The Children's Social Health Monitor New Zealand

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Injuries Arising from the Assault, Neglect, or Maltreatment of Children

Introduction

Child maltreatment has been defined as any act of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. Child abuse (acts of commission) includes physical, sexual and emotional abuse, and fabricated or induced illness. Child neglect (acts of omission) includes failure to: provide for a child’s physical and emotional needs; obtain necessary medical or dental care; ensure a child has access to education; provide adequate supervision, and prevent exposure to violent environments [1]. Child abuse and neglect have both short term and lifelong physical, psychological, and behavioural consequences for individuals and consequences for society. Survivors of childhood sexual abuse are at risk for a wide range of medical, psychological, behavioural, and sexual disorders [2]. Studies on child abuse or neglect and subsequent mental and physical health outcomes suggest a causal relationship between non-sexual child maltreatment and a range of mental disorders, suicide attempts, drug use, and risky sexual behaviour [3].

Most child maltreatment is perpetrated by parents or guardians, many of whom were themselves maltreated as children [3,4]. Poverty, sole parenthood, the presence of a non-biological parent in the household, mental health problems, domestic violence, and alcohol and drug abuse increase the probability of abusive parenting [3,4]. Characteristics that make a child more difficult to care for than usual, for example crying a lot, having a “difficult temperament”, or being disabled, may increase a child’s risk of being maltreated, especially where there are other demographic or family risk factors [5].

A UNICEF report on child maltreatment deaths from 1994 to 1998 ranked New Zealand near the bottom in the OECD [6] with a rate of 1.2 deaths per 100,000 children under 15 years, double the OECD median. Over the period 2002–2012 New Zealand’s rates of child death due to assault have not improved [7].

The following section reviews hospital admissions and mortality from injuries arising from the assault, neglect, or maltreatment of children aged 0–14 years using information from the National Minimum Dataset and the National Mortality Collection.

Data Source and Methods

Definition

1. Hospital admissions for injuries arising from the assault, neglect, or maltreatment of children 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, as were admissions with a primary diagnosis outside of the ICD-10-AM S00–T79 injury range.

Denominator: NZ Statistics NZ Estimated Resident Population

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

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 2000–2013, hospital admissions for injuries arising from the assault, neglect, or maltreatment of children declined gradually, while mortality during 2000–2011 remained relatively static. On average during 2000–2011, approximately 8 children per year died as a result of injuries arising from assault, neglect, or maltreatment (Figure 1).

Figure 1. Hospital admissions (2000–2013) and deaths (2000–2011) due to injuries arising from the assault, neglect, or maltreatment of New Zealand children aged 0–14 years

Source: Numerator: Admissions: National Minimum Dataset (emergency department cases excluded); Mortality: National Mortality Collection; Denominator: Statistics NZ Estimated Resident Population; Note: numbers of deaths are per two year period

New Zealand Distribution by Age and Gender

In New Zealand during 2009–2013, hospital admissions for injuries arising from the assault, neglect, or maltreatment of children exhibited a U-shaped distribution with age, such that rates were higher for infants aged less than one year and for those over eleven years of age. In contrast, mortality was highest for infants less than one year, followed by those aged one and two years (Figure 2).

The gender balance for admissions was relatively even during infancy and early childhood, however, admissions for males became more predominant as adolescence approached (Figure 2).

Figure 2. Hospital admissions (2009–2013) and deaths (2007–2011) due to injuries arising from the assault, neglect, or maltreatment of New Zealand children by age and gender

Source: Numerator: Admissions: National Minimum Dataset (emergency department cases excluded); Mortality: National Mortality Collection; Denominator: Statistics NZ Estimated Resident Population 

New Zealand Trends by Ethnicity

In New Zealand during 2000–2013, 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 European/Other children declined during this period, rates for Māori children increased during the early-to-mid 2000s, but declined during 2010–2013. In contrast, admissions for Pacific children declined during the early-to-mid 2000s, but increased in 2010–2011 before declining again in 2012–2013 (Figure 3).

Figure 3. Hospital admissions for injuries arising from the assault, neglect, or maltreatment of children aged 0–14 years by ethnicity, New Zealand 2000–2013

Source: Numerator: National Minimum Dataset (emergency department cases excluded); Denominator: Statistics NZ Estimated Resident Population; Note: Ethnicity is level 1 prioritised

Distribution by NZDep Index Decile, Ethnicity and Gender

In New Zealand during 2009–2013, hospital admissions for injuries arising from the assault, neglect, or maltreatment of children were significantly higher for males and for those from average to more deprived areas (NZDep deciles 3–10). Admissions were also significantly higher for Māori and Pacific children than for European/Other children, and significantly lower for Asian/Indian children (Table 1).

Table 1. Hospital admissions for injuries arising from the assault, neglect, or maltreatment of children aged 0–14 years by NZDep Index decile, ethnicity and gender, New Zealand 2009–2013

Assault, neglect, or maltreatment admissions

Children 0–14 years

Variable

Rate

Rate ratio

95% CI

Variable

Rate

Rate ratio

95% CI

NZ Deprivation Index decile

Prioritised ethnicity

Deciles 1–2

4.41

1.00

Māori

31.24

2.60

2.23–3.03

Deciles 3–4

8.97

2.04

1.37–3.02

Pacific

23.39

1.95

1.55–2.44

Deciles 5–6

15.48

3.51

2.45–5.04

Asian/Indian

6.51

0.54

0.37–0.79

Deciles 7–8

21.89

4.97

3.52–7.02

European/Other

12.01

1.00

Deciles 9–10

31.52

7.16

5.12–10.0

 

 

 

 

Gender

Female

13.45

1.00

Male

21.18

1.57

1.36–1.82

Source: Numerator: National Minimum Dataset (emergency department cases excluded); Denominator: Statistics NZ Estimated Resident Population; Notes: Rate is per 100,000; Rate ratios are unadjusted; Ethnicity is level 1 prioritised; Decile is NZDep06

Nature of the Injury Sustained

During 2009–2013, the head was the most common site for injuries sustained as the result of the assault, neglect or maltreatment. For those aged 0–4 years, 59.3% of their injuries were to the head with the largest proportion being traumatic subdural haemorrhages and superficial head injuries. For children aged 5–9 years, 39.3% of their injuries were to the head, and were more commonly superficial. The next most common site was the abdominal/lower back/spine/pelvis area followed by the upper limb. For children aged 10–14 years, 55.5% of injuries were to the head, the most common being fractures of the skull or facial bones. The next most common site of injury for this age group was the upper limb (Table 2).

Table 2. Nature of injuries arising from assault, neglect, or maltreatment in hospitalised children 0−14 years by age group, New Zealand 2009–2013

Table 2. Nature of injuries arising from assault, neglect, or maltreatment in hospitalised children 0−14 years by age group, New Zealand 2009–2013

Primary diagnosis

Number: total 2009−2013

Number: annual average

Rate per 100,000

Percent

Assault, neglect, or maltreatment

Children aged 0–4 years

Traumatic subdural haemorrhage

88

17.6

5.78

22.7

Superficial head injury

76

15.2

4.99

19.6

Fracture skull or facial bones

16

3.2

1.05

4.1

Other head injuries

50

10.0

3.28

12.9

Injuries to thorax (including rib fractures)

5

1.0

0.33

1.3

Injuries to abdomen, lower back, and pelvis

26

5.2

1.71

6.7

Injuries to upper limb

30

6.0

1.97

7.8

Fractured femur

16

3.2

1.05

4.1

Other injuries to lower limb

8

1.6

0.53

2.1

Maltreatment

42

8.4

2.76

10.9

Other injuries

30

6.0

1.97

7.8

Total

387

77.4

25.42

100.0

Children aged 5–9 years

Superficial head injury

20

4.0

1.34

18.7

Fracture skull or facial bones

3

0.6

0.20

2.8

Concussion

3

0.6

0.20

2.8

Other head injuries

16

3.2

1.07

15.0

Injuries to abdomen, lower back, and pelvis

20

4.0

1.34

18.7

Injuries to upper limb

14

2.8

0.94

13.1

Other injuries to lower limb

6

1.2

0.40

5.6

Maltreatment

8

1.6

0.54

7.5

Other injuries

17

3.4

1.14

15.9

Total

107

21.4

7.19

100.0

Children aged 10–14 years

Fracture skull or facial bones

61

12.2

4.06

20.9

Concussion

37

7.4

2.46

12.7

Superficial head injury

24

4.8

1.60

8.2

Other head injuries

40

8.0

2.66

13.7

Injuries to thorax (including rib fractures)

10

2.0

0.67

3.4

Injuries to abdomen, lower back, and pelvis

22

4.4

1.46

7.5

Injuries to upper limb

48

9.6

3.19

16.4

Fractured femur

3

0.6

0.20

1.0

Other injuries to lower limb

12

2.4

0.80

4.1

Maltreatment

11

2.2

0.73

3.8

Other injuries

24

4.8

1.60

8.2

Total

292

58.4

19.42

100.0

Source: National Minimum Dataset (emergency department cases excluded)


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. Maniglio R. 2009. The impact of child sexual abuse on health: a systematic review of reviews. Clin Psychol Rev 29(7) 647-57

3. Norman RE, Byambaa M, De R, et al. 2012. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med 9(11) e1001349 http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001349

4. Duncanson MJ, Smith DAR, Davies E. 2009. Death and serious injury from assault of children aged under 5 years in Aotearoa New Zealand: A review of international literature and recent findings. Wellington: Office of the Children's Commissioner. http://www.occ.org.nz/assets/Uploads/Reports/Child-abuse-and-neglect/Death-and-serious-injury.pdf

5. Brown J, Cohen P, Johnson JG, et al. 1998. A longitudinal analysis of risk factors for child maltreatment: findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse & Neglect 22(11) 1065-78 http://www.sciencedirect.com/science/article/pii/S0145213498000878

6. UNICEF. 2003. A league table of child maltreatment deaths in rich nations.  Innocenti Report Card no. 5. Florence: UNICEF Innocenti Research Centre. http://www.unicef-irc.org/publications/pdf/repcard5e.pdf

7. NZ Mortality Review Data Group. 2013. NZ Child and Youth Mortality Review Committee 9th Data Report 2008 – 2012 Dunedin: University of Otago. http://www.hqsc.govt.nz/assets/CYMRC/Publications/CYMRC-ninth-data-report-2008-2012.pdf