How Should Clinicians and Health Care Organizations Promote Equity in Child Abuse and Neglect Suspicion, Evaluation, and Reporting?

Victims of child abuse and neglect come from every racial, ethnic, and socioeconomic background, yet clinical evaluation, reporting to child protective services, and responses to reports inequitably harm Black children and malign families of color. Racial bias and inequity in suspicion, reporting, and substantiation of abuse and neglect and in services offered and delivered, foster care placement, and criminal prosecution are widely documented. In response, clinicians and health care organizations should promote equity by educating clinicians about racial bias, standardizing evaluation using clinical decision support tools, and working with policy makers to support prevention services. If we decide that it is ethically justifiable for clinicians to err on the side of overreporting, we must ensure fair distribution of associated benefits and harms among all children and families.


The term vulnerable is often used to refer to a population at risk of being harmed and worthy of society’s protection. Children are inherently vulnerable due to their dependency on others to survive and flourish. This dependency puts them at risk of maltreatment, which includes neglect, abuse, and exploitation. States’ mandated reporter laws, which require clinicians to report suspected abuse and neglect to child protective services (CPS), were created as a way to protect children from such harm. Kim et al estimate that over one-third (37%) of all US children experience a CPS investigation by 18 years of age; the rates are higher for African American children (53%) and lower for Asians/Pacific Islanders (10%). While the benefit of protecting a child from abuse and neglect is clear, the harms of over- vs underreporting must also be considered, particularly when certain harms are experienced disproportionately among children from certain racial and ethnic groups.

Unwarranted reports—one consequence of overreporting—not only threaten the therapeutic relationship between the patient or family and clinician but also can result in significant emotional and financial hardships for children and families, including traumatic separation, stigmatization due to CPS involvement, missed workdays, and legal costs associated with the investigation. Such reports also increase the workload of already overburdened child welfare workers, creating a barrier to identifying and addressing true cases of abuse and neglect or arranging support services for families. Even if a report is unwarranted, children are at risk of both removal from their families and longer-term harms of foster care due to the bias that exists at every step of the child welfare decision-making process. Racial and ethnic differences have been identified in acceptance rates of reports for investigative response, substantiation of maltreatment, referral to services, and out-of-home placement. If we decide that these known harms of overreporting are ethically justifiable due to the benefit of protecting children from further maltreatment, we must ensure that the benefits and harms are fairly distributed among all children and families.


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