Even when the cause of the fractures turns out to be an accident, physicians are quicker to call for X-rays to detect previous abuse when the child is black or Hispanic. They're also far more liable to refer the case to child protection officials when treating minorities than they are when the patient is white.
Dr. Cindy Christian, director of the Safe Place program at Children's Hospital of Philadelphia and leader of the study, says physicians may be guilty of letting class and race lead them to diagnose abuse -- and to miss it, too.
"I do think that subconsciously we have personal biases. It's hard to think about bad things that could happen to children when in front of you is a family that may be like you," may share the same ZIP code, school and social set, Christian says.
The findings appear in tomorrow's issue of the Journal of the American Medical Association.
More than one in five of the 826,000 reported cases of child abuse in 1999 involved physical harm. Statistics show that black and Hispanic children are more likely to fall victim to child abuse. However, the new study suggests these figures may underestimate the prevalence of abuse in whites, and the true rate of abuse may not vary so much by race.
Christian and her colleagues studied 388 children under the age of 3 who had been admitted to the hospital with broken long bones (like an arm or leg) or a skull fracture. Roughly half were white, and nearly 60 percent were boys.
Doctors filed reports of suspected abuse in 22.5 percent of the cases involving white children, and nearly 53 percent of those in which the patients were minorities. Two independent reviewers determined that abuse occurred in 27.6 percent of the minority injuries and 12.5 percent of those to white children.
"We were able to break down whether the injuries were truly from abuse or accidental," Christian says. "If you were a victim, you were treated the same."
Babies under a year -- a time of life when accidental fractures are unusual -- received identical care regardless of race, as did children in whom a finding of abuse was confirmed by the outside experts.
But for older children, when the nature of the injuries was unclear to those experts, striking differences emerged. Doctors at the hospital were nearly five times as likely to order full-body X-rays for minority toddlers to look for prior fractures that might signal abuse. And they were three times as likely to refer black and Hispanic children to child protective services.
The differences held even when Christian's group tried to account for the effect of social and economic status, and the kind of health insurance the child's parents had.
In other words, Christian says, a black mother whose toddler tumbles down the stairs and breaks his leg is three times as likely to have the accident referred to child welfare authorities for investigation as is a white woman whose baby has an identical injury.
Christian says the bias cuts two ways: "For minority toddlers who have accidental injures, they're being overly scrutinized and probably reported too frequently" to child abuse authorities. "The concern is also that we're missing some of the abused white children because doctors are not doing the skeletal surveys" on them.
Dr. Allan DeJong, medical director of the Children's Advocacy Center of Delaware in Wilmington, helped review the cases in the study. He agrees the findings show "a certain amount of bias or perhaps even prejudice when we evaluate children who have injuries. The bias includes both not doing additional laboratory or imaging studies that we might do in certain cases, and that we also might not report certain cases to [child welfare agents]."
Minority children do seem to be somewhat more vulnerable to abuse than whites, he says. However, doctors can't let that guide their willingness to accept a parent's explanation of an injury. "It is important to take the facts in the case on the basis of the information provided, rather than accept on face value an explanation from whites, but not from the parents of poor minority children."
John Holton, vice president for research at Prevent Child Abuse America, a Chicago advocacy group, says if the new findings are accurate, "we're allowing white children to be at greater endangerment than minority children. We might be as a society creating a picture that child abuse and neglect is somebody else's problem, it's not in the domain of the large majority of kids, when it fact it could be."
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