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Are abusive fractures in young children becoming less common? Changes over 24 years
John M Leventhal1, Ilse A Larson, Denise Abdoo
1Department of Pediatrics, Yale University School of Medicine, P.O. Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA.
Insights
The proportion of abusive fractures in young children significantly decreased between 1979 and 2002. This decline in child abuse indicators may be linked to earlier identification of maltreatment and support for at-risk families.
Area of Science:
- Pediatric medicine
- Child abuse and neglect research
- Forensic pediatrics
Background:
- Fractures in young children can be indicators of serious injury, including abuse.
- Evaluating the rate of abusive fractures over time is crucial for understanding trends in child maltreatment.
Purpose of the Study:
- To determine if the proportion of fractures rated as abusive in children under 36 months of age increased or decreased over a 24-year period (1979-2002).
Main Methods:
- Retrospective review of medical records for children under 36 months with fractures at a pediatric hospital across three time periods: 1979-1983, 1991-1994, and 1999-2002.
- Independent ratings of abuse likelihood by clinicians and radiologists using explicit criteria and a seven-point scale.
- Logistic regression analysis to compare the odds of abuse across the time periods, controlling for covariates.
Main Results:
- The proportion of fractures rated as abusive decreased significantly from 22.5% in 1979-1983 to 10.0% in 1991-1994 and 10.8% in 1999-2002.
- The adjusted odds of a fracture being rated as abuse decreased by over 50% from the early period to the middle and late periods.
- No significant difference was found in the odds of abuse between the middle and late periods.
Conclusions:
- The rate of abusive fractures in young children substantially decreased over the study period at a major pediatric hospital.
- This decrease may be attributed to earlier recognition of less severe forms of maltreatment and increased availability of services for high-risk families.
Objective:
To determine whether the proportion of fractures rated as abusive in children <36 months of age evaluated at a regional pediatric hospital increased over a 24-year period from 1979 to 2002. Fractures were chosen as an example of serious injuries in young children.
Methods:
Medical records were abstracted for all children <36 months of age who were seen at a single pediatric hospital with a fracture during three time periods: 1979-1983, 1991-1994, and 1999-2002. After reviewing the abstracted and radiographic information, two clinicians (one an expert on child abuse) and two pediatric radiologists each rated the likelihood of abuse using explicit criteria and a seven-point scale from definite abuse to definite unintentional injury. Ratings were done independently; when disagreements occurred, the case was discussed, and a joint rating was agreed upon, if possible. The proportions of cases rated as abuse were compared over the three time periods, and logistic regression was used to calculate adjusted odds ratios (OR).
Results:
In the early, middle, and late samples, there were 200, 240, and 232 children, respectively, with fractures. The proportion of cases rated as abuse decreased from 22.5% in the early period to 10.0% in the middle period and was 10.8% in the late period (p<.001). When comparing the odds of abuse in the middle and late groups to the odds of abuse in the early group (controlling for age, gender, ethnicity, type of medical insurance, and site of pediatric care), the adjusted ORs were .31 (95% CI=.15, .62) for the middle group and .45 (95% CI=.23, .86) for the late group. Thus, the odds of a given case being rated as abuse decreased by over 50% from the early period to the middle and late time periods. No statistically significant difference was found when comparing the odds of abuse for the middle group to those of the late group, OR: 1.46 (95% CI=.69, 3.08).
Conclusions:
The proportion of abusive fractures in young children decreased substantially from 1979-1983 to 1991-1994 and 1999-2002 at a major pediatric hospital. We speculate that this decrease may reflect early recognition of less serious forms of maltreatment and the availability of services to high-risk families.
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