Social Intuition and Social Information in Physical Child Abuse Evaluation and Diagnosis.

Abstract

Poor and minority children with injuries concerning for abuse are evaluated and diagnosed for abuse differentially. We hypothesized that 2 steps in the decision-making process would influence evaluation and diagnosis: social intuition from meeting the family and objective social information associated with child abuse risk. Between 2009 and 2013, 32 child abuse pediatricians (CAPs) submitted 730 child abuse consultations including original medical evaluations and diagnoses. CAPs evaluated and diagnosed each other's cases. Comparisons of evaluations and diagnoses were made by levels of social understanding available to the CAP: meeting the family (social intuition and information), reading the case (social information), and reading the case without social information. Evaluations were compared with a consensus gold standard by using logistic regression modeling adjusting for child and CAP characteristics. Diagnostic categories were compared by level of social understanding and diagnostic certainty by using contingency tables. CAPs without access to social intuition were approximately twice as likely to perform gold standard evaluations for neurotrauma and long bone fracture compared with CAPs who met families. Diagnostic agreement fell from 73.3% (95% confidence interval [CI]: 70.1%-76.5%) when social information was present to 66.5% (95% CI: 63.1%-70.0%) when social information was restricted. In cases with less certainty, agreement dropped to 51.3% (95% CI: 46.0%-56.7%). Social intuition and information play a role in the physical child abuse decision-making process, which may contribute to differential diagnosis. Simple interventions including decision tools, check lists, and peer review may structure evaluations to ensure children's equal treatment.