Association of Pediatric Abusive Head Trauma Rates With Macroeconomic Indicators



      We aimed to examine abusive head trauma (AHT) incidence before, during and after the recession of 2007–2009 in 3 US regions and assess the association of economic measures with AHT incidence.


      Data for children <5 years old diagnosed with AHT between January 1, 2004, and December 31, 2012, in 3 regions were linked to county-level economic data using an ecologic time series analysis. Associations between county-level AHT rates and recession period as well as employment growth, mortgage delinquency, and foreclosure rates were examined using zero-inflated Poisson regression models.


      During the 9-year period, 712 children were diagnosed with AHT. The mean rate of AHT per 100,000 child-years increased from 9.8 before the recession to 15.6 during the recession before decreasing to 12.8 after the recession. The AHT rates after the recession were higher than the rates before the recession (incidence rate ratio 1.31, P = .004) but lower than rates during the recession (incidence rate ratio 0.78, P = .005). There was no association between the AHT rate and employment growth, mortgage delinquency rates, or foreclosure rates.


      In the period after the recession, AHT rate was lower than during the recession period yet higher than the level before the recession, suggesting a lingering effect of the economic stress of the recession on maltreatment risk.


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        • Barlow K.M.
        • Minns R.A.
        Annual incidence of shaken impact syndrome in young children.
        Lancet. 2000; 356: 1571-1572
        • Keenan H.T.
        • Runyan D.K.
        • Marshall S.W.
        • et al.
        A population-based study of inflicted traumatic brain injury in young children.
        JAMA. 2003; 290: 621-626
        • Duhaime A.C.
        • Christian C.W.
        • Rorke L.B.
        • et al.
        Nonaccidental head injury in infants—the “shaken-baby syndrome”.
        N Engl J Med. 1998; 338: 1822-1829
        • Kotch J.B.
        • Browne D.C.
        • Ringwalt C.L.
        • et al.
        Risk of child abuse or neglect in a cohort of low-income children.
        Child Abuse Negl. 1995; 19: 1115-1130
        • Freisthler B.
        • Merritt D.H.
        • LaScala E.A.
        Understanding the ecology of child maltreatment: a review of the literature and directions for future research.
        Child Maltreat. 2006; 11: 263-280
        • Berger L.
        • Brooks-Gunn J.
        Socioeconomic status, parenting knowledge and behaviors, and perceived maltreatment of young low-birth-weight children.
        Social Serv Rev. 2005; 97: 237-267
        • Cancian M.
        • Slack K.S.
        • Yang M.Y.
        The Effect of Family Income on Risk of Child Maltreatment.
        University of Wisconsin–Madison Institute for Research and Policy, Madison, Wisc2010
        • Eckenrode J.
        • Smith E.G.
        • McCarthy M.E.
        • et al.
        Income inequality and child maltreatment in the United States.
        Pediatrics. 2014; 133: 454-461
        • Drake B.
        • Pandey S.
        Understanding the relationship between neighborhood poverty and specific types of child maltreatment.
        Child Abuse Negl. 1996; 20: 1003-1018
        • Coulton C.J.
        • Korbin J.E.
        • Su M.
        • et al.
        Community level factors and child maltreatment rates.
        Child Dev. 1995; 66: 1262-1276
        • Keenan H.T.
        • Marshall S.W.
        • Nocera M.A.
        • et al.
        Increased incidence of inflicted traumatic brain injury in children after a natural disaster.
        Am J Prev Med. 2004; 26: 189-193
        • Curtis T.
        • Miller B.C.
        • Berry E.H.
        Changes in reports and incidence of child abuse following natural disasters.
        Child Abuse Negl. 2000; 24: 1151-1162
        • National Bureau of Economic Research
        US Business Cycle Expansions and Contractions.
        National Bureau of Economic Research, Cambridge, Mass2014
      1. The State of the Nation's Housing. Joint Center for Housing Studies of Harvard University, Boston2011
        • Sermons M.
        • Witte P.
        State of Homelessness in America: A Research Report on Homelessness.
        National Alliance to End Homelessness and Homelessness Research Institute, Washington, DC2011
        • Lovell P.
        • Isaacs J.
        The Impact of the Mortgage Crisis on Children.
        First Focus, Washington, DC2008
      2. America's Children: Key National Indicators of Well-being, 2011. Federal Interagency Forum on Child and Family Statistics, Washington, DC2011
        • Berger R.P.
        • Fromkin J.B.
        • Stutz H.
        • et al.
        Abusive head trauma during a time of increased unemployment: a multicenter analysis.
        Pediatrics. 2011; 128: 637-643
        • Huang M.I.
        • O'Riordan M.A.
        • Fitzenrider E.
        • et al.
        Increased incidence of nonaccidental head trauma in infants associated with the economic recession.
        J Neurosurg Pediatr. 2011; 8: 171-176
        • Xiang J.
        • Shi J.
        • Wheeler K.K.
        • et al.
        Paediatric patients with abusive head trauma treated in US emergency departments, 2006–2009.
        Brain Inj. 2013; 27: 1555-1561
        • Rajmil L.
        • Fernandez de Sanmamed M.J.
        • Choonara I.
        • et al.
        Impact of the 2008 economic and financial crisis on child health: a systematic review.
        Int J Environ Res Public Health. 2014; 11: 6528-6546
        • Wood J.N.
        • Medina S.P.
        • Feudtner C.
        • et al.
        Local macroeconomic trends and hospital admissions for child abuse, 2000–2009.
        Pediatrics. 2012; 130: e358-e364
        • Frioux S.
        • Wood J.N.
        • Fakeye O.
        • et al.
        Longitudinal association of county-level economic indicators and child maltreatment incidents.
        Matern Child Health J. 2014; 18: 2202-2208
      3. United States Census Bureau. Intercensal estimates of the resident population by five-year age groups, sex, race, and Hispanic origin for counties: April 1, 2000 to July 1, 2010. Available at: Accessed November 7, 2013.

      4. United States Census Bureau. Annual estimates of the resident population for counties: April 1, 2010 to July 1, 2012. Available at: Accessed November 7, 2013.

        • Kan J.
        Sources of Foreclosure Data. MBA Research DataNotes.
        Mortgage Bankers Association, Washington, DC2008
        • United States Census Bureau
        2009–2011 American Community Survey.
        US Dept of Commerce, Washington, DC2011
      5. United States Census Bureau. 2010 Census Data. Washington, DC: US Dept of Commerce. Available at: Accessed November 7, 2013.

        • Lambert D.
        Zero-inflated poisson regression, with an application to defects in manufacturing.
        Technometrics. 1992; 34: 1-14
        • Brooks-Gunn J.
        • Schneider W.
        • Waldfogel J.
        The great recession and the risk for child maltreatment.
        Child Abuse Negl. 2013; 37: 721-729
        • Finkelhor D.
        • Jones L.
        Have Sexual Abuse and Physical Abuse Declined Since the 1990s?.
        Crimes Against Children Research Center, University of New Hampshire, Durham, NH2012
        • Millett L.
        • Lanier P.
        • Drake B.
        Are economic trends associated with child maltreatment? Preliminary results from the recent recession using state level data.
        Child Youth Serv Rev. 2011; 33: 1280-1287
        • Child Welfare Information Gateway
        Differential response to reports of child abuse and neglect.
        U.S. Department of Health and Human Services, Children's Bureau, Washington, DC2014
        • Finkelhor D.
        • Jones L.
        Updated Trends in Child Maltreatment, 2007.
        Crimes Against Children Research Center, University of New Hampshire, Durham, NH2009
        • Shanahan M.E.
        • Zolotor A.J.
        • Parrish J.W.
        • et al.
        National, regional, and state abusive head trauma: application of the CDC algorithm.
        Pediatrics. 2013; 132: e1546-e1553
        • Aboa-Eboule C.
        • Mengue D.
        • Benzenine E.
        • et al.
        How accurate is the reporting of stroke in hospital discharge data? A pilot validation study using a population-based stroke registry as control.
        J Neurol. 2013; 260: 605-613
        • Hooft A.
        • Ronda J.
        • Schaeffer P.
        • et al.
        Identification of physical abuse cases in hospitalized children: accuracy of International Classification of Diseases codes.
        J Pediatr. 2013; 162: 80-85
        • Berger R.
        • Parks S.
        • Fromkin J.
        • et al.
        Assessing the accuracy of the International Classification of Diseases codes to identify abusive head trauma: a feasibility study.
        Inj Prev. 2015; 21: e133-e137