Underascertainment of child abuse mortality in the United States

Context Mortality figures in the United States are believed to underestimat e the incidence of fatal child abuse. Objectives To describe the true incidence of fatal child abuse, determine t he 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 Classificatio n 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 ident ified in the search and 259 cases were reviewed after exclusion of fetal de aths and deaths of children who were not residents of North Carolina. 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 deter mined. The rate of child abuse homicide increased from 1.5 per 100 000 pers on-years in 1985 to 2.8 in 1994. Of all 259 child homicides, the state vita l records system underrecorded the coding of those due to battering or abus e by 58.7%. Black children were killed at 3 times the rate of white childre n (4.3 per 100 000 vs 1.3 per 100 000). Males made up 65.5% (133/203) of th e known probable assailants. Biological parents accounted for 63% of the pe rpetrators of fatal child abuse. From 1985 through 1996, 9467 homicides amo ng US children younger than 11 years were estimated to be due to abuse rath er 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 underasc ertainment of child abuse homicides in vital records systems persists despi te greater societal attention to abuse fatalities. Improved recording of su ch incidences should be a priority so that prevention strategies can be app ropriately targeted and outcomes monitored, especially in light of the incr easing rates.