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ELECTRONIC ARTICLE: Patricia G. Schnitzer and Bernard G. Ewigman Child Deaths Resulting From Inflicted Injuries: Household Risk Factors and Perpetrator Characteristics Pediatrics 2005; 116: e687-e693 [Abstract] [Full text] [PDF]

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Responst to ""Child Deaths Resulting From Inflicted Injuries: Household Risk Factors and Perpetrato"

Donald E. Mathis   (22 November 2005)

Identification of Inflicted Injury: Potential for Bias

Steve Piecuch, MD, MPH, Ramona Yubontoy, MD Attending Pediatrican, East New York Diagnostic and Treatment Center, Brooklyn, NY   (24 November 2005)

Responst to ""Child Deaths Resulting From Inflicted Injuries: Household Risk Factors and Perpetrato" 22 November 2005
Donald E. Mathis, Editor The Fourteen Percenter Send letter to journal: Re: Responst to ""Child Deaths Resulting From Inflicted Injuries: Household Risk Factors and Perpetrato" fourteenpercenter{at}yahoo.com Donald E. Mathis	Regarding "Child Deaths Resulting From Inflicted Injuries: Household Risk Factors and Perpetrator Characteristics" http://pediatrics.aappublications.org/cgi/content/full/116/5/e687 http://pediatrics.aappublications.org/current.shtml#ELECTRONIC_ARTICLE Nationwide, statistics for child abuse and murder are far away from your findings. Prevent Child Abuse Wisconsin http://www.preventchildabusewi.org/perpetrators.htm said regarding child abusers: "May be male or female -Data from 21 states indicate that 61.8% of perpetrators were female." The U.S. Department of Health and Human Services reported in their "Child Maltreatment 2003: Summary of Key Findings" http://nccanch.acf.hhs.gov/pubs/factsheets/canstats.cfm that "Approximately 80 percent of (child abuse) perpetrators were parents. Other relatives accounted for 6 percent, and unmarried partners of parents accounted for 4 percent of perpetrators." This contrasts sharply with your recent findings. The Health and Human Services report goes on to contradict your study further, "Women also comprised a larger percentage of all perpetrators than men: 58 percent compared to 42 percent." Perhaps it was your small group (149 children), the limits of age (less than five), or the small region (Missouri) that yielded results so different from larger studies. I would seriously question the Missouri Child Fatality Review Program, the source of the author's statistics. By the authors' own admission, "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." Also of note was the exclusion of statistics from Sudden Infant Death Syndrome. I find interesting that many cases of SIDS are found to be cases of Munchausen's Syndrome by Proxy. Inclusion of these other relevant data would certainly alter the authors' findings. Mothers, not fathers, are the main perpetrators of child abuse and death. I would dare say that mothers' intimate partners abuse and murder children more often than birth fathers. And it is only after recognition of such facts that we may begin to help the perpetrators - and in so doing - prevent child abuse and filicide. Conflict of Interest: None declared
Identification of Inflicted Injury: Potential for Bias 24 November 2005
Steve Piecuch, MD, MPH, Clinical Associate Professor of Pediatrics State University of New York, Downstate Medical Center, Brooklyn, NY, Ramona Yubontoy, MD Attending Pediatrican, East New York Diagnostic and Treatment Center, Brooklyn, NY Send letter to journal: Re: Identification of Inflicted Injury: Potential for Bias stevepiecuch{at}aol.com Steve Piecuch, MD, MPH, et al.	This study of child fatalities caused by inflicted injuries in Missouri was based upon the Child Fatality Review Program database, which relied upon investigations conducted by county-based multidisciplinary review teams (CBRT’s). The authors concluded that the majority of the perpetrators were male, resided in the household with the mother, and were either the child’s biologic father or the mother’s male companion. In households where unrelated adults resided, the unrelated household member was the perpetrator in the large majority of cases. Several questions can be raised regarding the methodology. While it is unlikely that a potential case of fatal inflicted injury would go uninvestigated, it is possible that the quality of the investigations conducted by individual CBRT’s varied, potentially resulting in misclassification of cases. For example, we do not know the level of training and experience of those doing the investigation in each county. We do not know how many cases were investigated by a medical examiner and how many were autopsied. The authors state that not all SIDS cases are fully investigated in Missouri. If that is the case, then it seems reasonable to question the quality of the childhood death investigations. The circumstances of death are not always obvious. Some cases of inflicted injury must have been misclassified as accidental and vice versa. We once cared for an infant who fell down a flight of stairs while in a walker and sustained a fatal epidural hemorrhage. While we accepted the family’s account of what had occurred, an infant pushed down the stairs by an angry parent could have had similar injuries. It is possible that bias entered into the classification of cases and the identification of perpetrators. It may be easier to believe that a male, particularly the mother’s live-in male companion, or an unrelated adult household member, would intentionally inflict a fatal injury on a child. Family members may be more willing to implicate an unrelated abuser than a relative. It is hypothetically possible that men and women utilize different methods to inflict injury, with the methods utilized by men being more readily identified as intentional. The mothers of children determined to have died of inflicted injury were more likely to be of minority background and lower socioeconomic status and to have had prior contact with child protective services. It is possible that child fatalities in such families were more aggressively investigated making it more likely that inflicted injury would be identified (either correctly or incorrectly) as the cause of death. Non-minority, less deprived families may have had access to more resources, including legal representation, reducing the likelihood that intentional injury would be identified. The overall effect would be bias away from the null, making it more likely that families of children who died of intentional injury would be found to differ from control families. While it is possible or even probable that the observed differences do exist, this bias would tend to exaggerate them. The authors make several appropriate recommendations for the prevention of intentional injury. They also suggest that welfare-to-work programs may increase the risk of inflicted injury by exposing children to male caretakers. This is an assertion with significant public policy implications and it would be interesting to know how many of the mothers of the victims identified in this study were employed outside the home and how many were doing so because of compulsory welfare-to-work programs. Welfare-to-work has the potential to reduce the risk of fatal inflicted injury, by improving the financial status of women and freeing them from dependence upon male abusers. Mathis, in the review of this article posted November 22, 2005, asserts that the findings of this study differ from those available from other sources which identify mothers as responsible for most cases of abuse and neglect. Mathis appears to be referring to abused and neglected children in general. This study is of a specific subpopulation of abused children, victims of fatal inflicted injury, and the findings are fully consistent with those of other studies. This is a very well done study of a relatively large number of cases and provides useful information for the pediatrician as well as for those involved in the investigation of suspected child abuse and neglect. Conflict of Interest: None declared