Evaluation of Physical Abuse and Neglect
It may be difficult to identify children who are victims of physical abuse. Many injuries are not pathognomonic, and the diagnosis may not be obvious. The history given by the caregiver may be misleading or incomplete, causing a delay or mistake in diagnosis. In addition, victims of abuse often are too young to provide a history. Although only a small percentage of injuries seen by healthcare professionals are the result of abuse, there are a number of historical and physical findings that should raise the suspicion of nonaccidental trauma.
Diagnosing child abuse requires knowledge of child development, the epidemiology of trauma, mechanisms of injury in children, and the differential diagnosis of various forms of injury. The medical evaluation includes a history, physical examination, indicated laboratory and diagnostic studies, and observation of the caregiver–child interaction. Careful attention to the possibility of child maltreatment in the differential diagnosis generated when evaluating children for injuries is essential. There is a growing body of evidence highlighting the devastating consequences of cases in which an initial evaluation fails to diagnose abuse only to present again for care later with additional injuries. These later injuries could have been prevented had the child been accurately diagnosed as having been maltreated when they first presented on the initial or previous evaluations. Completing a detailed history and physical examination is paramount because many cases of abuse are first detected by identifying discrepancies between the history and physical findings. It is ideal for two individuals, such as a physician and nurse or social worker, to obtain a history together. The likelihood that important questions will be missed decreases if more than one person is present to interview the family. In addition, information can be recorded by one person, while the other asks questions. After the interview, the questioners can review information for accuracy.
KeywordsMedical evaluation Documentation Physical exam Medical history Interview process
- American Academy of Pediatrics, Section on Radiology. (1991). Diagnostic imaging of child abuse. Pediatrics, 87, 262–264.Google Scholar
- American College of Radiology-Society for Pediatric Radiology (ACR-SPR) ACR-SPR Practice Parameter for the Performance and Interpretation of Skeletal Surveys in Children. (2016). https://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf
- Bruschweiler, W., Braun, M., Dirnhofer, R., & Thali, M. J. (2003). Analysis of patterned injuries and injury-causing instruments with forensic 3D/CAD supported photogrammetry (FPHG): An instruction manual for the documentation process. Forensic Science International, 132, 130–138.CrossRefGoogle Scholar
- Cattaneo, C., Marinelli, E., Di Giancamillo, A., Di Giancamillo, M., Travetti, O., Vigano’, L., Poppa, P., Porta, D., Gentilomo, A., & Grandi, M. (2006). Sensitivity of autopsy and radiological examination in detecting bone fractures animal model: Implications for the assessment of fatal child physical abuse. Forensic Science International, 164(2), 131–137.CrossRefGoogle Scholar
- International Association for Identification, Scientific working Group on Imaging Technologies (SWGIT), Recommendations and Guidelines for the Use of Digital Image Processing in the Criminal Justice System, version 2.0. (2006, January). Available at http://www.theiai.org/guidelines/swgit/index.php. Accessed 17 Dec 2008.
- International Association for Identification, Scientific working Group on Imaging Technologies SWGIT, Section 17, Digital imaging technology issues for the courts, version 1.0. (2008, June). Available at http://www.theiai.org/guidelines/swgit/guidelines/section_17_v1-0.pdf. Accessed 17 Dec 2008.
- Kleinman, P. K. (Ed.). (1998). Diagnostic imaging of child abuse. Baltimore: Williams and Wilkins.Google Scholar
- Levin, A. (1990). Ocular manifestations of child abuse. Ophthalmology Clinics of North America, 3, 249–264.Google Scholar
- Ludwig, S. (2005). Psychosocial emergencies: Child abuse. In G. R. Fleisher, H. M. Henretig, & S. Ludwig (Eds.), Textbook of pediatric emergency medicine (5th ed., pp. 1761–1802). Baltimore: Williams and Wilkins.Google Scholar
- Mukerji, S. K., & Siegel, M. J. (1987). Rhabdomyolysis and renal failure in child abuse. American Journal of Radiology, 148, 1203–1204.Google Scholar
- Ricci, L. R., & Smistek, B. S. (2000). Photodocumentation in the investigation of child abuse. National Institute of Justice. https://www.ncjrs.gov/pdffiles1/ojjdp/160939.pdf
- Roesler, T. A. L., & Jenny, C. (2009). Medical child abuse: Beyond Munchausen syndrome. Elk Grove Village, IL, USA, American Academy of Pediatrics.Google Scholar
- Schmitt, B. D., Grosz, C. A., & Carroll, C. A. (1976). The child protection team: A problem oriented approach. In R. E. Helfer & C. H. Kempe (Eds.), Child abuse and neglect: The family and the community (pp. 91–113). Cambridge, MA: Ballinger.Google Scholar
- Shelov, S. P., Hanneman, R. E., & The American Academy of Pediatrics. (1998). Complete and authoritative guide, caring for your baby and young child birth to age 5. New York: Bantam Books.Google Scholar
- Shelov, S. P., Hannemann, R. D., & The American Academy of Pediatrics The Complete and Authoritative Guide (Eds.). (2004). Caring for your baby and young child: Birth to age 5 (4th ed.). New York: Bantam Books.Google Scholar
- Shelov, S. P., Hannemann, R. D., & The American Academy of Pediatrics the Complete and Authoritative Guide (Eds.). (2014). Caring for your baby and young child: Birth to age 5 (6th ed.). New York: Bantam Books.Google Scholar
- Wood, J. N., & Ludwig, S. (2010). Child Abuse. In G. Fleisher & S. Ludwig (Eds.), Textbook of pediatric emergency medicine, 6E (pp. 1656–1700). Philadelphia: Wolters Klumer/Lippincott Williams & Wilkins.Google Scholar