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An epidemiological study of child abuse
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Child Abuse and Neglect, vol. 3, pp 601 - 605. 0 Pergamon Press Ltd., 1979. Printed inGreatBritain.
AN EPIDEMIOLOGICAL
STUDY OF CHILD ABUSE
Susan Jean Creighton N.S.P.C.C.,
1
Riding House Street, London WlP 8AA
ABSTRACT An analysis is presented of 905 cases notified to N.S.P.C.C. Special Unit Registers of Suspected Non-Accidental Injury during 1976. INTRODUCTION In 1976, thirteen per cent of the child population of England and Wales were living in areas These were maintained by N.S.P.C.C. covered by Registers of Suspected Non-Accidental Injury. Special Units sited in Manchester, Leeds, Newcastle upon Tyne, Northampton, Coventry, Nottingham and Goldthorpe. The areas covered by their Registers In 1976 Included both Children aged less than Metropolitan Counties and Districts and Non-Metropolitan Counties. 16 years* living in these areas were notified to their Register if they fulfilled the following criteria:"All physically inJured children where the nature of the injury is not consistent with the account of how it occurred or where other factors indicate that there is a reasonable suspicion that the Injury was inflicted or not prevented by any iS In exceptional circumstances, person having custody, charge or care of the child. children who have neverrreceived a suspected non-accidental injury but are considered to be at serious risk of injury by the notifier, may be accepted for registration". 905 such children were registered with N.S.P.C.C. Special Units in 1976, mostly by Social Of these, 656 had been injured and 249 were thought to be'at serious Service Departments. This represents a registration rate of 0.68 per thousand children and an risk of injury. injury rate of 0.5 per thousand children less than 15 years old. Amongst the injured were 12 children whose injuries were subsequently Judged to have been caused accidentally. The data on these has been excluded from the analysis. The injured children were divided into five categories depending on the type and severity of These categories were 'Fatal', 'Serious', 'Moderate', 'Failure to Thrive' their injury. (? to T) and 'Sexual Abuse'. The 24s'uninJured children notified to the Registers as being at serious risk of non-accidental injury were assigned to a separate 'Prodromal' category. All cases which resulted in death, where the cause of death was medically confirmed to be due to non-accidental injury were put in the 'Fatal' category. 'Serious' injuries included all fractures, head Injuries, internal injuries, severe burns and ingestion of toxic substances. 'Moderate' injuries included all soft tissue injuries of a superficial nature. Infants and children whose weight fell progressively below that expected for their age, and where there was no medical explanation for the condition, were registered in the 'Failure to Thrive' category. The 'Sexual Abuse' category comprised those children suspected of having been sexually abused but without any accompanying physical injury. Seven children were fatally injured, 91 seriously and 520 moderately, 24 failed to thrive and there were
*Four years in Leeds Metropolitan
District 601
602
S.J. Creighton
two cases of sexual abuse. Three of the dead children came from one family, where the father had killed them, his wife and the cleaning lady, before setting fire to the public house where they lived and committingsuicide by throwing himself into the flames. Table 1 shows the breakdown of cases by severity of injury. TABLE 1 Number of Registered Children by Severity of Injury Severity of Injury Fatal Serious Moderate Failure to Thrive Sexual Abuse Rate per 1,000 linder15's*
Number of Cases
Percentage
9: 520 24 2
[lt*:l {“;:;;
0.5
Accidentalinjuries Prodromal
12 249
Total registered
905
Rate per 1,050 under 15's*
( 0:3t
0.68
*Populationestimates,1976 (O.P.C.S.,1977) The majority of the injured children (81 per cent) received soft tissue injuriesonly, mostly bruising,with the head and face the commonest site, The percentageof moderately injured children in the sample was larger than that of a previous study (Creightonand Owtram, 1977) on the children registeredwith the five N.S.P.C.C.Special Units operational There was a correspondingdecrease in fatal and serious injuries from 2% in in 1975. 1975 to 15% in 1976. The absolute numbers, as well as the percentages,of fatal and serious injuries fell between the two years in spite ot an increasedsample size. The types of injury which have shown the largest decrease have been skull fractures,brain and eye damage i.e. serious head injuries. In view of the concern shown by various authors (Oliver,1975; Eppler and Brown, 1977) at the proportionof children amongst the mentally retarded populationwhose symptoms seem to have been initiatedby an incident of abuse, this decrease in serious head injuries,since the introductionof registersand their associatedmanagement procedures,is an encouragingsign.
The injured childrendiffered significantlyfrom the national distributionof childrenaged less than 16 in their age, sex and birthweight. They were younger, more likely to be boys and had lower birthweightseven when social class was controlled, The younger the child the more likelihoodthere was of the injury being serious, a finding which has been shown in other epidemiologicalstudies (Friedrich,1976; Gonzales-Pardoand Thomas, 1977). Table 2 shows the distributionof the different categoriesof severity of injury by the age of the child. Boys outnumberedgirls in the ratio of 5:4 in each group except the 0 - 6 months and the 15 - 16 year olds. Gil (1970) and Friedrich (1376) found that over the age of 12 years girls were more likely to be reported than boys, which Gil ascribed to parental panic at their adolescentdaughters'burgeoningheterosexualrelationships. The preponderance of girls in the 0 - iimonth age group of the 1976 data is more difficult to explain.
603
An EpidemiologicalStudy
TABLg 2 Age of Child
Severity of InJury by Age of Child
Fatal
Serious
O- mths
2 (28.6)
25 (27.4)
6- mths
1 ( 14.3)
l- yrs 2- yrs
1 ( 14.3)
4- yrs
z (10.9)
13 (14.3)
35 ( 6.7)
4 (16.7)
( 8.2)
17 (18.7)
62 (11.9)
4 (16.7)
(12.9)
20 (22.0)
121 (23.3)
8 (33.3)
43 ( 8.3) 145 (27.9) 71 (13.7)
1
14.3)
lo- yrs
2
28.6)
5 ( 5.5) 1 (
7 (100)
F to T 7 (29.2)
5- yrs 15-16~~s
Moderate
Sexual Abuse
36 ( 6.9)
2 ( 2.2) 8 ( 8.8)
Totals
Total
Severity of Injury
1.1)
91 (loo)
(23.3) 1 (50)
( 7.1) (24.1)
1 (50)
(12.3)
1 ( 4.1)
( 1.2)
7 ( 1.3) 520 (100)
24 (100)
2 (loo)
(100)
Informationwas available on the birth weight of nearly half the sample of injured children. Of these, some 16.1% weighed less than 2,500 grams at birth. This is significantlymore (Chi square = 53.2 with 6 df. p<.OOl) than the national distributionof 7.8 for Social Classes IV and V and 'UnsupportedMothers' taken from a recent representativesample (Chamberlainet al., 1975). The birthweightsof the 'prodromal'cases showed a similar distribution. There was a high rate of illegitimacyamongst the sample compared to national distributionscontrolledfor age of mother (c.S.O.,~). If only the cases with information on legitimacyare consideredthe figure rises to 3%. Friedrich (1976) and Smith (1975) found similar rates amongst their samples. 34.5% of the injured children had been Injured on a previous occasion,a similar percentage to that of the childrenregistered in 1975. The childrenwho had been injured before registrationwere, on average, four months younger than those without such a history.
Only 52$ of the InJured childrenwere living with both natural parents at the time of the incident. 22% were living with their mother and a father substituteand 2% were living with one parent alone, usually the mother. These atypical parental situationsare associatedwith a high rate of marital discord In the registeredchild's family at the time of the incident. Of all the stress factors thought to have had a possible contributory effect, marital discord was cited most frequently. The mean ages of the male and female caretakerswere 30 and 26% years respectively. The male caretakerswere in mainly semi-skilledand unskilledoccupationsand a third of them were unemployedat the time of the incident. 34% of the male and 12.4% of the female caretakershad a criminalrecord. Males were just as likely to have committedviolent as non-violentoffenceswhereas females were four times as likely to have committednon-violent crimes. Although the ratio of violent to non-violentoffences is higher in males than females in the general population (C.S.O.,7)it is not as marked as in this sample. There was informationon the perpetratorin two thirds of the cases. Mothers or mother substituteswere suspected in 44s of these cases and fathers or father substitutesin 46.s. Siblings, other relatives,other adults or childrenwere implicatedIn the remainder. In those familieswhere there were two natural parents mothers were suspected in 375 and fathers in 5% of the cases. In familieswhere there were mother or father substitutes, the substituteswere suspectedof inJuring the child twice as often as the natural parent. When compared to the familieswith two natural parents the mothers with father substitutes don't differ significantlybut the fathers with mother substitutesdo (Chi square = 5.1 with 1 df. p<.O25). There was a slight tendency for mothers to injure younger children and fathers older ones and also for mothers to injure their childrenmore seriously.
604
S.J. Creighton
Fathers were over twice as liable to prosecution as mothers even though adult court proceedings were brought more often in the case 0:‘ serious injuries.
THE FAMILIES Just over half the injured children came from families with three or more children. The equivalent percentage for the national distribution of unskilled and semi-skilled workers Family sizes ranged from 1 to 12 with an average of 2.9 children. is 29.1% (c.s.0,,6). This over representation of large families in the register sample can be partly attributed to earlier parenthood. The injured child was three times as likely to be born to a mother aged lees than 20 years as a child from a similar socio-economic backwound. Although 50.8% of the children came from families with three or more children 76$ of them were either the first or second born in thei? families. Both the family size and birth order distributions of the injured children differed si@ficantly (Chi square = 196.9 for family size and 17.3 for ordinal position with 3 d.f. p(.OOl) from national samples of similar social class with the register sample having larger families and more fourth and later born children. The differences intween the sample and national distributions in family size were considerably more marked than those of birth order however. This complex interaction between family size and ordinal position was also found in the sample registered in 1975.
THEEN-VIRBNMENT The families'type of accommodation, tenure and amenities were found not to differ quantitatively from the national distribution for similar social classes. Nearly half the sample had been living in their present accommodation for less than a year and 30$ had been there for less than six months. Only 8% had been resident for over five years The mobility of families with compared to 7% for manual workers generally (C.S.O.,6). abused children remarked on by Gil (1970) is shown clearly in this sample. The four most frequently quoted stress factors judged to have been present at the time of of the notified injury were marital discord, financial problems, unemployment and a poor self-image on the part of the parents. That this period was a stressful one for the families is indicated by the fact that over 50 per cent of them had four or more stress factors present then.
SUlWARY There were more school age children registered in 1976 than in previous years, in line with the growing concern of the education authorities over the problem of child abuse. The features which distinguished the 1976 sample from national distributions controlled for social class remained the same. The youngest age groups, boys and low birth weiats were .a11 over represented ailongst the in,jured chiltire~ iihilst early pa?enthood, large faxilies and abnormal family structures, low social class, high unemplo:jment and mobility characterised their parents. In spite of: this seeming lack of change workers in the field should be encouraged by the continued decrease in serious injuries, and serious head injuries in particular, shown in successive register samples.
REFERENCES Central Statistical
Office (1975)
Social Trends 1975 (no.6), HMSO, London.
Central Statistical
Office
Social Trends 1976 (No.~), HMSO, London.
Chamberlain, London.
(l976)
G.V.P., Chamberlain,
R. and Claireaux, A. (1975) British Births 1970, Heinemann,
Creighton, S.J. and Owtram, P.J. (1977) Child Victims of Physical Abuse, N.S.P.C.C., London.
An EpidemiologicalStudy
605
M. Eppler and G. Brorq-n, Child abuse and neglect: preventablecauses of mental retardation, Child Abuse and Neglect, 1, j@3 (1977). U.N. Friedrich, Epidemiologicalsurvey of physicalchild abuse, Texas Med., 72, 81 (1976). Gil, D. (1970) Violence against Children: Physical Child Abuse in the United States, Harvard University Press, Cambridge,Mass. L. Gonzalez-Pardoand M. Thomas, Child abuse and neglect: epidemiologyin Kansas, J. Kansas Med. Sot., 78, 65 (1977). Office of PopulationCensusesand Surveys (1977) Populationestimates1970 (provisional) I.975(revised),PPl no.2, HMSO, London. J.E. Oliver, Microcephalyfollowingbaby batteringand shaking,Brit. Med. J., 2, 262 (1975). Smith, S.bI.(1975) The Battered Child Syndrome,Butterworth,London.
Child Abuse and Neglect, vol. 3, pp 601 - 605. 0 Pergamon Press Ltd., 1979. Printed inGreatBritain.
AN EPIDEMIOLOGICAL
STUDY OF CHILD ABUSE
Susan Jean Creighton N.S.P.C.C.,
1
Riding House Street, London WlP 8AA
ABSTRACT An analysis is presented of 905 cases notified to N.S.P.C.C. Special Unit Registers of Suspected Non-Accidental Injury during 1976. INTRODUCTION In 1976, thirteen per cent of the child population of England and Wales were living in areas These were maintained by N.S.P.C.C. covered by Registers of Suspected Non-Accidental Injury. Special Units sited in Manchester, Leeds, Newcastle upon Tyne, Northampton, Coventry, Nottingham and Goldthorpe. The areas covered by their Registers In 1976 Included both Children aged less than Metropolitan Counties and Districts and Non-Metropolitan Counties. 16 years* living in these areas were notified to their Register if they fulfilled the following criteria:"All physically inJured children where the nature of the injury is not consistent with the account of how it occurred or where other factors indicate that there is a reasonable suspicion that the Injury was inflicted or not prevented by any iS In exceptional circumstances, person having custody, charge or care of the child. children who have neverrreceived a suspected non-accidental injury but are considered to be at serious risk of injury by the notifier, may be accepted for registration". 905 such children were registered with N.S.P.C.C. Special Units in 1976, mostly by Social Of these, 656 had been injured and 249 were thought to be'at serious Service Departments. This represents a registration rate of 0.68 per thousand children and an risk of injury. injury rate of 0.5 per thousand children less than 15 years old. Amongst the injured were 12 children whose injuries were subsequently Judged to have been caused accidentally. The data on these has been excluded from the analysis. The injured children were divided into five categories depending on the type and severity of These categories were 'Fatal', 'Serious', 'Moderate', 'Failure to Thrive' their injury. (? to T) and 'Sexual Abuse'. The 24s'uninJured children notified to the Registers as being at serious risk of non-accidental injury were assigned to a separate 'Prodromal' category. All cases which resulted in death, where the cause of death was medically confirmed to be due to non-accidental injury were put in the 'Fatal' category. 'Serious' injuries included all fractures, head Injuries, internal injuries, severe burns and ingestion of toxic substances. 'Moderate' injuries included all soft tissue injuries of a superficial nature. Infants and children whose weight fell progressively below that expected for their age, and where there was no medical explanation for the condition, were registered in the 'Failure to Thrive' category. The 'Sexual Abuse' category comprised those children suspected of having been sexually abused but without any accompanying physical injury. Seven children were fatally injured, 91 seriously and 520 moderately, 24 failed to thrive and there were
*Four years in Leeds Metropolitan
District 601
602
S.J. Creighton
two cases of sexual abuse. Three of the dead children came from one family, where the father had killed them, his wife and the cleaning lady, before setting fire to the public house where they lived and committingsuicide by throwing himself into the flames. Table 1 shows the breakdown of cases by severity of injury. TABLE 1 Number of Registered Children by Severity of Injury Severity of Injury Fatal Serious Moderate Failure to Thrive Sexual Abuse Rate per 1,000 linder15's*
Number of Cases
Percentage
9: 520 24 2
[lt*:l {“;:;;
0.5
Accidentalinjuries Prodromal
12 249
Total registered
905
Rate per 1,050 under 15's*
( 0:3t
0.68
*Populationestimates,1976 (O.P.C.S.,1977) The majority of the injured children (81 per cent) received soft tissue injuriesonly, mostly bruising,with the head and face the commonest site, The percentageof moderately injured children in the sample was larger than that of a previous study (Creightonand Owtram, 1977) on the children registeredwith the five N.S.P.C.C.Special Units operational There was a correspondingdecrease in fatal and serious injuries from 2% in in 1975. 1975 to 15% in 1976. The absolute numbers, as well as the percentages,of fatal and serious injuries fell between the two years in spite ot an increasedsample size. The types of injury which have shown the largest decrease have been skull fractures,brain and eye damage i.e. serious head injuries. In view of the concern shown by various authors (Oliver,1975; Eppler and Brown, 1977) at the proportionof children amongst the mentally retarded populationwhose symptoms seem to have been initiatedby an incident of abuse, this decrease in serious head injuries,since the introductionof registersand their associatedmanagement procedures,is an encouragingsign.
The injured childrendiffered significantlyfrom the national distributionof childrenaged less than 16 in their age, sex and birthweight. They were younger, more likely to be boys and had lower birthweightseven when social class was controlled, The younger the child the more likelihoodthere was of the injury being serious, a finding which has been shown in other epidemiologicalstudies (Friedrich,1976; Gonzales-Pardoand Thomas, 1977). Table 2 shows the distributionof the different categoriesof severity of injury by the age of the child. Boys outnumberedgirls in the ratio of 5:4 in each group except the 0 - 6 months and the 15 - 16 year olds. Gil (1970) and Friedrich (1376) found that over the age of 12 years girls were more likely to be reported than boys, which Gil ascribed to parental panic at their adolescentdaughters'burgeoningheterosexualrelationships. The preponderance of girls in the 0 - iimonth age group of the 1976 data is more difficult to explain.
603
An EpidemiologicalStudy
TABLg 2 Age of Child
Severity of InJury by Age of Child
Fatal
Serious
O- mths
2 (28.6)
25 (27.4)
6- mths
1 ( 14.3)
l- yrs 2- yrs
1 ( 14.3)
4- yrs
z (10.9)
13 (14.3)
35 ( 6.7)
4 (16.7)
( 8.2)
17 (18.7)
62 (11.9)
4 (16.7)
(12.9)
20 (22.0)
121 (23.3)
8 (33.3)
43 ( 8.3) 145 (27.9) 71 (13.7)
1
14.3)
lo- yrs
2
28.6)
5 ( 5.5) 1 (
7 (100)
F to T 7 (29.2)
5- yrs 15-16~~s
Moderate
Sexual Abuse
36 ( 6.9)
2 ( 2.2) 8 ( 8.8)
Totals
Total
Severity of Injury
1.1)
91 (loo)
(23.3) 1 (50)
( 7.1) (24.1)
1 (50)
(12.3)
1 ( 4.1)
( 1.2)
7 ( 1.3) 520 (100)
24 (100)
2 (loo)
(100)
Informationwas available on the birth weight of nearly half the sample of injured children. Of these, some 16.1% weighed less than 2,500 grams at birth. This is significantlymore (Chi square = 53.2 with 6 df. p<.OOl) than the national distributionof 7.8 for Social Classes IV and V and 'UnsupportedMothers' taken from a recent representativesample (Chamberlainet al., 1975). The birthweightsof the 'prodromal'cases showed a similar distribution. There was a high rate of illegitimacyamongst the sample compared to national distributionscontrolledfor age of mother (c.S.O.,~). If only the cases with information on legitimacyare consideredthe figure rises to 3%. Friedrich (1976) and Smith (1975) found similar rates amongst their samples. 34.5% of the injured children had been Injured on a previous occasion,a similar percentage to that of the childrenregistered in 1975. The childrenwho had been injured before registrationwere, on average, four months younger than those without such a history.
Only 52$ of the InJured childrenwere living with both natural parents at the time of the incident. 22% were living with their mother and a father substituteand 2% were living with one parent alone, usually the mother. These atypical parental situationsare associatedwith a high rate of marital discord In the registeredchild's family at the time of the incident. Of all the stress factors thought to have had a possible contributory effect, marital discord was cited most frequently. The mean ages of the male and female caretakerswere 30 and 26% years respectively. The male caretakerswere in mainly semi-skilledand unskilledoccupationsand a third of them were unemployedat the time of the incident. 34% of the male and 12.4% of the female caretakershad a criminalrecord. Males were just as likely to have committedviolent as non-violentoffenceswhereas females were four times as likely to have committednon-violent crimes. Although the ratio of violent to non-violentoffences is higher in males than females in the general population (C.S.O.,7)it is not as marked as in this sample. There was informationon the perpetratorin two thirds of the cases. Mothers or mother substituteswere suspected in 44s of these cases and fathers or father substitutesin 46.s. Siblings, other relatives,other adults or childrenwere implicatedIn the remainder. In those familieswhere there were two natural parents mothers were suspected in 375 and fathers in 5% of the cases. In familieswhere there were mother or father substitutes, the substituteswere suspectedof inJuring the child twice as often as the natural parent. When compared to the familieswith two natural parents the mothers with father substitutes don't differ significantlybut the fathers with mother substitutesdo (Chi square = 5.1 with 1 df. p<.O25). There was a slight tendency for mothers to injure younger children and fathers older ones and also for mothers to injure their childrenmore seriously.
604
S.J. Creighton
Fathers were over twice as liable to prosecution as mothers even though adult court proceedings were brought more often in the case 0:‘ serious injuries.
THE FAMILIES Just over half the injured children came from families with three or more children. The equivalent percentage for the national distribution of unskilled and semi-skilled workers Family sizes ranged from 1 to 12 with an average of 2.9 children. is 29.1% (c.s.0,,6). This over representation of large families in the register sample can be partly attributed to earlier parenthood. The injured child was three times as likely to be born to a mother aged lees than 20 years as a child from a similar socio-economic backwound. Although 50.8% of the children came from families with three or more children 76$ of them were either the first or second born in thei? families. Both the family size and birth order distributions of the injured children differed si@ficantly (Chi square = 196.9 for family size and 17.3 for ordinal position with 3 d.f. p(.OOl) from national samples of similar social class with the register sample having larger families and more fourth and later born children. The differences intween the sample and national distributions in family size were considerably more marked than those of birth order however. This complex interaction between family size and ordinal position was also found in the sample registered in 1975.
THEEN-VIRBNMENT The families'type of accommodation, tenure and amenities were found not to differ quantitatively from the national distribution for similar social classes. Nearly half the sample had been living in their present accommodation for less than a year and 30$ had been there for less than six months. Only 8% had been resident for over five years The mobility of families with compared to 7% for manual workers generally (C.S.O.,6). abused children remarked on by Gil (1970) is shown clearly in this sample. The four most frequently quoted stress factors judged to have been present at the time of of the notified injury were marital discord, financial problems, unemployment and a poor self-image on the part of the parents. That this period was a stressful one for the families is indicated by the fact that over 50 per cent of them had four or more stress factors present then.
SUlWARY There were more school age children registered in 1976 than in previous years, in line with the growing concern of the education authorities over the problem of child abuse. The features which distinguished the 1976 sample from national distributions controlled for social class remained the same. The youngest age groups, boys and low birth weiats were .a11 over represented ailongst the in,jured chiltire~ iihilst early pa?enthood, large faxilies and abnormal family structures, low social class, high unemplo:jment and mobility characterised their parents. In spite of: this seeming lack of change workers in the field should be encouraged by the continued decrease in serious injuries, and serious head injuries in particular, shown in successive register samples.
REFERENCES Central Statistical
Office (1975)
Social Trends 1975 (no.6), HMSO, London.
Central Statistical
Office
Social Trends 1976 (No.~), HMSO, London.
Chamberlain, London.
(l976)
G.V.P., Chamberlain,
R. and Claireaux, A. (1975) British Births 1970, Heinemann,
Creighton, S.J. and Owtram, P.J. (1977) Child Victims of Physical Abuse, N.S.P.C.C., London.
An EpidemiologicalStudy
605
M. Eppler and G. Brorq-n, Child abuse and neglect: preventablecauses of mental retardation, Child Abuse and Neglect, 1, j@3 (1977). U.N. Friedrich, Epidemiologicalsurvey of physicalchild abuse, Texas Med., 72, 81 (1976). Gil, D. (1970) Violence against Children: Physical Child Abuse in the United States, Harvard University Press, Cambridge,Mass. L. Gonzalez-Pardoand M. Thomas, Child abuse and neglect: epidemiologyin Kansas, J. Kansas Med. Sot., 78, 65 (1977). Office of PopulationCensusesand Surveys (1977) Populationestimates1970 (provisional) I.975(revised),PPl no.2, HMSO, London. J.E. Oliver, Microcephalyfollowingbaby batteringand shaking,Brit. Med. J., 2, 262 (1975). Smith, S.bI.(1975) The Battered Child Syndrome,Butterworth,London.