Pediatricians May Show Bias in Abuse Assessments

August 16, 2010 — Black children are more likely to be evaluated for abuse than white children with comparable injuries, according to a new study from The Children’s Hospital of Philadelphia, raising concerns some children are being subjected to unnecessary testing while other cases of abuse go undiagnosed.

The study, which appears online today in the journal Pediatrics, looked at 3,063 infants admitted to 39 different pediatric hospitals with traumatic brain injuries not related to car accidents. The researchers compared the race and economic status of families with the subsequent diagnosis of child abuse after traumatic brain injury. Black families and families with governmental insurance were more likely to come under scrutiny than white families and families with private insurance. 

Standard guidelines for abuse evaluation recommended

“These results show a need for the development and implementation of standard guidelines regarding who gets evaluated for abuse and neglect so we avoid these biases,” said study leader Joanne N. Wood, MD, MSHP, a pediatric researcher at The Children’s Hospital of Philadelphia. “The concern is that we may subject children who are not getting abused to unnecessary tests and also miss actual abuse cases. We know from other studies that when physicians fail to recognize and diagnose abuse, children may suffer further abuse that results in more injury or even death.” 

Infants under 1 year of age are mostly likely to experience and die from child abuse and neglect. About one in 45 infants were victims of child abuse and neglect in the U.S. in 2007 and more than 700 died that year as a result.

In the study, a little more than one-third of the infants received a diagnosis of child abuse. Black infants and publicly insured or uninsured infants were more likely to undergo tests such as skeletal surveys. However, white children were more likely to receive a diagnosis of child abuse once a skeletal survey was ordered.

“These results raise concerns that different thresholds for suspicion of child abuse were being used for children of different races and economic levels,” said David Rubin, MD, MSCE, a pediatric researcher at Children’s Hospital and a senior author on the study. “Recognizing that racial disparities exists is the first step toward healthcare providers correcting those discrepancies.”

First study to analyze abuse biases data nationally

The authors had no information on the race or other characteristic of the physicians who ordered the skeletal surveys or reported the suspected abuse. While past studies have shown these biases exist at one or a few hospitals, this is the first study to look nationally and show similar results from a wide network of pediatric hospitals.

Study limitations

The authors suggest the finding may be limited because they were unable to examine the records of each child to determine the true likelihood of abuse. And, the study could wrongly classify a case based on inaccuracies in the medical chart.

Authors of the abuse assessment bias study

Other study authors are Samantha Schilling, MD, and Ron Keren, MD, MPH, of Children’s Hospital; Matthew Hall, PhD, of the Child Health Corporation of America in Shawnee Mission, Kansas; and Nandita Mitra, PhD, of The University of Pennsylvania School of Medicine.

More information

“Disparities in the Evaluation and Diagnosis of Abuse Among Infants with Traumatic Brain Injury,” Pediatrics published online August 16, 2010. 

Read the abstract.