The papers by Ziegler et al.1 in the May/June issue of this journal and by Taitz et al.2 published last year remind us child abuse does not always present to experts. Ziegler et al. reviewing assessment of fractures in young children in a general hospital emergency department report poorly documented medical histories suggesting the possibility of inflicted injury was often not considered. Taitz et al. reviewed cases seen in a tertiary children's hospital emergency department. Poor history documentation was again common indicating child abuse was often not a differential diagnosis even in a paediatric setting. Review of a well-publicized child homicide in New Zealand revealed that the child had presented to various medical services on multiple occasions before the fatal assault.3 In a review of 32 fatal abuse cases in infants, 55% suffered previous trauma before death.4 Assuming a fracture was caused by accidental rather than inflicted injury may have fatal consequences at the next presentation. Child mortality data from New Zealand indicate that 8% of child deaths between 1 and 4 years of age are because of inflicted injury.5 This is proportionally similar to mortality in this age group because of infection (7%), cancer (8%) and central nervous system diseases (9%). Deficiencies in history taking and physical examination when child abuse is a differential diagnosis are concerning in the light of these statistics. We would not accept missing cases of meningococcal septicaemia or acute leukaemia for similar reasons. Child abuse is not, of course, always fatal but for those exposed to any form of family violence consequences can be life-long. Adolescents questioned in the Christchurch Health and Development study in New Zealand reported rates of 38% for childhood exposure to interparental violence of various forms.6 For up to 11%, this included exposure to physical violence. A number of studies have now shown that interparental or spousal violence significantly increases the risk of child abuse, with risk increasing with younger child age and frequency of interparental abuse.7-9 As abuse of children coexists in approximately 50% of families where there is physical spousal abuse, it seems likely that at least 5–6% of children in our communities are at risk of physical abuse by caregivers. Other Christchurch study data reporting that 8% of children had experienced severe physical punishment at home and 4% of severe and abusive treatment is consistent with this.10 Child abuse does not always result in fractures, but long-term effects can include behavioural and mental health problems including suicide, criminal outcomes such as property offending and other adverse health outcomes.6, 11, 12 Effects on early brain development are now well documented.13 Child abuse is a serious health problem affecting a significant proportion of the paediatric population and we have a responsibility as health professionals to ensure the diagnosis is made and children are protected. Child abuse often presents acutely to junior doctors not planning a career in paediatrics. Reviewing what medical students are taught about the topic is therefore important. A 1992 survey of family violence curricula in Australian Medical schools found all had teaching on child abuse but teaching time, the number of disciplines involved and teaching methods used varied widely.14 Academics in the USA have advocated for a more comprehensive family violence curricula and the importance of this topic is recognized by students.15-17 We need to ensure that these attitudes are reflected in local curricula. Representatives from the paediatric departments of the five New Zealand clinical schools met in December 2003 to discuss family violence curricula. This meeting was proposed by the child abuse committee of the Paediatric Society of New Zealand and funded by the Ministry of Health. A wide variety of teaching was found to be occurring both in terms of methodology and in time allotted to the subject. Teaching was most extensive in the only centre with an academic paediatrician with clinical expertise in child abuse. This curriculum was developed when an academic community paediatrician was also on staff. Our review concluded that four main areas should be addressed when teaching about child abuse and family violence: Consciousness raising: Students need to understand that family violence is a major public health problem in our community. Students may find the subject distressing, as they cannot comprehend how anybody could hurt a child, especially one of their own. They need to understand family dysfunction and how it contributes to child abuse risk. Some students would have been victims themselves and this will affect how they approach the subject.18-20 Acknowledgement at the beginning of a tutorial that the subject may be difficult for those who have had personal experience of abuse may be helpful. Role of teamwork: Students should understand that family violence is best managed by a multidisciplinary approach. Consultation is important. Paediatricians expert in the area should make themselves available for consultation with colleagues assessing children in a setting where the diagnosis is not yet clear. Paediatricians also have a role in ensuring that non-paediatric departments seeing significant numbers of children in their hospital, have regular updates on the management of suspected abuse. This requires time and resources. History and communication skills: Taking a comprehensive history in a supportive manner is the key to exploring issues related to family violence. The use of a checklist in an emergency department will increase awareness of the possibility of abuse when young children with injuries are assessed and at least insure better histories of the injury are documented.21 Clinical signs of abuse and their major differentials: A good knowledge of the clinical signs of abuse and signs and symptoms that may mimic abuse is essential. Children should be examined thoroughly for other indicators of abuse when it is part of the differential diagnosis. Doctors also need to know which investigations are appropriate to confirm or rule out alternative diagnoses. Various teaching methods can be used including self-directed computer-based programmes.22 Direct teaching alone about domestic violence screening may not change practice if students do not see teachers modelling the taught behaviour.23 Clinical skills are successfully taught using standardized patients and actors with whom students can practise history taking and communication skills.24 Students should be taught specifically how to ask difficult questions such as those about potential to harm children and history related to maternal depression. The curriculum should also be examinable. This review has focused on medical school education about child abuse although we also should increase teaching in the early postgraduate years. However, the basis of our medical education is still the education that we receive at medical school. With this in mind academic departments of Paediatrics and Child Health in Australia are seeking to work together to share resources.25 Child abuse and related issues are on the agenda for discussion in 2005. Family violence, including child abuse and neglect, is not a rare or esoteric problem in our clinical practice. It is common and has major implications for the long-term health of many of those affected. The time assigned to this topic in the medical curriculum should reflect that. Blackwell Publishing Asia apologizes for having omitted this manuscript from the May/June issue of the Journal of Paediatrics and Child Health in which it was supposed to have been published. This manuscript was to be published simultaneously with the Original Research article “Assessment and follow-up of suspected child abuse in preschool children with fractures seen in a general hospital emergency department” by D. S. Ziegler, A. C. Piper and J. Sammut (41–5/6: 251–255). The publisher apologizes to Dr Elder and the readership for the omission and any confusion it may have caused.