• M E Herman-Giddens, G Brown, S Verbiest, P J Carlson, E G Hooten, E Howell, and J D Butts.
• Office of the Chief Medical Examiner, Department of Health and Human Services, Raleigh, NC, USA. mherman-giddens@unc.edu
• JAMA. 1999 Aug 4; 282 (5): 463467463-7.

ContextMortality figures in the United States are believed to underestimate the incidence of fatal child abuse.ObjectivesTo describe the true incidence of fatal child abuse, determine the proportion of child abuse deaths missed by the vital records system, and provide estimates of the extent of abuse homicides in young children.Design And SettingRetrospective descriptive study of child abuse homicides that occurred over a 10-year period in North Carolina from 1985-1994.CasesThe Medical Examiner Information System was searched for all cases of children younger than 11 years classified with International Classification of Diseases, Ninth Revision codes E960 to E969 as the underlying cause of death and homicide as the manner of death. A total of 273 cases were identified in the search and 259 cases were reviewed after exclusion of fetal deaths and deaths of children who were not residents of North Carolina.Main Outcome MeasureChild abuse homicide.ResultsOf the 259 homicides, 220 (84.9%) were due to child abuse, 22 (8.5%) were not related to abuse, and the status of 17 (6.6%) could not be determined. The rate of child abuse homicide increased from 1.5 per 100000 person-years in 1985 to 2.8 in 1994. Of all 259 child homicides, the state vital records system underrecorded the coding of those due to battering or abuse by 58.7%. Black children were killed at 3 times the rate of white children (4.3 per 100000 vs 1.3 per 100000). Males made up 65.5% (133/203) of the known probable assailants. Biological parents accounted for 63% of the perpetrators of fatal child abuse. From 1985 through 1996, 9467 homicides among US children younger than 11 years were estimated to be due to abuse rather than the 2973 reported. The ICD-9 cause of death coding underascertained abuse homicides by an estimated 61.6%.ConclusionsUsing medical examiner data, we found that significant underascertainment of child abuse homicides in vital records systems persists despite greater societal attention to abuse fatalities. Improved recording of such incidences should be a priority so that prevention strategies can be appropriately targeted and outcomes monitored, especially in light of the increasing rates.

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