Assessing the Nonaccidentally Injured Child

For the physician faced with the assessment of a child for suspected physical injury, the following points should be remembered:

• Physical abuse often overlaps with other forms of abuse.

• Abuse may involve other siblings and family members.

• Abuse may recur and escalate.

• Younger children and infants are more at risk of physical injury and death than older children.

• The aim of recognition and early intervention is to protect the child, prevent mortality and morbidity, and diagnose and improve disordered parenting.

• Early intervention in families may prevent more serious abuse and subsequent removal of children into care.

• The medical examination is important, but it is only one part of the wider assessment of the child and family.

A recommended approach to the pediatric assessment is as follows:

1. Obtaining background information from professionals, e.g., social worker or police officer, if accompanying the family, or by telephone before the assessment.

2. Full pediatric history from the parent/caregiver and child. Remember to document the responses and the questions asked and any spontaneous disclosures.

3. Assessment of the "whole child," including:

• Growth plotted on a percentile chart.

• Development: is this child developmentally capable of what has been described? Is this child's developmental delay part of a wider picture of abuse or neglect?

• A description of the child's demeanor and behavior: is the child's behavior normal for age?

• Full physical examination, including genitalia and anus.

• Description of injuries: types of lesions, sites, sizes, shapes and patterns, colors, and estimate of ages.

4. Legible, signed, dated, hand-written, contemporaneous record of the assessment with drawings of injuries detailing measurements.

5. Photographs of injuries.

6. Appropriate investigations (discussed in Subheading

7. Ask to assess siblings.

8. Initial information gathering from other professionals (e.g., family doctor, health visitor, or teachers from nursery or school) already involved with the family. This does not replace the formal investigation procedures but may be helpful for the examining physician, who must consider the wider picture to formulate an opinion and guide the child protection agencies.

9. Provision of a clear, factual report detailing the findings, summarizing the assessment, and providing a medical opinion for child protection agencies and any criminal proceedings.

10. Maintenance of written records of contacts with families and professionals.

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