Year of Publication
OBJECTIVES: Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (pre-consultation referral).
METHODS: Children <5 years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with pre-consultation referral adjusting for CAP's final assessment of abuse likelihood.
RESULTS: Among the 61% (1005/1657) of cases with pre-consultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Pre-consultation referrals ranged from 25% to 77% of cases across 10 hospitals (P<0.001). In multivariable analyses, pre-consultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P<0.05). The difference in pre-consultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P=0.023 for interaction of insurance and abuse likelihood category). There were no differences in pre-consultation referral based on race or ethnicity.
CONCLUSIONS: Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.