What is the focus of the clinical history to evaluate suspected physical child abuse?

Updated: Apr 24, 2017
  • Author: Angelo P Giardino, MD, MPH, PhD; Chief Editor: Caroly Pataki, MD  more...
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Childhood is a time of accidental injuries. Understanding the developmental level and abilities of the child is essential in determining if the history provided by the parent or caregiver is a possible or plausible explanation for the child's injury. Once the full extent of the injury is determined based on physical examination, radiology, and laboratory workup, the healthcare provider can further assess the plausibility of the explanation offered by the parent or caregiver. A history that is implausible based on what a child at that level is capable of doing should raise a high degree of concern for possible maltreatment.

Whenever a child is injured, a complete history of the circumstances surrounding the injury, as well as a detailed injury history, is essential. Basic questions include the following:

  • When was the child last 100% well?

  • What was the date and time of the injury and when was it first noted?

  • Where did the injury occur?

  • Who witnessed the injury?

  • What was happening prior to the injury?

  • What did the child do after the injury?

  • What did the caregiver do after the injury?

  • How long after the injury did the caregiver wait until seeking care for the child?

  • What symptoms was the child exhibiting, and what, if any, remedies did the caregiver attempt?

  • Inquire about specific details related to the injury, such as height of the fall, landing surface, and temperature of water (if scald burn), among others.

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