Mortality figures in the United States are believed to underestimate
the incidence of fatal child abuse.
To describe the true incidence of fatal child abuse, determine the proportion
of child abuse deaths missed by the vital records system, and provide estimates
of the extent of abuse homicides in young children.
Design and Setting
Retrospective descriptive study of child abuse homicides that occurred
over a 10-year period in North Carolina from 1985-1994.
The Medical Examiner Information System was searched for all cases of
children younger than 11 years classified with International
Classification of Diseases, Ninth Revision codes E960 to E969 as the
underlying cause of death and homicide as the manner of death. A total of
273 cases were identified in the search and 259 cases were reviewed after
exclusion of fetal deaths and deaths of children who were not residents of
Main Outcome Measure
Child abuse homicide.
Of the 259 homicides, 220 (84.9%) were due to child abuse, 22 (8.5%)
were not related to abuse, and the status of 17 (6.6%) could not be determined.
The rate of child abuse homicide increased from 1.5 per 100,000 person-years
in 1985 to 2.8 in 1994. Of all 259 child homicides, the state vital records
system underrecorded the coding of those due to battering or abuse by 58.7%.
Black children were killed at 3 times the rate of white children (4.3 per
100,000 vs 1.3 per 100,000). Males made up 65.5% (133/203) of the known probable
assailants. Biological parents accounted for 63% of the perpetrators of fatal
child abuse. From 1985 through 1996, 9467 homicides among US children younger
than 11 years were estimated to be due to abuse rather than the 2973 reported.
The ICD-9 cause of death coding underascertained
abuse homicides by an estimated 61.6%.
Using medical examiner data, we found that significant underascertainment
of child abuse homicides in vital records systems persists despite greater
societal attention to abuse fatalities. Improved recording of such incidences
should be a priority so that prevention strategies can be appropriately targeted
and outcomes monitored, especially in light of the increasing rates.