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Journal of Nursing Scholarship
Volume 40, Issue 1, Pages 91-97
Published Online: 21 Feb 2008
Physical Injury and Safety
Household Composition and Fatal Unintentional Injuries Related to
Child Maltreatment
Patricia G. Schnitzer 1 , Bernard G. Ewigman 1
1 Patricia G. Schnitzer, RN, PhD, Alpha Iota, Assistant Professor,
Sinclair School of Nursing, University of Missouri, Columbia, MO;
Bernard G. Ewigman, MD, MSPH, Professor and Chairman, Department of
Family Medicine, Pritzker School of Medicine, University of Chicago,
Chicago, IL. This study was funded by National Institute for Child
Health and Human Development grant 5K08HD01377. The authors are
grateful to Missouri's Department of Social Services and Department of
Health and Senior Services for providing data for this research. We
also thank Gus Kolilis and his staff at the State Technical Assistance
Team for responding to numerous requests for additional information,
and Darla Horman for data management. Correspondence to Dr. Schnitzer,
S331, Sinclair School of Nursing, University of Missouri, Columbia, MO
65211. E-mail: schni...@health.missouri.edu
Copyright 2008 Sigma Theta Tau International
KEYWORDS
injury • fatality • child maltreatment • child neglect • risk factors
• case-control study
Journal of Nursing Scholarship, 2008; 40:1, 91–97. © 2008 Sigma Theta
Tau International.
ABSTRACT
Purpose : To determine if household composition is an independent risk
factor for fatal unintentional injuries related to child
maltreatment.
Design : A population-based, case-control study using data from the
Missouri Child Fatality Review Program for 1992–1999.
Methods : Children under age five who died during the 8-year study
period were eligible for study. Cases were defined as children who
died of an unintentional injury that occurred when a parent or other
adult caregiver: (a) was not present, (b) was present but not capable
of protecting the child, (c) placed the child in an unsafe sleep
environment, or (d) failed to use legally mandated safety devices.
Controls were randomly selected from children who died of natural
causes. Household composition was classified based on relationship of
the adults living in the household to the deceased child. The five
household composition categories were households with: (a) two
biologic parents and no other adults, (b) one biologic parent and no
other adults, (c) one or two biologic parents and another adult
relative, (d) stepparents or foster parents, and (e) one or two
biologic parents and another unrelated adult. Logistic regression
analyses were conducted and odds ratios estimating the risk of
maltreatment-related unintentional death associated with each
household category compared to the reference households: those with
two biologic parents and no other adults.
Findings : Three hundred eighty children met the case definition.
Children residing within households with adults unrelated to them had
nearly six times the risk of dying of maltreatment-related
unintentional injury (adjusted odds ratio [aOR] 5.9; 95% confidence
interval [95% CI] 1.9–17.6). Children residing with step or foster
parents and those living with other, related adults were also at
increased risk of maltreatment death (aOR 2.6, 95% CI 1.0–6.5; and aOR
2.1, 95% CI 1.0–4.5, respectively). Risk was not elevated for children
in households with a single biologic parent and no other adults in
residence.
Conclusions : Young children residing in households with unrelated
adults, step-parents, or foster parents are at increased risk of fatal
unintentional injury related to maltreatment. Nurses can use the
findings of this study to facilitate injury prevention by identifying
families at risk for fatal unintentional injuries and providing these
families with targeted education or referral.
--------------------------------------------------------------------------------
Accepted for publication August 17, 2007.
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1547-5069.2007.00211.x About DOI
Article Text
Injuries are the leading cause of death among children after the 1st
year of life in the United States (US; Baker, O'Neill, & Karpf, 1992;
Centers for Disease Control and Prevention [CDC], 2005), and an
important contributor to child death globally (World Health
Organization [WHO], 2005). In the US, the leading causes of fatal
unintentional injury among children less than 5 years old include
drowning, suffocation, being burned or in a fire, falling, being
struck by a motor vehicle, and being in a motor vehicle accident (CDC,
2006); motor vehicle accidents and drowning are responsible for most
deaths by injury worldwide (WHO, 2005). Established risk factors for
childhood injuries include: maternal factors such as being young,
single, and unemployed; low socioeconomic status; and male gender
(Larson & Pless, 1988; Rivara & Mueller, 1987). Because young children
are physically and developmentally unable to care for themselves,
parents and other adult caregivers have a critical role in protecting
young children from injury hazards.
Child maltreatment (a term used to encompass all forms of abuse and
neglect) is a problem of significant magnitude globally, and physical
injury is an important consequence of maltreatment. Fatal injuries are
relatively rare outcomes of maltreatment with an estimated 1,400 to
2,000 deaths annually in the US (Administration for Children and
Families [ACF], 2006; McClain, Sacks, Froehlke, & Ewigman, 1993), and
at least 31,000 deaths each year world wide (WHO, 2006). The majority
of fatal maltreatment occurs among children less than age five (ACF,
2006; McClain et al., 1993; WHO 2006). Moreover, population-based
research indicates that the majority of fatal injuries among children
under 5 years old are attributable to maltreatment (Ewigman, Kivlahan,
& Land, 1993; Landen, Bauer, & Kohn, 2003). Consequently, the
identification of risk factors for fatal child maltreatment-related
injuries is an important priority and is necessary for developing
evidence-based intervention strategies. Furthermore, knowledge of key
risk factors for maltreatment-related injuries can be used by nurses
to identify children and families at increased risk, and might provide
an opportunity to intervene before a serious injury occurs.
An increase in child maltreatment in single-parent and step-families
has been shown in historical studies indicating that 35%–54% of
maltreated children live in single-parent households or with
stepfamilies (Baldwin & Oliver, 1975; Wilson & Daly, 1987; Wilson,
Daly & Weghorst, 1980). However, these studies were typically based on
administrative samples, that is they only included children reported
to or substantiated by child-protective-service agencies, and none
examined fatal maltreatment. Most also lacked a nonmaltreated
comparison group and therefore, estimation of risk (if any) associated
with living in households with single or step parents was not possible
in these studies, nor was control of confounding.
Background
After research indicated that 52% of child maltreatment-related injury
deaths were misclassified on death certificates—usually as accidental
deaths (Ewigman et al., 1993), Missouri enacted legislation mandating
a comprehensive, statewide, child fatality review program (CFRP) in
1991. The goals of the program were to accurately identify the
circumstances and causes of all child deaths, determine if the death
was the result of maltreatment, and use the information obtained
during the review to prevent injury to other children. The CFRP
consists of 115 multidisciplinary teams—one in each of Missouri's
counties and the City of St. Louis—the composition of which includes
the county prosecuting attorney (Chair) and the coroner or medical
examiner (C/ME) in addition to representatives from law enforcement,
child protective services, public health, emergency services, and the
juvenile court.
The process for review is as follows. The death of every child less
than age 18 is reported to the C/ME who, along with the Chair of the
CFRP team, reviews the circumstances of the death. If the death was
due to natural causes and was expected (e.g., infant born with severe
birth defects and expected to die), the C/ME and CFRP Chair fill out
the forms and the review is complete. If, however, the death meets any
of approximately 20 criteria (e.g., all injury deaths; unexpected,
unexplained, or suspicious deaths; deaths possibly related to
malnutrition or delay in seeking medical care), the death is reviewed
by the full multidisciplinary team. Reviews take place within days or
a few weeks of the death and during the review, all team members
contribute any information they have on the circumstances of the
child's death and about prior contacts with the child or family.
Standard data collection forms are used to record details about the
circumstances of the child's death and other information about the
child and their family obtained during the review process. Information
about the decedent and household members (including their
relationships) are recorded for each death, even if the death is not
reviewed by the full team. The completed forms are compiled by state-
level program personnel in the Department of Social Services who
routinely monitor completion of the forms and provide annual,
statewide training to ensure consistent and accurate data collection
by local teams.
Our findings in a study to analyze the first 3 years of CFRP data
showed that households with unrelated adults residing with the
decedent child were associated with significant increased risk of
fatal child maltreatment (adjusted OR [aOR] 8.8; 95% confidence
interval [95% CI] 3.6–21.5) (Stiffman, Schnitzer, Adam, Kruse, &
Ewigman, 2002). Risk was also increased for households where the
decedent resided with step or foster parents (aOR 4.7; 95% CI 1.6–
12.0), and households with other adults related to the decedent, e.g.,
grandparents, aunts, uncles; aOR 2.2; 95% CI 1.1–4.5 (Stiffman et al.,
2002). Risk was not elevated in households where the decedent resided
with a single parent and no other adults. This study was the first
population-based study of which we were aware to document an increased
risk of fatal maltreatment in households where men unrelated to the
decedent child reside and to show that single parenthood per se was
not a risk factor. However, the sample size was insufficient to
analyze maltreatment deaths caused by inflicted injuries separately
from unintentional injuries. These separate analyses are critical
because they might reveal different causal mechanisms.
For the present study, we obtained 5 years of additional CFRP data and
conducted separate analyses of children who died of injuries inflicted
by a parent or other adult caregiver and of those children who died of
maltreatment-related unintentional injuries. Our analysis of inflicted
injury deaths documented that children under age 5 residing with a
single parent and another unrelated adult had exceptionally high risk
of inflicted injury death (aOR 47.6; 95% CI 10.4–218; Schnitzer &
Ewigman, 2005). Risk was not significantly elevated for any other
household composition category, including households with a single
parent and no other adults in residence. The purpose of the present
analysis is to determine if household composition is an independent
risk factor for fatal unintentional injuries related to maltreatment
among children under 5 years old.
Methods
Study Design, Population, and Data Sources
We conducted a population-based case-control study using data from the
Missouri Child Fatality Review Program (CFRP) and Missouri birth
certificates. All children less than 5 years old who died in Missouri
between January 1, 1992 and December 31, 1999 were eligible for study.
CFRP data were provided by the Missouri Department of Social Services
(MDSS) in both electronic format and hard copy. Once case and control
children were selected for the study, the MDSS provided documentation
of child abuse and neglect reports received concerning these children
and the Missouri Department of Health and Senior Services provided
information from the children's birth certificate. All study team
members signed MDSS confidentiality statements and access to study
data was limited to the study team. This study was exempt from review
by the Health Sciences Institutional Review Board at the University of
Missouri.
Case Definition and Selection of Cases
Our child maltreatment case definition is based on the definition
developed by the National Institute of Child Health and Human
Development Working Group on Standard Definitions for Child Injury
Data, which states: "Child maltreatment is behavior directed toward a
child, which is outside the norms of conduct, and entails a
substantial risk of causing physical or emotional harm. Behaviors
include both actions and omissions (failure to act), and may be
intentional or unintentional." (Christoffel et al., 1992). The focus
of this study is on fatal unintentional injuries that meet this
definition of maltreatment. We operationalized this definition to
include deaths that occurred when the adult responsible for
supervising the child: (a) was not present at the time of the fatal
injury event, (b) was present but not capable of protecting the child
(e.g., intoxicated), (c) placed the child in an unsafe sleep
environment, or (d) failed to use legally mandated safety devices
(e.g., child restraints in a motor vehicle).
The first author (PGS) reviewed the CFRP data forms of every child
under age 5 who died of an injury or undetermined cause during the 8-
year study period. In addition to standardized items collected for
each type of injury (e.g., whether appropriate restraints were worn),
the data forms often contain detailed narrative descriptions of how
the injury occurred, which along with the standard items, were used to
determine whether the death met the case definition. For cases in
which there was uncertainty as to whether the case definition was met,
the second author (BGE) was consulted, the circumstances discussed,
and consensus reached.
Identification and Selection of Controls
Children who died of natural causes during the study period were
eligible to serve as controls. However, we excluded infants who lived
7 days or less (under the assumption that they probably never left the
hospital and therefore, unlike the study participants, were never
members of a household). We also excluded children whose household
information was missing from the CFRP form, and those whose death
resulted from sudden infant death syndrome (SIDS) because of the
potential for inflicted injury deaths of infants to be misclassified
as SIDS. Once infants meeting these exclusion criteria were
identified, we created a list of all children eligible to be in
control groups. Using a random number generator, we selected one
eligible control for each case child. The controls were frequency
matched to cases by month of age for infants, and by year for children
ages 1–4. Although selecting a higher ratio of controls per case would
have increased the power of the study, we had too few eligible
controls to select even two controls per case while maintaining the
age matching.
Exposure and Outcome Variables
The outcome of interest for this study was unintentional injury death
related to maltreatment injuries (as defined above). The primary
exposure variable was the decedent's household composition. We
classified household composition into five mutually exclusive
categories, based on relationship of the adults in the household to
the decedent child. The categories were households with: (a) two
biologic parents and no other adults, (b) one biologic parent and no
other adults, (c) one or two biologic parents and another adult
relative, (d) stepparents or foster parents, and (e) one or two
biologic parents and another unrelated adult. The five households (one
case and four controls) with adoptive parents were included in the
category of two biologic parents based on the assumption that adoptive
parents' motivation for becoming parents is strong, making them more
similar to biologic parents than to step or foster parents.
We developed rules to ensure that each case and control was classified
in only one household composition category. If the decedent resided
with an unrelated adult the household was classified in the unrelated
adult category, regardless of the other adult household members. If
the decedent resided with a step or foster parent in addition to
another related adult, the household was classified in the step or
foster parent category.
Statistical Analyses
We determined the distribution of all variables of interest and
potential confounding variables using univariate and bivariate
methods. We calculated odds ratios (ORs) and 95% confidence intervals
(95% CI) using logistic regression. In this study, the OR shows an
estimate of the risk of maltreatment-related unintentional injury
death associated with each household composition category when
compared to the reference category: households with two biologic
parents and no other adults.
Confounding variables (confounders) are variables that are related to
both exposure and outcome variables (Rothman & Greenland, 1998).
Potential confounders were identified from the literature and from
bivariate analyses of these data. Age is a well documented confounder
of child injury risk which we controlled for by matching cases to
controls by child age. Other potential confounders identified in this
study included child factors (race), maternal factors (age, education,
marital status, prenatal care, and Medicaid eligibility at child's
birth), and household factors (siblings under age 5, prior child
protective services reports on the child or other household members).
We considered a variable to be a confounder if its individual
inclusion in a logistic regression model with household composition
resulted in a change in the odds ratio of 10% or more (Rothman &
Greenland, 1998).
In preparation for conducting multivariate regression analyses, we
imputed missing values by assigning them the value represented by the
low-risk category. For example, records missing information on the
mothers' prenatal care were assigned a code reflecting initiation of
care in the first trimester of pregnancy. Imputation of missing
variables allows the use of all data for regression analyses, and has
been found to generate less biased results (Harrell, Lee, & Mark,
1996). Assigning the low risk category for missing variables results
in a more conservative effect estimate.
We then used multivariate logistic regression to calculate the aOR of
the relationship between household composition and risk of
unintentional injury death related to maltreatment while controlling
for the identified confounding variables. All statistical analyses
were conducted using SAS, version 8.2.
Findings
We identified 901 deaths that occurred during the 8-year study among
children under age 5 because of injury or undetermined causes. After
reviewing the CFRP records for each of the deaths we determined that
380 (42.2%) deaths met our case definition for inclusion as a
maltreatment-related unintentional injury death. Of the remaining 521
deaths: 149 (28.6%) were caused by inflicted injuries, 107 (20.5%)
were unintentional-injury deaths that did not meet our maltreatment
case definition, and 104 (20.0%) were deaths without adequate
information to determine if the case definition was met. Thirty-three
deaths were determined to be from natural causes and 128 were deaths
of unknown or undetermined cause, without adequate additional
information to further classify for this study.
Most of the cases included in this study met our definition of
maltreatment-related unintentional injury death because a parent, or
other adult responsible for supervising them, was not present when the
fatal injury occurred (n=164, 43.1%). In addition, over 100 infants
died as a result of being placed in an unsafe sleep environment
(n=103, 27.1%), and 63 (16.6%) deaths resulted from parental failure
to use mandated safety devices (61 were unrestrained passengers in
motor vehicles, 2 were not wearing floatation devices and drowned).
The parent(s) of 50 (13.2%) children were present but not capable of
protecting them (usually because of drug or alcohol use) when the
fatal injury occurred.
The distribution of child, maternal, and household variables for cases
and controls is shown in Table 1. Thirty-six percent of the children
were infants when they died, 57% were less than 2-years old and 75%
were less than age 3. Cases were more likely than were controls to be
male, born to young, unmarried, Medicaid-eligible mothers who had less
than a high school education, and received late or no prenatal care
during pregnancy. Cases were also more likely to reside in households
with siblings under age 5 and have a prior report of child abuse or
neglect concerning themselves and others in the household.
Table 1. Distribution of Select Child, Maternal, and Household
Variables for Cases and Controls, Maltreatment-Related Unintentional
Injury Death, Missouri, 1992–1999
--------------------------------------------------------------------------------
Variable Cases (%) Controls (%) Odds ratio (95%CI)
Child variables:
Sex
Male 245 (64) 195 (51) 1.7 (1.3–2.3)
Female 135 (36) 185 (49) 1.0
Race
Black/other 107 (28) 107 (28) 1.0 (0.7–1.4)
White 273 (72) 273 (72) 1.0
Maternal variables:
Age at child's birth
<25 years old 208 (55) 157 (41) 1.8 (1.3–2.5)
25+ years old 127 (33) 176 (46) 1.0
Missing (92) 45 (12) 47 (12)
Education at child's birth
<High school 140 (37) 89 (23) 2.0 (1.4–2.8)
High school graduate 189 (50) 240 (63) 1.0
Missing (102) 51 (13) 51 (13)
Marital status at child's birth
Not married 175 (46) 139 (37) 1.5 (1.1–2.1)
Married 159 (42) 194 (51) 1.0
Missing (93) 46 (12) 47 (12)
Month of first prenatal visit
None, 5th–9th month 70 (18) 36 (9) 2.2 (1.4–3.4)
1st–4th month 259 (68) 289 (76) 1.0
Missing (106) 51 (13) 55 (15)
Medicaid eligible at child's birth
Eligible 200 (53) 147 (39) 1.9 (1.4–2.6)
Not eligible 118 (31) 166 (44) 1.0
Missing (129) 62 (16) 67 (18)
Household variables:
Siblings under the age of 5
Yes 185 (49) 76 (20) 3.8 (2.8–5.3)
No 179 (47) 281 (74) 1.0
Missing (39) 16 (4) 23 (6)
Prior report of abuse/neglect on anyone in the household
Yes 113 (30) 47 (12) 2.3 (1.6–3.5)
No 176 (46) 172 (45) 1.0
Missing (252) 91 (24) 163 (43)
Prior report of abuse/neglect on decedent
Yes 18 (5) 10 (3) 1.8 (0.8–4.0)
No 362 (95) 370 (97) 1.0
--------------------------------------------------------------------------------
Although the majority of both cases (56%) and controls (63%) lived in
households with two biologic parents and no other adults (Table 2),
more cases than controls lived in households with step or foster
parents, other relatives, or other unrelated adults. In fact, 20% of
cases and only 6% of controls lived in households with adults other
than biologic parents.
Table 2. Multivariate Logistic Regression Results for the
Association Between Household Composition and Risk of Maltreatment-
Related Unintentional Injury Death, Missouri, 1992–1999
--------------------------------------------------------------------------------
Household composition category Case households (N=380), n (%) Control
households (N=380), n (%) Adjusteda OR (95%CI)
Two biologic parents only 213 (56) 239 (63) 1.0 (Reference)
One biologic parent only 92 (24) 119 (31) 0.7 (0.5–1.1)
Other relative present 29 (8) 11 (3) 2.1 (1.0–4.5)
Step or foster parent 18 (5) 7 (2) 2.6 (1.0–6.5)
Unrelated adult(s) 28 (7) 4 (1) 5.9 (1.9–17.6)
--------------------------------------------------------------------------------
a Late/no prenatal care, sibs < age 5, prior child abuse or neglect
reports on child or household.
--------------------------------------------------------------------------------
Compared to children residing with two biologic parents, children
living in households with adults unrelated to them had nearly six
times the risk of dying of unintentional injury related to
maltreatment (aOR 5.9; 95% CI 1.9–17.6). There was a two-fold or
greater increased risk of dying of a maltreatment-related
unintentional injury death for children living with step or foster
parents, or with other relatives (Table 2). There was no increased
risk noted for children residing in households with one biologic
parent and no other adults (aOR 0.7; 95% CI 0.5–1.1). This
multivariate logistic regression analysis controlled for identified
confounding variables including: late or no prenatal care, siblings
less than age 5 in the household, and prior child abuse or neglect
reports on the child or others in the household.
Discussion
We found that children less than 5 years of age living in households
with adults not related to them were six times as likely to die of a
maltreatment-related unintentional injury than were children residing
with two biologic parents. Children living with step or foster
parents, as well as those residing with other related adults (e.g.,
grandparents, aunt, uncle) also had elevated risk; twice that of
children residing with two biologic parents and no other adults.
This study is consistent with and adds to the results of our previous
research indicating the role of household composition as an
independent risk factor for fatal child maltreatment, and reinforces
our earlier findings that children living in households with an adult
unrelated to them have significantly increased risk of fatal injury
related to maltreatment (Stiffman et al., 2002). It also verifies that
risk remains when unintentional injury deaths are analyzed separately
from inflicted injuries; providing evidence that the increased risk of
maltreatment reported previously is not all accounted for by the
extremely high risk of inflicted injury death in households with
unrelated adults (aOR 47.6; 95% CI 10.4–218; Schnitzer & Ewigman,
2005).
In this analysis, we also found significantly elevated risk in
households with step or foster parents and those with adult relatives
in residence, indicating that young children incur excessive risk of
fatal maltreatment-related unintentional injury when residing with any
adult who is not a biologic parent. This is in contrast to our
published results on inflicted-injury deaths where households with
unrelated adults accounted for virtually all the excess risk of
household composition (Schnitzer & Ewigman, 2005). This finding is
consistent with the belief that different etiologies exist for
inflicted versus unintentional injuries related to maltreatment.
Our finding that children living with single parents (and no other
adults) did not have an increased risk of maltreatment-related
unintentional injury death also supports our earlier results, and is
important. Historical studies (Baldwin & Oliver, 1975; Wilson & Daly,
1987; Wilson et al., 1980) consistently reported that living with a
single parent is a risk factor for child abuse and neglect, in
contrast to our findings. The CFRP data contain household composition
details not typically obtained in prior research nor available in
administrative data. This household detail permitted categorization of
household composition based on the relationship of the adults in the
household to the decedent child, which allowed analysis of households
with a single parent separately from households with a single parent
and other (related or unrelated) adults in residence. Had we limited
our analysis to data comparing single-parent families to two parent
families, without separating single-parent households with and without
other adults, we would have erroneously concluded that single-parent
families are at higher risk of fatal maltreatment-related
unintentional injury. Like others, we would have missed the important
distinction of increased risk in households with single parents and
other adults, but no added risk in households with a single-parent
only.
The cumulative results of our research on household composition and
risk of maltreatment-related death indicate that household composition
is an independent risk factor for both fatal inflicted injury and
unintentional injuries related to maltreatment. We still do not know
the specific mechanism by which household composition confers risk;
however, it is likely to be a proxy for other, possibly known, but
unmeasured factors. We know both unintentional injuries and fatal
maltreatment are associated with lower socioeconomic status, young
maternal age, and lower maternal educational attainment, all factors
considered in our research. They are also associated with maternal
depression and lack of social support, information not available in
our data. However, health care providers will rarely have complete and
detailed information on all potential risk factors available to them
as they assess their patients. Information on household composition is
relatively easy to obtain and can be used either alone or in
combination with other established risk factors to identify young
children at risk for unintentional injury related to maltreatment.
An important finding in this study is that although relative risk to
children living with adults other than biologic parents is increased,
the majority of fatally maltreated children resided with two biologic
parents, indicating that the absolute risk to children in households
with unrelated adults is small. This apparent contradiction occurs
because the majority of fatally maltreated children refers to the data
on cases only (descriptive epidemiology) while the relative risk
reflects the comparison of cases to the control children. Because a
higher proportion of children who died of maltreatment-related
injuries (7%) than those dying of natural causes (1%) lived with
unrelated adults, the relative risk was higher.
Despite the low absolute risk, household composition is associated
with other measures of child well being, and we suspect it is a risk
factor for nonfatal maltreatment as well. In addition to identifying
potentially high-risk families, the results of this study can be used
by nurses (and other professionals who have frequent contact with
families with young children such as day care providers and WIC
clinics) in many ways. All the deaths included in this study were
potentially preventable. Nurses (and other health and child care
professionals) can have an important role in injury prevention by
offering the parents of young children information and directing them
to resources available to help them protect their children and provide
a safe environment. For example, 61 (16.0%) of the children in this
study were unrestrained passengers in motor vehicle accidents.
Ensuring the availability and correct use of child passenger
restraints can prevent hundreds of deaths and thousands of nonfatal
injuries each year. Also, 103 (27.1%) infants died as a direct result
of an unsafe sleeping environment. Recommendations for safe infant
sleeping include placing infants on their backs to reduce the risk of
SIDS; and placing infants in a crib that has proper spacing between
crib slats and a firm mattress covered by a tight fitting sheet, and
keeping soft objects and loose bedding out of the crib to reduce the
risk of unintentional suffocation. Finally, most of the children in
this study were fatally injured when the adult responsible for
supervising them was not present. Although there are no supervision
standards for children of all ages that are agreed upon by parents and
professionals, there is consensus that children under age 5 require
nearly constant adult supervision (Peterson, Ewigman, & Kivlahan,
1993). Children in this age group are not developmentally able to
distinguish injury risk or "learn from their mistakes." Nurses are
trusted health care professionals who frequently have contact with
parents and have the opportunity to provide information and resources
for injury prevention, including the need for nearly constant
supervision of young children. In the context of limited time and
resources in clinical settings, nurses might prioritize for
intervention those households in which unrelated adults, step, or
foster parents reside.
In addition to educational and injury-prevention implications in the
clinical setting, our findings have policy implications. The mothers
of children who died of maltreatment-related injuries in this study
were younger, less well educated, had lower income and were more
likely to have other young children in the home when compared to
mothers of children who died of natural causes. Although we don't know
the exact mechanism by which household composition increases risk,
state and federal policies that provide resources for families with
young children have the potential to address many known risk factors
and improve the health and well being of vulnerable children and
families.
This study has several limitations. Including children who died of
natural causes as controls ensured analogous data for cases and
controls and is appropriate for an initial population-based study;
however, the results provide little insight into how such cases differ
from living children, a question we would ultimately like to answer.
Use of existing data also resulted in a limited number of variables
for study and excluded examination of several notable risk factors for
child injury including child behavior and other parental, social, and
environmental characteristics. In addition, although the teams receive
annual training on how to accurately complete the data forms, and the
counties with the most child deaths have much experience doing so, the
reliability of the data have never been formally assessed.
Furthermore, we were not able to adequately assess interaction effects
because of the number of covariates and the relatively small number of
study subjects. Assessment of interaction might have provided
additional insight into specific variables that contribute to
increased risk for children in certain households. The number of
covariates relative to study subjects likely also contributed to the
imprecise effect estimates reflected by moderately wide confidence
intervals.
Despite these limitations, this study has many important strengths. It
is a population-based study for which we had access to a unique,
comprehensive, statewide CFRP database. In contrast, most previous
studies used data or recruited participants exclusively from child
protective service agencies, severely limiting the generalizability of
the findings. Another strength of the CFRP data is the inclusion of
detailed household information, which permitted the finite
classification of household composition based on the relationship of
the adults to the decedent child. Furthermore, the CFRP data include
considerable detail on the circumstances of the child's death,
information necessary for the application of our behavior-based
maltreatment case definition. We operationalized this case definition
by using objective criteria to consistently classify maltreatment-
related injury deaths for this research; criteria that can be used by
others to generate comparable data. Although this is a strength of
this research, it is important to note that the maltreatment deaths
identified here would not necessarily meet criteria used by a child
protective services agency to substantiate child abuse or neglect.
Analysis of the subset of maltreatment fatalities caused by
unintentional injuries is another study strength. The number of study
participants was large enough to assess the nature of the association
and the results contribute important additions to our understanding of
the complex nature of child maltreatment.
Conclusions
Household composition is an independent risk factor for fatal
maltreatment-related unintentional injuries among children under age
5. Young children residing with a single parent and another adult
unrelated to them have a risk of fatal maltreatment-related
unintentional injury that is six times that of children residing in
households with two biologic parents; the risk is double for children
residing with step or foster parents, or adults related to them.
Importantly, risk was not elevated among children residing with a
single parent and no other adults. Most of the children sustained
fatal injuries when the adult responsible for supervising them was not
present or when placed in unsafe sleeping environments, and all of the
fatal injuries were potentially preventable.
Nurses are trusted health professionals who often encounter families
with young children. Because time is rarely sufficient to adequately
address all important prevention topics in the clinical setting,
recognizing key injury risk factors can help nurses identify high-risk
families. Once identified, these families can be provided (or referred
for) appropriate education or resources for protecting their children.
For example, knowing that infants living with adults unrelated to them
are at increased risk of death in unsafe sleeping environments, nurses
can quickly assess infant sleeping arrangements in high-risk families
and provide educational information (about having infant sleep on
back, in a crib, and so on) and referral to services (safe cribs
program) when indicated. Likewise, nurses could initiate discussion of
age-appropriate supervision and resources for child care with the
parents of toddlers. Injuries remain the leading cause of death among
children of all ages and nurses have a unique opportunity to play an
important role in preventing childhood injury. Understanding key
injury risk factors can help with prevention efforts.
References
Administration for Children and Families. (2006). Child maltreatment
2003 . Retrieved March 19, 2007, from http://www.acf.hhs.gov/programs/cb/pubs/cm04/index.htm
Baker , S.P. , O'Neill , B. , Karpf , R.S. (1992). The injury fact
book (2nd ed.). New York : Oxford University Press.
Baldwin , J.A. , Oliver , J.E. (1975). Epidemiology and family
characteristics of severely-abused children. British Journal of
Preventive and Social Medicine , 29 , 205–221. Links
Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control. (2005). 10 leading causes of injury,
United States, 2004, all races, both sexes, disposition: All cases .
Retrieved March 19, 2007, from http://www.cdc.gov/ncipc/wisqars/nonfatal/quickpicks/quickpicks_2004/allinj.htm
Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control. (2006). WISQARS leading causes of death
reports, 1999 - 2004. Customized report . Retrieved March 19, 2007,
from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html
Christoffel , K.K. , Scheidt , P.C. , Agran , P.F. , Kraus , J.F. ,
McLoughlin , E. , Paulson , J.A. (1992). Standard definitions for
childhood injury research: Excerpts of a conference report.
Pediatrics , 89 , 1027–1034.
Ewigman , B. , Kivlahan , C. , Land , G. (1993). The Missouri child
fatality study: Underreporting of maltreatment fatalities among
children younger than 5 years of age, 1983 through 1986. Pediatrics ,
91 , 330–337. Links
Harrell , F.E. , Jr ., Lee , K.L. , Mark , D.B. (1996).
Multivariable prognostic models: Issues in developing models,
evaluating assumptions and adequacy, and measuring and reducing
errors. Statistics in Medicine , 15 , 361–387. Links
Landen , M.G. , Bauer , U. , Kohn , M. (2003). Inadequate
supervision as a cause of injury deaths among young children in Alaska
and Louisiana. Pediatrics , 111 , 328–331. Links
Larson , C.P. , Pless , I.B. (1988). Risk factors for injury in a 3-
year-old birth cohort. American Journal of Diseases of Children ,
142 , 1052–1057. Links
McClain , P.W. , Sacks , J.J. , Froehlke , R.G. , Ewigman , B.G.
(1993). Estimates of fatal child abuse and neglect, United States,
1979 through 1988. Pediatrics , 91 , 338–343. Links
Peterson , L. , Ewigman , B. , Kivlahan , C. (1993). Judgments
regarding appropriate child supervision to prevent injury: The role of
environmental risk and child age. Child Development , 64 , 934–950.
Links
Rivara , F.P. , Mueller , B.A. (1987). The epidemiology and causes
of childhood injuries. Journal of Social Issues , 43 (2), 13–31.
Links
Rothman , K.J. , Greenland , S. (1998). Modern epidemiology .
Philadelphia : Lippincott-Raven.
Schnitzer , P.G. , Ewigman , B.G. (2005). Child deaths resulting
from inflicted injuries: Household risk factors and perpetrator
characteristics. Pediatrics , 116 , e687–e693. Links
Stiffman , M.N. , Schnitzer , P.G. , Adam , P. , Kruse , R.L. ,
Ewigman , B.G. (2002). Household composition and risk of fatal child
maltreatment. Pediatrics , 109 , 615–621. Links
Wilson , M. , Daly , M. (1987). Risk of maltreatment of children
living with stepparents. In R.J. Gelles J.B. Lancaster (Eds.), Child
abuse and neglect: Biosocial dimensions (pp. 215–232). New York :
Aldine De Gruyter.
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composition and the risk of child abuse and neglect. Journal of
Biosocial Science , 12 , 333–340. Links
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prevention. A global call to action . Retrieved August 14, 2007, from
http://whqlibdoc.who.int/publications/2005/9241593415_eng.pdf
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Dan Sullivan
parents, or foster parents are at increased risk of fatal
unintentional injury related to maltreatment."
=======================
Comments, grag?
After all... it's from YOUR message!
You really don't read what you post!
:- )))))
Dan Sullivan
And more that grag obviously didn't read.
======================
Conclusions
Household composition is an independent risk factor for fatal
maltreatment-related unintentional injuries among children under age
5. Young children residing with a single parent and another adult
unrelated to them have a risk of fatal maltreatment-related
unintentional injury that is six times that of children residing in
households with two biologic parents; the risk is double for children
residing with step or foster parents, or adults related to them.
Importantly, risk was not elevated among children residing with a
single parent and no other adults.
======================
Greegor
and
http://www3.interscience.wiley.com/cgi-bin/fulltext/119422313/HTMLSTART
Methods : Children under age five who died during the 8-year study
period were eligible for study. Cases were defined as children who
died of an unintentional injury that occurred when a parent or other
adult caregiver: (a) was not present, (b) was present but not capable
of protecting the child, (c) placed the child in an unsafe sleep
environment, or (d) failed to use legally mandated safety devices.
Controls were randomly selected from children who died of natural
causes. Household composition was classified based on relationship of
the adults living in the household to the deceased child. The five
household composition categories were households with: (a) two
biologic parents and no other adults, (b) one biologic parent and no
other adults, (c) one or two biologic parents and another adult
relative, (d) stepparents or foster parents, and (e) one or two
biologic parents and another unrelated adult. Logistic regression
analyses were conducted and odds ratios estimating the risk of
maltreatment-related unintentional death associated with each
household category compared to the reference households: those with
two biologic parents and no other adults.
Dan, Did you notice that step parents and fosters were lumped
together?
Dan Sullivan
>
> Dan, Did you notice that step parents and fosters were lumped
> together?
You finally read what you posted!!!
Call the New York Times!!!
Kent Wills
wrote:
>Subject: Study: Kids safer with biological parents FULL TEXT
Lisa Watkins' daughter learned this all too well. She was abused
by Lisa's live in boyfriend (Gregory Scott Hanson).
"My family's case is for Neglect, but we are treated
in virtually every regard as child abusers, marked on
the Child Abuse registry, for example."
-- Gregory Scott Hanson, wife and child abuser.
Message-ID: <35120b16.04011...@posting.google.com>
Kent Wills
<dsul...@optonline.net> wrote:
>"Young children residing in households with unrelated adults, step-
>parents, or foster parents are at increased risk of fatal
>unintentional injury related to maltreatment."
>
Lisa's daughter learned this first hand. Though I think Greg's
acts of abuse were 100% intentional. Fortunately, the child was
removed before the abuse could become fatal.
>=======================
>
>Comments, grag?
>
>After all... it's from YOUR message!
>
>You really don't read what you post!
>
>:- )))))
I don't think Greg is able to read the articles. His mind
operates at around a fourth-grade level (seriously), so the text will
be beyond his ability to comprehend.
Mike Dobony
All I see are responses to the original post. Where is the full text? I
do know that boyfriends, especially live-in boyfriends accounts for a
significant number of sexual and physical abuse cases against children.
When will people learn that live-in relationships are deadly and stupid!
Greegor
> do know that boyfriends, especially live-in boyfriends accounts for a
> significant number of sexual and physical abuse cases against children.
> When will people learn that live-in relationships are deadly and stupid!
I once worked in a convenience grocery store that was
near a police station that was closed for some reason.
The store was robbed every single week, aboutt
half of the time using a real or fake snub nose pistol,
half of the time knife.
It was in a white neighborhood, but a "project" was
a few miles away. During the time I was there it
was never robbed by a white person. I asked people
who had worked there longer, they had never been
robbed by a white person.
It was politically incorrect to watch black people
more, but it was common sense in that situation.
Simple matter of survival.
The Police there did concealed stakeouts of several
convenience stores, including the one I was at.
It's very strange working a cash register knowing that
if somebody tries to rob the store they were
going to get their head blown off right there.
A few robbers died, the robbery rate plummeted
and eventually the Police station was manned again.
Mike, What would you do with those statistics?
Of course nonrelated caretakers are more dangerous.
Do you propose that mothers should never make
efforts to find a step parent?
Would you ban all step parenthhood?
Just presume they're all guilty based on the statistics?
You wouldn't apply that to black people would you?
When are people going to learn?
Isn't that a misapplication of statistics?
Are you a bureaucrat?
Some of them think that way.
Miraculously never about foster care, however.
THOSE stats are to be omitted, gerrymandered,
selected out, or explained away somehow.
Full text in message at this link.
http://groups.google.com/group/alt.support.child-protective-services/msg/b69270d7d9703ea2