Infanticide

Underascertainment of child abuse fatalities in France: retrospective analysis of judicial data to assess underreporting of infant homicides in mortality statistics

OBJECTIVES

Test the hypothesis of an underestimation of infant homicides in mortality statistics in France; identify its causes; examine data from the judicial system and their contribution in correcting this underestimation.

METHODS

A retrospective, cross-sectional study was carried out in 26 courts in three regions of France of cases of infant deaths submitted to the courts, 1996-2000, with follow-up of their files until case closing (1996-2008). For each case, cause of death established by the courts was compared with ICD cause of death as coded in official mortality statistics.

RESULTS

We examined 247 cases. Shortcomings in investigations were noted (autopsies: 75% of cases; fundus examination: 11%; diagnosis of sudden infant death syndrome [SIDS] without autopsy: 41%). Eighty deaths were considered homicides by the courts. Homicide rates in the court study are 2-3.6 times higher than those in mortality statistics. Nearly 1/3 of "accidental" deaths and 1/4 of deaths from unknown cause in mortality statistics are homicides. Mechanisms of underascertainment are: physicians' inappropriate death certification and underreporting of suspicious cases; inadequate investigation of cases; incomplete communication of final medical and forensic results to the mortality statistics department.

CONCLUSIONS

In a country where neither transportation of the body to a hospital nor autopsy is obligatory, judicial data can make an important contribution to correcting mortality statistics.

PRACTICE IMPLICATIONS

This study led to the first French protocol for investigating sudden unexpected deaths in infancy (SUDI). The protocol includes a physician "training" section focused on understanding the symptomatology and risk factors of violence, as well as the quality of death certification.

Characteristics of infant homicides: findings from a U.S. multisite reporting system

OBJECTIVE

The purpose of this study was to describe homicides of infants (children <2 years of age) in the U.S.

METHODS

Cases were derived from the National Violent Injury Statistics System; 71 incidents involving 72 infant homicides were in the data set. Type 1 involved beating/shaking injuries inflicted by a caretaker; type 2 involved all other homicides (including neonaticide, intimate partner problem-related homicide, crime-related death, and other types).

RESULTS

Seventy-five percent of the incidents were type 1 incidents, perpetrated mainly by men (83%; typically the infant's father or the boyfriend of the infant's mother). In 85% of the type 1 incidents, the infant was transported to the hospital, usually at the initiative of the perpetrator or another household member. In almost one half of the type 1 incidents, a false story was offered initially to explain the injuries. In contrast, the type 2 incidents (16 cases) were perpetrated mainly by women (11 of 16 cases) and involved methods such as poisoning, drowning, sharp instruments, or withdrawal of food and water; most infants were not taken to the hospital. Although 93% of incidents were perpetrated by caretakers, the large differences between the 2 incident types suggest different avenues for prevention.

CONCLUSIONS

The circumstances involved in the type 1 homicides (beatings by caretakers) suggested that those attacks occurred impulsively, death was unintended, and emergency care was summoned, often with a false story. Previous abuse was suspected in more than one half of those incidents.

Child deaths resulting from inflicted injuries: household risk factors and perpetrator characteristics

OBJECTIVE

To determine the role of household composition as an independent risk factor for fatal inflicted injuries among young children and describe perpetrator characteristics.

DESIGN, SETTING, AND POPULATION

A population-based, case-control study of all children < 5 years of age who died in Missouri between January 1, 1992, and December 31, 1999. Missouri Child Fatality Review Program data were analyzed. Cases all involved children with injuries inflicted by a parent or caregiver. Two age-matched controls per case child were selected randomly from children who died of natural causes.

MAIN OUTCOME MEASURE

Inflicted-injury death. Household composition of case and control children was compared by using multivariate logistic regression. We hypothesized that children residing in households with adults unrelated to them are at higher risk of inflicted-injury death than children residing in households with 2 biological parents.

RESULTS

We identified 149 inflicted-injury deaths in our population during the 8-year study period. Children residing in households with unrelated adults were nearly 50 times as likely to die of inflicted injuries than children residing with 2 biological parents (adjusted odds ratio: 47.6; 95% confidence interval: 10.4-218). Children in households with a single parent and no other adults in residence had no increased risk of inflicted-injury death (adjusted odds ratio: 0.9; 95% confidence interval: 0.6-1.9). Perpetrators were identified in 132 (88.6%) of the cases. The majority of known perpetrators were male (71.2%), and most were the child's father (34.9%) or the boyfriend of the child's mother (24.2%). In households with unrelated adults, most perpetrators (83.9%) were the unrelated adult household member, and only 2 (6.5%) perpetrators were the biological parent of the child.

CONCLUSIONS

Young children who reside in households with unrelated adults are at exceptionally high risk for inflicted-injury death. Most perpetrators are male, and most are residents of the decedent child's household at the time of injury.

Household composition and risk of fatal child maltreatment

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 evaluate 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 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).

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.