Emergency clinicians face challenges in recognizing maltreatment in children. First, child maltreatment frequently occurs in young, nonverbal children who are unable to provide a history or in older children who may be too scared or feel loyal to their abuser and may not disclose the abuse. Second, caregivers may intentionally provide a false history or no history of trauma, which can mislead clinicians who often rely on the history provided by a caregiver to guide their diagnostic evaluation. Third, biases of the clinician may prevent consideration of abuse in the differential diagnosis. Finally, traumatic injuries due to abuse can be occult and present as medical chief complaints such as fussiness or vomiting.58
Taking a complete history is necessary to distinguish accidental from abusive injury. It is important to let caregivers provide a full history, without interruption, to assure it is not influenced by clinician interpretations and questions; clarifying questions should follow the initial history. It is vital to document the mechanism of injury described by caregivers, the onset of symptoms, and the child’s developmental abilities. Asking about the last time a child was at his/her baseline state may help determine the timing of the injury. If there is no history of a traumatic injury, the emergency clinician should ask how the child may have sustained the injury, noting if the history provided is an implausible cause of the presenting injury or is inconsistent with the child’s developmental capabilities.
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