Historical redlining and neighborhood deprivation are associated with caregiver exclusion following evaluation for suspected child physical abuse: A multicenter study

BACKGROUND: Neighborhood socioeconomic disadvantage, measured by Area Deprivation Index (ADI), is associated with disparities in health care and child welfare responses following evaluation for suspected child physical abuse. We sought to determine whether historical redlining and contemporary spatial social polarization strengthen associations between neighborhood disadvantage and caregiver exclusion at discharge, a system-level outcome reflecting child welfare involvement. METHODS: This multicenter retrospective cohort study included children (age <18 y) admitted with suspected/ confirmed physical abuse at 7 New York pediatric trauma centers (2011-2023). Home addresses were linked to neighborhood disadvantage measures, including ADI, Social Vulnerability Index, Child Opportunity Index, Index of Concentration at the Extremes for race, income, and racialized economic segregation, and a Historic Redlining Score (HRS). The primary outcome was caregiver exclusion at discharge (legal removal from the home environment). Univariable and multivariable mixed-effects models adjusted for age, Injury Severity Score, and admission year. RESULTS: Of 1,242 patients, 517 (41.6%) experienced caregiver exclusion. These children were more often Black (29.6% vs. 20.0%, p < 0.001) and lived in neighborhoods with greater disadvantage [median (interquartile range); ADI: 78.0 (52.3 to 93.0) vs 52.5 (18.0 to 84.0); Child Opportunity Index: 26.0 (5.0 to 51.0) vs 31.0 (8.0 to 62.5), p < 0.001], compared with those without caregiver exclusion. Compared with ADI Quartile 1, children in the most disadvantaged neighborhoods (ADI: Q4) had 4.93-fold higher odds of caregiver exclusion (95% CI: 2.75 to 8.85). Inclusion of HRS improved model performance (area under the curve: 0.825 → 0.833); each unit increase in HRS increased the odds of caregiver exclusion by 38% (p = 0.045). CONCLUSIONS: Neighborhood deprivation is strongly associated with caregiver exclusion following hospitalization for suspected child physical abuse. This relationship is strengthened by incorporating historical redlining measures. These findings highlight the intersection of structural neighborhood disadvantage and system-level responses to child safety concerns, suggesting that historic patterns of disinvestment may continue to shape child welfare involvement. (J Trauma Acute Care Surg 2026;00:000-000.