Public Release: 

Minority children more likely to be evaluated for physical abuse

Abuse in white children may be overlooked in assessing injured toddlers

Children's Hospital of Philadelphia

Philadelphia, Pa. - Minority children are more likely to be evaluated for physical abuse and reported to authorities than white children with comparable injuries, say researchers who studied hospital records at an urban pediatric hospital. Researchers at The Children's Hospital of Philadelphia found that African-American and Latino toddlers with accidental injuries were over five times more likely than Caucasian toddlers to receive a skeletal survey, an examination ordered when a physician suspects abuse.

Researchers, who studied hospital records for 388 children younger than age 3 who were hospitalized for fractures at Children's Hospital between 1994 and 2000, report their findings in the October 2 issue of the Journal of the American Medical Association. Of the records studied, many of the children had been referred from other hospitals, and it was not always clear whether the referring hospital or Children's Hospital performed the survey or filed the report.

"Although rates of substantiated physical abuse have been reported to be higher in minority children than in Caucasian children, it is unclear whether abuse actually occurs more frequently or whether it is more likely to be reported in minority children," said senior author Cindy W. Christian, M.D., a child abuse expert and co-director of Safe Place: The Center for Child Protection and Health at The Children's Hospital of Philadelphia.

"Previous reports have suggested that minority children are over-represented in child abuse reporting, and Caucasian children are under-represented," she added. "Our study lends support to those findings." The study was the first to examine racial differences in evaluating and reporting fractures of the arms, legs or skull in children. The researchers did not include children with fractures from car crashes or with injuries in which the responsible party admitted committing abuse.

Dr. Christian's team found that under further analysis, abusive injuries in their sample were more common among minority children than among Caucasian children by rates of 27.5 percent to 12.5 percent, respectively. However, when the researchers adjusted for the likelihood of abuse, minority children aged one to three years (toddlers) were significantly more likely to receive a skeletal survey and to be reported to child welfare authorities. The researchers measured likelihood of abuse by having an expert reviewer analyze medical records without knowing the child's name, race, or other identifying details. The reviewer rated each child's injury as accidental, abusive, or indeterminate.

The discrepancies between the two racial groups were most pronounced in toddlers with accidental and indeterminate injuries. Compared to their Caucasian counterparts, toddlers with accidental injuries were over five times more likely to be evaluated for child abuse, and over three times more likely to be reported to child protective services if they were African American or Latino. Below one year of age, racial disparities were not significant.

The authors had no information on the race or other characteristics of the physicians who ordered the skeletal surveys or reported the suspected abuse. In addition, children in the study were frequently referred from community hospitals, but it was not always evident whether the survey or abuse report originated at the referring hospital or at Children's Hospital. Therefore, the authors could not analyze differences among hospitals in evaluating and reporting suspected abuse.

"In addition to suggesting that abuse is over-detected in minority children, this study suggests that cases of abuse may be missed in some Caucasian children," said Dr. Christian. "Recognizing that racial disparities exist is the first step toward health care providers correcting those discrepancies. This study is a reminder for health care providers to be as thorough and objective as possible in evaluating children with injuries, to ensure that victims are not overlooked. "


Dr. Christian's co-authors on the paper were Wendy G. Lane, M.D., M.P.H.; David M. Rubin, M.D.; and Ragin Monteith, M.D. Drs. Lane and Rubin worked as fellows under Dr. Christian when the research was performed at The Children's Hospital of Philadelphia, while Dr. Monteith was a medical student at the University of Pennsylvania School of Medicine. Dr. Rubin remains at Children's Hospital, Dr. Lane is now at the University of Maryland School of Medicine and Dr. Monteith is now at Children's National Medical Center in Washington, D.C.

The Children's Hospital of Philadelphia identifies and treats more victims of abuse and neglect than any medical institution in Pennsylvania. Safe Place: The Center for Child Protection and Health at Children's Hospital, is one of the nation's most comprehensive centers dedicated to addressing the healthcare needs of neglected and abused children, and children in foster care. Staffed by an interdisciplinary team of physicians, social workers and psychologists, the Center is a major resource for clinical services, research, education and advocacy. Last year, Children's Hospital created an endowed chair in the Prevention of Child Abuse and Neglect, which is held by Dr. Christian.

Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is ranked today as the best pediatric hospital in the nation by a comprehensive Child magazine survey. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 381-bed hospital recognition as a leading advocate for children and adolescents from before birth through age 19. For more information, visit

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