If a doctor notices bruising on your child, you might be surprised to find yourself accused of abuse. The real-life drama that ensues from such encounters is playing out in doctors’ offices and emergency rooms across the country. Here are some of the things we’ve heard from our patients:
Even more than the words, the emotions speak volumes. The intimate warmth of the doctor-patient relationship immediately dissolves into a frigid animus more typical of a legal proceeding. The analogy is apt, because each party almost certainly understands the potential consequences of involving child protective services and the justice system.
Just as the word “surprised” does not capture the outrage a parent feels at being accused of violating their most sacred trust, the word “accused” does not accurately reflect the new “think less, screen more” approach being advocated by physicians. “Think less, screen more” refers to a protocol of X-rays initiated by specific patterns of bruising, rather than a doctor’s impression of a parent’s propensity for abuse. The new threshold for screening is necessary, because doctors routinely miss cases of abuse.
In 1962, the journal JAMA published the landmark article “The Battered-Child Syndrome,” which first drew the attention of the medical community to the epidemic of child abuse. Yet, in 1999, a study found that one-third of adolescent cases of abusive head trauma were still being missed. Twenty years later, little has changed, as study after study confirm that doctors continue to miss cases of child abuse.
One reason for the lack of change is bias.
Doctors have a hard time imagining abuse in affluent, white families. Conversely, they suspect abuse more frequently in poor families and in African-American and Hispanic families. Data show that doctors are about twice as likely to fail to detect abusive head trauma in white children as they are in minority children. And a remarkable 30-year study suggests that doctors may perpetuate this detection bias across multiple generations of a given family.
With “think less, screen more,” screening is based on the child’s examination, rather than their parents’ race, ethnicity, or status. Objective, high-risk criteria—such as bruising of the torso, ears or neck—prompt doctors to perform the testing that can identify abuse.
An uncomfortable byproduct of the new paradigm is that some non-abused children will be screened, and some non-abusive parents will be offended. Challenging as these encounters may be, children must be protected and biases must be rectified. The only way to achieve these goals is by implementing policies based on objective criteria.
When a societal need is at stake, societal attitudes can change. We accept child car seats as an essential safety measure. We accept vaccinating our children to protect them against rare, but serious, diseases. Ensuring that such programs are applied to everyone guards against the potential for bias.
More than half a century after the publication of the Battered-Child Syndrome, it is time to accept the societal need for broader screening for child abuse.
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