Child Abuse & Neglect, Vol. 16, pp. 627-635, 1992

0145-2134/92 $5.00 + .00 Copyright © 1992 Pergamon Press Ltd.

Printed in the U.S.A. All rights re.fred.

FATALITY AFTER REPORT TO A CHILD ABUSE REGISTRY IN WASHINGTON STATE, 1973-1986 EUGENE E. SABOTTA AND ROBERT L. D a v i s Office of Epidemioiogy, Washington State Department of Health, Olympia, WA

Abstract--Between 1973 and 1986, 11,085 children born in Washington State were reported to the state child abuse registry. We analyzed the fatality rate subsequent to reported abuse for this cohort of children compared to a population of nonabused children matched on sex, county of birth, and year of birth. Children reported to the child abuse registry had an almost threefold greater risk of death than the comparison population. A report of physical abuse carried the greatest risk of subsequent death. However, the relative risks were also elevated for children who suffered neglect or sexual abuse. Children reported to the registry were almost 20 times more likely than the comparison population to die from homicide. Children less than I year of age at time of reported abuse had the highest fatality rate subsequent to abuse, but adolescents had the highest relative risk for fatality after abuse, compared to the population of nonabused children. Rates of fatality subsequent to abuse were equal for males and females. Although this study could not measure the extent to which any given intervention reduced the risk of subsequent fatality in abused children, registries can serve a valuable function in identifying subpopulations at risk and quantifying that risk relative to the general population.

Key Words--Child abuse, Fatality, Registries.

INTRODUCTION ALTHOUGH CONVENTIONAL WISDOM assumes there is a poor prognosis for victims of child abuse, there are remarkably few epidemiological studies that support this assumption. We are unaware of any studies that have followed populations of abused children over time to analyze their rates of mortality compared to the general population of nonabused children. A number of studies have attempted to describe the association between child abuse and child fatality in hopes of preventing fatality after abuse. Studies out of Oregon (Jacquot & Roberts, 1986) and New York City (Fontana & Alfaro, 1982) have found that roughly 45-55% of fatally abused children had previously been reported to the respective children's services division. In Ohio, 25% of fatal child abuse cases had a previous intervention by the children's protective services (Showers, Apolo, Thomas, & Beavers, 1985). Several other studies have shown that child homicide is preceded by physical or sexual abuse at rates greater than that found in the general pediatric population (Hollander, 1986; Jason, Williams, Burton, & Rochat, 1982). This present study was designed to measure the mortality risk for children prior to age 18 reported to the Washington State child abuse registry, compared to a coho~ of children with no abuse reported. We also attempted to further quantify the risk according to type of reported abuse, some specific demographic characteristics of the abused child, and type of fatality outcome that occurred subsequent to the reported abuse. Received for publication May 15, 1991; final revision received September 25, 1991; accepted November 4, 1991. Requests for reprints may be sent to Robert L. Davis, M.D., Department of Pediatrics, Mail Stop RD-20, University of Washington Medical Center, Seattle, WA 98195. 627

628

L. k. Sabotta and R. I. Davis

METHODS The basic data of children abused and reported to the state's child abuse registry during the years 1973-1986 were made available for this study by the Child Protective Services Unit of the Washington State Department of Social and Health Service's Children, Youth and Family Services Program. Fatality data came from this state's vital statistics data files. Causes of death were classified according to the International Classification of Diseases, Ninth Revision (ICD-9). From 1973 through 1986, 22,931 children under the age of 18 were reported from the regional Children's Protective Services field offices to the Washington State child abuse registry. These 22,931 reports of suspected child abuse consisted of cases for which a caseworker was assigned, an investigation begun, and the report of abuse was substantiated. Intake calls where a case was determined not to warrant investigation or assignation of a caseworker were not reported to the registry, were not counted in the total of 22,931 reports listed above, and were not included in this study. The state child abuse registry was linked via child's name and birthdate to the Washington State birth file, which identified 11,085 children from the child abuse registry as having been born in Washington State. There were a total of 11,846 children reported to the registry who were not identified in the Washington State birth file and therefore not included in the study. Many of these children had been born outside of Washington State and suitable controls for the comparison population were not available. The remainder of the 11,846 children did not match to the birth file because the child's name changed in the interval between birth and time of reported abuse, or because of an inadequate match in the computer program, which required an exact match on name and birth date. A nonabused comparison population was established by selecting, for each of the 11,085 children born in Washington State and reported to the child abuse registry, the next three adjacent birth records of the same sex in the birth file. Since the birth file is arranged by year of birth and county of birth, this selection produced a comparison population matched according to sex, county of birth, and year of birth. Both populations were then linked to the Washington state death file for the years 1973 through 1986 to identify deaths occurring in children less than 18 years of age. This study was specifically interested in evaluating the risk of fatality in children surviving their first reported child abuse, compared to the general risk of fatality in a comparable nonabused population of children. Children whose report to the child abuse registry coincided with the time of their death were excluded from further study. Deaths in the nonabused population that occurred prior to or at the time of the reported abuse of the matched abused child were replaced to ensure that both populations had equivalent length of exposure to risk of death. The length of time a child was at risk of death depended on his or her age at time of report and how near to 1986 the incident was reported. Total years of risk were calculated for each population, and the difference in risk of death between the two populations was calculated using the Mantel-Haenzsel chi-square statistics.

RESULTS There were 61 deaths in 67,367 total years of risk subsequent to abuse in the population of children reported to the child abuse registry, and 63 deaths in 202,525 total years of risk in the comparison population of nonabused children (Table 1). The fatality rate for all children under 18 years of age reported to the child abuse registry was 9.1 deaths per 10,000 years of risk, whereas the rate for the comparison population was 3.1 deaths per 10,000 years of risk (Relative risk [RR] 2.9; 95th percent confidence interval [c.i.] 2.1, 4.1).

Fatality after report to a child abuse registry

629

Table 1. Risk of Death Subsequent to Reported Case of Abuse, According to Type of Reported Abuse. Washington State, 1973-1986 Physical Abuse*

No." Years b Deathsc

Rated

Neglect**

Sexual Abuset

Total e't

Abused

Nonabused

Abused

Nonabused

Abused

Nonabused

Abused

Nonabused

3,345 19,568 20 10,2

10,035 58,923 15 2.6

4,199 32,340 25 7.7

12,597 97,194 33 3.4

2,992 11,823 9 7.6

8,976 35,490 13 3.7

10,532 67,367 61 9.1

31,608 202,525 63 3.1

"Number of children in abused and nonabused populations. ~Total years at risk. eTotal number of deaths in population group, dRate of death per 10,000 years at risk. ~Totals include cases where > l abuse type was reported. * p < .01 (Relative risk [RR] 4.0; 95th percent confidence interval [c.i.] 2.0, 7.8). **p < .01 (RR 2.3; 95th c.i. 1.4, 3.8). tp = .08 (RR 2.1; 95th c.i..9, 4.9). ¢p < .01 (RR 2.9; 95th c.i. 2.1, 4.1).

Children who had been reported for physical abuse had the greatest risk for subsequent death, 10.2 deaths per 10,000 years at risk, compared to 2.6 deaths per 10,000 years at risk for the comparison population of nonabused children. Children with reports of physical neglect or sexual abuse had rates of subsequent death of 7.7 and 7.6 deaths per 10,000 years at risk, respectively. The elevated risks for deaths were statistically significant for children who had a report of either physical abuse (RR 4.0; 95th percent c.i. 2.0, 7.8) or physical neglect (RR 2.3; 95th percent c.i. 1.4, 3.8), but not for children with a report of sexual abuse (RR 2.1; 95th percent c.i. 0.9, 4.9). The causes of death are shown in Table 2. For each type of fatality, the difference in rates between the two populations was statistically significant. As shown in Table 2, the relative risk was greatest for homicide (RR 18.0; 95th c.i. 4.0, 80.6), followed by motor vehicle accidents (RR 2.8; 95th c.i. 1.2, 6.2), other diseases (RR 2.3; 95th c.i. 1.3, 4.0), and other nonintentional injuries (RR 2.2; 95th c.i.I, l, 4.2). Of the two children who committed suicide, both were females who had previously been reported as having been sexually abused. Figures 1 and 2 show the distribution of the different types of abuse according to sex and age at time of abuse. There is a similar pattern of physical abuse and neglect among males and females. However, the number of reported cases of sexual abuse decreased after 6 years of age in males, while the number of reported cases of sexual abuse in females had two distinct plateaus, one at age 3 through 10, and a second, higher plateau at ages 11 through 14. The risk of death was greater in both the abused males and females compared to the nonabused populations (Table 3). There was no difference between males and females in the rate of death subsequent to abuse. Table 2. Risk of Specific Cause of Death Subsequent to Reported Abuse, According to Cause of Death

Homicide*

Transport Accidents (including motor vehicle accidents)**

Disease*

Other Nonintentional Injury~

Total 0

Abused Nonabused Abused Nonabused Abused Nonabused Abused Nonabused Abused Nonabused Deaths Rate" Yearsb

12 1.8

2 .1

11 1.6

12 .6

21 3.1

28 1.4

15 2.2

21 1.0

61 9.1 67,367

63 3.1 202,525

"Rate of death per 10,000 person years of risk. bTotal years at risk. Total column includes suicide deaths; Homicide = 1CD-9 codes E950-E969; Transport = ICD-9 codes E800-E848; Other nonintentional injury = ICD-9 codes E880E949; Disease = ICD-9 codes 001-799. * p < .01 (Relative risk [RR] 18.0; 95th percent confidence index [cA.] 4.0, 80.6). **p < .05 (RR 2.8; 95th c.i. 1.2, 6.2). tp = .01 (RR 2.3; 95th c.i. 1.3, 4.0). *p < .05 (RR 2.2; 95th c.i. 1.1, 4.2). ~p < .01 (RR 2.9; 95th c.i. 2.1, 4.1).

630

E. E. Sabotta and R, L. Davis

number of cases 300 ~ 2

5

0

;

~

100 ............................

Fatality after report to a child abuse registry in Washington State, 1973-1986.

Between 1973 and 1986, 11,085 children born in Washington State were reported to the state child abuse registry. We analyzed the fatality rate subsequ...
667KB Sizes 0 Downloads 0 Views