Child Abuse Hospitalizations Rise, Especially Among Poor

Diedtra Henderson

October 01, 2012

October 1, 2012 — Even as child protective workers reported a decrease in the number of substantiated cases of physical abuse of children, the nation's hospitals told a different story. The number of children younger than 18 years hospitalized with serious injuries due to abuse rose by a small, but statistically significant, amount from 1997 to 2009, according to a study by John M. Leventhal, MD and Julie R. Gaither, RN, MPH, MPhil, both from the Yale School of Medicine, New Haven, Connecticut, reported online October 1 in Pediatrics.

Data from the US Child Protective Services gathered for the National Child Abuse and Neglect Data System (NCANDS) have shown a 55% decline in the yearly incidence of substantiated cases of physical abuse of children between 1992 and 2009. Similarly, "periodic reports from the National Incidence Studies (NIS), which were congressionally mandated studies conducted in 1978–1980, 1986–1987, 1993–1994, and 2005–2006…have shown decreases over time in the occurrence of physical abuse," the authors write. However, neither source taps data on children hospitalized with serious injuries due to abuse. Nor has any previous study used national data to look at incidence rates of children hospitalized for serious injuries due to physical abuse.

To this end, Dr. Leventhal and Ms. Gaither used data from the Kids' Inpatient Database, a weighted sample of discharges from US acute-care hospitals. They excluded a number of cases, including injuries caused by air guns or firearms and injuries that occurred outside of the home, as well as cases coded as neglect, child sexual abuse, or rape. They compared hospitalizations due to abuse with hospitalizations for injuries not due to abuse, and all other hospitalizations, which substantially decreased during the same time period.

Among children hospitalized for serious injuries due to physical abuse — including traumatic brain injury, fracture, skin injury or open wound, burns, and abdominal injuries — the percentage of white children declined from 47.8% in 1997 to 46.3% in 2009. Among such hospitalizations, children poor enough to qualify for Medicaid soared from 59% in 1997 to 74.1% in 2009 (P < .0001). Mirroring other studies, they find high rates of serious injuries due to abuse in infants' first year of life.

"Overall, the incidence increased 4.9 % from 6.1 per 100 000 in 1997 to 6.4 per 100 000 children in 2009; the trend over time was statistically significant (P < .01). For children < 1 year of age, the increase was 10.9% from 56.2 to 62.3 per 100 000 (P < .05)," the study authors write. "In 1997, the incidence of children dying due to abusive injuries was 0.25 per 100 000 children, and this increased to 0.36 per 100 000 children in 2009 (P < .01)," Dr. Leventhal and his colleague add.

Among the study limitations, the results may have been affected by changes over time in the codes used to characterize causes of injuries. In addition, the authors relied on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes to identify serious injuries due to physical abuse, but few studies have examined the accuracy of ICD-9-CM codes in identifying children hospitalized for physical abuse. Finally, they could not take into account changes in the quality of medical care over time.

Because of the overwhelming number of poor children among those hospitalized because of serious abuse, the study authors noted the impact of poverty as a potential stressor and advocated for Medicaid to target funding to prevent such serious injuries and deaths.

"Such programs will require substantial resources, effective strategies to help parents and other caregivers respond in nonviolent ways to the stresses and frustrations of caring for young children, and the targeting of large numbers of families," the study authors conclude. "In the 1990s, in response to a high rate of sudden infant death syndrome in the United States, a national campaign was successfully implemented to have all infants sleep in the supine position. This campaign resulted in a 50% decrease in the occurrence of the syndrome. A similar national campaign will be required to address serious abusive injuries in children."

The Yale School of Medicine’s Department of Pediatrics provided funding for the study. Dr. Leventhal reported being principal investigator on grants to Yale University to support the child abuse programs and prevention programs and having provided expert testimony in cases of child abuse. Ms. Gaither has disclosed no relevant financial relationships.

Pediatrics. Published online October 1, 2012. Abstract