Assessment: History Taking and Diagnosis

A key diagnostic feature of abuse or neglect is a discrepancy between the clinical findings and the history given for the problem by the parent or caregiver. Most parents who accompany their injured child to the physician or dentist act in a concerned manner, asking questions regarding the health status of their child. Some parents may even feel an unwarranted guilt that, to some degree, they are responsible for the injury to their child. Abusive adults usually have no questions and may appear withdrawn or unconcerned.30 Many wait hours or even days before seeking medical or dental attention for their child, even in situations of life-threatening injuries. The following action outlines what the dentist should do in cases of suspected cases of child maltreatment:

  • Before treatment begins, the child should be evaluated for any physical or behavioral signs of maltreatment.
  • If abuse is suspected, question the child first, away from the parent, about the cause of his or her injury. Seek the same information from the parent(s) to see if both accounts are similar.
  • Note findings in the patient’s chart with detailed description of the injuries and accounts given for their occurrence.
  • The dentist should always document personal opinion why child maltreatment is suspected.
  • If a report will be filed with proper authorities, the parent(s) should always be informed.
  • If in doubt, call your Child Protection or an equivalent agency.