Stanford Medicine finds racial disparities in child abuse reporting

Black children who are injured because of suspected child abuse are reported to Child Protective Services more frequently than are white children and those of other races, a new Stanford School of Medicine study has found.

Parents and other caregivers rarely admit to injuring their children, so reports rely in part on providers’ gut feelings, which can be influenced by unconscious, systemic bias, the researchers said. Medical caregivers are “mandated reporters” who must alert authorities when they think children might be victims of abuse.

The potential for bias in doctors’ and nurses’ decisions about which injuries should be reported to Child Protective Services can lead to more investigations of Black families and potentially more episodes of abuse for the white children whose cases are not referred to the authorities.

The research also found that Black children’s injuries were still disproportionately reported as suspected abuse regardless of whether the children were poor or not. Poverty is considered a risk factor for abuse. The Stanford study examined whether children had public or private insurance as a marker for family income.

The researchers used two sets of data of nearly 800,000 traumatic injuries to children ages 1 to 17 from 2010 to 2014 and from 2016 to 2017, taken from the National Trauma Data Bank, which is maintained by the American College of Surgeons. The data showed 1% of the injuries were suspected to be caused by abuse, based on medical codes used to report different types of abuse.

The outcomes for children of abuse are grim. Compared to the general population of children with traumatic injuries, suspected child abuse victims were younger (a median age of 2 years old versus 10 years), more likely to have public insurance (77% versus 43%) and more likely to be admitted to the intensive care unit (68% versus 48%). The suspected child abuse victims also were 10 times more likely than the general population of children with traumatic injuries to die of their injuries in the hospital, with 8.2% of suspected abuse victims versus 0.84% of all children with traumatic injuries dying during hospitalization, the study found.

Among suspected child abuse victims, 1% were Asian, 0.3% Native Hawaiian/Pacific Islander, 2% American Indian and 12% other race, with the proportions of children in the suspected child abuse group and in the general population of injured children being similar, the researchers said.

But Black patients were disproportionately over-identified among suspected child abuse victims. They comprised 33% of suspected child abuse victims and 18% of the general population of traumatically injured children. White children comprised 51% of suspected child abuse victims and 66% of the general population of traumatically injured children.

Some experts have argued that disproportionate reporting of injured Black children reflects only that their families tend to have lower incomes, not that medical professionals are subject to bias, the researchers said, but the Stanford study did not find that to be true.

“Even when we control for income — in this case, via insurance type — African American children are still significantly over-represented as suspected victims of child abuse,” senior study author Dr. Stephanie Chao, assistant professor of surgery at Stanford Medicine, said.

Black children’s injuries also were reported to authorities when they had lower injury-severity scores, meaning there was more suspicion for children with less-severe injuries among the Black racial group, Chao said.

The reverse was true for white victims of child abuse. Medical professionals overall had a higher threshold for suspecting white families of abuse and a lower threshold for suspecting Black families. Yet white children in the suspected abuse group were more likely than Black children to have worse injuries, and they were more likely to have been admitted to the intensive care unit, the researchers found.

Although white suspected child abuse patients were more severely injured and had an in-hospital mortality of 9% compared to 6% among Black patients, Black suspected child abuse patients were hospitalized longer, despite controlling for insurance type.

Chao said such medical bias based on race is injurious to both Black and white children.

“If you over-identify cases of suspected child abuse, you’re separating children unnecessarily from their families and creating stress that lasts a lifetime. But child abuse is extremely deadly, and if you miss one event — maybe a well-to-do Caucasian child where you think, ‘no way’ — you may send that child back unprotected to a very dangerous environment. The consequences are really sad and devastating on both sides,” Chao said.

To combat racial bias, Chao and her colleagues designed a universal screening system, in use at Stanford Medicine Children’s Health since 2019, which evaluates every time a child younger than 6 years old has an injury sustained in a private home. The electronic medical record automatically sends an alert to the organization’s child abuse team. Pediatricians and social workers with specialized abuse-detection training check the medical record for other indications of abuse. If the medical record shows any red flags, the staff who admitted the patient to the emergency department or hospital is alerted to consider if further examination or a Child Protective Services report is warranted.

This more equitable method of screening injured children helps to safeguard against decisions made primarily by medical providers’ gut feelings, Chao said.

She is also working with Epic, the nation’s largest electronic medical record company, to include an automated child abuse screening tool in its system. The tool will be tested at several medical institutions later this year.

“Everyone means well here, but the consequences of getting these reports wrong are pretty dire in either direction. If we don’t recognize bias and always chalk it up to something else, we can’t fix the problem in a thoughtful way. Now, I hope we can recognize it and work toward a solution,” Chao said.