Systemic Racism in Child Abuse Reporting by Clinicians
Black children, American Indian/Alaskan Native children, Native Hawaiian/Pacific Islander children, multiracial children and Hispanic children (here after referred to as people, children or families of color*) are overrepresented in child abuse and neglect cases [1]. The argument that people of color are inferior parents and have problem-children who misbehave more than white kids is and old, tired, and simply inaccurate explanation, not to mention blatantly racist. Child abuse and neglect are just as common in while families as families of color. White families are simply not reported as often. So why are more children of color getting separated from their families and subjected to the broken child welfare system?
A racial realist would explain this as unsurprising, ordinary and everyday racism. Racism is not just unfavorable attitudes towards non-white people; it is a system of allocating privileges and status. To see how this system and its effects become common, it is worth looking at American history from the viewpoint of people of color. In doing this we can practice revisionist history. The majority perspective claims that child abuse was named and recognized as a societal problem only in 1962 with the Henry Kempe paper “The Battered Child Syndrome” which described the clinical findings of injuries that are most likely to be due to abuse rather than accidental. [2] Certainly, others recognized it, described it and fought for child’s rights prior to this. [3] A brief look into history in America and it is clear that child abuse and child separation from families starts in America’s infancy. Children were separated from families and abused as slaves with the trans-Atlantic slave trade and throughout slave trading amongst Americans until abolition. Once slavery was abolished, harm and family separation continued to be systematically enacted on children of color. Native American children were separated and abused in boarding schools in the campaigns to “save the man, kill the Indian”. Children are still being taken from parents at the border and within the states with immigration as the excuse. Today, children of color are still being disproportionately displaced from their families with parental incarceration because people — parents — of color are disproportionately incarcerated. The foster care system now ends up participating in modern day child snatching though child protective services with tip-offs from government mandated reporters, which includes clinicians. All of these systems of family separation and child abuse, traumatization, and cultural violence were government supported and considered by most (white people) to be “in the best interests of the child”. It is important to note that family separation and removal of the child from home is devastating in ways to children of color that white children most likely do not experience. Most foster families are financially stable, background checks and government approved and the results is that they are mostly white families. Thus, when children of color are removed and placed in white foster homes, they lose a vital link to their culture and will be cared for and guided by adults who have not experienced the racism the children of color have experienced and will experience. Telling the story in this way challenges the people who think the child welfare system is a pure and simple good thing.
All of these systems — chattel slavery, Native American boarding schools, mass incarceration and child protective services — together demonstrate that racism continues to thrive in institutional ways with little conscious or explicit plan to hurt people of color, yet all of them did and many continue to. The rest of this piece will focus on the role of clinicians in reporting to Child Protection Services (CPS) and the colorblind approach to evaluating the reasons a clinician decides to report or not.
The first thing a clinician must consider with reporting is that it is mandatory. There are penalties for not reporting suspected or probable abuse or neglect in every state yet the details change by state. [4] Certainly, this hard rule has the benefits of missing less cases of child abuse or neglect, leaves the responsibilities of investigating and determining about abuse up to experts in child abuse evaluation so the clinician can concentrate on being a clinician, and enforces a culture ensuring safety of children from immediate harm. These can all be viewed as positives of the child welfare system. However, the mandate also complicates the issue. It can impair or destroy the carefully build therapeutic relationship between doctor and patient or doctor and patient’s parents. A doctor who is transparent about reporting to parents can lead a parent to flee with the child out of fear of being reported, potentially causing more harm to the child.
Another complication of mandated reporting is that it is a colorblind approach. In general, if you suspect abuse or neglect, you must report. It is not, if you suspect abuse or neglect, but understand the historical context and weight the harms and benefits of reporting, you could consider reporting. This is significant because, simply the act of being investigated for abuse or neglect is extremely traumatizing for most families. Even if the children are too young to know why a stranger is visiting their home or asking them questions, the stress on the parents can certainly affect the child-parent relationship and even affect a parent’s ability to do good parenting. [5] When we subject all families to the stress of a CPS investigation “equally” families of color who are systematically excluded from certain forms of social and financial capital may be more strongly impacted by the stress of such an accusation. If this affects a parent’s ability to stay calm when a child misbehaves, to take care of themselves by perhaps going to an AA meeting, or causes a parent to miss work or important time to meet their child’s needs, this can be used as another reason to separate the child from the family when support and equity for this family is what is truly needed.
It should not be underestimated that calling CPS is a difficult decision. Yes, you could be getting a kid out of a really dangerous situation but you could also be causing significant stress on the family. Usually, it is not clearly one or the other and clinicians often find themselves weighing these harms on top of knowing that they may be penalized for not following the mandate. As an aside, as you will see below, the mandate does not come up as an explicit reason for reporting child abuse or neglect.
Further, clinicians often are not involved in the resolution of the case, planning for keeping family united (ex. by improving parenting, meeting child’s needs and ensuring safety for the child) and they do not get to know the outcome as sometimes the parents choose to find another doctor, the child is placed with a foster family or relatives outside the area or the child dies. Imagine how you would feel not knowing if you made the right choice.
Some folks studying overrepresentation of black kids in the child protection cases have concluded that blacks are not overrepresented in child abuse cases reported once you control for poverty. [6] This is saying that race is not a risk factor for being reported to CPS, being poor is. But who is historically excluded from economic opportunity and financial security from the start of this country? People of color and specifically, Black folks. Thus while race may not be a risk factor, racism is. Yet, racism is rarely studied. The best we have are qualitative studies the ones below that can sometimes identify racism in the way the studies are designed, conducted or interpreted which I will do below.
The following table shows two major studies researching the factors identified as increasing or decreasing a provider’s likelihood of reporting.
However, this research into clinician reporting begs a critical lens. While the Flaherty study found more proportional reporting rates based on race when children had state sponsored insurance (presumably lower socioeconomic status [SES]), they found that black children were at an increased rate of being reported if they had private insurance (presumably higher SES). [7] This observation further shows bias in reporting that is not controlled by poverty like in the Drake paper. In fact, it shows that increased family wealth paradoxically increases the rate of reporting of black families to CPS. Thus, even in families who have managed to afford private insurance and presumably are able to support themselves in spite of centuries of systemic oppression, mandated reporters participating in child protection services still manage to target them.
In the Jones study [8], they interviewed providers via phone for reasons the clinicians did or did not report. The responses collected were the recollected and reasoned out opinions of providers. Providers are not likely to admit that their bias is what prompted them to report a family of color but not a white family. Thus, the reasons collected in this study are inherently biased to paint each provider in a self-serving positive light. We do not know the race of the children and families reported by the providers but 89% of the providers studied were white. Nearly all of the stated and coded reasons described by these white providers for reporting a case to CPS are subjective and have the potential for conscious (and obscured, retrospectively) or unconscious racial bias.
Structural determinism says that systemic and institutional racism will continue on as it currently does unless we disrupt the systems that create it. The hard and fast rules of who gets reported which starts the process of investigation, child removal from home and family dissolution have room for nuance, reframing, and even room for more accurate identification. Clinicians can question and challenge the mandatory reporter rule and demand to stay involved in the outcome of their patient’s investigation. Racial equity and steps towards reparations for the historical harm done by the child welfare system can be incorporated into families subjected to CPS investigation. Communities can develop networks of self-surveillance and community-child nurturing so mandatory reporters and CPS are not needed. Dismantling systems of financial oppression and access to a living wage would be one start to undoing the disproportionality of children of color involved in CPS cases. Ultimately, the racism that is embedded in the child welfare system in the United States will not eliminated without undoing of racism in other interacting systems. We must start with challenging the systems. We must continue with action.
Note: Many Asian subgroups were not included in title children, families or people “of color” and were not addressed in this piece. While the groups of color referred to in this piece are overrepresented in child welfare reports, [1] has found that those sorted into a category of Asian were underreported. This finding is worth critical analysis in of itself.
[1] Maguire-Jack K, Font SA, Dillard R. Child protective services decision-making: The role of children’s race and county factors. American Journal of Orthopsychiatry. May 2019. doi:10.1037/ort0000388 .
[2] Kempe, C., Silverman, F., Steele, B., Droegemueller, W., & Silver, H. (n.d.). The battered-child syndrome. JAMA : The Journal of the American Medical Association., 181, 17–24.
[3] Nancy Krieger, PhD. Does Racism Harm Health? Did Child Abuse Exist Before 1962? On Explicit Questions, Critical Science, and Current Controversies: An Ecosocial Perspective. Am J Public Health. 2003;93:194–199. Online access: https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.98.Supplement_1.S20
[4] Jeffrey L. Brown. Physicians have ethical, legal obligation to report child abuse. AAP News Mar 2012, 33 (3) 20; DOI: 10.1542/aapnews.2012333–20 Online access: https://www.aappublications.org/content/33/3/20.1
[5] Code D. Kids Pick up on Everything: Parental Stress Is Toxic to Kids. Place of publication not identified: Createspace; 2011.
[6] Drake B, Lee SM, Jonson-Reid M. Race and child maltreatment reporting: Are Blacks overrepresented?. Child Youth Serv Rev. 2009;31(3):309–316. doi:10.1016/j.childyouth.2008.08.004
[7] Flaherty EG, Sege RD, Griffith J, et al. From suspicion to report: primary care clinician decision-making. Pediatrics. 2008;122 (3). Online access: https://pediatrics.aappublications.org/content/122/3/611#ref-23
[8] Jones R, Flaherty EG, Slora E, et al. Clinicians’ description of factors influencing their reporting of suspected child abuse: report of the Child Abuse Reporting Experience Study Research Group. Pediatrics.2008;122 (2):259– 266. online access: https://pediatrics.aappublications.org/content/122/2/259.long
