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Household Composition and Risk of Fatal Child Maltreatment

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Approximately 2000 children die annually in the United States from maltreatment. Although maternal and child risk factors for child abuse have been identified, the role of household composition has not been well-established. Our objective was to evaluate household composition as a risk factor for fatal child maltreatment. Population-based, case-control study using data from the Missouri Child Fatality Review Panel system, 1992-1994. Households were categorized based on adult residents' relationship to the deceased child. Cases were all maltreatment injury deaths among children <5 years old. Controls were randomly selected from natural-cause deaths during the same period and frequency-matched to cases on age. The main outcome measure was maltreatment death. Children residing in households with adults unrelated to them were 8 times more likely to die of maltreatment than children in households with 2 biological parents (adjusted odds ratio [aOR]: 8.8; 95% confidence interval [CI]: 3.6-21.5). Risk of maltreatment death also was elevated for children residing with step, foster, or adoptive parents (aOR: 4.7; 95% CI: 1.6-12.0), and in households with other adult relatives present (aOR: 2.2; 95% CI: 1.1-4.5). Risk of maltreatment death was not increased for children living with only 1 biological parent (aOR: 1.1; 95% CI: 0.8-2.0). Children living in households with 1 or more male adults that are not related to them are at increased risk for maltreatment injury death. This risk is not elevated for children living with a single parent, as long as no other adults live in the home.
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DOI: 10.1542/peds.109.4.615
2002;109;615-621 Pediatrics
Bernard G. Ewigman
Michael N. Stiffman, Patricia G. Schnitzer, Patricia Adam, Robin L. Kruse and
Household Composition and Risk of Fatal Child Maltreatment
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Household Composition and Risk of Fatal Child Maltreatment
Michael N. Stiffman, MD, MSPH*; Patricia G. Schnitzer, PhD‡; Patricia Adam, MD, MSPH§;
Robin L. Kruse, PhD, MSPH‡; and Bernard G. Ewigman, MD, MSPH‡
ABSTRACT. Objective. Approximately 2000 children
die annually in the United States from maltreatment.
Although maternal and child risk factors for child abuse
have been identified, the role of household composition
has not been well-established. Our objective was to eval-
uate household composition as a risk factor for fatal child
maltreatment.
Methodology. Population-based, case-control study
using data from the Missouri Child Fatality Review
Panel system, 1992–1994. Households were categorized
based on adult residents’ relationship to the deceased
child. Cases were all maltreatment injury deaths among
children <5 years old. Controls were randomly selected
from natural-cause deaths during the same period and
frequency-matched to cases on age. The main outcome
measure was maltreatment death.
Results. Children residing in households with adults
unrelated to them were 8 times more likely to die of
maltreatment than children in households with 2 biolog-
ical parents (adjusted odds ratio [aOR]: 8.8; 95% confi-
dence interval [CI]: 3.6–21.5). Risk of maltreatment death
also was elevated for children residing with step, foster,
or adoptive parents (aOR: 4.7; 95% CI: 1.6–12.0), and in
households with other adult relatives present (aOR: 2.2;
95% CI: 1.1–4.5). Risk of maltreatment death was not
increased for children living with only 1 biological par-
ent (aOR: 1.1; 95% CI: 0.8–2.0).
Conclusions. Children living in households with 1 or
more male adults that are not related to them are at
increased risk for maltreatment injury death. This risk is
not elevated for children living with a single parent, as
long as no other adults live in the home. Pediatrics 2002;
109:615–621; epidemiology, injury, child abuse and neglect,
fatalities, mortality, maltreatment, case-control study,
death, risk factors, behavior.
ABBREVIATIONS. CFRP, Missouri Child Fatality Review Panel;
SIDS, sudden infant death syndrome; aOR, adjusted odds ratio;
CI, confidence interval.
Maltreatment of children causes an estimated
2000 deaths annually in the United States.
1
Ninety percent of these deaths occur among
children 5 years of age, making maltreatment the
leading cause of injury fatality in this age group.
1,2
Reports of fatal child abuse and neglect as well as
child homicide rates are rising steadily.
3–5
However,
methodologic challenges in child maltreatment re-
search have hampered identification of important
risk factors and the development of effective preven-
tion strategies.
6
Several studies have identified the following ma-
ternal risk factors for fatal child maltreatment and
child homicide
3,5,7–13
: young maternal age,
3,5,8,9,12,13
12 years of maternal education,
3,5,8,9
late or no pre-
natal care,
3,5,9,12,13
unmarried parents,
3,8,9,12
black
race,
3,5,12,13
and higher parity.
13
Child characteristics
that are risk factors include male gender
9,13
and low
birth weight.
3,7,8,12
Previously documented maltreat-
ment is a strong risk factor for child homicide.
10,11
These studies are limited by their lack of information
on household composition at the time of the child’s
death. Another limitation is their use of death certif-
icate designation of homicide or intentional injury as
the criterion for maltreatment. Because most mal-
treatment deaths are neither intentional nor homi-
cide, studies that use those narrower terms to define
maltreatment miss more than half of the cases.
2,4
The association of household composition with
child maltreatment has been studied for over 20
years. The earliest reports identified substantial
proportions (35%–54%) of maltreated children in
single-parent households and in stepfamilies.
14–16
Subsequent studies suggest an increased risk of mal-
treatment in such households.
17–21
However, these
studies are descriptive, lack a nonabused comparison
group, and do not control for confounding. To ade-
quately determine risk factors for fatal child mal-
treatment, researchers need data on maternal, child,
and family factors, including household composi-
tion.
6,22
To better recognize fatal maltreatment of children,
the state of Missouri in 1991 mandated the Missouri
Child Fatality Review Panel (CFRP) system. This
system ensures that child deaths (birth through age
17) are comprehensively reviewed and that stan-
dardized data are collected.
23–25
Because standard
items include household composition—people living
in the decedent child’s household at the time of death
and their relationships to the child—the CFRP data
are uniquely suited to evaluate risk factors for mal-
treatment fatality, including household composition.
From the *HealthPartners Research Foundation, Minneapolis, Minnesota;
‡Center for Family Medicine Science, Department of Family and Commu-
nity Medicine, University of Missouri–Columbia, Missouri; §Department of
Family Practice and Community Health, University of Minnesota, Minne-
apolis, Minnesota.
This work was completed at the Department of Family and Community
Medicine, University of Missouri–Columbia.
Received for publication Apr 5, 2001; accepted Sep 27, 2001.
Reprint requests to (M.N.S.) HealthPartners, 8450 Seasons Pkwy, Wood-
bury, MN 55125. E-mail: michael.n.stiffman@healthpartners.com
PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad-
emy of Pediatrics.
PEDIATRICS Vol. 109 No. 4 April 2002 615
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We report here a case-control study of household
composition and risk of fatal child maltreatment us-
ing these CFRP data.
METHODS
Population and Data Sources
Our study population included all Missouri resident children
5 years of age who died in Missouri from January 1, 1992, to
December 31, 1994. State law mandates that each county CFRP
collect and record information on each deceased child. First, the
county coroner or medical examiner and Chair of the Child Fatal-
ity Review Team systematically review each child death and com-
plete a data Form 1. Then, a county-level interdisciplinary child
fatality review teamincluding law enforcement, child protective
services, public health, medicine, the coroner or medical examiner,
and the county prosecuting attorneyconvenes to further review
deaths that meet any of 19 criteria (Table 1), and complete a data
Form 2. Deaths not meeting these criteria may also be reviewed at
the discretion of the panel chair. In addition to gathering detailed
information on the circumstances of each death, data on house-
hold members and their relationship to the decedent children are
gathered on all deceased children, regardless of cause of death,
even if the county CFRP team does not review the death. These
household composition data include the number of children in the
household; the parent or guardians marital status; the number of
adults in the household; how the adults were related to the child
decedent and to each other; their age and gender; plus the de-
ceased childs age, race, gender, and county of residence. For each
decedent, we obtained and linked the completed CFRP data
forms, the computerized CFRP data file, documentation of sub-
stantiated child abuse and neglect, Medicaid eligibility status,
birth certificate data, and death certificate data. All children with
a Missouri death certificate had a matched CFRP form, and 95%
had a matched birth certificate.
The study protocol was exempted from review by the institu-
tional review board at the University of Missouri Health Sciences
Center.
Case Definition
Our case definition of maltreatment is based on the definition
of the National Institute of Child Health and Human Develop-
ment Working Group on Standard Definitions for Child Injury
Data: 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.
26
We defined maltreatment injuries as those
that were either inflicted directly by a parent or other adult
caregiver responsible for the child at the time of injury, or that
resulted when the parent or caretaker failed to protect the child
from a hazardous circumstance. These failure-to-protect deaths
were considered maltreatment if the adult responsible for the
child was not present at the time of the fatal injury event, failed to
use legally mandated safety protective devices (car seats or water
flotation devices), or was present but was not capable of protect-
ing the child (intoxicated). Examples of hazardous circumstances
include handling a loaded gun, playing with a cigarette lighter, or
playing near a body of water or busy street.
Three authors (M.N.S., P.A., B.G.E.) manually reviewed all
hard copy data sources on all children less than age 5 who died
from an injury and whose death had been reviewed by the full
CFRP (N291). The investigators examined the injury circum-
stances and identified deaths meeting the maltreatment case def-
inition. We included cases regardless of whether the death oc-
curred in or out of the home, and regardless of the relationship of
the person in charge of the child at the time of death. When the
circumstances of a death were unclear, or when the files contained
conflicting information, we obtained copies of the autopsy reports,
reviewed the circumstances with the State Technical Assistance
Team for the CFRP system, and/or consulted a forensic patholo-
gist for a recommendation to guide our decision. We excluded
deaths that remained undetermined or that lacked sufficient in-
formation to be classified as maltreatment.
Selection of Controls
Children under age 5 who died of natural causes were eligible
to serve as controls. We excluded natural cause deaths related to
prematurity or congenital anomalies because the majority of these
children died before hospital discharge and therefore were never
members of a household in the same manner as cases. Deaths
related to unmet needswere also excluded. We included sud-
den infant death syndrome (SIDS) deaths as natural-cause deaths.
SIDS is a diagnosis of exclusion for the unexplained sudden death
of an infant 1 year old after 1) thorough case investigation,
including performance of an autopsy, 2) examination of the death
scene, and 3) review of the clinical history.
27
Missouris mandatory
CFRP review of all unexplained deaths among children 1 year of
age leaves little likelihood that a child abuse death could be
misclassified as a SIDS death.
Controls were randomly selected from the eligible deaths and
frequency-matched to cases by age at death. This matching was by
month of age for children 12 months old and by year of age for
children 1 through 4 years old. Our goal was to match 2 controls
to each case. To ensure the deaths were in fact attributable to
natural causes and that SIDS criteria were documented, we ran-
domly selected and reviewed 10% of controls. This review con-
firmed that the random sample of controls died of natural causes
or SIDS.
Classification of Household Composition
We classified households into 5 mutually exclusive categories:
households with 1) 2 biological parents of the deceased child and
no other adults, 2) 1 biological parent and no other adults, 3) 1 or
2 biological parents and another adult relative resident (grand-
mother, aunt, etc), 4) at least 1 step, foster, or adoptive parent, and
5) 1 or 2 biological parents and another, unrelated adult resident
(paramour, friend). Households in categories 3 through 5 with
residents in 1 category were coded using the following hierar-
chy. Households with an unrelated adult present were classified
in the last category, regardless of other household members.
Households with a step, foster, or adoptive parent in addition to
another relative were categorized in the step, foster, adoptive
parent group. Households with 2 biological parents and no other
adult residents were the reference group for analysis.
Statistical Analysis
We examined univariate and bivariate distributions of the vari-
ables of interest. We calculated odds ratios using logistic regres-
sion. The odds ratio provides an estimate of the relative risk of
maltreatment death associated with the particular household com-
position category.
Adjusted odds ratios (aORs) were calculated with logistic re-
gression, controlling for confounding factors. Based on prelimi-
nary analyses, potential confounding variables (those related to
both household composition and maltreatment death) were the
childs sex, race, age, and Medicaid-eligibility status; mothers age,
TABLE 1. Criteria for Child Fatality Review by the Full, Mul-
tidisciplinary County Panel, Missouri, 1992-1994
Sudden unexplained death, age 1y
Death unexplained/undetermined manner
Division of Family Services reports on the decedent or other
persons in the residence
Decedent in Division of Family Services custody
Possible inadequate supervision
Possible malnutrition or delay in seeking medical care
Possible suicide
Possible inflicted injury
Any firearm injury
Injury not witnessed by person in charge at the time of injury
Death attributable to confinement
Bathtub or bucket drowning
Suffocation or strangulation
Any poisoning
Severe unexplained injury
Pedestrian vehicle/driveway injury
Suspected sexual assault
Death attributable to any fire injury
Other suspicious findings (in injuries such as electrocution,
crush injury, or fall)
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education, and late or no prenatal care; the presence of siblings
under age 5 in the household, and a previous Division of Family
Services substantiation of abuse. We considered a variable to be a
confounder if inclusion in the logistic regression model resulted in
a change in the effect estimate of 10% or more.
28
Missing data were
imputed. Imputation is less biased than deleting records with
missing values when developing multivariable models.
29
Missing
data were coded to the low-risk or reference category for that
variable. For example, mothers educationwas missing for 49
(10.4%) of the 471 study participants, and these were coded as
high school graduate.
Subgroup Analyses
To evaluate whether the association between household com-
position and maltreatment death might differ for deaths caused by
inflicted injuries versus deaths from exposure to hazards, we
conducted 2 separate logistic regression analyses, 1 for each of
these subgroups.
We conducted 2 additional subgroup analyses to determine
whether the effects of household composition were different for
homicide cases, and substantiated child abuse or neglect cases.
Most studies of child maltreatment have used the homicide des-
ignation on the death certificate or substantiation of child abuse or
neglect by the appropriate state agency to define maltreatment.
Although we believe that these case definitions lead to substantial
misclassification and missed cases, we performed these analyses
so our findings could be compared with previous literature.
RESULTS
There were 2591 Missouri resident children under
age 5 that died in Missouri from 1992 through 1994.
A total of 952 deaths related to congenital malforma-
tions (427), prematurity (259), and other or undeter-
mined cause of death (266) were excluded, leaving
1639 deaths for study (Fig 1). Of the 291 injury
deaths, 175 (60%) met the study definition of mal-
treatment; 296 controls were selected from the 1348
eligible noninjury deaths. We were unable to select 2
controls for each case because of a lack of eligible 2-
and 3-year-old controls.
In 55 (31%) of the 175 maltreatment deaths, a par-
ent or other caregiver directly inflicted the fatal in-
jury. Of these, 39 (71%) were inflicted by shaking,
dropping, or hitting the child; 11 (20%) involved the
use of physical objects including firearms; and the
method of injury for the remaining 5 (9%) inflicted
injury deaths was unknown.
One hundred twenty (69%) maltreatment deaths
resulted when a parent or caregiver failed to protect
the child from a hazard. These deaths resulted from
fires (37, 31%), drowning (31, 26%), unsafe sleeping
arrangements (17, 14%), motor vehicles (17, 14%),
choking or strangulation (8, 7%), and other miscella-
neous hazards, including falls from heights, poisons,
and electrocution (10, 8%).
Select child, maternal, and household variables are
presented in Table 2. Compared with controls, chil-
dren who died of maltreatment were more likely to
be male, black, and the third or later child born to
their mother. Their mothers were more likely to have
been unmarried, have had less than a high school
education when the child was born, and to have
sought prenatal care after the fourth month of preg-
nancy, or not at all. Case children also were more
likely to have resided in households: 1) including
another relative, step-parent, or unrelated adult res-
ident, 2) where siblings 5 years old also lived, and
3) where abuse or neglect had been previously sub-
stantiated. Additional variables such as birth weight
and gestational age were evaluated in the univariate
and bivariate analyses but were not used in addi-
tional analyses because we found no differences be-
tween cases and controls. The age and education of
the childs father had over 40% of missing values,
and were not analyzed further.
Household Composition and Risk of Maltreatment
Death
Children residing in households with adults unre-
lated to them had the highest risk of maltreatment
death compared with decedent children residing in
households with 2 biological parents and no other
adults (aOR: 8.8; 95% confidence interval [CI]: 3.6
21.5; Table 2). Children in households with step,
foster, or adoptive parents also had an increased risk
of maltreatment death (aOR: 4.7; 95% CI: 1.612.0)
as did children in households with other relatives
present (aOR: 2.2; 95% CI: 1.14.5).
The majority (83%) of households with at least 1
unrelated adult resident consisted of the childs bio-
logical mother and her boyfriend. Similarly, 70% of
Fig 1. Selection of cases and controls from
population of children who died in Missouri,
19921994.
ARTICLES 617
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the case households (and only 30% of control house-
holds) in the step, foster, and adoptive category con-
tained a biological mother and stepfather. Therefore,
the increased risk of maltreatment death we found
occurs primarily in households including biologi-
cally unrelated adult males and boyfriends of the
childs mother. Thirty-nine percent of our control
children resided in households with only 1 biological
parent. Risk was not increased for children in house-
holds with 1 biological parent and no other adult
residents. Based on national data on household com-
position from the Federal Interagency Forum on
Child and Family Statistics,
30
we calculated a popu-
lation attributable risk of 12% for households with
single mothers and their partners, and 8% for step-
parent households. In our study, the partners were
mainly boyfriends; the identity of the partners were
not specified in the Federal Interagency Forum on
Child and Family Statistics data.
Subgroup Analyses
We considered subgroups of maltreatment deaths
by inflicted injury and exposure to hazardous cir-
cumstances. aORs for each household category were
similar to findings for all maltreatment deaths, ex-
cept for households with an unrelated adult (Table
3). Nineteen (34%) of the 55 children who died of
inflicted injuries lived in households with a steppar-
ent
4
or another unrelated adult.
15
Most of these in-
juries (15 of 19) were inflicted by the mothers boy-
friend or childs stepfather. The risk of death
attributable to an inflicted injury among children in
TABLE 2. Distribution of Select Child, Maternal, and Household Variables for Cases and Controls
Variable (Number Missing) Cases (%) Controls (%) Odds Ratio (95%CI)
Child variables
Sex
Male 117 (67) 162 (55) 1.7 (1.12.5)
Female 58 (33) 134 (45) Reference
Race
Black 63 (36) 78 (26) 1.6 (1.12.4)
White/other 112 (64) 218 (74) Reference
Age at death
1 y old 65 (37) 115 (39) 1.5 (0.83.1)
1 y old 39 (22) 75 (25) 1.4 (0.73.0)
2 y old 33 (19) 38 (13) 2.3 (1.15.1)
3 y old 25 (14) 33 (11) 2.0 (0.94.6)
4 y old 13 (7) 35 (12) Reference
Medicaid eligibility
Eligible 96 (55) 147 (50) 1.2 (0.91.8)
Not eligible 79 (45) 149 (50) Reference
Birth order (24)
Third or subsequent 83 (47) 87 (29) 2.2 (1.43.5)
Second child 38 (22) 81 (27) 1.1 (0.61.9)
First child 48 (27) 110 (37) Reference
Maternal variables
Age at childs birth (29)
20 y old 44 (25) 60 (20) 1.2 (0.81.9)
20 y old 127 (73) 211 (71) Reference
Education at childs birth (49)
Less than high school 82 (47) 96 (32) 1.7 (1.12.5)
High school graduate 82 (47) 162 (55) Reference
Marital status at childs birth (46)
Not married 98 (56) 121 (41) 1.8 (1.22.6)
Married 65 (37) 141 (48) Reference
Month of first prenatal visit (49)
None 8 (5) 8 (3) 1.7 (0.65.2)
5th9th month 35 (20) 35 (12) 1.7 (1.03.0)
1st4th month 123 (70) 213 (72) Reference
Household variables
Household composition*
One biological parent only 41 (23) 83 (28) 1.2 (0.82.0)
Other relative present 20 (11) 20 (7) 2.5 (1.34.9)
Step, other parent present 14 (8) 7 (2) 5.0 (2.112.0)
Other, unrelated adult present 29 (17) 7 (2) 10.3 (4.921.9)
Two biological parents only 71 (41) 177 (60) Reference
Siblings under the age of 5 (42)
Yes 102 (58) 92 (31) 3.1 (2.14.6)
No 62 (35) 173 (58) Reference
Previous Division of Family Services
substantiation of abuse
Yes 19 (11) 5 (2) 7.1 (2.917.1)
No 156 (89) 291 (98) Reference
Residence
Urban 72 (41) 126 (43) 0.9 (0.71.4)
Nonurban 103 (59) 170 (57) Reference
* Two controls lived in institutions, not residences, at the time of their death so they were not included in the household composition
classification.
618 HOUSEHOLD COMPOSITION AND RISK OF FATAL CHILD MALTREATMENT
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households with another unrelated adult was 27
times the risk of natural death.
Two additional subgroup analyses considered the
52 (30%) maltreatment deaths recorded as homicides
on death certificates and the 78 (45%) deaths substan-
tiated as child abuse or neglect fatalities by the Mis-
souri Department of Social Services (Table 4). The
aORs for step, foster, and adoptive parent house-
holds were again somewhat higher, and they were
markedly higher for households with unrelated
adults than for our broader maltreatment case defi-
nition.
Perpetrators
We had perpetrator information for most of the 55
maltreatment deaths that resulted from an inflicted
injury (Table 5). Of these 21 children, 38% sustained
injuries inflicted by a biological parent (18% by the
biological mother and 20% by the biological father).
Fourteen of the children (25%) were injured by their
mothers boyfriend, whereas only 1 child (2%) was
injured by their fathers girlfriend. The perpetrator
was unknown or not identified for 7 children (13%).
Table 5 also identifies the household composition
category of the decedent child. It is worth noting,
however, that perpetrators were not necessarily res-
idents of the decedent childs household.
DISCUSSION
Our study shows that Missouri children who died
from maltreatment injury were more likely to reside
in households with an unrelated adult, primarily an
adult male, than were children who died of natural
causes. This study also clarifies the role of single-
parent households as a risk factor for maltreatment
death. We found that children who died from mal-
treatment injury were no more likely than controls to
live in households with a single biological parentas
long as there were no other adults in the household.
Previous studies have not measured household com-
position or were unable to control for multiple vari-
ables. Our study design and unique data allowed us
to determine that 2 key risk factors are living with a
stepfather or the mothers boyfriend. This is the first
population-based case-control study to document an
increased risk of maltreatment death in households
where men unrelated to the decedent child reside
and the first to show that the increased risk in single-
parent households is present only when other adults
also reside in the house.
Our findings support previous studies and add
important new information to this body of literature.
A majority (58%) of our maltreated children resided
in households with only 1 biological parent (with or
without other adults). This proportion is similar to
the 35% to 57% of abused children residing with
single-parent families or stepfamilies cited in the lit-
erature.
1416,19
In contrast to past research, we found no increased
risk of maltreatment death in households with a
single biological parent and no other adult resident.
This may be attributable to our ability to categorize
households with only 1 biological parent separately
from households that also had other adults. For ex-
ample, the Third National Incidence Study of Child
Abuse and Neglect reported that children living with
single parents had 77% and 87% greater risk, respec-
tively, of harm by physical abuse and physical ne-
glect compared with children living with 2 parents.
21
No additional household composition data were re-
ported. Our findings suggest that the National Inci-
dence Study findings may reflect the increased risk
TABLE 3. aOR for the Association Between All Maltreatment Deaths, Deaths Attributable to Inflicted Injuries, and Deaths Attrib-
utable to Exposure to Hazards, and the Relationship of the Deceased Child to the Adults in the Household (Household Composition)
Household Composition aOR* (95% CI) for
All Maltreatment Deaths
(n175)
aOR(95% CI) for
Deaths Attributable
to Inflicted Injury
Only (n55)
aOR(95% CI) for
Deaths Attributable to
Exposure to Hazards
Only (n120)
Two biological parents only Reference Reference Reference
One biological parent only 1.1 (0.82.0) 0.9 (0.32.1) 1.4 (0.82.4)
Other relative present 2.2 (1.14.5) 2.2 (0.76.7) 2.2 (1.04.9)
Step, foster, adoptive parent 4.7 (1.612.0) 5.0 (1.122.9) 5.1 (1.715.3)
Other, unrelated adults present 8.8 (3.621.5) 26.9 (7.2100.2) 6.5 (2.318.1)
* Adjusted for presence of siblings under age 5 in the household, and previous Division of Family Services substantiation of abuse.
Adjusted for the decedents age, race, and medicaid status, mothers age and month of first prenatal visit, presence of siblings under age
5 in the household, and previous Division of Family Services substantiation of abuse.
Adjusted for the decedents Medicaid status, mothers education, presence of siblings under age 5 in the household, and previous
Division of Family Services substantiation of abuse.
TABLE 4. aOR for Homicide Deaths and Substantiated Abuse and Neglect Deaths
Household Composition aOR* (95% CI) for
Homicide
Deaths (n52)
aOR* (95% CI) for Substantiated
Abuse and Neglect
Deaths (n78)
Two biological parents only Reference Reference
One biological parent only 1.0 (0.42.5) 1.5 (0.73.1)
Other relative present 2.6 (0.88.2) 1.8 (0.65.1)
Step, foster, adoptive parent 6.1 (1.327.9) 8.3 (2.428.2)
Other, unrelated adults present 30.5 (8.1115.1) 17.9 (5.558.8)
* Adjusted for the decedents age, race, and Medicaid status; mothers age and month of first prenatal visit; presence of siblings under age
5 in the household; and previous Division of Family Services substantiation of abuse.
ARTICLES 619
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among single-parent households in which an unre-
lated adult male also resides.
Wilson and Daly
19
reported increased injury risk
for children living with single mothers resulted most
often from abuse, not by their mother, but by their
mothers boyfriend. Our data show the same pattern.
The reason children were more likely to die from
maltreatment if an unrelated adult resided in the
household is not clear. We suspect it may be the
result of a combination of factors. Perhaps the pres-
ence of an unrelated adult in the home is a marker
for instability in the household. It is also possible
that unrelated adults are not as keenly involved in
protecting children from harm as their biological
parents. In any event, our data cannot establish
cause-and-effect relationships, but it can identify as-
sociations and provide information for future ave-
nues of research.
Our studys strengths are attributable primarily to
the unique population-based CFRP data we used.
These data permitted classification of injury deaths
based on a definition of fatal maltreatment that was
developed to guide research and prevention. This
definition does not rely on knowledge of intent or on
labels assigned by law enforcement, the medical ex-
aminer, or the state child protective services agency.
Therefore, biases limiting much previous research
the underreporting of child abuse deaths and the
misclassification of infant and child homicides as
unintentional injury deathwere virtually elimi-
nated in this study.
2,4,3133
The detailed CFRP data on
household composition also made apparent the key
role of the unrelated adult male. Although 53 chil-
dren who died of SIDS served as controls, misclassi-
fication of an abuse death as SIDS would bias our
results toward the null.
We view the ability to use this research definition
of maltreatment as a study strength. We believe it
more accurately and completely identifies child mal-
treatment than the social or legal designation of child
abuse and neglect. To make our findings comparable
with other research or existing data, we have in-
cluded subgroup analyses using the more traditional
designations of substantiated child abuse or neglect
and homicide.
Using a control group of children who died of
natural causes is a limitation of this study. Although
this design allows us to compare children who die of
maltreatment with other children who die, it pro-
vides no insight on how fatally maltreated children
may differ from children who lived. A second limi-
tation is our inability to address risk factors for our
reference population, the 41% of maltreatment
deaths among children that resided in households
with 2 biological parents and no other adults. Finally,
the small number of study participants reduces the
precision of effect estimates (especially in subgroup
analyses) and limits analyses of other potential risk
factors and interaction effects.
Maltreatment accounts for most injury deaths
among young children, yet fatal maltreatment itself
is relatively uncommon. Although the relative risk of
fatal maltreatment is increased substantially if an
unrelated adult male resides with a child, the abso-
lute risk is relatively low. Therefore, most children in
this circumstance will not die from maltreatment.
Research is needed to show how household compo-
sition and other risk factors affect morbidity and
mortality related to child maltreatment, and what
interventions may reduce the risk. In the meantime,
professionals concerned with protecting children
should note the presence of unrelated adult males in
the home as 1 of many factors to consider when
assessing a childs risk for fatal maltreatment.
TABLE 5. Household Composition Category and Perpetrator of Injury for Children Who Died of Inflicted Injuries, Missouri,
1992-1994
Perpetrator Household Composition Category Total
2 Biological
Parents
1 Biological
Parent Only
Other
Relative
Step/Foster/
Adoptive
Other, Unrelated
Adult
Biological parent
Biological mother 5 3 2 10
Biological father 8 1 1 1 11
Unrelated male
Boyfriend of mother 1 1 12 14
Stepfather 213
Boyfriend/husband of babysitter 1 1 2
Male friend not living with mother 2 2
Related male
Uncle 11
Unrelated female
Girlfriend of father 11
Other
Babysitter 1 1
Sibling/step-sibling/half-sibling 18 y old 3 3
Unknown perpetrator
Child in care of
Babysitter 11
Grandmother and aunt 1 1
Stepfather and mother 1 1
Biological mother and father 2 2
Unknown 2 2
Total 20 10 6 4 15 55
620 HOUSEHOLD COMPOSITION AND RISK OF FATAL CHILD MALTREATMENT
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ACKNOWLEDGMENTS
Dr Stiffman was funded, in part, by faculty development grant
DHHS 5 D15 57 00811; Dr Adam was funded, in part, by NRSA
training grant 5T32 PE1700107; and Dr Kruse was funded, in
part, by NRSA training grant PE1003801. All were academic
fellows in the Department of Family and Community Medicine at
the University of MissouriColumbia during a portion of the time
this research was conducted. Drs Schnitzer and Ewigman were
funded, in part, by a grant from the American Academy of Family
Physicians to the Center for Family Medicine Science in the De-
partment of Family and Community Medicine.
We would like to thank Darla Horman for her conscientious
data management; Katherine Kaufer Christoffel, MD, MPH, for
her helpful consultation and review of an earlier version of this
manuscript; and Jay Dix, MD, forensic pathologist, for his time
and expertise. The Missouri Department of Health, the Missouri
Department of Social Services, and the State Technical Assistance
Team for the CFRP system and all the county CFRP teams made
the study possible through their diligent data collection and state-
of-the-art investigation system. Gary Stangler, Director of the Mis-
souri Department of Social Services, deserves special acknowledg-
ment for his unfailing support of this research.
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DOI: 10.1542/peds.109.4.615
2002;109;615-621 Pediatrics
Bernard G. Ewigman
Michael N. Stiffman, Patricia G. Schnitzer, Patricia Adam, Robin L. Kruse and
Household Composition and Risk of Fatal Child Maltreatment
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Between 1973 and 1986, 11,085 children born in Washington State were reported to the state child abuse registry. We analyzed the fatality rate subsequent to reported abuse for this cohort of children compared to a population of nonabused children matched on sex, county of birth, and year of birth. Children reported to the child abuse registry had an almost threefold greater risk of death than the comparison population. A report of physical abuse carried the greatest risk of subsequent death. However, the relative risks were also elevated for children who suffered neglect or sexual abuse. Children reported to the registry were almost 20 times more likely than the comparison population to die from homicide. Children less than 1 year of age at time of reported abuse had the highest fatality rate subsequent to abuse, but adolescents had the highest relative risk for fatality after abuse, compared to the population of nonabused children. Rates of fatality subsequent to abuse were equal for males and females. Although this study could not measure the extent to which any given intervention reduced the risk of subsequent fatality in abused children, registries can serve a valuable function in identifying subpopulations at risk and quantifying that risk relative to the general population.
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This study was undertaken to quantify various risks to children as a function of the identity of the person(s) in loco parentis. The household circumtances of children in Hamilton (a midsized Canadian city) were surveyed by telephone, and combined with information on child abuse victims, runaways, and juvenile offenders, to arrive at victimization rates according to age and household type.Both abuse and police apprehension were least likely for children living with two natural parents. Preschoolers living with one natural and one stepparent were 40 times more likely to become child abuse cases than were like-aged children living with two natural parents. Whereas abuse risk was significantly higher for children living with a stepparent than for those with a single parent, the reverse was true of the risk of apprehension for criminal offenses.Several variables were examined as possible confounds of household composition. Socioeconomic status, family size, and maternal age at the child's birth were all predictors of abuse risk, but these factors differed little or not at all between natural-parent and stepparent families and could not account for the stepparent-abuse association. As predicted from Darwinian considerations, stepparents themselves evidently constitute a risk factor for child abuse.
Article
Killings of children less than five years of age by stepfathers versus (putative) genetic fathers are compared on the basis of Canadian and British national archives of homicides. In addition to previously reported differences in gross rates, the two categories of killings differed in their attributes. Beatings constituted a relatively large proportion of steppaternal homicides, whereas genetic fathers were relatively likely to shoot or asphyxiate their victims. A substantial proportion of killings by genetic fathers, but almost none of those by stepfathers, were accompanied by suicide and/or uxoricide. These contrasts lend support to the hypothesis that the differential risks incurred by children in different household types reflect the differential parental solicitude that is predictable from an evolutionary model of parental motivation.
Article
Severe child abuse in north-east Wiltshire was studied retrospectively during the period 1965-71, and prospectively for 18 months from January 1972, after a period of consultative activity with those actively involved to increase awareness of the phenomenon. Severe abuse was strictly defined. A rate of 1 per thousand children under four years old was obtained, together with a death rate of 0-1 per thousand. The families of the retrospective series of abused children were studied in detail and identifying characteristics of large family size, youthfulness, low social-class, instability, and gross psychiatric, medical, and social pathology described. The implications of the ascertainment and death rates are discussed in relation to data from some other studies, and the need emphasized for detailed studies of the apparent clustering of disorder in the families, using linked record systems.
Article
As awareness of the huge human and other costs of injury has grown, research has expanded. There has not been any standard set of terminology for use in this research. As a result, research and surveillance data are too often difficult to interpret and compare. To overcome this impediment to gains in needed knowledge about childhood injuries, a conference was held in 1989 by the National Institute of Child Health and Human Development to develop a set of standard definitions. The full conference report is available from the US Government Printing Office. This report presents excerpts, emphasizing those--core--variables likely to be of use to the largest number of investigators. The conference recommendations presented address cross-cutting factors (age, race/ethnicity, location, socioeconomic status, and biopsychosocial development), effect modifiers (exposure, medical risk factors, substance abuse, time, injury severity, and social risk factors), and specific injuries (motor vehicle injuries, central nervous system injuries, falls, fire/burns, drowning, and violence). It is expected that childhood injury investigators will strive to meet the recommendations of this conference and that use of these definitions will lead to improvements in research and, ultimately, to revision of the definitions.
Article
Interagency child death review teams have emerged in response to the increasing awareness of severe violence against children in the United States. Since 1978, when the first team originated in Los Angeles, Calif, child death review teams have been established across the nation. Approximately 100 million Americans or 40% of the nation's population now live in counties or states served by such teams; most have been formed since 1988. Multiagency child death review involves a systematic, multidisciplinary, and multiagency process to coordinate and integrate data and resources from coroners, law enforcement, courts, child protective services, and health care providers. This article provides an introduction to the unique factors and magnitude of suspicious child deaths, and to the concept and process of interagency child death review. Future expansion of this process should lead to more effective multiagency case management and prevention of future deaths and serious injuries to children from child abuse and neglect.
Article
Death certificate of children less than 8 years of age who were killed between 1979 and 1986 were linked to their Ohio birth certificates and compared with those of Ohio children born in 1983 (controls). Having an unmarried mother increased risk of homicide almost fivefold (odds ratio 4.87). Having a teenage mother, a mother who had not graduated from high-school, and being of Black race or low birthweight each increased the risk by approximately threefold. Increases in the proportion of children born to unmarried mothers may contribute to increases in childhood homicide rates.
Article
A retrospective study of risk factors for traumatic infant deaths in Oregon occurring from 1973 through 1982 was performed using vital records and medical examiner records. A total of 146 such deaths occurred during this period. Relative risks were calculated for various risk factors in the study group compared with all Oregon births. Factors found to be significantly associated with all traumatic deaths were low maternal age, out-of-hospital birth, unwed mother, late or no prenatal care, low birth weight, and low maternal education. Race, sex, and birth order were not associated with traumatic infant death. The traumatic deaths were grouped into homicides and accidents. The same risk factor associations, with the exception of out-of-hospital birth, were found for each group.