Child Abuse is the Primary Cause of Infant Homicides

Child abuse of any sort is difficult to understand, but the homicide of infants by caretakers is beyond most people's imagination. A new study sheds some light on who commits these acts.
Fujiwara, T., Barber, C., Schaechter, J., & Hemenway, D. (2009). Characteristics of Infant Homicides: Findings From a U.S. Multisite Reporting System PEDIATRICS, 124 (2) DOI: 10.1542/peds.2008-3675

The study reports on 72 cases drawn from the National Violent Injury Statistics System. The system was developed to provide detailed information from multiple sources--death certificates, coroner/medical examiner reports, police reports, and crime laboratories--to be used for public health research. The purpose of this study was to describe features of different types of infant homicide (under age 2) to inform prevention efforts.

Three-quarters of infant homicides were due to beating/shaking by a caretaker (Type 1). The perpetrator was most often the father (43%) or the mother's boyfriend (30%). In almost all cases, emergency medical treatment was sought by either the abuser or another household member. The authors conclude that Type 1 homicides are impulsive and largely unintentional in nature. However, in most cases there was evidence of prior physical abuse. Their recommendations for prevention are early identification of child abuse and education directed at male caretakers.

In contrast, most Type 2 homicides were committed by women (69%), were intentional, and no medical treatment was sought. The deaths were related to domestic violence, psychosis, other crime, or occurred within 24 hours of birth. There were too few cases of each kind to draw conclusions useful for prevention. A larger study would be needed.

Of note, nearly half of the Type 1 homicides were caused by shaking. Young adult males with little or no experience can find it difficult to care for a baby that continually cries. Some will shake a baby out of frustration and anger to stop it crying without realizing the damage shaking will cause. Not all shaken babies die, but survivors' injuries may include severe brain damage, blindness, learning disabilities, and physical impairments.

One hospital-based prevention education program directed at both parents has been successful in reducing the number of cases, and the program has been replicated elsewhere (Upstate New York Shaken Baby Syndrome Education Program). The basic elements of this and other prevention education are to raise awareness of injuries caused by shaking and teach caretakers how to soothe a crying baby and cope with their own frustration.

For more information: The National Center on Shaken Baby Syndrome

This post was featured in Grand Rounds Vol. 5 No. 51, comes to Paramedicine! « Medic999

Grand Rounds Blog Carnival Vol. 5, No. 44

I've been included in this week's edition of Grand Rounds hosted by Doc Gurley. Grand Rounds is "a weekly summary of the best health blog posts on the internet. Each week a different blogger takes turns hosting Grand Rounds, and summarizing the best submissions for the week...It's the oldest and most popular medical blog carnival on the internet." More info, and the schedule for upcoming editions is available at Better Health Blog.

Thanks to Doc Gurley for including my submission Ten Common Causes of Child Trauma Due to Violence.

Keep Kids Safe This Summer

The National Center for Missing and Exploited Children has released Ten Safety Tips to Help Parents Keep Children Safe This Summer:

  1. MAKE SURE children know their full names, address, telephone numbers and how to use the telephone.
  2. BE SURE children know what to do in case of an emergency and how to reach you using cell phone or pager number. Children should have a neighbor or trusted adult they may call if they're scared or there's an emergency.
  3. REVIEW the rules with your children about whose homes they may visit and discuss the boundaries of where they may and may not go in the neighborhood.
  4. MAKE SURE children know to stay away from pools, creeks, or any body of water without adult supervision
  5. CAUTION children to keep the door locked and not to open the door or talk to anyone who comes to the door when they are home alone.
  6. DON'T drop your children off at malls, movies, video arcades or parks. These are not safe places for children to be alone. Make certain a responsible adult supervises your younger children at all times when they are outside and away from home.
  7. TEACH your children in whose vehicle they may ride. Children should be cautioned to never approach any vehicle, occupied or not, unless accompanied by a parent or other trusted adult.
  8. BE SURE your children know their curfew and check in with you if they are going to be late. If children are playing outside after dark, make sure they wear reflective clothing and stay close to home.
  9. CHOOSE babysitters with care. Obtain references from family, friends, and neighbors. Many states now have registries for public access to check criminal history or sex-offender status. Observe the babysitter's interaction with your children, and ask your children how they feel about the babysitter.
  10. CHECK out camp and other summer programs before enrolling your children. See if a background screening check is completed on the individuals working with the children. Make sure there will be adult supervision of your children at all times, and make sure you are made aware of all activities and field trips offered by the camp or program.

Free Mall Girls Riding on The Escalator Creative Commons

But what about teenagers?

I always recommend that parents pay close attention to the whereabouts of younger teenagers. Middle-schoolers in particular are more likely than younger children to be home alone during the summer. Ages of 12 to 15 are riskier due to lack of experience, immature decision-making, and an overwhelming desire to spend time with peers. They are more likely to have friends over while parents are at work, go somewhere without permission, and be enticed into forbidden activities by older teens they meet at the mall or other teen hang-outs. Because younger teens can't anticipate negative consequences that may arise in social situations, they are more likely than older teenagers to end up in unsafe circumstances beyond their control.

Some common-sense tips:

Contact friends' parents to confirm plans and adult supervision. Don't trust the older siblings of your child's friends to be good supervisors. Chaperone or discreetly shadow your teenager at the mall, movies, and other public venues.

Don't rely only on cell phone contact from your teen. It's too easy for them to disguise their location. Call home numbers to confirm your teen's whereabouts.

Don't make it too easy for teens to predict your schedule. Come home early once in awhile, drop by unexpectedly, and call at unpredictable times. This prevents them being able to count on leaving and getting back before you come home from work.

Assume you have to double-check all plans. At the same time, avoid giving your teen the impression that you don't trust him. Let her think that you are an anxious and over-protective parent. This will decrease power struggles and help your teen save face when he has to decline an invitation that breaks your rules.

The National Center for Missing and Exploited Children also has a summer safety tip sheet for kids. Although written for children, the tips can still apply to young teens.

Please share any other parent tips you might have for child and teen safety and have a safe summer!

Parents Are Concerned about Psychiatric Medications

Popular press coverage has once again raised concern about the use of psychiatric medications to treat emotional and behavioral problems in children. A recent study has linked the use of stimulant medication (such as Ritalin) with 10 deaths in a sample of 564 children and adolescents who died suddenly for unexplained reasons. It's important to note that the study was unable to demonstrate that stimulant medication was the cause of the deaths. For an explanation of the study see Questions Raised About Stimulants and Sudden Death from the National Institute of Mental Health.

Each wave of negative news reports about rare side-effects increases mistrust of psychiatric medications. Previous examples include the long-standing controversy over anti-depressants' effects on suicidal thoughts and behavior. As a result, parents reject medication despite substantial evidence of beneficial effects. Parents are already concerned about whether medications are safe and effective for treating their children's problems. Sensational headlines and profiles of tragic cases only serve to raise fears and provide little helpful information. Seldom is sufficient attention paid to the larger context of risks and benefits for using, and for not using, medication. Stories that end with the usual caveat "these results may not apply to individuals" and a recommendation to "consult your physician" do little to reduce parents' anxiety and confusion.

Yet parents must rely on the professional opinions of physicians--either their child's pediatrician or a child psychiatrist. (My bias is towards the latter--see my previous post.) Research on safety and effectiveness is incomplete, especially, for newer medications. Factors that must be considered in choosing a medication include accurate diagnoses, appropriate and effective dosage, common and uncommon side effects, and interactions with other medications. The effects on children's long-term development may not be known because studies are not completed until long after approval by the U.S. Food and Drug Administration. "Off-label" use of medications that have not been approved for children or other conditions is common with little or no evidence of safety or effectiveness.

Don't get me wrong, I am not advocating the wide-spread use of psychiatric medications. I understand parents' reluctance to consider medication and I am also cautious about recommending it's use. I generally don't suggest medication unless a patient's symptoms are severe (for example, Major Depression), it's a standard treatment for a particular condition (such as ADHD), or there has been insufficient response to psychological therapies. In addition, research has demonstrated for certain conditions that medication or psychotherapy is equally effective, but it is the combination that is most effective. In any case, a careful evaluation is needed to determine what is the best course to take for a particular child or adolescent.

I also believe an underlying factor in negative public response is lack of acceptance that serious mental illness exists among children and adolescents. Popular myths continue to undermine efforts to identify and treat children before their conditions become disabling and affect their long-term development. Contrast the sometimes hysterical public rejection of psychiatric medications associated with very rare serious side effects to the continued acceptance of medications that treat "real" conditions like pain despite much more common side effects. Tara Parker-Pope's blog post Reasons Not to Panic Over a Painkiller and Dr. Rob's Tylenol can Kill are examples of more balanced responses to the recent concerns over acetaminophen.

Besides relying on professional opinions, parents can also educate themselves about psychiatric medications. Here are some good sources of information:
This post was featured in Grand Rounds, Vol. 5, No. 46: Emergiblog