Marcia E. Herman-Giddens, Gail Brown, Sarah Verbiest, Pamela J. Carlson, Elizabeth G. Hooten, Eleanor Howell, John D. Butts. Underascertainment of Child Abuse Mortality in the United States. JAMA. 1999;282(5):463–467. doi:10.1001/jama.282.5.463
Author Affiliations: Office of the Chief Medical Examiner (Drs Herman-Giddens, Brown, and Butts, and Mss Verbiest, Carlson, and Hooten) and State Center for Health Statistics (Ms Howell), Department of Health and Human Services, Raleigh, NC; Department of Maternal and Child Health, School of Public Health, University of North Carolina, Chapel Hill (Dr Herman-Giddens).
Context Mortality figures in the United States are believed to underestimate
the incidence of fatal child abuse.
Objectives To describe the true incidence of fatal child abuse, determine the proportion
of child abuse deaths missed by the vital records system, and provide estimates
of the extent of abuse homicides in young children.
Design and Setting Retrospective descriptive study of child abuse homicides that occurred
over a 10-year period in North Carolina from 1985-1994.
Cases The Medical Examiner Information System was searched for all cases of
children younger than 11 years classified with International
Classification of Diseases, Ninth Revision codes E960 to E969 as the
underlying cause of death and homicide as the manner of death. A total of
273 cases were identified in the search and 259 cases were reviewed after
exclusion of fetal deaths and deaths of children who were not residents of
Main Outcome Measure Child abuse homicide.
Results Of the 259 homicides, 220 (84.9%) were due to child abuse, 22 (8.5%)
were not related to abuse, and the status of 17 (6.6%) could not be determined.
The rate of child abuse homicide increased from 1.5 per 100,000 person-years
in 1985 to 2.8 in 1994. Of all 259 child homicides, the state vital records
system underrecorded the coding of those due to battering or abuse by 58.7%.
Black children were killed at 3 times the rate of white children (4.3 per
100,000 vs 1.3 per 100,000). Males made up 65.5% (133/203) of the known probable
assailants. Biological parents accounted for 63% of the perpetrators of fatal
child abuse. From 1985 through 1996, 9467 homicides among US children younger
than 11 years were estimated to be due to abuse rather than the 2973 reported.
The ICD-9 cause of death coding underascertained
abuse homicides by an estimated 61.6%.
Conclusions Using medical examiner data, we found that significant underascertainment
of child abuse homicides in vital records systems persists despite greater
societal attention to abuse fatalities. Improved recording of such incidences
should be a priority so that prevention strategies can be appropriately targeted
and outcomes monitored, especially in light of the increasing rates.
The true incidence of fatal child abuse in the United States is unknown.
Prevention of homicide by caregivers calls for very different strategies and
allocation of resources than prevention of stranger homicide. Some research
suggests that the incidence of child abuse homicide may be increasing and
that the increase does not seem to be related to improved recognition.1,2 On the other hand, other research reports
a decrease in maltreatment deaths.3 Confusion
about the incidence and related prevention and intervention issues arises,
in part, from underascertainment of fatal child abuse. Despite the growth
of state fatality review teams over the last decade,4
absence of accurate data continues and is due to a number of factors including
restrictions and inaccuracies in coding causes of death, incomplete or inaccurate
information on death certificates and in police reporting, varying case definitions,
lack of perpetrator information, and the absence of a national system for
reviewing child homicides with categorization into abuse or nonabuse. Inaccuracies
may further arise when neglect deaths are included in estimates of child maltreatment
and/or abuse homicide because of widely varying definitions of what constitutes
neglect and the lack of designation of most neglect deaths as homicides in
medical examiner or law enforcement systems.
The North Carolina Medical Examiner's (ME's) office investigates all
child homicides and has access to perpetrator information through its own
records and contact with law enforcement agencies. This source enabled us
to complete a case by case review of all child homicides in North Carolina
from 1985 through 1994 under the auspices of the North Carolina Child Fatality
Prevention Team5,6 to describe
the true incidence of fatal child abuse, to determine the proportion of child
abuse deaths missed by the vital records system, and to provide estimates
of the extent of abuse homicides of young children in the United States and
their underascertainment by US vital records.
The North Carolina ME System investigates and certifies all deaths in
North Carolina that are of a sudden and unexpected nature including all apparent
sudden infant death syndrome cases. By guidelines and practice, autopsies
are performed for all such deaths.5 Our centralized
ME system provides the most accurate method in North Carolina for capturing
homicides because the Federal Bureau of Investigation's Supplementary Homicide
Report is based on voluntary reports.7 The
ME information system was searched for all ME cases of children aged 10 years
and younger with International Classification of Diseases,
Ninth Revision (ICD-9)8
codes E960 through E969 as the underlying cause of death and homicide as the
manner of death during the 10-year period from 1985 through 1994. The category
E960 through E969 includes the ICD-9 classifications
Homicide and Injury Purposely Inflicted by Other Persons. Category E967 is
Child Battering and Other Maltreatment. For a homicide to be coded E967, the
decedent must be younger than 18 years and the death certificate must list
evidence consistent with prior abuse, or the certifier specify abuse, beating,
or other maltreatment.9,10 A homicide
due to an injury occurring from a single isolated episode such as a stabbing,
shooting, or hanging is specifically excluded even if committed by a caregiver.
This study looked at all fatalities recorded in the ME system
as homicides. Electronic data were downloaded for all 273 cases identified
in the ME information system search. Fetal deaths (not involving a live birth)
and deaths of children who were not residents of North Carolina were excluded.
The ME record (including ME report, autopsy report, toxicology report, and
notes to the file) of the remaining 259 cases were reviewed, and the case
characteristics and narratives were entered into a database and merged with
the electronic data for each case. The ICD-9 E codes
assigned by nosologists from the state vital records system were obtained
from the State Center for Health Statistics.
The definition of
child abuse homicide for the study was that developed by the North Carolina
State Child Fatality Prevention Team: the killing of a child by a person,
usually older than 12 years, who was responsible for the child's health or
welfare.6 Baby-sitters and parents' partners,
in addition to parents, are considered caregivers. The term caregiver is used instead of caretaker because
caretaker has a specific legal definition in North Carolina related to child
protection services. Unintentional injuries, such as drownings of unsupervised
toddlers, though usually considered neglect deaths, are not classified as
homicides and were not included in this study because of the focus on abuse
fatalities only. We used the definition above to characterize each case as
abuse, nonabuse, or undetermined as a result of insufficient perpetrator information
in the ME records and police records. The 17 undetermined cases were not included
in the analysis.
Child abuse homicides were further researched
to determine if the perpetrator could be identified. Local law enforcement
officials were interviewed when possible (88 cases) and victim witness coordinators
at local district attorneys' offices were contacted in the majority of cases.
Homicide rates per 100,000 children aged 10 years and younger
were calculated using North Carolina population estimates, obtained from the
North Carolina Office of State Planning, for each of the 10 years of the study.
The population of children aged 10 years and younger in 1985 was estimated
to be 931,247 and increased to 1,084,494 by 1994. According to the US Census,
in 1990, 69% of North Carolinians younger than 11 years were white, 28% black,
and 3% other minorities. Age-, race-, and sex-specific rates were calculated
using the associated population numbers. Race- and race-sex–specific
population estimates were calculated by applying the 1990 census percentages
of blacks and whites younger than 11 years to the 10-year total and sex-specific
population estimates. Rates with a numerator of 20 or less were not calculated
due to the potential for rate instability. Statistical analyses of the homicide
rates were based on the Poisson distribution. The percentage underascertainment
of coding of child abuse deaths was calculated by subtracting the number of
fatalities coded as abuse from the actual number of abuse deaths then dividing
by the total number of all homicides.
A minimum estimate of abuse
deaths for the United Staes was calculated by applying the overall proportion
of homicides of children younger than 10 years found in our study to be due
to battering or abuse to US homicide statistics for children younger than
10 years for 1985 through 1996. A maximum estimate was computed by adding
the proportion of cases (6.6%) with insufficient information to determine
whether or not abuse was a factor to the overall proportion.
Data were analyzed using SAS statistical analysis and Epi
Info software.11,12 Statistical
evaluation included simple regression analysis and χ2 tests. P<.05 was considered statistically significant.
Table 1 shows the characteristics
of child abuse homicides among children aged 10 years and younger in North
Carolina from 1985 through 1994. Child abuse accounted for 84.9% (220/259)
of all child homicides. Twenty-two child homicides (8.5%) were not related
to abuse, and the status of 17 (6.6%) could not be determined. The rate for
child abuse homicides increased during the period by a mean of 12.3% per year
(95% confidence interval [CI], 3.0%-21.6%) (Figure 1). Table 2 presents
information on the 203 identified perpetrators of child homicides from 1985
through 1994 by sex and relationship to the victim.
There were 12 cases that probably
involved sexual abuse of the victim (8 girls, 4 boys). The age range for these
cases was 2 months to 10 years. Six cases had sufficient evidence to show
that sexual abuse had actually occurred. These findings included trauma to
the genitalia or rectum, physical evidence of rape, and sexual mutilation.
In the other 6 cases, the history suggested that the child had been sexually
abused because of the circumstances in which the body was found (unclothed),
suspicious autopsy findings, or a prior history of sexual abuse.
The number (220) of homicides due to child battering or abuse identified by
the study was 3.2 times higher than the number (68) reported by the North
Carolina vital records system (Table 3).
Table 4 shows the numbers of homicides of children younger than
10 years in the United States from 1985 through 1996 and the estimate for
deaths resulting from child abuse based on North Carolina data. Sixty percent
of deaths likely to be due to battering or abuse were not coded as such in
the vital records system. Table 5,
with numbers aggregated in 5-year periods for statistical stability, compares
North Carolina child homicide rates to those of the United States.
Almost 60% of the homicides found to be due to abuse were not coded
as such by the North Carolina vital records system. Because ICD coding requirements are the same for every state, it is reasonable
to assume that similar proportions of underrecording occur nationally due
to the nosologists' dependency on death certificate information and ICD coding requirements. In addition, North Carolina child
homicide rates are close to US averages (Table 5). Our study focused on abuse homicides rather than the entire
spectrum of child maltreatment. Because our methods involved review of the
complete ME file of all identified child homicides, our data provide exact
figures on coding underascertainment of child abuse homicides within the spectrum
of recognized child homicides.
For the United States, we estimated
that 6494 more children were killed by fatal child abuse from 1985 through
1996 than reflected by vital records coding. The new version of ICD (ICD-10), in use since January 1999, does
not have any significant changes in the requirements for applying the E967
(now Y07) child battering code. Until coding and death certification procedures
and criteria are revised, the limitations of such data should be strongly
emphasized and estimates for the proportions of underascertainment provided
when vital records data are used for child abuse homicide statistics. Several
earlier studies have pointed out deficiencies in coding but underestimated
the full extent of the underascertainment of abuse homicides in the group
of all child homicides due to either small sample size, lack of actual record
and perpetrator review, limitations of the data sources used, or focus on
all maltreatment deaths and not just homicides.10,14,15
At present, the only method to accurately capture abuse fatality data is a
comprehensive review of every child homicide that includes examination of
perpetrator status and acknowledges that single instances of any kind of trauma
can constitute abuse. Revisions in death certification and ICD coding criteria to require inclusion of perpetrator data and changes
in the battering definition are needed to improve the recording of the true
extent of child abuse fatalities. Such a change could result in increased
resources directed toward investigation, prevention, and criminal justice
Although the public may believe that biological parents
are less likely to kill their own offspring, we found they accounted for 63%
of the perpetrators of fatal child abuse. The findings from this study indicate
that caregiving males, biological parents, and caregivers of children younger
than 1 year are the most common perpetrators of fatal abuse and, therefore,
need to be especially targeted in prevention efforts. Earlier US studies of
fatal child abuse also found males to be the most likely perpetrators16,17; however, other studies found mothers
to be the most likely assailants.18- 20
Strangers were responsible for only 3% of all child homicides in North Carolina
in this 10-year period. The public, as well as law enforcement officers, need
a heightened sensitivity to the reality that most victims of child homicide
are killed by parents or caregivers. This knowledge could lead to increased
reporting of suspected maltreatment and more intense intervention when abuse
Frequently cited estimates for annual child maltreatment
deaths of approximately 2000 for children 17 years and younger and 1200 for
those 4 years and younger include figures for neglect deaths,3,14- 16
and are the mean from the upper estimate in studies by Ewigman et al14 and McClain et al3,15
from 1979 through 1988. Neglect deaths in these studies were implied to include
those from causes listed as illnesses or unintentional injuries such as drownings
or falls for which child protective services had determined that lack of proper
care or supervision was a factor in the death. Both studies14,15
estimated that homicides represented only 30% of total death estimates from
maltreatment (abuse and neglect) or an upper estimate of approximately 600
per year for children 17 years and younger. Our study, which estimates a mean
of 789 per year from 1985 through 1996 for children 9 years and younger only,
suggests that the extent of child abuse homicides is underestimated in child
maltreatment studies as well as in vital records data.
has several weaknesses. We were unable to collect information on the victims'
socioeconomic status, child protective service history, or history of previous
injuries. This information would have allowed a better understanding of the
contributing factors involved in child homicides. Our homicide numbers are
likely to be somewhat lower than the true number because some deaths may not
have been recognized as homicides, leading to misclassification of the manner
of death as either undetermined, accidental, or natural (as in the case of
a homicide misdiagnosed as sudden infant death syndrome). However, our method
is unlikely to have exaggerated the number of homicides and thus provides
a reasonable basis for accurate minimum estimates.
has been known for years that homicide is the leading cause of injury deaths
among infants in the United States,21,22
few public policy or prevention strategies reflect this fact. Furthermore,
the true incidence of child abuse homicides is unknown. Our finding of a 12.3%
per year increase in the rate of North Carolina child abuse fatalities from
1985 through 1994 denotes a serious problem in our culture and one that we
found to disproportionately affect black children. Nationally, homicide rates
for children younger than 10 years increased from 2.06 per 100,000 in 1985
to 2.43 in 1994 and the rates for infants aged 1 year or younger rose from
5.31 to 7.91.13 As pointed out by Overpeck
et al,22 the increase is unlikely due to better
detection of homicides because death review teams have not been in place long
enough to affect detection. In addition, review of child deaths by fatality
review teams is not yet universal. It is possible that an enhanced concern
for child abuse fatalities and a more critical approach to death certification
could account for some of the increase nationwide in the numbers of deaths
classified as homicides, although there are no data to support this contention.
Further study to determine the reasons for the increasing fatal
violence against children would aid in determining where to direct prevention
efforts. Factors that appear to put black children at 3 times the risk of
white children for dying at the hands of their caregivers should be distinguished
from the effects of social class and socioeconomic status. The need to collect
accurate data on child abuse homicides and to devise primary strategies for
the prevention of child homicides is urgent.