A new study by Stanford researchers found disparities linked to race in hospital reports of suspected child abuse amongst Black and white children.

Researchers examined a national registry of trauma patients from 950 hospitals across the country and controlled for income levels based on data from the National Trauma Data Bank, which vets the data that is submitted multiple times. The study found that Black children were disproportionately over-identified as children of abuse and overrepresented among suspected child abuse victims compared to their proportion in the United States population. The study found that the overall average injury level of Black victims of child abuse was lower than the average level for white victims; however, Black children were over-reported as victims. Additionally, for similar levels of injury, Black children were kept at the hospital longer than their white counterparts.

“One of the big problems with child abuse is that there’s no central source of truth,” said assistant professor of surgery Stephanie Chao, who was a senior author on this paper. “With a lot of other medical diseases, you’re right or wrong because a biopsy will come back and say, yes, it was cancer. Child abuse is much more gray than that and a lot of it relies on provider suspicion.”

According to data, Black children made up 33% of suspected child abuse victims yet only 18% of the pediatric trauma population, referring to children experiencing severe physical or psychological trauma. Meanwhile, white children comprised 51% of the population of suspected child abuse victims but made up 66% of the pediatric trauma population.

“I think that it’s important to point out that there are discrepancies and recognize that maybe the system is not perfect and do more studies to figure out exactly what part of the system can be fixed, so that we can fix it,” Chao said.

The researchers found that white children that were suspected of abuse were more likely to have worse injuries and more likely to have been admitted to the intensive care unit than Black children that were suspected of abuse.

“There are social determinants of health and those manifest in lots of different ways,” said professor of general surgery David Spain, who was a co-author of this study. “The bar of suspicions can be very different, based on all our preconceived notions. It does really seem to be an element of prejudice.”

Spain recommends implementing standardized criteria to help eliminate any potential subconscious or conscious bias when reporting suspected child abuse.

“The first step is you have to be aware that there’s subjectivity in [reporting child abuse],” Spain said. “If you have standards, it doesn’t matter what the family appears to look like or how they interact — if they meet criteria A, B and C, then we’re going to report this or have it investigated. I think you just, as much as you can, try to remove the subjectivity.”

For the community of board-certified child abuse pediatricians, these results may be expected, but this study is important for raising awareness about this issue, says clinical assistant professor Melissa Egge, who specializes in child abuse pediatrics.

“The results are not surprising,” said Egge, who has personally observed racial differences in reporting child abuse in her work. “Both underreporting and overreporting can have negative consequences for the child and family. It is important for healthcare and social service workers to be aware of implicit and explicit racial biases that may affect reporting and management practices.”

Chao and her colleagues plan on validating their results by examining different data sets with different limitations, as well as examining the process of screening for child abuse. They plan on surveying emergency rooms to gain an understanding of how well-prepared first-line providers are for handling possible cases of child abuse.

Chao is also working with Epic, the medical record provider of the majority of patients in the nation, to implement an automated child abuse screening tool in its system.

“Processes and things that we have thought have always worked well are being questioned a little bit more, which is always important for both self improvement and societal improvement,” Chao said. “I don’t think medicine is immune to that. I think this is the opportunity to improve the way we do things and really benefit all patients.”