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Lane WG, Rubin DM, Monteith R, Christian CW. Racial Differences in the Evaluation of Pediatric Fractures for Physical Abuse. JAMA. 2002;288(13):1603–1609. doi:10.1001/jama.288.13.1603
Context Child maltreatment is a significant problem within US society, and minority
children have higher rates of substantiated maltreatment than do white children.
However, it is unclear whether minority children are abused more frequently
than whites or whether their cases are more likely to be reported.
Objectives To determine whether there are racial differences in the evaluation
and Child Protective Services (CPS) reporting of young children hospitalized
Design, Setting, and Patients Retrospective chart review conducted at an urban US academic children's
hospital among 388 children younger than 3 years hospitalized for treatment
of an acute primary skull or long-bone fracture between 1994 and 2000. Children
with perpetrator-admitted child abuse, metabolic bone disease, birth trauma,
or injury caused by vehicular crash were excluded.
Main Outcome Measures Ordering of skeletal surveys and filing reports of suspected abuse.
Results Reports of suspected abuse were filed for 22.5% of white and 52.9% of
minority children (P<.001). Abusive injuries,
as determined by expert review, were more common among minority children than
among white children (27.6% vs 12.5%; P<.001).
Minority children aged at least 12 months to 3 years (toddlers) were significantly
more likely to have a skeletal survey performed compared with their white
counterparts, even after controlling for insurance status, independent expert
determination of likelihood of abuse, and appropriateness of performing a
skeletal survey (adjusted odds ratio [OR], 8.75; 95% confidence interval [CI],
3.48-22.03; P<.001). This group of children was
also more likely to be reported to CPS compared with white toddlers, even
after controlling for insurance status and likelihood of abuse (adjusted OR,
4.32; 95% CI, 1.63-11.43; P = .003). By likelihood
of abuse, differential ordering of skeletal surveys and reporting of suspected
abuse were most pronounced for children at least 12 months old with accidental
injuries; however, differences were also noted among toddlers with indeterminate
injuries but not among infants or toddlers with abusive injuries. Minority
children at least 12 months old with accidental injuries were more than 3
times more likely than their white counterparts to be reported for suspected
abuse (for children with Medicaid or no insurance, relative risk [RR], 3.08;
95% CI, 1.37-4.80; for children with private insurance, RR, 3.74; 95% CI,
Conclusion While minority children had higher rates of abusive fractures in our
sample, they were also more likely to be evaluated and reported for suspected
abuse, even after controlling for the likelihood of abusive injury. This suggests
that racial differences do exist in the evaluation and reporting of pediatric
fractures for child abuse, particularly in toddlers with accidental injuries.
Child maltreatment is a significant problem within US society. Approximately
826 000 cases of child maltreatment were substantiated in the United
States in 1999, of which more than 175 000 (21.3%) were cases of physical
abuse.1 Rates of substantiated child maltreatment
were highest among black children and other racial and ethnic minorities.
While there were 10.6 cases of substantiated maltreatment for every 1000 white
children, the rates for black, Hispanic, and Indian/Alaskan Native children
were 25.2, 12.6, and 20.1 cases/1000 children, respectively.1
While minority children have higher rates of substantiated maltreatment
compared with white children, it is unclear whether minority children are
abused more frequently, are more likely to be reported for abuse, or whether
minority reports are more likely to be substantiated. It is possible that
biases on the part of mandated reporters may contribute to these differences.
Such biases may lead to abuse being overlooked in nonminority children and/or
overidentified in minority children. Several studies have indicated that black
and other minority children may be overrepresented in child maltreatment reporting
compared with white children. Hampton and Newberger2 compared
National Incidence and Prevalence Study of Child Abuse and Neglect-1 data
with actual child abuse hotline reports and found that hospitals were more
likely to report suspected abuse among black and Latino children, and to avoid
reporting among white children. Jenny et al3 reviewed
missed cases of abusive head trauma and found that inflicted injuries were
more often overlooked in white children compared with minority children.
The overrepresentation of minority children in the child welfare system,
and previous research documenting the existence of racial differences in the
evaluation and treatment of possible abuse, prompted us to investigate whether
reporting differences exist in our own community. We chose to examine differences
in the evaluation and reporting of long-bone and skull fractures because we
could find no previous examination of this topic in our review of the medical
literature. Our primary goal was to determine whether minority children are
more likely than white children to be reported to Child Protective Services
(CPS) for suspected abuse. Our second goal was to determine whether minority
children are more likely than white children to be medically evaluated for
abuse by having a skeletal survey performed.
All children younger than 3 years admitted to the Children's Hospital
of Philadelphia between 1994 and 2000 for treatment of an acute primary skull
or long-bone fracture were identified from a hospital database of discharge International Classification of Diseases, Ninth Revision codes.
Long-bone fractures included fractures of the humerus, radius, ulna, femur,
tibia, or fibula. Primary criteria for admission to the hospital included
concern about possible child abuse or a parent's ability to care for the child,
need for surgical intervention or cast-care teaching for children with femur
fractures, delay in time to casting due to significant swelling, young age
of the child, and other significant diagnoses or injuries warranting admission.
The initial cohort identified from this search consisted of 550 children.
Charts from 28 (5.1%) children were unavailable for review and were therefore
excluded. An additional 28 cases were excluded because the primary reason
for admission was not treatment of an acute primary skull or long-bone fracture
(2 patients admitted for same-day surgery and 26 patients in whom fractures
were noted incidentally). Patients were also excluded if the injury was the
result of perpetrator-admitted child abuse (n = 2), a vehicular or bicycle
crash (n = 38), birth trauma (n = 9), or if the diagnostic evaluation revealed
the presence of metabolic or other bone disease (n = 19). As there were only
12 Asian children in the cohort, these children were excluded to simplify
the data analysis. The remaining 414 children became the participants for
the study. Children were not excluded if they had other injuries in addition
to the skull or long-bone fractures.
Hospital charts of these 414 children were abstracted by a senior medical
student (R.M.). Demographic data were obtained, including the child's race/ethnicity
(white vs black or Hispanic), age (<12 months vs ≥12 months [≥12
months to 3 years defined as toddlers]), and insurance status (private vs
none or Medicaid). Demographic information was obtained from the child's admission
data sheet, as reported by the child's parent or caretaker. Also abstracted
was specific information about the injury, including reported mechanism, presence
of other injuries, history or identification of previous injury, and diagnostic
studies performed. The main outcome measures were the ordering of a skeletal
survey to detect occult fractures and the reporting of the case to CPS.
To simplify the data analysis, several covariates in the model were
condensed into a single measure referred to as likelihood of abuse. One author
(C.W.C.) reviewed a brief history of each case, including the age of the child,
reported mechanism, past medical history and history of previous injury, and
presence of other external injury. The author was blinded to the child's name,
insurance status, and racial/ethnic background. The author was also blinded
to child protection team involvement and, whenever possible, specific historical
details that might identify the child. As only 45% of cases were reviewed
by the child protection team during hospitalization, the majority of cases
had never been reviewed previously by the authors. Additionally, the 177 patients
in this study that were seen by the child protection team represent only a
fraction of the more than 1000 inpatient cases evaluated by the team during
the time frame of this study.
After reviewing each history, the author was asked if a skeletal survey
should be performed. If a skeletal survey was requested and had been obtained,
the result of the study was provided. Based on the history and study results,
the reviewer was then asked whether the case should be identified as likely
or definitely accidental (subsequently referred to as accidental), indeterminate,
or likely or definitely abusive (subsequently referred to as abusive). The
ordering of a skeletal survey was determined to be appropriate if the reviewer
had wanted it to be performed.
While specific algorithms do not exist to help distinguish accidental
from abusive fractures, several authors have identified factors that indicate
an increased risk for abusive injury.4-6 These
factors include: absence of reported injury, reports of very minor injury,
and long-bone fractures in children younger than 1 year. In our study, child
abuse was also determined by the presence of serious injury to other organ
systems or multiple fractures in the absence of metabolic bone disease, including
injuries in different stages of healing. Guidelines have been published for
the ordering of skeletal surveys; however, they leave much room for clinical
judgment. The American Academy of Pediatrics Section on Radiology has stated
that skeletal surveys should be mandatory in all children younger than 2 years
with suspected abuse. For children between 2 and 5 years of age, the decision
to order a skeletal survey should be "handled individually, based on the specific
clinical indicators of abuse."7 The American
Academy of Pediatrics recommendations and the above-cited child abuse literature
were incorporated into the clinical decisions to order a skeletal survey and
to identify an injury as abusive or accidental.
Because of possible subjectivity in determining the likelihood of child
abuse, a random sample of 100 patients was reviewed by an expert in child
abuse from outside our institution. We calculated interrater reliability (κ)
for these cases to strengthen the validity of the likelihood of abuse variable.
This study was reviewed and exempted by the Children's Hospital of Philadelphia
institutional review board.
Initial analysis included determining means for continuous variables
and frequencies for categorical variables. Because the likelihood of abuse
changes dramatically at 1 year of age, when most children become ambulatory,
age was coded as a dichotomous variable denoting children younger or older
than 12 months of age.4 Bivariate χ2 analysis was used to demonstrate crude associations between the 2
outcome measures (ordering of skeletal survey and CPS reporting) and covariates
that included race, age, insurance status, and likelihood of abuse. Logistic
regression was used to measure the independent association of race with ordering
of a skeletal survey, while controlling for likelihood of abuse, appropriateness
of ordering a skeletal survey, age, and insurance status. Logistic regression
analysis was also used to report the association between race and CPS reporting,
while controlling for age, likelihood of abuse, and insurance status. Models
were validated using the technique of Hosmer and Lemeshow.8 Because
this was a retrospective cohort study and the results of the logistic regressions
reported odds ratios (ORs), we used conditional standardization to estimate
relative risks (RRs) with 95% confidence intervals (CIs) of the outcome by
race for differing levels of the covariates.9 The
RRs were estimated from the logistic regression by fixing the covariates at
clinically meaningful levels and estimating CIs from the variance/covariance
matrix. All data were analyzed using STATA statistical software, version 6.0
(StataCorp, College Station, Tex). P<.05 was considered
After initial exclusions were made, a total of 414 children were available
for data analysis. Information about race was missing for 26 children (6.3%).
These children were compared with the total cohort, the white group, and the
minority group using bivariate χ2 analysis to determine which
group's baseline characteristics they most closely resembled. The results
of this analysis justified their exclusion from further analysis (Table 1).
After these final exclusions were made, 388 children remained. Slightly
more than half of the population was minority and 58% were male children.
The mean (SD) age of the total cohort was 13.0 (10.7) months. Although the
mean (SD) age of the minority children (11.8 [10.0] months) was slightly lower
than that of the white children (14.2 [11.2] months), the distribution of
age was nonparametric and the median ages were quite similar (8.5 vs 10.5
months, respectively; P = .14). Nearly half (48.5%)
of the children (n = 188) had skeletal surveys performed. However, more than
65% (n = 128) of minority children had skeletal surveys performed, while only
31% (n = 60) of white children had this test performed (P<.001). Fewer CPS reports were filed for white children compared
with minorities (43 [22.5%] vs 101 [52.9%]; P<.001).
Also listed in Table 1 are
the proportions of minority and white children with accidental, abusive, and
indeterminate injuries. Of the white children, 75.5% (n = 145) had accidental
injuries. More of the minority children experienced abuse (54 [27.6%] vs 24
[12.5%]; P<.001). Because of concerns regarding
subjectivity in this abuse assessment, interrater reliability was determined.
We calculated a conservative unweighted κ of 0.68 (82% agreement). This
constituted substantial agreement,8 thus validating
our own reviewer's independent assessment.
Table 2 provides unadjusted
RRs for obtaining a skeletal survey and reporting suspected child abuse by
race, insurance status, likelihood of abuse (accident, indeterminate, or abuse),
and age. Minority children were more likely to have skeletal surveys performed
(RR, 2.07; 95% CI, 1.64-2.60; P<.001) and to be
reported for suspected abuse (RR, 2.36; 95% CI, 1.76-3.17; P<.001) than were white children. Children with private insurance
were less likely to have skeletal surveys performed (RR, 0.58; 95% CI, 0.46-0.74; P<.001) and less likely to be reported for suspected
abuse (RR, 0.37; 95% CI, 0.27-0.50; P<.001) than
were children with Medicaid or no insurance. Age and abuse assessment were
also significant determinants of skeletal survey ordering and child abuse
The independent association of race with the ordering of a skeletal
survey, while controlling for likelihood of abuse, appropriateness of skeletal
survey, insurance status, and age, is examined in Table 3. A test for interaction indicated that this association
was modified by the age of the child, such that the association was more pronounced
in the older children (≥12 months). Minority children aged at least 12
months were significantly more likely to have a skeletal survey performed
than were white children in the same age group (adjusted OR, 8.75; 95% CI,
3.48-22.03; P<.001). Racial differences in ordering
of skeletal surveys for children younger than 12 months had only borderline
significance (adjusted OR, 2.01; 95% CI, 1.00-4.04; P =
.05). There was no difference in ordering of skeletal surveys by insurance
status (adjusted OR, 0.93; 95% CI, 0.51-1.69; P =
Point-estimated RRs of obtaining a skeletal survey were derived from
the ORs and are presented in Table 4,
stratified by likelihood of abuse, age, insurance status, and the appropriateness
of ordering a skeletal survey. Differences in skeletal survey ordering between
minority and nonminority children became more pronounced as age increased
and as the likelihood of abuse decreased. Minority children aged at least
12 months with accidental injuries were more than 5 times more likely to have
a skeletal survey obtained than were their white counterparts, particularly
when the skeletal survey was not indicated (with private insurance, RR, 5.53;
95% CI, 2.89-8.16; without private insurance, RR, 5.39; 95% CI, 2.41-8.36).
In contrast, minority children younger than 1 year with abusive injuries had
a nearly equal likelihood of a skeletal survey being performed as their white
counterparts. This racial difference in ordering skeletal surveys preferentially
in older minority children was also seen among those with indeterminate injuries.
The independent association of race with reporting of suspected child
abuse, while controlling for likelihood of abuse, age, and insurance status,
is examined in Table 5. Most significant
was that racial differences again were noted in the reporting of suspected
abuse to CPS. This association was modified by age, such that reporting differences
by race were noted only for children aged at least 12 months (adjusted OR,
4.32; 95% CI, 1.63-11.43; P = .003). This association
remained significant, even after adjustment for major confounding variables,
including likelihood of abuse (for indeterminate injuries, adjusted OR, 6.19;
95% CI, 3.16-12.13; P<.001; for abusive injuries,
adjusted OR, 42.30; 95% CI, 17.45-102.54; P<.001)
and insurance status (adjusted OR, 0.36; 95% CI, 0.18-0.71; P = .003).
Point-estimated RRs of reporting to CPS were derived from the ORs and
are presented in Table 6, stratified
by likelihood of abuse and insurance status. Similar to the ordering of skeletal
surveys, differences in reporting between minority and nonminority children
became more pronounced with increasing age and decreasing likelihood of abuse.
Minority children aged at least 12 months with accidental injuries were more
than 3 times more likely to be reported to child welfare (with private insurance,
RR, 3.74; 95% CI, 1.46-6.01; without private insurance, RR, 3.08; 95% CI,
1.37-4.80). In contrast, minority children younger than 1 year with abusive
injuries had a nearly equal likelihood of being reported to child welfare
as white children. Interestingly, in the indeterminate category of abuse,
minority children were reported to CPS at greater frequency than their white
counterparts, particularly in the older age group. The magnitude of this effect
was less dramatic than for the ordering of skeletal surveys.
Despite abusive injuries occurring more commonly among minority children,
our results showed that there was still a significant difference in the evaluation
of skull and long-bone fractures for abusive injury between minority and nonminority
children. These racial differences remained significant, even after adjustment
for the likelihood of abuse. We also controlled for insurance status and found
that, despite the protective effect that higher socioeconomic status affords,
the effect of race on ordering of skeletal surveys and reporting to CPS remains
significant. Interestingly, the large differences in ordering a skeletal survey
and reporting between the racial groups were most pronounced in toddlers with
accidental and indeterminate injuries. Minority toddlers with accidental injuries
were more likely to have skeletal surveys and be reported to CPS than were
their white counterparts.
These results are concerning, but not surprising, as a number of other
studies have identified differences in health care provision between minorities
and nonminorities. For example, several studies have documented that minorities
receive unequal care for cardiac conditions. Nonwhite patients presenting
to the emergency department with angina or acute myocardial infarction appear
to be hospitalized less often than white patients.10,11 Minority
patients are also less likely to receive cardiac procedures such as cardiac
catheterization, coronary angioplasty, and bypass surgery.12-17 Racial
differences have also been noted in the treatment of early-stage lung cancer
and in analgesic provision in the emergency department.18,19 Racial
differences have been documented in psychiatric care as well. Research has
shown that clinicians spend less time with and prescribe more medication for
blacks compared with whites,20,21 and
blacks are more frequently labeled as psychotic.22
Racial differences have also been documented in the field of child abuse.
Although all 3 National Incidence Studies of Child Abuse and Neglect have
shown no racial differences in maltreatment,23 black
and Hispanic children are more likely than white children to be involved in
the child welfare system.1,2 This
disparity may be due to racial differences in the reporting rates for minority
and white children as documented by Hampton and Newberger2 in
their analysis of reporting by hospitals and Jenny et al3 in
their review of patients with head trauma. Both underreporting of whites and
overreporting of minorities may contribute to these differences.24
We found it quite interesting that significant differences were identified
not only in skeletal survey ordering by race but also in reporting to child
welfare. However, the magnitude of this effect was small when compared with
the ordering of skeletal surveys. We suspect that when a fracture is thought
to be inflicted, physicians are aware of their legal mandate to report to
CPS and do so with less consideration of other factors, consciously or unconsciously,
such as race. However, physicians may still express biases by searching for
additional injuries and reporting more frequently in minority patients.
Minority children with fractures of indeterminate origin had more skeletal
surveys ordered than white children with injuries of indeterminate origin.
Furthermore, although these numbers were small, white children with fractures
of indeterminate origin were less likely to be reported to CPS. Perhaps skeletal
surveys were ordered more frequently for minority children to provide assurance
that additional injuries were not missed, while this assurance was not deemed
necessary among white children. Our expert reviewer requested that a skeletal
survey be performed on nearly all of these children; however, while 29 of
34 minority children in this category had a survey completed, only 9 of 23
white children received the test. For both infants and toddlers with indeterminate
injuries, the absolute proportion of white children who were reported was
less than 50%. It is quite possible that cases of abuse were overlooked in
white children because no study was performed, and that some of the overall
differences in child abuse reporting may have been the result of underdetection
of abuse among white children rather than overdetection among minorities.
This finding is not surprising, in light of previous data demonstrating that
white race can delay the diagnosis of child abuse.3
There were a number of limitations to this study. Abusive injuries were
more common among minority children in our study, a finding supported or suggested
by several authors24,25 but refuted
by others.23,26,27 Unfortunately,
we were unable to measure a number of potential factors, such as single and/or
teenage parenthood, depression, unemployment, stress, and lack of social support,
that may have contributed to racial differences in actual rates of abuse.
Differential reporting of abuse to CPS by race was seen among toddlers
with accidental and indeterminate injuries. Racial biases may have played
a role in this differential reporting. However, other factors that we were
unable to measure in this study may also have contributed. For example, we
were unable to account for the role that supervision played in the decision
to file a report of suspected abuse. It is possible that some toddlers with
accidental injuries were reported to CPS because they were unsupervised when
the injury occurred. Whether minority children were more likely to be playing
without adult attention and were reported for this reason remains unknown.
Furthermore, it is possible that lapses in supervision by minority families
were more often reported to CPS because of concerns about possible neglect.
In addition, we were unable to account for other factors such as parental
drug use that may have contributed to the decision to report.
Our study was also limited by other factors. First, we only reviewed
charts of patients hospitalized for their fractures. Therefore, the differences
in evaluation and reporting of suspected abuse applies only to this population
and cannot be generalized. However, we suspect that differences in evaluation
and reporting by race might be even more pronounced if we had included children
who were treated in the emergency department and released. In our experience,
children who are suspected victims of child abuse are more likely to be admitted
to the hospital. Therefore, if white children were less likely to be suspected,
it is possible that they were differentially discharged from the emergency
department compared with minority children. A comparison between evaluation
and reporting of admitted vs released patients by race warrants further study.
Patients included in this study were frequently referred from other
hospitals. Many of these children had CPS reports filed by outside physicians,
prior to their transfer to our hospital. We were unable to determine for all
patients whether the skeletal survey or CPS report had been generated at our
institution or at an outside facility. Therefore, we can make no conclusions
about whether our own staff was responsible for differential evaluation and
reporting, or whether this was more likely to occur at community hospitals.
In addition, we had no information on the race or other characteristics of
the physician ordering the skeletal survey or reporting suspected abuse. Therefore,
we were unable to control for these factors in our analysis.
In 1990, the Council on Ethical and Judicial Affairs of the American
Medical Association published a review of black-white disparities in health
care and made several recommendations.28 These
recommendations suggested greater awareness among physicians of existing and
potential disparities in treatment and continued development of practice parameters,
including criteria that would preclude or diminish racial disparities in health
care decisions. This article has sought to identify disparities in the evaluation
and reporting of fractures for possible abuse. Clearly, differences do exist
in the evaluation and reporting of pediatric fractures for suspected abuse,
particularly in toddlers with accidental injuries. Additional education regarding
racial differences in health care and identification of abusive injuries may
be warranted within our community.
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