Risk of Fatal Injury in Young Children Following Abuse Allegations: Evidence From a Prospective, Population-Based Study

摘要

Objectives. We examined variations in children’s risk of an unintentional or intentional fatal injury following an allegation of physical abuse, neglect, or other maltreatment. Methods. We linked records of 514?232 children born in California from 1999 to 2006 and referred to child protective services for maltreatment to vital birth and death data. We used multivariable Cox regression models to estimate variations in risk of fatal injury before age 5 years and modeled maltreatment allegations as time-varying covariates. Results. Children with a previous allegation of physical abuse sustained fatal injuries at 1.7 times the rate of children referred for neglect. Stratification by manner of injury showed that children with an allegation of physical abuse died from intentional injuries at a rate 5 times as high as that for children with an allegation of neglect, yet faced a significantly lower risk of unintentional fatal injury. Conclusions. These data suggest conceptual differences between physical abuse and neglect. Findings indicate that interventions consistent with the form of alleged maltreatment may be appropriate, and heightened monitoring of young children referred for physical abuse may advance child protection. In the United States in 2011, 6.2 million children were referred to child protective services (CPS) for abuse or neglect. 1 When the demographic profile of referred children is compared with that of the general population, it becomes clear these children face multiple individual, 2–4 family, 5–7 and community 8,9 risk factors. Among children referred to CPS, however, the accurate identification of those for whom the threat is most immediate and consequential has proven difficult. 10 High rates of maltreatment rereferrals among children with initially unfounded allegations, 11–13 and child maltreatment deaths despite CPS involvement, 1 point to the challenge of accurately assessing children’s current and future risk of abuse and neglect. One possible indicator of the nature and severity of the physical threat faced by a child is the type of alleged maltreatment. Nationally, more than three quarters of children are referred to CPS for neglect (78.5%); far fewer are referred as possible victims of physical abuse (17.6%). 1 Despite high rates of concurrence between maltreatment types, 14–17 it is notable that physical abuse is alleged for only a minority of children. Because of the ambiguity surrounding what constitutes child neglect (broadly defined as acts of parental omission that endanger children), 17 an allegation of physical abuse for a child younger than 5 years may be a more reliable marker of safety concerns that necessitate CPS intervention. In other words, although many children referred for neglect may also experience varying degrees of physical abuse, if the physical abuse is so severe or chronic that it is explicitly alleged, this may be an important signal of risk. Public health researchers use variations in rates of death as population-based indicators reflective of broader group disparities in health, safety, and well-being. 18,19 Similarly, variable rates of fatalities among children previously referred for maltreatment may provide a means of differentiating among high-risk subsets of children. Although death is a relatively rare event, group differences in fatality rates suggest variable exposures to antecedent risk factors. Previous research indicates that children with a history of CPS referrals have an increased risk of death by injury and other causes. 20–24 We examined whether children previously referred for physical abuse had an increased risk of both unintentional and intentional fatal injury compared with children referred for neglect and children referred for other forms of maltreatment.