Methods. California birth records from 1999-2006 were probabilistically linked to state child welfare and death records. This dataset covers the full population of children born in California between 1999 and 2006 (4,317,738 births) and captures both child protective services reports and deaths occurring through each child's fifth birthday or January 1, 2008. Extended Cox Regression models were used to examine the unadjusted and adjusted risk of injury death during the first five years of life. A first report of maltreatment was entered into the model as a time-varying covariate; characteristics at birth were modeled as baseline covariates.
Results. Children with a prior report of physical abuse died from injuries at over 11.5 times the rate of unreported children in the general population (HR: 11.76, 95% CI [9.59, 14.42]). After adjusting for baseline covariates, a prior allegation of physical abuse was associated with a rate of injury death that was 7 times that observed among unreported children (HR: 7.39, 95% CI [5.93, 9.20]). When the model was restricted to intentional injury fatalities and absent any covariate adjustments, physically abused children were observed to die at over 70 times the rate of children with no prior allegation of maltreatment (HR: 73.65, 95% CI [54.77, 99.04]). After accounting for other risk factors, children previously identified as possible victims of physical abuse died of injuries at over 35 times the rate of unreported children (HR: 38.49, 95% CI [27.30, 54.27]). These rates of death were notably higher than not only those children who had not been reported, but also children who were reported for sexual abuse (χ2(1)=6.9, p=.009), neglect (χ2(1)=150.9, p<.001), and other maltreatment (χ2(1)=56.1, p<.001).
Conclusions and Implications. This study suggests that an allegation of physical abuse involving a child under five years of age signals a far greater risk of death than does any other allegation type. Although data which support this finding have consistently appeared in official national fatality data arising from NCANDS, as well as other studies examining risk of death following CPS contact, the heightened rate of death associated with a physical abuse allegation has been little discussed. The findings emerging from this study highlight the potential to strategically tailor the level of case monitoring for children reported for physical abuse. Further supporting practices and policies specific to children reported for physical abuse is the fact that children alleged to have been physically abused represent only a small fraction of all children reported to CPS, providing an easy group to target. In summary, this study indicates that the 12% of children reported for reasons of physical abuse face a much greater risk of injury death than the 88% of children reported for other reasons.