to child abuse assessments and for law
    enforcement agencies working jointly with the department at
    the local level in processes for child abuse assessments. The
    department of justice may provide training and other
    assistance to support the activities of a child protection
    assistance team.
    
    Iowa Code § 915.35
    (4)(a)–(b) (2015).
    Second, the evidence confirms the forensic interviewer also referred
    A.W. to Dr. Harre’s office. As the majority points out, Dr. Harre testified
    that A.W. was referred to her by the emergency room that saw A.W. on
    July 3, 2013.    However, Dr. Harre stated in her report that A.W. was
    referred to the center by the emergency room. Dr. Harre indicated in the
    second sentence of her report that A.W. was referred to her office by the
    forensic interviewer.   Moreover, as the majority opinion acknowledges,
    the forensic interviewer only got involved in the investigation after the
    police “made a referral call.”
    The further significance of the fact that the forensic interviewer
    also referred A.W. to Dr. Harre lies in Dr. Harre’s recognition that the
    forensic interviewer’s primary concern is investigative, not diagnostic or
    therapeutic.    Dr. Harre testified as follows concerning the role of the
    forensic interviewer in child abuse investigations:
    Q. And is the forensic interview helpful in pursuing a
    diagnosis and treatment for the child? A. It’s helpful in the
    investigative aspect. Michele does—if she does recognize
    that there are concerns that would benefit from a medical
    assessment, she will indicate that she definitively thinks that
    a medical assessment should be included in the process to
    the investigative team and to the family.
    32
    If the purpose of referring a child for a medical assessment is purely
    diagnostic or therapeutic, there would be no need for the forensic
    interviewer to alert “the investigative team” of anything.
    Third, the timing of the conversation between Dr. Harre and A.W.
    and the information available to Dr. Harre before that conversation took
    place suggests her primary concern was not diagnostic or therapeutic. If
    the purpose of Dr. Harre’s conversation with A.W. was diagnostic or
    therapeutic, common sense suggests Dr. Harre would have sought, or
    the forensic interviewer would have provided, a copy of the forensic
    interviewer’s report or a copy of the recorded interview before Dr. Harre
    met with A.W.      Yet Dr. Harre testified she had no knowledge of the
    statements A.W. made to the forensic interviewer prior to speaking with
    A.W.:
    Q. What information were you provided—let me
    rephrase that. Were you provided a copy or information
    regarding Michele Mattox’s interview of the child prior to
    your interview? A. No.
    Q. So you weren’t familiar at the time of the interview
    with any of the statements that were made by [A.W.] to
    Michele Mattox? A. Correct.
    The fact that Dr. Harre remained unfamiliar with the content of the
    forensic interview is particularly conspicuous in light of the surrounding
    circumstances. Dr. Harre and the forensic interviewer both work at the
    Child Protection Response Center.         Thus, when Dr. Harre examined
    A.W., she had available to her a complete account of what happened to
    A.W. in her own words prepared by someone who worked in the very
    same office. The forensic interviewer recorded her interview with A.W. on
    July 10.    Dr. Harre met with A.W. on July 31, three weeks after the
    33
    forensic interviewer conducted the interview and forwarded her notes to
    law enforcement.
    Similarly, the delay that occurred between the alleged delinquent
    act on July 2 and the conversation between Dr. Harre and A.W. suggests
    the purpose of that conversation was not diagnostic or therapeutic. If
    Dr. Harre’s purpose had been to assess whether A.W. required medical or
    mental health treatment due to the alleged delinquent act, it seems
    unlikely that Dr. Harre would have assessed A.W. on July 31, nearly a
    full month after J.C. allegedly committed the delinquent act.
    Fourth, Dr. Harre sent her report to the county attorney’s office.
    This fact weighs significantly in favor of concluding the statements at
    issue were testimonial because it confirms that Dr. Harre understood
    herself to be cooperating with law enforcement in the investigation of the
    allegations against J.C. In fact, Dr. Harre not only sent the report to the
    office charged with prosecuting the alleged delinquent act, she also
    addressed it to the very individual responsible for prosecuting J.C. This
    fact belies any claim that Dr. Harre did not have a primary purpose of
    assisting law enforcement in prosecuting J.C.
    Finally, the circumstances existing when the conversation between
    Dr. Harre and A.W. occurred are unlike those the Supreme Court relied
    upon to conclude the statements in Clark were nontestimonial. Notably,
    Dr. Harre   interviewed   and   examined   A.W.   long   after   the   police
    department had opened an investigation into the alleged delinquent act.
    In Clark, the victim made statements to his teachers prior to the
    initiation of any investigation. 576 U.S. at ___, 
    135 S. Ct. at 2178
    , 
    192 L. Ed. 2d at 312
    .
    Furthermore, because Dr. Harre and A.W. spoke nearly a month
    after the alleged delinquent act occurred, the statements A.W. made
    34
    during that conversation were neither made nor elicited “in the context of
    an ongoing emergency” in which “the immediate concern was to protect a
    vulnerable child” from the threat of future abuse. 
    Id.
     at ___, 
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at
    315–16.           There is no evidence to suggest
    Dr. Harre’s questions “were primarily aimed at identifying and ending the
    threat” to A.W. in order to protect her from immediate harm. 
    Id.
     at ___,
    
    135 S. Ct. at 2181
    , 
    192 L. Ed. 2d at 316
    .
    Additionally, the conversation between Dr. Harre and A.W. was far
    from spontaneous or informal.      Cf. 
    id.
       A.W. made the statements at
    issue in response to questions posed to her by an unfamiliar person in
    an unfamiliar setting.      Dr. Harre is not a teacher or primary care
    physician who had a preexisting relationship with A.W. Dr. Harre’s office
    is not a preschool classroom where A.W. was accustomed to spending
    time.    Though the conversation with Dr. Harre was unlike a formal
    interrogation in that a law enforcement officer was not present, it was not
    entirely informal.    For example, Dr. Harre discussed the concept of
    truthfulness with A.W. near the start of their conversation.
    As the majority opinion points out, A.W. was very young when she
    made the statements at issue in this case, and she made them outside
    the presence of the police or the prosecutors charged with prosecuting
    the case.    I also agree with the majority opinion’s conclusion A.W.
    certainly did not make the statements with the intent that they be used
    to prosecute J.C.    However, nothing in Clark suggests these facts are
    adequate to decide this case. On the contrary, Clark acknowledges the
    primary-purpose test is a necessary component of the analysis when a
    defendant raises a confrontation challenge to determine whether the
    statement at issue was testimonial or not. 
    Id.
     at ___, 
    135 S. Ct. at
    2180–
    81, 
    192 L. Ed. 2d at 315
    .
    35
    In contrast to Clark, the facts of this case suggest the primary
    purpose of the conversation between Dr. Harre and A.W. was to obtain
    statements from A.W. that the county attorney could introduce in court.
    The primary purpose of Dr. Harre’s conversation with A.W. was to gather
    evidence to be supplied to the very individual tasked with prosecuting
    J.C.    The evidence indicates Dr. Harre understood herself to be
    cooperating with law enforcement in their investigative efforts.         Law
    enforcement regularly relied upon her office as a tool in those efforts as
    part of its standard operating procedure.       Had the police department
    anticipated the information Dr. Harre obtained would not be made
    available for use in its investigation, surely at least one of the officers
    within the department would have interviewed A.W. Though A.W. does
    not speak clearly, she was able to communicate effectively to Dr. Harre
    and the forensic investigator. There is no reason to believe she would
    have been unable to communicate during an interview with a police
    officer, or before the court in a juvenile proceeding, if appropriate
    safeguards were in place.
    Accordingly, because the totality of the circumstances indicate the
    conversation during which A.W. made the statements contained in
    Dr. Harre’s report and testimony was intended to generate a substitute
    for trial testimony, I conclude those statements were testimonial. Police
    officers cannot enlist third parties to act on their behalf in order to gather
    statements to be used in court and later claim the statements were
    nontestimonial.
    For the same reason, I conclude the statements contained in
    Michelle Mattox’s report and testimony were testimonial. As the majority
    opinion acknowledges, Mattox conducted a forensic interview of A.W.
    after police “made a referral call, and law enforcement was present when
    36
    it occurred.” Additionally, Mattox recorded the interview and provided a
    copy of the recording to the county attorney’s office. Mattox also sent a
    copy of the report she generated after the interview to both the assistant
    county attorney in charge of prosecuting J.C. and the detective assigned
    to investigate him. In short, the evidence indicates Mattox intentionally
    played an investigative role in the law enforcement investigation into the
    alleged delinquent act.
    For these reasons, I would reverse the finding of delinquency and
    remand the case for a new hearing.
    Hecht and Appel, JJ., join this dissent.