The Children's Social Health Monitor New Zealand

Revision alert! Figures in this Technical Report have been updated to reflect the Statistics New Zealand and Treasury data error announced 27 February 2014

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The Assault, Neglect and Maltreatment of Children

Introduction

Child maltreatment has been defined as any act of commission or omission by a parent or caregiver that results in harm, or the potential for harm, to a child [1]. It includes neglect, physical, sexual and emotional abuse, and fabricated illness [2], with physical abuse potentially leading on to disability or death. In New Zealand, hospital admissions for child maltreatment are much higher for children from more socioeconomically deprived areas [3].

The psychological effects of maltreatment, which can persist into adulthood, include anxiety, depression, substance misuse, and self-destructive, oppositional or antisocial behaviours. Childhood exposure to maltreatment has also been linked to difficulties in forming or sustaining close relationships in adulthood, as well as issues with employment and parenting capacity [4].

As a consequence, there has been an increasing awareness of the need to identify vulnerable children early, so that services and interventions can be put in place to protect them from on-going or future harm. The White Paper for Vulnerable Children [5] and the New Zealand Children’s Action Plan [6] outline potential ways forward in this area.

Broadening the Child Assault Measure

The previous NZ Children’s Social Health Monitor monitored hospital admissions for injuries arising from the assault, neglect or maltreatment of children aged 0—14 years from its inception, due to concerns about the potential impacts of the recent economic downturn on family cohesion. However, this indicator excluded children discharged directly from the Emergency Department (ED), or those with a primary diagnosis outside of the injury range (ICD-10-AM S00—T79). The inpatient injury focus was selected because of regional inconsistencies in the uploading of ED cases to the National Minimum Dataset (NMDS), and because inpatient injury admissions were seen as a relatively stable measure of serious harm, which could be monitored consistently over time.

With the consistency of uploading ED cases to the NMDS improving, and with Government policy increasingly focusing on the early identification of children vulnerable to abuse, the launch of the new Technical Report was seen as a good opportunity to review the scope of this indicator, with a view to determining whether a broader focus would yield additional information on the extent to which New Zealand children are exposed to assault, neglect or maltreatment.

With these issues in mind, the following section is split into two parts:

  1. Hospital admissions and mortality for injuries arising from assault, neglect or maltreatment in children 0—14 years: This section, which uses an identical methodology to the Children’s Social Health Monitor, reviews hospital admissions with a primary diagnosis of injury (ICD-10-AM S00—T79) and an external cause code of intentional injury (ICD-10-AM X85—Y09). In this analysis, all admissions with an ED specialty code on discharge have been excluded, as have those admissions where the primary diagnosis lies outside of the ICD-10-AM S00—T79 injury range.
  2. Hospital admissions for assault, neglect or maltreatment in children aged 0—4 years: This section reviews all hospital admissions with an external cause code of intentional injury (ICD-10-AM X85—Y09). It includes both inpatient and emergency department injury admissions, as well as those with a primary diagnosis outside of the S00—T79 injury range (the majority of whom were admitted for observation or for other reasons). Further detail on the rationale for broadening the focus of this indicator, and the selection of the 0—4 year age group, is included at the beginning of this sub-section.

Hospital Admissions and Mortality from Injuries Arising From the Assault, Neglect or Maltreatment of Children 0—14 Years

Data Source and Methods

Definition

1. Hospitalisations for injuries arising from the assault, neglect or maltreatment of children aged 0—14 years

2. Deaths from injuries arising from the assault, neglect or maltreatment of children aged 0—14 years

Data Source

1. Hospital Admissions

Numerator: National Minimum Dataset: Hospital admissions for children (0—14 years) with a primary diagnosis of injury (ICD-10-AM S00—T79) and an external cause code of intentional injury (ICD-10-AM X85—Y09) in any of the first 10 External Cause codes. As outlined in Appendix: The National Minimum Dataset, in order to ensure comparability over time, all cases with an Emergency Department Specialty Code (M05—M08) on discharge were excluded.

Denominator: NZ Statistics NZ Estimated Resident Population (projected from 2007)

2. Mortality

Numerator: National Mortality Collection: Deaths in children (0—14 years) with a clinical code (cause of death) of Intentional Injury (ICD-10-AM X85—Y09).

Denominator: NZ Statistics NZ Estimated Resident Population (projected from 2007)

Interpretation

The limitations of the National Minimum Dataset are discussed at length in Appendix: The National Minimum Dataset. The reader is urged to review this Appendix before interpreting any trends based on hospital admission data.

New Zealand Trends

In New Zealand during 2000—2012, hospital admissions for injuries arising from the assault, neglect or maltreatment of children declined, while mortality during 2000—2010 remained relatively static. On average during 2000—2010, eight children per year died as a result of injuries arising from assault, neglect or maltreatment (Figure 1).

Figure 1. Hospital Admissions (2000—2012) and Deaths (2000—2010) due to Injuries Arising from the Assault, Neglect or Maltreatment of New Zealand Children 0—14 Years

Source: Numerator Admissions: National Minimum Dataset; Numerator Mortality: National Mortality Collection; Denominator: Statistics NZ Estimated Resident Population (projected from 2007); Note: Emergency Department cases excluded; *2010‒11 Number of Deaths is for one year only (2010)

New Zealand Distribution by Age and Gender

During 2008–2012, hospital admissions for injuries arising from the assault, neglect or maltreatment of children exhibited a U-shaped distribution with age, with rates being higher for infants less than one year and those over eleven years of age. In contrast, mortality was highest for infants less than one year, followed by pre-school aged children. While the gender balance for admissions was relatively even during early childhood, admissions for males became more prominent as adolescence approached (Figure 2).

Figure 2. Hospital Admissions (2008–2012) and Deaths (2006–2010) due to Injuries Arising from the Assault, Neglect or Maltreatment of New Zealand Children by Age and Gender

Source: Numerator Admissions: National Minimum Dataset; Numerator Mortality: National Mortality Collection; Denominator: Statistics NZ Estimated Resident Population (projected from 2007); Note: Emergency Department cases excluded

New Zealand Trends by Ethnicity

During 2000–2012, hospital admissions for injuries arising from assault, neglect or maltreatment were consistently higher for Māori and Pacific children than for European/Other and Asian/Indian children. While rates for Māori children increased during the early to mid-2000s, they declined during 2010–2012, while trends for Pacific children were more variable. Admissions for European/Other children declined during the early-mid 2000s, but then increased slightly during 2010–2012, while admissions for Asian/Indian children exhibited a general downward trend (Figure 3).

Figure 3. Hospital Admissions for Injuries Arising from the Assault, Neglect or Maltreatment of Children 0—14 Years by Ethnicity, New Zealand 2000–2012

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007); Note: Ethnicity is Level 1 Prioritised; Emergency Department cases excluded

New Zealand Distribution by Ethnicity and Gender

During 2008–2012, hospital admissions for injuries arising from the assault, neglect or maltreatment of children were significantly higher for males. Rates were also significantly higher for Māori > Pacific > European/Other > Asian/Indian children (Table 1).

Table 1. Hospital Admissions for Injuries Arising from the Assault, Neglect or Maltreatment of Children 0—14 Years by Ethnicity and Gender, New Zealand 2008–2012

Admissions for Injuries Arising from Assault, Neglect or Maltreatment

Children 0—14 Years

Variable

Number: Annual Average

Rate per 100,000

Rate Ratio

95% CI

Ethnicity

Asian/Indian

4.8

5.39

0.45

0.30—0.68

European/Other

58.8

12.03

1.00

 

Māori

77.0

34.19

2.84

2.44—3.31

Pacific

20.6

23.21

1.93

1.54—2.42

Gender

Female

60.4

13.89

1.00

 

Male

100.8

22.05

1.59

1.38—1.83

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007); Note: Rate Ratios are unadjusted; Ethnicity is Level 1 Prioritised; Emergency Department cases excluded

Nature of the Injury Sustained

During 2008–2012, traumatic subdural haemorrhages and superficial head injuries were the most common injuries sustained as the result of the assault, neglect or maltreatment of children aged 0—4 years. For children aged 5—12 years head, upper limb and abdominal/lower back/pelvic injuries predominated (Table 2).

Table 2. Nature of Injuries Arising from the Assault, Neglect or Maltreatment in Hospitalised Children 0—12 Years by Age Group, New Zealand 2008–2012

Primary Diagnosis

Number: Total 2008—2012

Number: Annual Average

% of Total

Assault, Neglect or Maltreatment

Children 0—4 Years

Traumatic Subdural Haemorrhage

89

17.8

22.7

Superficial Head Injury

76

15.2

19.4

Fracture Skull or Facial Bones

19

3.8

4.8

Other Head Injuries

50

10.0

12.8

Injuries to Upper Limb

24

4.8

6.1

Injuries to Thorax (including Rib Fractures)

9

1.8

2.3

Injuries Abdomen, Lower Back and Pelvis

26

5.2

6.6

Fracture Femur

14

2.8

3.6

Other Injuries to Lower Limbs

12

2.4

3.1

Maltreatment

49

9.8

12.5

Other Injuries

24

4.8

6.1

Total

392

78.4

100.0

Children 5—12 Years

Superficial Head Injury

32

6.4

16.7

Concussion

18

3.6

9.4

Fracture Skull or Facial Bones

14

2.8

7.3

Other Head Injuries

27

5.4

14.1

Injuries to Upper Limb

26

5.2

13.5

Injuries Abdomen, Lower Back and Pelvis

23

4.6

12.0

Injuries to Lower Limbs

13

2.6

6.8

Maltreatment

13

2.6

6.8

Other Injuries

26

5.2

13.5

Total

192

38.4

100.0

Source: National Minimum Dataset; Emergency Department cases excluded

Hospital Admissions for the Assault, Neglect or Maltreatment of Children 0—4 Years

Background

While monitoring hospital admissions for injuries arising from assault, neglect or maltreatment provides insights into the number of children experiencing serious physical harm, it provides little information on those children experiencing less serious injuries, or whose main reason for admission was unrelated to a specific injury diagnosis. Further, it is unclear whether recent trends in assault admissions in children reflect a real decrease in children’s risk of abuse, changes in the coding of hospital admission data, or changes in the way in which Emergency Departments (ED) and Paediatric Units manage the care of children deemed to be at risk of harm.

With these issues in mind, an analysis was undertaken of all hospital admissions in children aged 0—14 years, where an intentional injury (ICD-10-AM X85—Y09) code was identified in any of the first 10 external causes. This analysis included inpatient admissions, as well as those cases discharged directly from the ED, or with a primary diagnosis outside of the S00—T79 injury range. The key findings from this analysis were:

  1. While inpatient injury admissions in children aged 0—14 years had declined during 2000—2012, ED discharges for assault-related injuries had increased, as had those admissions with an intentional injury external cause code and a primary diagnosis outside of the S00—T79 injury range (Figure 4).

  2. The age distribution of inpatient admissions differed from those discharged from ED, with inpatient admissions being the most common in infants and those aged twelve years and over, while the majority of ED cases were in children aged twelve or more years. In contrast, a higher proportion of those with a primary diagnosis outside of the ICD-10-AM injury range were infants (Figure 5).

Figure 4. Hospital Admissions for Assault, Neglect and Maltreatment in Children Aged 0—14 Years by Admission Category, New Zealand 2000—2012

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007); Note: Emergency Department cases included

Figure 5. Hospital Admissions for Assault, Neglect and Maltreatment in Children Aged 0—14 Years by Age and Admission Category, New Zealand 2008–2012

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007)

Unfortunately little information was available on the context in which these assault-related injuries were occurring, making it difficult to determine whether the pattern of assaults changed as children grew older. For example, whether a greater proportion of assaults in young males aged 12—14 years arose from incidents with peers, rather than in the home environment. Further, around 20% of admissions with a non-injury related primary diagnosis had received a Z045 code (examination and observation following inflicted injury), while 12.3% had received a Z043 code (examination and observation following accident) and 4.7% a Z044 code (examination and observation following alleged rape and seduction), suggesting that many of these cases may have been similar to those admitted with a primary diagnosis in the S00—T79 injury range.

Thus, it was decided that a new child assault, neglect and maltreatment indicator should be created, which focused only on preschool aged children, in order to best capture those events likely to occur in the family/home environment. The breadth of the indicator was broadened however, to include not only inpatient admissions but also those discharged directly from ED, as well as those with a primary diagnosis outside of the ICD-10-AM S00—T79 injury range.

Data Source and Methods

Definition

1. Hospitalisations for the assault, neglect or maltreatment of children aged 0—4 years

Numerator: National Minimum Dataset: Hospital admissions for children (0—4 years) with an external cause code of intentional injury (ICD-10-AM X85—Y09) in any of the first 10 External Cause codes. Both inpatient admissions and cases with an ED Specialty Code (M05—M08) on discharge are included in the analysis.

Denominator: NZ Statistics NZ Estimated Resident Population (projected from 2007)

Interpretation

The limitations of the National Minimum Dataset are discussed at length in Appendix: The National Minimum Dataset. The reader is urged to review this Appendix before interpreting any trends based on hospital admission data.

New Zealand Trends

During 2000—2012, inpatient admissions for injuries arising from the assault, neglect or maltreatment of children aged 0—4 years fluctuated, while assault—related injuries that were managed in ED, and those with a primary diagnosis outside of the ICD-10 S00—T79 range gradually increased. Overall, admissions related to assault, neglect or maltreatment were relatively static during the early 2000s, but increased between 2004—05 and 2010—11, before declining slightly in 2012 (Figure 6).

Figure 6. Hospital Admissions for the Assault, Neglect or Maltreatment of Children 0—4 Years, New Zealand 2000–2012

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007)

Distribution by Primary Diagnosis

During 2008–2012, the most severe injuries were seen in children 0—4 years who were admitted as inpatients, with 22.7% of inpatient assault injury admissions being for traumatic subdural haemorrhages, and a further 4.8% being for fractures of the skull or facial bones. Of those children with injuries who were managed in ED, 21.8% had a superficial head injury, with a further 9.1% receiving a concussion. Of those with a primary diagnosis outside the ICD-10 S00-T79 injury range, 52.8% were admitted for observation, with the majority of these being observed following an inflicted injury or accident. A range of other respiratory and infectious diseases however, also contributed to admissions in this category (Table 3).

Table 3. Table 3. Hospital Admissions for the Assault, Neglect or Maltreatment of Children 0—4 Years by Category and Primary Diagnosis, New Zealand 2008–2012

Primary Diagnosis

Number: Total 2008−2012

Number: Annual Average

% of Total

Children 0—4 Years

Inpatient Assault Injuries

Traumatic Subdural Haemorrhage

89

17.8

22.7

Superficial Head Injury

76

15.2

19.4

Fracture Skull or Facial Bones

19

3.8

4.8

Concussion

3

0.6

0.8

Other Head Injuries

47

9.4

12.0

Injuries to Upper Limb

24

4.8

6.1

Injuries to Thorax including Rib Fractures

9

1.8

2.3

Injuries Abdomen, Lower Back and Pelvis

26

5.2

6.6

Fracture Femur

14

2.8

3.6

Other Injuries to Lower Limbs

12

2.4

3.1

Maltreatment

49

9.8

12.5

Other Injuries

24

4.8

6.1

Total

392

78.4

100.0

Emergency Department Assault Injuries

Superficial Head Injury

12

2.4

21.8

Concussion

5

1.0

9.1

Other Head Injuries

10

2.0

18.2

Injuries to Upper Limb

4

0.8

7.3

Injuries Abdomen, Lower Back and Pelvis

5

1.0

9.1

Injuries to Lower Limbs

5

1.0

9.1

Maltreatment

9

1.8

16.4

Other Injuries

5

1.0

9.1

Total

55

11.0

100.0

Primary Diagnosis Outside Injury Range

Examination and Observation Following Inflicted Injury

31

6.2

28.2

Examination and Observation Following Accident

19

3.8

17.3

Examination and Observation for Other Specified Reasons

8

1.6

7.3

Respiratory Tract Infections

10

2.0

9.1

Skin Infections

5

1.0

4.5

Lack of expected normal physiological development

4

0.8

3.6

Gastroenteritis

3

0.6

2.7

Surgical Follow-up care

3

0.6

2.7

Meningitis

3

0.6

2.7

Other Infectious Diseases

3

0.6

2.7

Other Medical Conditions

16

3.2

14.5

Various Symptoms and Signs

5

1.0

4.5

Total

110

22.0

100.0

Source: National Minimum Dataset

Distribution by Age and Gender

During 2008–2012, inpatient admissions for injuries arising from the assault, neglect or maltreatment of children, as well as those with a primary diagnosis outside of the ICD-10 S00-T79 injury range, were highest in infants aged less than one year, with rates then tapering off rapidly with increasing age. In contrast, assault related injuries managed in the ED were more evenly distributed across the first five years (Figure 7).

Figure 7. Hospital Admissions for to the Assault, Neglect or Maltreatment of Children Aged 0—4 Years by Age and Gender, New Zealand 2008–2012

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007)

New Zealand Trends by Ethnicity

During 2000–2012, hospital admissions for assault, neglect or maltreatment were consistently higher for Māori and Pacific children aged 0—4 years, than for European/Other and Asian/Indian children. While large year to year variations (possibly as the result of small numbers) made trends difficult to interpret for most ethnic groups, for Māori children there was a reasonably consistent increase in rates between 2002–03 and 2008–09, which was followed by a decrease in rates during 2010–2012. Small numbers however, precluded a more detailed breakdown by admission category (Figure 8).

Figure 8. Hospital Admissions for the Assault, Neglect or Maltreatment of Children 0—4 Years by Ethnicity, New Zealand 2000—2012

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007); Note: Ethnicity is Level 1 Prioritised

New Zealand Distribution by Ethnicity and Gender

During 2008–2012, hospital admissions for assault, neglect or maltreatment were significantly higher Maori and Pacific > European/Other > Asian/Indian children aged 0—4 years, and for males. When broken down by category, inpatient and ED assault injury admissions were also significantly higher for Maori and Pacific > European/Other > Asian/Indian children, while admissions with a primary diagnosis outside of the ICD-10 S00-T79 injury range were significantly higher for Maori and Pacific > Asian/Indian and European/Other children. Inpatient assault injury admissions were also significantly higher for males than for females, although gender differences in the other two categories did not reach statistical significance (Table 4).

Table 4. Hospital Admissions for the Assault, Neglect or Maltreatment of Children 0—4 Years by Ethnicity and Gender, New Zealand 2008–2012

Variable

Number: Annual Average

Rate per 100,000

Rate Ratio

95% CI

Variable

Number: Annual Average

Rate per 100,000

Rate Ratio

95% CI

Children 0—4 Years

Total Assault, Neglect or Maltreatment Admissions

Asian/Indian

3.2

9.73

0.46

0.27—0.76

Female

47.8

31.82

1.00

 

European/Other

33.6

21.26

1.00

 

Male

63.6

40.20

1.26

1.07—1.49

Māori

59.8

70.02

3.29

2.73—3.98

 

Pacific

14.8

46.17

2.17

1.65—2.85

Inpatient Assault Injuries

Asian/Indian

1.4

4.26

0.26

0.12—0.55

Female

32.8

21.84

1.00

 

European/Other

26.0

16.45

1.00

 

Male

45.6

28.83

1.32

1.08—1.61

Māori

41.8

48.94

2.97

2.39—3.70

 

Pacific

9.2

28.70

1.74

1.25—2.44

Emergency Department Assault Injuries

Asian/Indian

0.8

2.43

1.13

0.38—3.36

Female

4.4

2.93

1.00

 

European/Other

3.4

2.15

1.00

 

Male

6.6

4.17

1.42

0.83—2.44

Māori

5.0

5.85

2.72

1.47—5.04

 

Pacific

1.8

5.62

2.61

1.16—5.86

Primary Diagnosis Outside Injury Range

Asian/Indian

1.0

3.04

1.14

0.43—3.03

Female

10.6

7.06

1.00

 

European/Other

4.2

2.66

1.00

 

Male

11.4

7.21

1.02

0.70—1.48

Māori

13.0

15.22

5.73

3.50—9.37

 

Pacific

3.8

11.85

4.46

2.40—8.30

Source: Numerator: National Minimum Dataset; Denominator: Statistics NZ Estimated Resident Population (projected from 2007); Note: Rate Ratios are unadjusted; Ethnicity is Level 1 Prioritised


References

1. Leeb R, Paulozzi L, Melanson C, et al. 2008. Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control

2. National Collaborating Centre for Women’s and Children’s Health. 2009. When to suspect child maltreatment (Clinical Guideline). London: Royal College of Obstetricians and Gynaecologists. http://guidance.nice.org.uk/CG89/

3. Craig E, Jackson C, Han D, et al. 2007. Monitoring the Health of New Zealand Children and Young People: Indicator Handbook. Auckland: Paediatric Society of New Zealand & New Zealand Child and Youth Epidemiology Service

4. Ministry of Health. 2002. Family Violence Intervention Guidelines Child and Partner Abuse. Wellington: Ministry of Health http://www.health.govt.nz/publication/family-violence-intervention-guidelines-child-and-partner-abuse

5. Bennett P. 2012. The White Paper for Vulnerable Children. Volume I. Wellington: New Zealand Government.

6. Bennett P. 2012. Children’s Action Plan: Identifying, Supporting and Protecting Vunlerable Children. Wellington: Ministry of Social Development.