Mortality and hospital admissions by violence among children under 15 years in the Valencian Autonomous Community (2007-2011)

INTRODUCTION

The World Health Organization (WHO) considers that violence against children is never justifiable and can be prevented. In 1996, the WHA49.25 resolution was adopted during the 49^{th World Health Assembly, which declared violence a leading and growing worldwide public problem and called all member states to approach it from a public health perspective.1}

The international recommendations advise states to use national indicators based on internationally agreed standards and to ensure that data are compiled, analysed and disseminated to monitor progress over time. The data should be disaggregated by sex, age, setting (urban or rural), household and family characteristics, education and ethnicity.2

However, a singular characteristic of violence is its hiding. Children that are victims of violence hide it due to shame, fear of social rejection, feelings of guilt and the lack of accessible reporting systems. Agents and witnesses of violence against children hide it out of fear of legal sanction or the possibility of losing custody of minors. And professionals, despite their legal and ethical duty to report,4 may be reluctant to do so out of fear of “false positives” (misdiagnosis and its potential social and legal repercussions),3 a lack of confidence in the effectiveness of the interventions of official child protective services, and the possibility of becoming involved in law suits.

There is strong evidence that most cases of abuse or any other type of violence against minors are not reported, even in countries where reporting is legally mandated. Child abuse statistics based on data from official public services (health care, education, judiciary, social welfare, law enforcement) underestimate the prevalence of violence against children, as suggested by comparisons with community-based self-report surveys.2 It is estimated that data from public institutions reflect between 6% and 10% of the true magnitude of the phenomenon and that only approximately 1% of children subject to violence sustain lesions requiring medical attention.5

The manifestations of violence against children vary by age, with a higher risk of severe injury in babies and children aged less than 5 years due to their greater vulnerability, the challenges in diagnosis due to the impossibility of obtaining a statement from the victim, and the invisibility of these acts in society, which usually unfold in the private sphere. Some of the causes of death due to violence that are most difficult to identify are infanticide by suffocation, poisoning or drowning, which are often misrepresented as sudden infant death.6,7

When it comes to sex-related differences, there is more evidence of physical abuse in boys and sexual abuse in girls, which is influenced by social constructs of gender.8

Community-based studies conducted in Europe have found a prevalence of 9.6% for sexual abuse (13.4% in girls and 5.7% in boys); 22.9% for physical abuse; and 29.1% for emotional abuse. Few studies have analysed neglect, but the estimated prevalence in international studies is 16.3% for physical neglect and 18.4% for emotional neglect.9

In Spain, several studies have estimated the prevalence of child sexual abuse between 7% and 15% in males and 13% and 22% in females.10-13 Of the population between 11 and 18 years of age, 11.4% report having been hit, kicked, pushed, shaken, or locked up at their school in the past two months.14

According to the Centro Reina Sofía for the study of violence, the mortality due to child abuse has tripled between 1997 and 2001, with a similar distribution for both sexes. Furthermore, physical abuse and neglect are more frequent in boys, while sexual abuse is more frequent in girls.15

The study on children aged less than 15 years in the Autonomous Community of Valencia (ACV) for the 2001–2006 period showed that mortality due to violence was higher in boys and increased with age, with a predominance of deaths by homicide. On the other hand, hospital admissions due to violence were more frequent in girls, with a predominance of self-harm (suicide attempts) and the 10-14 year age group.16

It is essential that we establish the characteristics and extent of violence in our region and the factors associated to it (inequities in health) in order to plan and evaluate the interventions implemented in different service settings related to minors (health care, education, social services, law enforcement…).17 This allows the implementation of the necessary changes to reduce its frequency and severity. The health care system has sources of information collected routinely and systematically (death records and discharge summaries) that include data that are coded homogeneously regarding the impact of violence on health (International Classification of Diseases), allowing their analysis and comparison. We have used these sources in our study with the purpose of analysing the mortality and hospital admissions (in public hospitals) due to violence in children aged less than 15 years in the ACV during the 2007–2011 period.

MATERIALS AND METHODS

Design

We conducted an observational retrospective study of the routine health databases of the Registro de Mortalidad (Registry of Mortality) of the Autonomous Community of Valencia and the hospital records known as Conjunto Mínimo Básico de Datos (Minimum Basic Data Set [CMBD]) of public hospitals of the Autonomous Community of Valencia.

Period under study

We studied the period from 2007 to 2011, both years included. Since these are infrequent events, we analysed a five-year period to reduce random errors and increase statistical power.

Geographical setting

The Autonomous Community of Valencia. Further disaggregation by geographical territory is not advisable considering the number of identified cases.

Reference population

The reference population consisted of children aged less than 15 years that were official residents included in the Sistema de Información Poblacional (Population Information System [SIP]) of the ACV during the period under study (n = 3 956 448). To analyse the nationality of the children admitted to hospital, we used the number of inhabitants per year reported by the Nacional de Estadística (National Institute of Statistics): 3 274 039 Spanish nationals versus 554 310 foreign nationals. The size of the municipality of residence and the social class of the patients were determined based on the population data of the Eurostat/OCDE for 2009, the year in the middle of the study period (3 521 239 in urban settings vs 435 209 in rural settings; 3 082 073 not at risk of social exclusion vs 874 375 at risk).

Classification of outcome variables

The causes of death were coded according to the International Classification of Diseases, 10^th revision (ICD-10) using the codes included in chapter 20, “External causes of morbidity and mortality”, that pertain to violence (X60-X99, Y00-Y09 and Y87). We excluded the case of a boy aged 4 years that died as a result of a suicide attempt (code X72 ICD-10: intentional self-harm by handgun discharge), as the cause of death was not considered consistent with the scientific literature in regards to attributing intent before age 5 to 6 years.18

The diagnoses at admission were coded using the external cause of injury codes of the International Classification of Diseases, 9^th revision, clinical modification (ICD-9CM codes E950–E969). Children could have been admitted more than once during the period under study, although this did not occur in any patient. We found that two patients had been transferred from a local hospital to a general hospital, one of whom was eventually transferred back to the local hospital for the same process. Their data were re-coded for the purposes of the epidemiological analysis as a single process and hospitalisation for each patient, including all the diagnostic and health care data. We excluded the admissions of two girls in the group aged 1 to 4 years that were coded as suicide (code E950.3: suicide and self-inflicted poisoning by tranquilizers, and code E-958: suicide by other means) that we considered to be coding errors, as it is believed that before 5 or 6 years of age children have very rudimentary notions of death and dying, and that it is highly improbable for them to actively seek death.18

Classification of explanatory variables

We considered a municipality rural if it had a population of 10 000 inhabitants or fewer, and larger municipalities as urban.

We calculated the risk of social exclusion using the APSIG index developed by the SIP that reflects the risk of social exclusion in item 26. We considered that there was risk of social exclusion when any of the five following categories were present in the family: unemployed, irregular immigrant, poor with social security benefits, poor without social security benefits, and undefined, which were clustered in the study (though not compared).

Analysis

The data were processed anonymously using an identifier that allowed their association with data from other sources in the health care system such as the SIP, safeguarding confidentiality.

We performed a descriptive analysis of the outcome variables, finding the rates of mortality and hospital admission and the mean length of stay. We then proceeded to study the distribution of the mortality and admission rate outcome variables based on the following explanatory variables: age group, sex and type of violence (self-harm or assault). For hospital admissions, we also analysed the association with nationality (Spanish vs foreign nationals), residential setting (rural vs urban) and risk of social exclusion. We calculated the corresponding rate ratios with their confidence intervals (CIs) and the statistical significance for a 95% confidence level (95% CI).

We calculated the proportionate hospital mortality due to violence, how it compared with overall mortality by all causes, and its statistical significance by means of Fisher’s test.

We have also described the circumstances at discharge and whether the corresponding form for reporting to child health and social services and child protective services (HNASIPM) was filed.

The study was approved by the ethics committee of the General Directorate of Public Health and the Centro Superior de Investigación en Salud Pública (Superior Centre for Research in Public Health) of the ACV (December 27, 2013).

RESULTS

In the 2007–2011 period there were a total of 1370 deaths in children aged less than 15 years in the ACV, twelve of which were due to violence, amounting to 0.95% of the total number of deaths.

The disaggregated mortality due to violence by age group and sex (Table 1) shows that infants aged less than 1 year are at highest risk of dying as a result of violence, with a rate of death due to violence of 0.7385/105 individuals per year, followed by the group aged 10 to 14 years, with a rate of 0.5768/105 individuals per year. In the group aged 10–14 years, mortality due to violence was 3.16 times more frequent than in the group aged 0–9 years (95% CI of the rate ratio, 0.86–12.64; not statistically significant). As for the distribution by sex, deaths due to violence were 2.85 times more frequent in boys than in girls (95% CI of the rate ratio, 0.71–16.37; not statistically significant).

When it came to the type of death by violence, 50% of the deaths were self-inflicted (suicide) and the other 50% resulted from assault (homicides). Table 2 summarises these data.

All the completed suicides took place in the group aged 10 to 14 years, and were 4.75 times more frequent in boys than in girls (95% CI of the rate ratio, 0.53–224.73; not statistically significant).

Homicide was 2.21 times more frequent in children aged less than 10 years compared to children aged 10 to 14 years (95% CI of the rate ratio, 0.24–104.64) and 1.90 times more frequent in boys than in girls (95% CI of the rate ratio, 0.27–21.01), differences that were not statistically significant (Tables 3 and 4).

Of the 198 067 discharges from public hospitals included in our study, 156 corresponded to patients that required admission as a result of violence (0.078%).

The rates of admission due to violence by age and sex (Table 5) show a predominance of the group of children aged 10 to 14 years, with 7.26 times the number of admissions of children aged less than 10 years (95% CI of the rate ratio, 5.02–10.51), and of girls, in whom admissions were 2.59 times more frequent than for boys (95% CI of the rate ratio, 1.83–3.67), differences that were statistically significant (P < .0001), while the rate of overall admissions for any cause was higher in boys and decreased with age (Table 6).

The reasons for admission due to violence were self-inflicted harm in 63.5% of cases (n = 99), most frequently by intentional medication overdose (n = 77); and assault in the remaining 36.5% (57 cases: 27 beatings, 5 stabbings, 3 rapes, and other types). Seventeen percent of patients admitted for self-harm had a diagnosis of mental illness.

Of all discharged patients that had been admitted due to violence, 61.5% were Spanish nationals aged less than 15 years (Table 7). The admission rate ratios by nationality showed that admissions due to violence were 3.56 times more frequent in foreign nationals than in Spanish nationals (95% IC for the rate ratio, 2.57–4.94), a difference that was statistically significant (P < .0001).

The comparison by size of the municipality of residence showed that 82% of children aged less than 15 years hospitalised due to violence resided in municipalities with populations of more than 10 000 inhabitants (Table 7). The admission rate ratios by type of municipality of residence showed that admissions due to violence were 1.76 times more frequent in residents of rural areas compared to residents of urban areas (95% CI, 1.17–2.66), a difference that was statistically significant (P < .0081).

Of all the admissions in the period under study, 27.6% corresponded to children aged less than 15 years that were at risk of social exclusion (Table 7). The admission rate ratios by risk of social exclusion showed that admissions due to violence were 1.61 more frequent in children aged less than 15 years at risk of social exclusion compared to those that were not at risk (95% CI, 1.12–2.31), a difference that was statistically significant (P < .0118).

After a mean length of stay of 3.9 days for admissions due to violence (mode, 1 day) compared to 4.9 days in overall admissions due to all causes (mode, 20 days), 89.7% of the patients (140 cases) were discharged home.

Two of the patients admitted due to violence died. They were two girls (1.28%) aged 11 and 14 years that completed suicide by means of medication overdose. The proportionate hospital mortality due to violence was 4.4 times greater than overall mortality due to all causes, which was 0.29% (565 cases) in the population under study, although the difference was not statistically significant (Fisher’s exact test, P = .075).

For the admissions due to violence, we only found was evidence that the mandated HNASIPM report had been filed from the healthcare setting in 13 (8.3%).

DISCUSSION AND CONCLUSIONS

The mortality due to violence in children aged less that 15 years in the ACV is higher than the 0.6% overall rate for Spain.15,19 We ought to note that the number of cases may be influencing the results of the epidemiological analysis.

Children are at highest risk of death by violence in the first year of life, consistent with other European countries.20 However, we must take into account the difficulty of making a differential diagnosis in this age group.6,7

More boys than girls die from violence, both as a result of suicides and of homicides, a fact that has been identified by the WHO worldwide and that has also been observed in Spain and the ACV.15,16,19

The causes of death were self-inflicted in 50% of the cases and associated to assault in the other 50%, with an increase in the frequency of suicide compared to the previous five-year period in the ACV (22%). This increase in suicide is consistent with the predictions of the WHO.16,19

In the suicide subgroup, the most frequent cause of death was hanging, strangulation or suffocation, followed by jumping off heights, all of them highly effective and lethal, which is consistent with what has been observed in the general population of Spain.21

The age and sex patterns observed in hospital admissions due to violence in children aged less than 15 years in the CVA were different than those observed in mortality due to violence. Thus, more girls were admitted than boys due to violence, and the frequency of admissions due to violence increased with age.

One salient finding was that the admissions related to self-harm (completed or attempted suicide) were twice as frequent as admissions related to assault, a difference that was statistically significant and that calls our attention to the suffering experienced by our young.

In regards to risk factors for suicidal behaviours, while other studies show a predominance of psychiatric comorbidities,21,22 only 17% of children admitted for self-harm in our study had a diagnosis of mental illness, a fact that suggests that mental illnesses are underdiagnosed in children in the ACV.

Two of the girls admitted for violence-related causes died of intentional self-poisoning with medications, a violence-related hospital mortality that is 4.4 times the overall mortality rate for all causes of admission in children aged less than 15 years. This difference was not statistically significant, which may have been due to the low frequency of these cases.

In our study, the factors that were significantly associated with a higher risk of hospital admission due to violence were: not being a Spanish national (three times the risk), residing in a rural setting (nearly twice the risk) and being at risk of social exclusion (nearly twice the risk).

The documentation on mortality and hospital admissions included cases of suicide attributed to children aged 4 years, a possibility that is not supported by scientific evidence.18 This casts doubts on the accuracy with which these events are coded, as there are instances in which it is difficult to identify infanticides by suffocation, poisoning or drowning that are presented as sudden infant death.6,7

Most of the children admitted due to violence are discharged to the home, where, if a family intervention or protective strategy is required but not implemented, violence can enter a recurrent cycle, usually with increasing severity and decreasing time intervals between episodes.

We found that a report had been filed using the HNASIPM form in only 8% of the cases of children admitted due to violence. This fact evinces the need to raise awareness in the profession about the importance of integrating the prevention of abuse in the child health checkups and adhering to the right of minors to have a process set in motion to improve their situation. There is a known link between suicide attempts in children and physical and sexual abuse.21

There is much left to do in the prevention and approach to violence against children in the health care setting. Planning effective intervention strategies requires improving the reporting of abuse in children receiving health care, linking the information obtained from different sources (report forms, data on severe morbidity and mortality), giving feedback to the various professionals that provide health care to children along with support and training, and creating formal channels for cooperation with other public services for minors.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare in relation with the preparation and publication of this article.

ABBREVIATIONS ICD-10: International Classification of Diseases, 10^th revision · ICD-9MC: International Classification of Diseases, 9^th revision, clinical modification · CMBD: Conjunto Mínimo Básico de Datos (Minimum Basic Data Set) · ACV: Autonomous Community of Valencia · HNASIPM: report form for child health and social services and child protective services · CI: confidence interval · WHO: World Health Organization · SIP: Sistema de Información Poblacional (Population Information System).

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