In the late 1960s, clinical reports of battered children led to the enactment of state laws throughout the United States that required medical providers to report instances of suspected child maltreatment to state child protection agencies.1 In the ensuing 40 years, a great deal has been learned about child maltreatment. However, although medical professionals generally receive some training on the recognition and reporting of suspected child maltreatment, many cases of child abuse go unrecognised and unreported, occasionally with tragic consequences.2

Child abuse reporting by medical professionals requires both knowledge and experience. Specific knowledge helps practitioners recognise known patterns and mechanisms of injury associated with abuse, as well as those patterns and mechanisms of injury that commonly result from childhood unintentional injuries. Basic knowledge of normal child development helps flag those incidents in which the history provided does not match the child’s age or ability. Moving beyond direct pattern recognition, recent research has also demonstrated that even when abuse is recognised, professionals must make an active decision to report the child to state authorities.3^–7 Their training, personal experiences and beliefs about the system in place for child protection all influence this decision.

This review will describe recent health services research that reveals the current barriers to reporting. Broadly classified, these can be divided into two major areas: failure to identify maltreatment, and deciding not to report suspected abuse to state authorities. From the point of view of the abused child, these barriers result in remarkably inconsistent medical evaluation and management.

Although child maltreatment consists of physical abuse, emotional abuse, sexual abuse and neglect, this review will focus on child physical abuse. Even though the elements of decision making vary somewhat depending on the type of maltreatment, the barriers we describe and the conclusions we present are …