Disparities in Child Abuse Evaluation Arise From Implicit Bias

Tara Haelle

January 06, 2021


Black and Latinx children are more likely to be evaluated for child abuse and referred to child protective services than their White peers, according to research discussed by Tiffani J. Johnson, MD, an assistant professor of emergency medicine at the University of California, Davis.

"These disparities in child abuse evaluation and reporting are bidirectional," she said. "We also recognize that abuse is more likely to be unrecognized in White children."

Johnson presented data on the health disparities in child abuse reporting in a session at the annual meeting of the American Academy of Pediatrics, held virtually this year. Health care disparities, as defined by the National Academy of Sciences, refers to differences in the quality of care between minority and nonminority populations that are not caused by clinical appropriateness, access, need, or patient preference, she explained. Instead, they result from discrimination, bias, stereotyping, and uncertainty.

Disparities Lead to Harm in All Children

For example, a 2018 systematic review found that Black and other non-White children were significantly more likely than White children to be evaluated with a skeletal survey. In one of the studies included, at a large urban academic center, Black and Latinx children with accidental fractures were 8.75 times more likely to undergo a skeletal survey than White children and 4.3 times more likely to be reported to child protective services.

"And let me emphasize that these are children who were ultimately found to have accidental fractures," Johnson said.

Meanwhile, in an analysis of known cases of head trauma, researchers found that abuse was missed in 37% of White children, compared with 19% of non-White children.

"These only represent the tip of the iceberg as a true number of cases of abuse may never really be detected because some cases are still unknown," Johnson told attendees. And the harm of these disparities runs in both directions.

"Failing to diagnose abuse in White children clearly puts them at increased risk for return visits and return evaluations for repeated abuse by the perpetrators," she said. But harm also can result from overreporting and investigation, including psychological trauma and a waste of limited resources. Overinvestigation also can erode family-physician relationships and perpetuate distrust of medical care in communities of color.

Yet at the same time, it's clear that Black children, adolescents, and young adults are not protected from harm in society more generally, when at home, where they learn, or where they play, Johnson said, referencing the deaths of Breonna Taylor and Tamir Rice as examples.

"And now we're seeing increased evidence that children are not protected in the health care center when we think about the many disparities that have been identified in the care and outcomes of children, including the disproportionality in terms of child abuse evaluation and referrals," Johnson said.

Racism is a root cause of that harm to Black children, she said, as the systemic structure of opportunities unfairly disadvantages some individuals and communities while unfairly advantaging others, thereby "sapping the strength of the whole society through the waste of human resources."

Tonya Chaffee, MD, MPH, a clinical professor of health sciences at the University of California, San Francisco, who attended the session, said she particularly appreciated "seeing data on which racial/ethnic populations have child abuse reports made and the disparities that exist that are similar to what we are noticing in our own institution."

Role of Individual-Level Implicit Bias and Racism

While institutional and structural racism play a substantial role in health care disparities, Johnson focused primarily on the impact of personal racism when it comes to child abuse evaluations, through overt discrimination, explicit bias, implicit bias, and stigmatization. The most challenging of these to identify and acknowledge is often implicit bias, a tendency to believe, even unconsciously, that some people or ideas are better than others, which results in unfair treatment.

For example, a 2016 study found that half of medical students and residents held at least one biological belief about differences between Black and White individuals that was actually false, such as Black people having more pain tolerance or stronger bones than White people, which then affected treatment recommendations.

"Implicit bias refers to our attitudes that lie below the surface, but they can still influence our behaviors," Johnson explained. She encouraged providers to take the implicit bias test online to learn about their own unrecognized implicit biases. These biases have a hand in influencing decisions particularly in fast-paced environments where cognitive load is high – such as EDs, where many child abuse evaluations occur.

For example, in one study Johnson led, the researchers measured implicit bias in participants before and after an ED shift to assess how cognitive load affected bias. They found that participants who care for more than 10 patients, the average score for implicit bias increased.

Similarly, "when the ED was more overcrowded, there was also increased bias at the end of the shift, compared to the beginning of the shift," Johnson said. She asked clinicians to take into consideration that at the start of the shift, they may feel well rested and freshly caffeinated, able to suppress or overcome the biases that they know they have.

"But our biases [are] more likely to come into play with every subsequent decision that we make throughout the day when we're engaged in clinical encounters," such as who does and does not receive a skeletal survey or get referred to child protective services, she said.

In another study where she hypothesized that resident physicians would have less bias on the child race implicit bias test than on the adult race one, Johnson reported that 85% of 91 residents working in an ED had an implicit pro-White/anti-Black bias in the test on adult race, but an even higher bias score – 91% – with child race.

Research has found that even children's names can conjure implicit bias when it comes to stereotypically "White-sounding" names versus stereotypically "Black-sounding names."

The implicit bias among clinicians extends beyond care of different children. Research has also identified association between higher implicit bias scores and less interpersonal treatment, less supportive communication, less patient-centered communication, poorer patient ratings of satisfaction, and greater patient-reported difficulty with following recommendations, Johnson said.

"I want you to think about that because I know that when we're engaging with parents and making decisions about whether or not we're going to do a skeletal survey or report someone for it, there is a lot of subjectivity that comes into play with how you're interacting with families," Johnson said. Those verbal and nonverbal cues may be triggering to parents, which then affects your interaction with them. Further, research shows that these biases may impact treatment decisions as well.

Personal-mediated racism also shows up in the use of stigmatizing language, Johnson said.

"When providers read stigmatizing language in the patient's medical records, it was associated with them having more negative attitudes about that patient," which then influenced their clinical decision-making, she said. "So when providers got primed with stigmatizing language, they subsequently had less aggressive pain management for those patients."

Clinical Implications for Patient Care

Johnson encouraged attendees to be careful about the language and tone they use in communicating with other health care providers and during documentation in medical records. Disparities in child abuse evaluation and reporting tend to be greater in EDs with more subjective conditions, whereas disparities are lower in departments with more established protocols.

She recommended several changes to practice that can reduce the impact of implicit bias. Universal screening for child abuse can increase how many injuries are found, but usually at the cost of increased resources and radiation. Another option is use of validated clinical decision support rules to identify who is at high or low risk for maltreatment, something Johnson is working on in her research.

But it's also important for individual providers to confront their personal biases. Evidence-based strategies for reducing bias include perspective taking, focusing on common identities with patients, using counter-stereotypical imaging, seeking increased opportunity for cross-cultural contact, and mindfulness meditation.

"When you interact with people of different backgrounds, it helps to reduce the impact of stereotypes in society about those individuals," Johnson told attendees. It's also important to recognize how diversity in your clinical team can reduce bias.

"We need to work with our institutions to confront racial biases in child abuse reporting and develop quality improvement projects to ensure reporting is done objectively," Chaffee said in an interview after attending the session. "This will require training and likely policy changes, including how reports are made to child welfare and/or the police moving forward."

This article originally appeared on MDedge.com, part of the Medscape Professional Network.


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