How Should Clinicians Minimize Bias When Responding to Suspicions About Child Abuse?


Clinicians have ethical and legal obligations to report suspected maltreatment of children. A decision to report suspected abuse is one of great ethical, clinical, and legal importance and can weigh heavily on clinicians who have established relationships with a family. Mandated reporting is done inequitably, however, with overreporting of families with low socioeconomic status and minoritized families and underreporting of families with high socioeconomic status and White families. This article canvasses evidence-based approaches to evaluating and reporting suspicion of child maltreatment in ways that minimize bias and promote equity.


A 9-month-old boy is brought to an Emergency Department (ED) by his mother. The baby’s mother reports that she slipped in an icy parking lot while lifting the baby from the car seat. She reports that, as she fell to the ground, the baby slipped out of her hands, hitting his head on the icy concrete. Physical examination of the baby reveals right-sided scalp swelling and multiple bruises on the torso and extremities. When asked about the bruises, the mother panicked, stating, “I didn’t think to check under my baby’s clothes. It was too cold. I just drove right here.” The ED physician and nurse caring for the baby are distressed by the severity of the baby’s injuries. The physician reviews the baby’s electronic health record (EHR). Notes from an ED visit 6 months ago include photographic and narrative documentation of 2 bruises on the then-3-month-old baby’s right arm. The physician and nurse confer quietly about what they observed, what they know, and how to respond.


The federal Child Abuse Prevention and Treatment Act (CAPTA) of 1974 and Victims of Child Abuse Act Reauthorization Act of 2018 seek to protect children from abuse and neglect. This federal legislation provides funding to support the prevention, assessment, investigation, prosecution, and treatment of child abuse and neglect and establishes a federal definition of child abuse and neglect. CAPTA also requires states to implement reporting procedures. Forty-four states, the District of Columbia, and US territories have designated professionals and other persons, including clinicians, to report suspected child abuse and neglect to community agencies in accordance with federal law. Standards for reporting vary by state, but a mandated reporter who suspects, has knowledge, or believes that a child has been abused or neglected is required to report. A reporter does not need to be certain or to prove that abuse or neglect occurred. This threshold for reporting is intended to identify children who are being abused, minimize harm, and prevent further abuse. Thus, individual mandated reporters may act without evidence-based protocols based on their own interpretation of CAPTA criteria, often relying on their intuition and “gut” feelings.


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