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Disparities in detection of suspected child abuse

      Highlights

      • Child abuse patients are more severely injured and have a higher mortality than other pediatric patients.
      • White children of abuse are more severely injured and have a higher hospital mortality than black children of abuse.
      • Black children are disproportionally overidentified as children of abuse and are hospitalized longer than white children despite being less severely injured.

      Abstract

      Background

      Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse.

      Methods

      The 2010–2014 and 2016–2017 National Trauma Data Bank was queried for trauma patients ages 1–17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race.

      Results

      Between 2010–2014 and 2016–2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16–24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1–15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type.

      Conclusions

      Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters.

      Type of study

      Treatment study.

      Level of evidence

      III.

      Keywords

      Abbreviations:

      ISS (Injury Severity Score), NTDB (National Traum Data Bank), US (United States), LOS (Length of Stay), ICU (Intensive Care Unit), SCA (Suspected Child Abuse), ED (Emergency Department)
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      References

      1. Department of Health U, Services administration for children H, administration on children youth F, children F. Child maltreatment 2020. 2020. doi:10.4135/9781544327457.n6.

        • Estroff J.M.
        • Foglia R.P.
        • Fuchs J.R.
        A comparision of accidental and nonaccidental trauma: it is worse than you think.
        J Emerg Med. 2015; 48: 274-279https://doi.org/10.1016/j.jemermed.2014.07.030
        • Crichton K.
        • Cooper J.
        • Minneci P.
        • Thackeray J.
        • Deans K.
        A national survey on the use of screening tools to detect physical child abuse.
        Pediatr Surg Int. 2016; 32: 815-818https://doi.org/10.1007/s00383-016-3916-z
        • Rosenfeld E.H.
        • Johnson B.
        • Wesson D.E.
        • Shah S.R.
        • Vogel A.M.
        • Naik-Mathuria B.
        Understanding non-accidental trauma in the United States: a national trauma databank study.
        J Pediatr Surg. 2019; 55: 693-697https://doi.org/10.1016/j.jpedsurg.2019.03.024
        • Discala C.
        • Sege R.
        • Li G.
        • Reece R.M.
        Child abuse and unintentional injuries: a 10-year retrospective.
        Arch Pediatr Adolesc Med. 2000; 154: 16-22
        • Gothard T.W.
        • Runyan D.K.
        • Hadlef J.L.
        The diagnosis and evaluation of child maltreatment.
        J Emerg Med. 1985; 3: 181-194https://doi.org/10.1016/0736-4679(85)90070-8
        • Goldson E.
        • Fitch M.J.
        • Wendell T.A.
        • Knapp G.
        Child abuse: its relationship to birthweight, apgar score, and developmental testing.
        Am J Dis Child. 1978; 132: 790-793https://doi.org/10.1001/archpedi.1978.02120330062016
        • White O.G.
        • Hindley N.
        • Jones D.P.
        Risk factors for child maltreatment recurrence: an updated systematic review.
        Med Sci Law. 2015; 55: 259-277
        • Woodman J.
        • Lecky F.
        • Hodes D.
        • Pitt M.
        • Taylor B.
        • Gilbert R.
        Screening injured children for physical abuse or neglect in emergency departments: a systematic review.
        Child Care Health Dev. 2010; 36: 153-164https://doi.org/10.1111/j.1365-2214.2009.01025.x
        • Marco M.
        • Maguire-Jack K.
        • Gracia E.
        • López-Quílez A
        Disadvantaged neighborhoods and the spatial overlap of substantiated and unsubstantiated child maltreatment referrals.
        Child Abus Negl. 2020; 104https://doi.org/10.1016/j.chiabu.2020.104477
        • Jenny C.
        • Hymel K.P.
        • Ritzen A.
        • Reinert S.E.
        • Hay T.C.
        Analysis of missed cases of abusive head trauma.
        J Am Med Assoc. 1999; 281: 621-626https://doi.org/10.1001/jama.281.7.621
        • Lane W.G.
        • Rubin D.M.
        • Monteith R.
        • Christian C.W.
        Racial differences in the evaluation of pediatric fractures for physical abuse.
        J Am Med Assoc. 2002; 288: 1603-1609
        • Hampton R.L.
        • Newberger E.H.
        Child abuse incidence and reporting by hospitals: significance of severity, class, and race.
        Am J Public Health. 1985; 75: 56-60https://doi.org/10.2105/AJPH.75.1.56
        • Trokel M.
        • Discala C.
        • Terrin N.C.
        • Sege R.D.
        Patient and injury characteristics in abusive abdominal injuries.
        Pediatr Emerg Care. 2006; 22: 700-704
        • Ards S.
        • Chung C.
        • Myers S.L.
        The effects of sample selection bias on racial differences in child abuse reporting.
        Child Abus Negl. 1998; 22: 103-115https://doi.org/10.1016/S0145-2134(97)00131-2
        • Escobar M.A.
        • Wallenstein K.G.
        • Christison-Lagay E.R.
        • Naiditch J.A.
        • Petty J.K.
        Child abuse and the pediatric surgeon: a position statement from the Trauma Committee, the board of governors and the membership of the American pediatric surgical association.
        J Pediatr Surg. 2019; 54: 1277-1285https://doi.org/10.1016/j.jpedsurg.2019.03.009
        • Wood J.N.
        • Hall M.
        • Schilling S.
        • Keren R.
        • Mitra N.
        • Rubin D.M
        Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury.
        Pediatrics. 2010; 126: 408-414https://doi.org/10.1542/peds.2010-0031
        • Hussey J.M.
        • Chang J.J.
        • Kotch J.B.
        Child maltreatment in the United States: prevalence, risk factors, and adolescent health consequences.
        Pediatrics. 2006; 118: 933-942https://doi.org/10.1542/peds.2005-2452
        • Roaten J.B.
        • Partrick D.A.
        • Nydam T.L.
        • Bensard D.D.
        • Hendrickson R.J.
        • Sirotnak A.P.
        • et al.
        Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center.
        J Pediatr Surg. 2006; 41: 2013-2015https://doi.org/10.1016/j.jpedsurg.2006.08.028
        • Paul A.R.
        • Adamo M.A.
        Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment.
        Transl Pediatr. 2014; 3: 195-207https://doi.org/10.3978/j.issn.2224-4336.2014.06.01
        • Brown J.
        • Cohen P.
        • Johnson J.G.
        • Salzinger S.
        A longitudinal analysis of risk factors for child maltreatment: findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect.
        Child Abus Negl. 1998; 22: 1065-1078https://doi.org/10.1016/S0145-2134(98)00087-8
        • Wu S.S.
        • Ma C.X.
        • Carter R.L.
        • Ariet M.
        • Feaver E.A.
        • Resnick M.B.
        • et al.
        Risk factors for infant maltreatment: a population-based study.
        Child Abuse Negl. 2004; 28: 1253-1264https://doi.org/10.1016/j.chiabu.2004.07.005
        • Gwirtzman Lane W.
        • Dubowitz H.
        • Langenberg P.
        • Dischinger P
        Epidemiology of abusive abdominal trauma hospitalizations in United States children☆.
        Child Abus Negl. 2012; 36: 142-148https://doi.org/10.1016/j.chiabu.2011.09.010
        • Ward A.
        • Iocono J.A.
        • Brown S.
        • Ashley P.
        • Draus J.M.
        Non-accidental trauma injury patterns and outcomes: a single institutional experience.
        Am Surg. 2015; 81: 835-838
        • Larimer E.L.
        • Fallon S.C.
        • Westfall J.
        • Frost M.
        • Wesson D.E.
        • Naik-Mathuria B.J.
        The importance of surgeon involvement in the evaluation of non-accidental trauma patients.
        J Pediatr Surg. 2013; 48: 1357-1362https://doi.org/10.1016/j.jpedsurg.2013.03.035
      2. National Center On Child Abuse And Neglect. National study of the incidence of child abuse and neglect 1980 (NIS-1). 1989.

      3. National Center On Child Abuse And Neglect. National study of the incidence of child abuse and neglect 1987 (NIS-2). 1990. 10.34681/K23K-EK30. </Dataset>

      4. Sedlak A., Broadhurst D.D. Third national incidence study of child abuse and neglect (NIS-3). NIS-3; child abuse: 1996.

      5. Sedlak A.J., Mettenberg J., Basena M., Petta I., McPherson K., Greene A., et al. Fourth national incidence study of child abuse and neglect (NIS-4): report to congress. Washington, DC: 2010.

      6. Trauma Quality Programs Participant Use File n.d. https://www.facs.org/quality-programs/trauma/tqp/center-programs/ntdb/datasets (accessed April 20, 2022).

      7. U.S. Census Bureau. Summary of modified race and census 2010 race distributions for the United States (US-MR2010-01). 2010 n.d. https://www.census.gov/data/datasets/2010/demo/popest/modified-race-data-2010.html (accessed July 15, 2020).

      8. Department of Health U, Services administration for children H, Administration on children youth F, Children F. Child maltreatment 2019. 2019.

      9. Hill R.B. An analysis of racial/ethnic disproportionality and disparity at the national, state, and county levels. 2007.

        • Maloney T.
        • Jiang N.
        • Putnam-Hornstein E.
        • Dalton E.
        • Vaithianathan R
        Black–white differences in child maltreatment reports and foster care placements: a statistical decomposition using linked administrative data.
        Matern Child Health J. 2017; 21: 414-420https://doi.org/10.1007/s10995-016-2242-3
        • Cort N.A.
        • Cerulli C.
        • He H.
        Investigating health disparities and disproportionality in child maltreatment reporting: 2002-2006.
        J Public Heal Manag Pract. 2010; 16: 329-336https://doi.org/10.1097/PHH.0b013e3181c4d933
      10. Department of Health U, Services administration for children H, administration on children youth F, children F. Child Maltreatment 2018. 2018.

        • Dyrbye L.
        • Herrin J.
        • West C.P.
        • Wittlin N.M.
        • Dovidio J.F.
        • Hardeman R.
        • et al.
        Association of racial bias with burnout among resident physicians.
        JAMA Netw Open. 2019; 2e197457https://doi.org/10.1001/jamanetworkopen.2019.7457
        • Mehta J.L.
        • Bursac Z.
        • Mehta P.
        • Bansal D.
        • Fink L.
        • Marsh J.
        • et al.
        Racial disparities in prescriptions for cardioprotective drugs and cardiac outcomes in veterans affairs hospitals.
        Am J Cardiol. 2010; 105: 1019-1023https://doi.org/10.1016/j.amjcard.2009.11.031
        • Esnaola N.F.
        • Ford M.E.
        Racial differences and disparities in cancer care and outcomes. Where's the rub?.
        Surg Oncol Clin N Am. 2012; 21: 417-437https://doi.org/10.1016/j.soc.2012.03.012
        • Marcelin J.R.
        • Siraj D.S.
        • Victor R.
        • Kotadia S.
        • Maldonado Y.A.
        The impact of unconscious bias in healthcare: how to recognize and mitigate it.
        J Infect Dis. 2019; 220: S62-S73https://doi.org/10.1093/infdis/jiz214
        • Johnson T.J.
        • Ellison A.M.
        • Dalembert G.
        • Fowler J.
        • Dhingra M.
        • Shaw K.
        • et al.
        Implicit bias in pediatric academic medicine.
        J Natl Med Assoc. 2017; 109: 156-163https://doi.org/10.1016/j.jnma.2017.03.003
        • Maguire S.
        • Upadhyaya M.
        • Evans A.
        • Mann M.
        • Haroon M.
        • Tempest V.
        • et al.
        A systematic review of abusive visceral injuries in childhood-their range and recognition.
        Child Abuse Negl. 2013; 37: 430-445https://doi.org/10.1016/j.chiabu.2012.10.009
        • Roaten J.B.
        • Partrick D.A.
        • Bensard D.D.
        • Hendrickson R.J.
        • Vertrees T.
        • Sirotnak A.P.
        • et al.
        Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes.
        Am J Surg. 2005; 190: 827-830https://doi.org/10.1016/j.amjsurg.2005.05.049
        • Barnes P.M.
        • Norton C.M.
        • Dunstan F.D.
        • Kemp A.M.
        • Yates D.W.
        • Sibert J.R.
        Abdominal injury due to child abuse.
        Lancet. 2005; 366: 234-235https://doi.org/10.1016/S0140-6736(05)66913-9
        • Davies F.C.
        • Coats T.J.
        • Fisher R.
        • Lawrence T.
        • Lecky F.E
        A profile of suspected child abuse as a subgroup of major trauma patients.
        Emerg Med J. 2015; 32: 921-925https://doi.org/10.1136/emermed-2015-205285
        • Pandya N.K.
        • Baldwin K.
        • Wolfgruber H.
        • Christian C.W.
        • Drummond D.S.
        • Hosalkar H.S.
        Child abuse and orthopaedic injury patterns: analysis at a level i pediatric trauma center.
        J Pediatr Orthop. 2009; 29: 618-625
        • Hymel K.P.
        • Laskey A.L.
        • Crowell K.R.
        • Wang M.
        • Armijo-Garcia V.
        • Frazier T.N.
        • et al.
        Racial and ethnic disparities and bias in the evaluation and reporting of abusive head trauma.
        J Pediatr. 2018; 198: 137https://doi.org/10.1016/J.JPEDS.2018.01.048
        • Slopen N.
        • Heard-Garris N.
        Structural racism and pediatric health—a call for research to confront the origins of racial disparities in health.
        JAMA Pediatr. 2022; 176: 13-15https://doi.org/10.1001/JAMAPEDIATRICS.2021.3594
        • Rosenthal C.M.
        • Parker D.M.
        • Thompson L.A.
        Racial disparities in child abuse medicine.
        JAMA Pediatr. 2022; 176: 119-120https://doi.org/10.1001/JAMAPEDIATRICS.2021.3601
        • Gonzalez D.O.
        • Deans K.J.
        Hospital-based screening tools in the identification of non-accidental trauma.
        Semin Pediatr Surg. 2017; 26: 43-46https://doi.org/10.1053/j.sempedsurg.2017.01.002
        • Chang D.C.
        • Misra Knight V.
        • Ziegfeld S.
        • Haider A.
        • Paidas C
        The multi-institutional validation of the new screening index for physical child abuse.
        J Pediatr Surg. 2005; 40: 114-119https://doi.org/10.1016/j.jpedsurg.2004.09.019
        • Escobar Jr, M.A.
        • Pflugeisen B.M.
        • Duralde Y.
        • Morris C.J.
        • Haferbecker D.
        • Amoroso P.J.
        • et al.
        Development of a systematic protocol to identify victims of non-accidental trauma.
        Pediatr Surg Int. 2016; 32: 377-386https://doi.org/10.1007/s00383-016-3863-8
        • Crichton K.G.
        • Cooper J.N.
        • Minneci P.C.
        • Groner J.I.
        • Thackeray J.D.
        • Deans K.J.
        A national survey on the use of screening tools to detect physical child abuse.
        Pediatr Surg Int. 2016; 32: 815-818https://doi.org/10.1007/s00383-016-3916-z
        • Louwers E.C.F.M.
        • Korfage I.J.
        • Affourtit M.J.
        • Scheewe D.J.H.
        • van de Merwe M.H.
        • Vooijs-Moulaert A.F.S.R.
        • et al.
        Effects of systematic screening and detection of child abuse in emergency departments.
        Pediatrics. 2012; 130: 457-464https://doi.org/10.1542/peds.2011-3527
        • Louwers E.C.F.M.
        • Korfage I.J.
        • Affourtit M.J.
        • Ruige M.
        • van den Elzen A.P.M.
        • de Koning H.J.
        • et al.
        Accuracy of a screening instrument to identify potential child abuse in emergency departments.
        Child Abus Negl. 2014; 38: 1275-1281https://doi.org/10.1016/j.chiabu.2013.11.005
        • Quiroz H.J.
        • Parreco J.
        • Easwaran L.
        • Willobee B.
        • Ferrantella A.
        • Rattan R.
        • et al.
        Identifying populations at risk for child abuse: a nationwide analysis.
        J Pediatr Surg. 2020; 55: 135-139https://doi.org/10.1016/j.jpedsurg.2019.09.069
        • Sonderman K.A.
        • Wolf L.L.
        • Madenci A.L.
        • Beres A.L.
        Insurance status and pediatric mortality in nonaccidental trauma.
        J Surg Res. 2018; 231: 126-132https://doi.org/10.1016/j.jss.2018.05.033
        • Raghavan R.
        • Brown D.S.
        • Allaire B.T.
        • Garfield L.D.
        • Ross R.E.
        • Hedeker D.
        Challenges in using medicaid claims to ascertain child maltreatment.
        Child Maltreat. 2015; 20: 83-91https://doi.org/10.1177/1077559514548316