Parental Caregiving in Unintentional Injuries: Towards Improved Detection and Surveillance of Supervisory Neglect in Young Children

Background and Purpose- Nearly all injuries are preventable, and excluding motor vehicle accidents, injuries suffered by infants and young children almost always occur at home. Unintentional injuries, as is true of intentional injuries, frequently result from direct actions (or inactions) of caregivers, and often fall along a neglect-spectrum of parental supervision. Despite its prevalence, supervisory neglect has received minimal attention as a source of child morbidity and mortality. This study describes the patterns of injury associated with supervisory neglect in a cohort of children in a single pediatric trauma center.

Methods- This study used quantitative and qualitative methodologies to investigate the occurrence of supervisory neglect during a retrospective review of data collected over six years in a pediatric hospital forensic registry of children suspected as victims of non-accidental trauma (sNAT) ( N = 533). Demographic information, injury characteristics, laboratory testing, imaging results, and documentation of interviews with caregivers surrounding the circumstances of the injury were collected. Qualitative software was used to classify types of supervisory neglect from qualitative interviews with caregiver pertaining to the mechanism that caused the child’s injury. Logistic regression was then used to assess risks associated with supervisory neglect.

Results- For children with injuries classified as resulting from supervisory neglect, 62.2% had isolated head injuries; 20.0% had evidence of previous intracranial bleeding or healing fractures. Caregivers reported having knowledge of what resulted in the injury in 80.7% of these children; and 55.9% of caregivers reported the child’s injury occurred during a fall. Qualitative software was then used to analyze interviews with caregivers surrounding the circumstances of the child’s injury, and isolated five non-mutually exclusive categories of supervisory neglect: 1) interrupted supervision (53.4%), 2) failure to adapt the home as a child-safe environment (26.7%), 3) non-compliance with child seats, carriers, and other equipment (12.8%), 4) inadequate substitute care (7.0%), and 5) rough handling (3.0%). Overall, children with injuries resulting from supervisory neglect were 15.5 times more likely to have a mechanism of reported injury that was classified as consistent with the injury (AOR 15.5, [p < .001]); 6.8 times more likely to present to the pediatric emergency department without altered loss of consciousness (AOR = 6.8, [p < .001]); and 3.7 times less likely to have bruising away from the reported injury (AOR = 3.7, [p < .001]).

Conclusions and Implications- In a single pediatric hospital, the most common injury pattern resulting from supervisory neglect was interrupted supervision in young children resulting in head trauma from a reported fall, no loss of consciousness, no bruising away from the head injury, and the reported mechanism of injury was consistent with the reported injury. Of these children, 20% had evidence of a prior head injury, suggesting that unintentional injuries sustained by young children are often a result of negligent caregiving that repeatedly exposes a child to age-inappropriate risks. In order to improve detection and prevent subsequent injuries associated with negligent supervision, supervisory neglect should be approached as a public health issue with a prioritization in early detection and intervention.