title: Curiosity and critical thinking: identifying child abuse before it is too late.
abstract: OBJECTIVE
  We reviewed medical records to identify factors contributing to not recognizing child abuse in cases where it was subsequently identified.
  
  
  METHODS
  Eighteen cases of delayed diagnosis of physical abuse were reviewed for qualitative themes. Missed abuse was defined by prior medical encounters that revealed findings concerning for physical abuse that were not recognized.
  
  
  RESULTS
  Clinical limitations contributing to a delay in diagnosis included inattention to skin and subconjunctival findings, acceptance of inadequate explanations for injuries, no history obtained from verbal children, insufficient exploration of signs and symptoms, nonadherence to the maltreatment pathway, and incorrect diagnoses from radiologic examinations. System-based limitations included limited medical record access or completeness and admission to less-than-optimal settings.
  
  
  CONCLUSIONS
  Having a greater index of suspicion for abuse may mitigate missed opportunities. With variability of medical training in child abuse, the factors we identified can be used as learning objectives for continuing medical education.
authors.affiliation: Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA amjackso@childrensnational.org.
authors.forename: Allison M
authors.initials: AM
authors.lastname: Jackson
authors.affiliation: Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA.
authors.forename: Katherine P
authors.initials: KP
authors.lastname: Deye
authors.affiliation: Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA.
authors.forename: Tina
authors.initials: T
authors.lastname: Halley
authors.affiliation: Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA.
authors.forename: Tanya
authors.initials: T
authors.lastname: Hinds
authors.affiliation: Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Rosenthal
authors.affiliation: Children's National Health System, Washington, DC, USA The George Washington University, Washington, DC, USA.
authors.forename: Eglal
authors.initials: E
authors.lastname: Shalaby-Rana
authors.affiliation: The George Washington University, Washington, DC, USA.
authors.forename: Ellen F
authors.initials: EF
authors.lastname: Goldman
mesh_terms: D002648:Child; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D004219:District of Columbia; D005106:Exploratory Behavior; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008499:Medical Records
keywords: child maltreatment; child physical abuse; medical education; missed diagnoses