Politics Masquerading as Medicine

    For a child who is suffering from abuse or neglect, a visit to a pediatrician can be a lifeline. Doctors may notice bruises or burns or fractures. They may hear a child describe severe corporal punishment or denial of food. They might observe concerning behavior on the part of the accompanying parent—signs of drug abuse or serious mental illness. Doctors are mandated reporters and if they reasonably suspect that a child is suffering from maltreatment, they are required to tell child protective services (CPS). 

    In a bizarre twist, though, two recent medical-journal articles advise doctors to refrain from reporting so many kids. They should instead “narrow the front door” of the child-welfare system in order to reduce racial disparities. Such ideologically driven warnings are not only based on faulty evidence but they also risk leaving vulnerable children in great danger. 

    The first article, which appeared in the medical journal Lancet, begins by extensively citing Dorothy Roberts—a law professor at the University of Pennsylvania who argues for abolishing the child-welfare system and replacing it with community support and cash transfers to poor people. It is odd to find that a medical-journal piece relies for its evidence on someone who has no background in medicine, let alone science. But the authors, Jocelyn Brown and Sayantani DasGupta—both of whom are doctors “of color” affiliated with Columbia University—argue that physicians’ and other “health-care colleagues” “dismiss an abuse diagnosis easily within middle class white families while over-evaluating and subsequently reporting Black and Brown children for, say, accidental falls from bed.” Well, now. In case that was too subtle, dear reader, these two physicians are calling their colleagues…racists. 

    Brown and DasGupta note that the “role of practitioner bias is a formidable one,” resulting in “disproportionalities and disparities in the field of child welfare based on race, ethnicities and other identities.” Nowhere do they note, though, the main reason for these disparities, which is that there are significant disparities in rates of maltreatment by race and ethnicity. Black children, for instance, suffer fatalities from abuse and neglect at three times the rate of white children. So, it would hardly be surprising to find that physicians are reporting black families to CPS at higher rates. Indeed, one could conclude it would be malpractice if they did not. In 2019, black children experienced known risk factors for maltreatment (poverty, single parent households, teen parents, poor education) at between two and three times the rates white children did.         

    They experienced a range of negative outcomes, such as very low birth weight, pre-term birth, infant mortality, and child maltreatment fatality, at rates that were generally two to three times that of white children. Despite this, black children are reported to CPS at less than twice the rate that white children are—about 1.8 times as often. Seen in this context, it is possible that black children are not over-reported to CPS at all, but may actually be under-reported. 

    The authors of the Lancet article also cite what they claim is the racist history of the child-protection system. But their research apparently doesn’t extend beyond Dorothy Roberts, who is an advocate more than a scholar. Brown and DasGupta begin with the 19th century, and suggest that it was only poverty that led to the removal of children from their families and that the “orphan trains” were a prime example of the “structural” flaws in the system. In fact, as John Myers has shown in his definitive History of Child Protection, these efforts began during colonial times; they were ramped up during the 19th century as more evidence of child abuse emerged. And the orphan trains, as anyone who has looked at pictures can easily see, were full of white children. 

    Nevertheless, DasGupta and Brown want doctors to consider the abolition of the child-welfare system. The authors acknowledge abolition “might feel frightening in this context to a pediatrician: how do we protect children if we do not have a system that identifies children who have been abused?” But they then quote the words of an “abolition activist” who notes, “Abolition is a vision of a restructured society where communities are safe and people have what they need: food, shelter, health care, education, art.” That’s not abolition. In the words of the great Long Island piano-playing philosopher, Mr. William Joel; That’s just a fantasy. 

    We will always have children who are going to be mistreated and who will need help—even if they have access to the “art” and “affordable fresh food produce” that the authors also dream of. The question is, what are we going to do for them? In an article for JAMA Pediatrics, Mical Raz of the University of Rochester Medical School, Josh Gupta Kagan of Columbia Law School, and Andrea Asnes of the Yale School of Medicine likewise advise clinicians to report fewer children to CPS because of racial disparities. 

    These authors also put forward some dangerous misconceptions about child maltreatment reports. First, they note that only a small percentage of reports are “substantiated,” suggesting that these cases aren’t real instances of maltreatment. Surprisingly, a large literature shows that substantiated and unsubstantiated children tend to be at similar risk of later maltreatment or other negative outcomes. Cases can only be substantiated when there is both serious harm and also clear evidence that the harm was inflicted by a caregiver, and many unsubstantiated cases include very serious concerns. 

    Nationally, in 2022, about two-thirds of children receiving post-response services to support their safety were “unsubstantiated.” Indeed, a significant percentage of cases reported never even get investigated—and are sent instead for “alternative response”—meaning that they could never be found to be substantiated or unsubstantiated. In Minnesota, for instance, more than 70 percent of the reports that were screened in were diverted to alternative response. 

    Raz and colleagues suggest that CPS reports “usually do not lead to supports for struggling families.” And so, rather than reporting, doctors should recommend food pantries and housing assistance to any families who seem to be struggling. The problem with this approach is that doctors don’t know why a child is experiencing maltreatment. It is highly unlikely that a child is severely malnourished because a family doesn’t know where a local food pantry is. More likely, the parents are denying a child food or the parents are suffering from drug addiction (up to 90% of child-welfare cases involve addiction) and handing a family the address of a food bank is not going to solve anything. 

    Doctors also have no idea whether, for instance, a child’s school has already tried this approach and nothing came of it. Let me put it this way: If everyone decides they are going to offer “support” and no one is going to suggest further investigation of the problem, the child will continue to suffer. Furthermore, CPS almost never engages families due to families simply not having enough resources to support their children. Most neglect cases are for issues like inadequate or hazardous shelter or leaving the child in the care of a person who poses a danger to the child. 

    Brown and DasGupta suggest that what we really need are not reports to CPS but anti-poverty programs. They claim that Medicaid expansion “resulted in decreased reported neglect rates” and that “affordable housing can help address child neglect and abuse.” Finally, they note that greater access to the Supplemental Nutrition Assistance Program (SNAP) has resulted in fewer child-protection reports and fewer foster-care placements. But it is all but impossible to do any kind of randomized experiments to test these hypotheses. 

    Foster care numbers, for instance, fluctuate depending on placement capacity, agency leadership and policy, substance-abuse rates, and a variety of other factors. Anyone who completed medical school and understands the kind of evidence required for real scientific studies would be embarrassed to see this cited in a medical journal. It is also worth pointing out that about half of CPS reports involve families above the poverty line, and the overwhelming majority of CPS-reported families are already receiving assistance from SNAP and Medicaid. 

    Parental drug use may not be a problem at all, according to Raz and colleagues. They note that “substance use alone does not establish child maltreatment” and it is “best addressed by treatment and support rather than a threat of CPS reporting.” But these two things are hardly mutually exclusive. Parents, just like everyone else who suffers from a substance-use disorder, are more likely to get treatment when there is some kind of accountability involved. 

    The most successful rehabilitation programs—including for doctors—involve frequent random testing and the threat that they will lose their licence permanently if they fail. The idea that parents with addiction problems should not be reported because doing so “perpetuat[es] racial inequities” is only perpetuating racial inequities in outcomes for children. Child maltreatment fatalities are on the rise, in part as a result of unsafe sleep involving intoxicated parents and paediatric poisonings due to children being exposed to parents’ drugs. 

    Finally, both the Lancet and the JAMA Pediatrics articles suggest that the great harm of doctors reporting families to CPS is that children might wind up separated from their parents through foster care. This, perhaps more than any other misconception perpetuated by the abolitionists, has the potential to make intelligent and well-meaning professionals question their own judgement. A doctor may wonder: Why should I report this child for some suspicious bruises or some malnourishment if someone is just going to take them from their parents. Won’t that be worse than a few bruises? 

    But family separation is hardly the primary response of CPS. In 2022, over four million calls involving roughly six million children were made to CPS hotlines. About fifty percent of those were screened out and no further action was taken. Of the roughly three million children in the remaining reports, about five percent (150,000) cases resulted in referral to the foster-care system. Among all children who do enter foster care, many, perhaps as many as a third, do not enter because of a child-abuse or -neglect report, but for other reasons, such as parental death. Even when all foster-care placements are considered together, CPS-related and not, only about five percent of American children ever enter the foster-care system during their lifetimes. Finally, over the last twenty years, the total number of children in care has declined from about 520,000 to about 370,000.

    The evidence on foster care is not what the abolitionists would have you believe, either. A recent paper from the National Bureau of Economic Research (NBER) suggests that time in foster care reduces the likelihood of adult criminal involvement by 25 percentage points and reduces the likelihood of conviction by 21 percentage points. The authors also found that there were better academic outcomes among kids who had spent time in foster care. “Foster care substantially reduces absences from school, improves math test scores, and appears to increase the likelihood of high school graduation and college enrollment.” Improved academic (and therefore job) prospects can also have the effect of decreasing criminal activity. An earlier study concluded that foster placement reduced the likelihood of a child being reported for maltreatment again. 

    The politicization of medicine has created all sorts of terrible unintended consequences in recent years—from the rush to surgically alter adolescents supposedly diagnosed with gender dysphoria to the closure of schools during the pandemic despite evidence that opening schools did not lead to more transmission of the virus. Policies like these have devastated a generation. Discouraging doctors from reporting child abuse and neglect will only put our most vulnerable children in greater danger. Some people need to be smarter; and we all need to do better. 

Write to Peter: magtour@icloud.com