Perceived social risk in medical decision-making for physical child abuse: a mixed-methods study

Medical decision-making in cases of suspected child abuse has important consequences. An incorrect diagnosis may return an abused child to the abusive home; conversely, it may subject non-abusive families to legal remedies and stigma. Prior studies have shown that physicians are more comfortable reporting poor children for abuse [1]; African American children are more likely than Caucasian children to undergo an abuse evaluation for fractures [2]; Caucasian children are less likely to be evaluated for abusive head trauma than minority children [3]; and decisions about discharging children home from the emergency department with a diagnosis of abuse depends upon socioeconomic status [4]. These studies documented differential decision-making in the evaluation and disposition of children with suspected physical abuse.

Differences in medical decision-making may reflect differences in risk indicators for abuse among poor and minority children not captured in administrative datasets. They may also reflect differences in treating physicians’ perceptions of the risk for abuse among poor and minority children. Social risk perception, defined here as the perceived risk for child abuse based on social aspects of the child’s medical evaluation rather than physical, laboratory, or radiologic aspects of the evaluation, may play a role in how children are evaluated. Medical assessments of child physical abuse risk may be particularly vulnerable to physicians’ perceptions of abuse risk as child abuse pediatricians (CAPs) incorporate the child’s entire social ecology into their evaluation [5]. Prior studies have not identified information important to decision making beyond socioeconomic status (SES) and race that may influence physicians’ perceptions of the child’s social risk for abuse.

The goals of this study were twofold: to define factors that CAPs incorporate into their social risk perception of physical child abuse when evaluating an injured child and to understand whether self-rated social risk perception influences the diagnosis of abuse. We hypothesized that CAPs would incorporate family characteristics other than published risk indicators into their perceptions of social risk and that risk perception would be associated with diagnostic decision-making.

This study found that the CAP perception of the child’s SES is strongly and independently linked to physician perception of risk for abuse after adjustment for physician, child and family characteristics. While the relationship of SES to differential child abuse evaluation has been described previously in non-CAP physicians [1, 4], this study shows that SES plays a role in CAP perceptions of abuse risk. The experimental model in this study that reversed social risks, demonstrates that CAP social risk perception is associated with diagnostic decision-making.

CAP risk perception for abuse encompasses child, family, parental and social risk indicators; social cues reflecting CAP impressions of the caregivers and their actions; and, non-social cues such as attendance at well child visits. After taking these factors into account, CAP perceptions of risk remained independently associated with the child’s perceived SES. While child abuse may be more prevalent in poor communities, population-based studies show that the attributable risk of poverty to abuse is low, [8] that is, most poor families do not abuse their children. Laskey’s study found that general pediatricians are more willing to consider an abuse diagnosis among poor children [1]. Our findings add to Laskey’s work by using clinical cases rather than scenarios, adjusting for multiple aspects of the social history, and quantifying physicians’ perceptions of SES. Prior studies have stratified patient SES based on public/private insurance status which provides little differentiation in this largely publicly insured population. Asking physicians to quantify their perception of SES allowed us to both stratify a race/SES association and to link their perception of SES to social risk.

CAP risk perception is important because it may unconsciously influence diagnostic decision-making. We changed CAP risk perception by reversing social elements of the cases while leaving the injury and medical history and findings intact. Reversal of social risk was associated with a change in CAP diagnosis in 40% of cases. This is not an insignificant change in diagnosis. In fact, the change in diagnostic decision from reversing social risk is a more significant change in diagnostic decisions than has been documented with follow-up skeletal surveys, a strongly recommended diagnostic test in the evaluation of child physical abuse [15, 16].

Our theoretical model proposes that risk perception may act through CAP diagnostic certainty. Certainty or confidence in diagnosis has been linked to common cognitive errors, such as biased evidence gathering, or failing to incorporate discrepant information that does not support a diagnosis (anchoring) [17]. High social risk in abuse cases is consistent with CAP expectations leading to certainty, but not necessarily leading to diagnostic accuracy [18]. The relationship of risk perception to certainty is a potential explanation for under-diagnosis of abuse in higher SES families (where risk perception is low leading to low certainty in the diagnosis of probably abuse) as documented by Jenny, and increased comfort for reporting abuse in low-income families (where risk perception is high leading to higher certainty for diagnosis of probable abuse) shown by Laskey. As minority families are disproportionately low income in the United States, this would lead to a differential evaluation of minority children evaluated for abuse as has been noted in the literature [19]. Our data support another potential role for risk perception. Risk perception may influence CAP concern about the consequences of misdiagnosis for children and families. Implicitly or explicitly, CAPs may weight concerns of a missed diagnosis of abuse more heavily than an incorrect diagnosis of abuse in cases with high risk perception and weight the incorrect diagnosis of abuse more heavily in cases with low risk perception.

If diagnostic decision-making is influenced by risk perception, it may be possible to correct this step of the diagnostic process. Some authors suggest that switching from an intuitive to analytic thinking process through the use of reflection or decision support tools, such as checklists may ‘de-bias’ decisions [20]. A small single center study that introduced specific guidelines to guide the medical evaluation of suspected abuse among head injured children reduced racial disparity in these evaluations [21]. This suggests that explicit protocols for clinical decision-making may reduce differential decision-making.

There are important limitations to this research. We made the assumption that physicians documented the major social risks that they felt were important to formulate perceived risk. If our assumption was incorrect, it is possible that the race/SES association is incorrect. Our assumption was supported by the change in perceived risk with the numbers and types of risk indicators and cues identified in the qualitative analysis. Additionally, prior studies reporting physicians’ results on implicit association tests have found that Caucasian physicians, like the general population, show an implicit preference for Caucasians, and African American physicians, as a group, do not show a preference [22]. This is consistent with our results. We did not perform inter- or intra-rater reliability of our scales; however, we did perform construct validity testing. We studied CAPs who were interested in participating in this project not a random sample. Participating CAPs may differ from the pool of all CAPs. There is likely an underlying rate of diagnostic disagreement between CAPs even when given the same information that is not taken into account in our analysis. To examine this, we performed a separate analysis that found that the CAP who saw the child and submitted the case disagreed with the CAPs who reviewed the case notes as written in 11% of the probable abuse cases with less than 2% changing from probable abuse to not abuse; 23% of the probable not abuse case changed, with a 2.6% change to probable abuse. This adds strength to our argument that the 40% change in diagnosis is linked to the change in risk perception. Finally, the number of minority physician participants in this study was low; thus, analyses of physician race should be interpreted cautiously. Strengths of this study include the national sample of CAPs, our ability to measure CAPs perceptions of risk and SES, to consider more nuanced social information than is found in administrative datasets, and to link a potential mechanism to the disparities in diagnosis.

CAPs have different perceptions of child abuse risk based on the child’s social ecology. Poor children are perceived to be at the highest risk for abuse independent of other social factors. Perceptions of social risk appear to shape diagnostic decision-making by influencing physician certainty related to a diagnosis of abuse. Our findings help to explain the differential decision- making for poor and minority children reported in the literature. Future research is warranted on the use of explicit decision-making tools to reduce this noted disparity.