Editor’s Note: Dr. Earl Chism (he/him/his) is a resident physician in pediatrics at the University of California, San Francisco. He is a member of the Pediatric Leaders Advancing Health Equity (PLUS) Program, and his interests include medical education and improving health outcomes by increasing representation in healthcare. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
When children are hurt, it’s our job to help them. In this role, we are sometimes confronted with the horrible scenario in which children are hurt intentionally. Non-accidental trauma (NAT), in addition to the physical and/or sexual damage it may cause, may also result in emotional, social, and legal harms for all parties involved. There must be systems in place to protect our children while also avoiding biased reporting, the likes of which can cause irreparable damage to families.
Dr. Arianne Baker of Dell Children’s Medical Center and colleagues in emergency medicine and pediatrics in Boston discuss this necessity in their article entitled “Reducing Disparities in Non-Accidental Trauma Evaluations in Emergency Departments,” being early released in Pediatrics this month (10.1542/peds.2024-067809).
The article opens with a discussion of some of the biases and disparities that exist in current NAT reporting. For example, Black children are disproportionately identified as suspected to have been abused, and these Black children are also more likely than their White peers to be referred to child protective services.
How do we help mitigate these disparities? The authors offer us several options:
- Support from Specialists: Both child abuse pediatricians (CAP) and child protection teams (CPT) can provide much-needed additional support in the cases of suspected NAT. The teams can help frontline providers determine next steps by using their expertise, which may limit the bias that exists when providers rely on “gut feeling.”
- Universal Screening Tools: The authors suggest using validated measures such as the TEN-4/TEN-4-FACESp and Escape clinical tools for universal screening in the emergency department. Universal screening would reduce bias and increase evaluations of children who would otherwise be missed.
- Standardized Clinical Pathways: Similar to universal screening, the use of standardized clinical pathways for evaluating suspected NAT would decrease the influence of bias and allow for more evidence-based decision-making.
- Health System Interventions: Electronic health record (EHR) additions, such as easy-to-use screening tools, embedded clinical decision tools based on diagnosis, and templated notes are all ways to help limit disparities at the hospital-system level. In addition to these interventions focused on the EHR, the article suggests system-wide trainings in NAT and trauma-informed care.
- Legislative Policy Change: At the state and national level, increased funding and access to CAPs and CPTs would expand the reach of their expertise and support, avoiding limitations due to distance or inadequate staffing. Legislation requiring universal screening could also increase the rates of detection of NAT while avoiding bias. Lastly, the authors suggest regulatory policy mandates such as CPT services at hospitals serving children and the use of validated tools for universal child abuse screening.
In all, the way our current system of evaluation and reporting NAT has been done is unacceptable. The use of any of these measures would help us move towards more equitable assessment of multiple factors, and move away from relying on heuristics and bias.
