Children are at highest risk for SBS/AHT when they are from 2 to 4 months old. All babies less than 1 year of age are at high risk for SBS/AHT because they cry longer and more frequently and they are easier to shake than older, larger children.
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For children under 1 year of age, the incidence of SBS/AHT varies, ranging from 20 to 30 cases per 100,000 children (Parks et al., 2012). A study of pediatric abusive head trauma cases in North Carolina suggested that as many as 3 to 4 American children each day experience severe or fatal head injuries as a result of child abuse (CDC, 2012).
The peak incidence and rapid decrease of SBS/AHT after this age are thought to be related to a decrease in the episodes of prolonged, inconsolable, and unpredictable crying (Parks et al., 2012). Nevertheless, AHT injuries have been reported in children up to age 5 (CDC, 2012).
Researchers at Yale University used the 2006 Kids’ Inpatient Database to determine the incidence of abusive head injuries and fractures in children under the age of 36 months. They looked at traumatic brain injuries only, traumatic brain injuries with skull fracture, and skull fractures only. They found an overlap in traumatic brain injuries and fractures attributable to abuse. Among children less than 12 months, traumatic brain injuries and/or fractures attributable to abuse occurred in 1 of 2000. Falls occurred more commonly than abuse, even among very young children (Leventhal et al., 2010). We will consider falls later in the course.
Kentucky has one of the highest rates of child maltreatment in the country (Children’s Bureau, 2011). In 2012 among the more than 1 million children living in Kentucky there were nearly 35,000 abuse or neglect reports that met the criteria for investigation. Nearly 10,000 of those reports—involving more than 15,000 children—were substantiated by investigators. Within this group, 22 fatalities and 33 near-fatalities were substantiated as related to abuse or neglect (Dept of Community Based Services, 2012).
In an attempt to uncover child abuse trends and risk factors in Kentucky, the Department of Community Based Services (DCBS) examined 214 cases of child abuse and neglect that resulted in death or serious injury between 2008 and 2012. In the DCBS review, the 214 children whose death or serious injury was the result of abuse or neglect, 57% were boys and 43% were girls (DCBS, 2012). Caucasian children accounted for 79% of the fatalities or near-fatalities and African American children accounted for 12% (DCBS, 2012). Head injury was by far the most common type of physical abuse, accounting for nearly half of the deaths and serious injuries (DCBS, 2012).
In Kentucky 91% of all cases of fatal or near fatal physical abuse were under the age of 4 (DCBS, 2012). The age of the child is consistently seen by caseworkers and policymakers as a predictive factor in cases of death or serious injury.
In Kentucky, as elsewhere, the age of the abuser is a factor in child abuse and neglect. In the 214 cases examined by DCBS, 77% of female and 54% of male perpetrators were below the age of 30 (DCBS, 2012).
It is difficult to ascertain the exact number of shaken baby cases because many are under-reported or never receive a diagnosis. The International Classification of Diseases (ICD) is used to code and classify mortality data from death certificates (see box below). Tracking AHT is challenging because the ICD-10 maltreatment syndrome codes (T74 or Y07) and the ICD-9-CM shaken baby syndrome code (995.55) are under-utilized by professionals who use the ICD coding system (Parks et al., 2012). This may result from a lack of information about the specific circumstances of the injury at the time the death certificate was completed or from a reluctance of physicians to diagnose and code for shaken baby syndrome.
ICD-10 abuse/maltreatment codes are not specific enough to capture the circumstances surrounding child assault, abuse, and maltreatment and to specify the types of perpetrators. Cause-of-death data, especially pertaining to assignment of abuse/maltreatment codes, could be improved if law enforcement records and state and local child death review systems was made available to the medical examiner or coroner before they certified the causes of death on the death certificate (Parks et al., 2012).
Classification of Diseases, Functioning, and Disability
The International Classification of Diseases (ICD) is used to code and classify mortality data from death certificates. It is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics.
These coding rules, published by the World Health Organization, improve the usefulness of mortality statistics by giving preference to certain categories, by consolidating conditions, and by systematically selecting a single cause of death from a reported sequence of conditions. The single selected cause of death is called the “underlying cause of death,” and the other reported causes are “non-underlying causes of death.” The combination of underlying and non-underlying causes is the “multiple causes of death.”
The lack of consistent information about the number of children affected by abusive head trauma limits the ability of the public health community to respond to this problem. It hinders attempts to gauge the magnitude of abusive head trauma in relation to other public health problems.
This lack of consistency also creates challenges in identifying those groups at highest risk who might benefit from focused intervention or increased services. It hampers efforts to monitor changes in the incidence and prevalence of abusive head trauma over time. In turn, this impedes the ability to monitor the effectiveness of abusive head trauma prevention and intervention activities (Parks et al., 2012).
Adverse childhood experiences including verbal, physical, or sexual abuse as well as family dysfunction, have been linked to a range of negative health outcomes in adulthood. Among them are substance abuse, depression, cardiovascular disease, diabetes, cancer, and premature mortality (MMWR, 2010).
The Adverse Childhood Experiences (ACE) Study assessed the association between childhood maltreatment and later-life health and well-being. The study examined whether a history of adverse childhood experiences was common in a randomly selected population of 26,229 adults in five states. Nearly 60% of respondents reported having at least one adverse childhood experience, and 8.7% reported five or more adverse childhood experiences (MMWR, 2010).
The ACE Study findings suggest that certain adverse experiences are major risk factors for the leading causes of illness and death as well as poor quality of life. Progress in preventing and recovering from health and social problems is likely to benefit from understanding that many of these problems arise as a consequence of adverse childhood experiences.