Preventable Injury Deaths:
A Population-Based Proxy of Child Maltreatment Risk
Emily Putnam-Hornstein, PhD
Center for Social Services Research
University of California, Berkeley
background
Maltreated children
known to child
protective services
Maltreated
children not
known to child
protective
services
motivation
• CPS: a racially biased sample of maltreated
children?
• a population-based metric of child
maltreatment risk / child welfare service
needs
• implications for how and where we intervene
to reduce racial disparities…as well as what
our short-term expectations should be
this study
• uses data from two public surveillance systems as a means
of assessing bias in one source (CPS data), using the more
complete data found in the other (vital injury death
records)
• exploits variations in injury fatality rates as a means of
quantifying bias in the racial distribution of maltreatment
victims identified by CPS
• hypothesized that racial variability in excess injury death
would be observed, but absent widespread bias on the
part of CPS, consistent counts of substantiations for each
excess death
child injury deaths
A mortality-based standard for
evaluating parental behavior may be
the closest we can get to “culturefree” definitions of neglect and abuse.
(S.R. Johannson, 1987)
why all injury fatalities?
• maltreatment-related, inflicted injuries are
severely undercounted in death records
– cannot capture racial bias in one data source, using another
source potentially corrupted by the same bias
• unintentional and intentional child injury
fatalities are falsely dichotomized – the outcome
is the same
– unintentional injury fatalities are largely preventable, occur
in the home, frequently reflect inadequate caregiving and
supervision (i.e., neglect), accompanied by the same risk
factors as intentional injury deaths
data
injury mortality rates
death statistical master files
year, age, race/ethnicity,
manner/mechanism of death
maltreatment rates
substantiation records
year, age, race/ethnicity,
maltreatment substantiations
population estimates
bridged-race postcensal est.
year, age, race/ethnicity
maltreatment rates (per 1,000) &
injury death rates (per 100,000)
Hispanic
21.6 per 1,000
20.7 per 1,000
18.8 per 100,000
16.9 per 100,000
Rate
0
20
40
60
White
60
Black
Asian/PI
40
62.8 per 1,000
7.0 per 1,000
45.5 per 100,000
0
20
12.3 per 100,000
0
1
2
3
4 0
1
2
Age
Death Rate
* Native American children excluded due to small cell sizes.
Substantiation Rate
3
4
excess injury deaths
• rates of excess (or preventable) injury mortality were
derived based on the difference between each racial
group’s rate of injury death and that of an achievable
baseline
semi-arbitrary
achievable death rate
excess deaths
?
?
Since, by its very definition, the “achievable death rate” is the upper bound
estimate of some unknown fraction of injury deaths that were actually
unavoidable…two other baselines were also considered.
excess injury deaths
Asian/PI
8.2
Hispanic
4.0
White
4.0
Black
14.9
Native American
18.5
All
4.5
0
10
Achievable Death Rate
20
30
Excess Death Rate
substantiations per excess death
definition:
the number of substantiated cases of maltreatment for every injury death
in excess of a specified baseline rate
• it was posited that in the absence of widespread
substantiation bias on the part of CPS, consistent
numbers of substantiated cases for each excess
death would be observed across racial groups
• differences in the number of substantiations per
excess death were treated as an indication that
CPS had substantiated a racially biased sample of
the full population of children at risk of
maltreatment / in need of child welfare services
substantiations per excess death
Excess Death defined as > 4 injury deaths per 100,000
White
Black
Hispanic
Native American
Asian/PI
Excess Death defined as > 6 injury deaths per 100,000
White
Black
Hispanic
Native American
Asian/PI
Excess Death defined as > 8.2 injury deaths per 100 000
White
Black
Hispanic
Native American
* Asian/PI
0
100
200
300
Number of Substantiations per Excess Death
* Excess death rate is equal to 0.
400
summary
• established an “achievable” baseline rate
of injury death
– computed rates of excess death
– alternative baselines set at 50% and 75% of this rate
• computed the corresponding number of
substantiated allegations of maltreatment
associated with each excess death
findings
• findings from this population-level analysis
align with other recent research suggesting that
racial disparities in rates of substantiated
maltreatment arise from real group-level
differences in risk
• per excess death, Black and Native American
children had rates of substantiated maltreatment
that were equivalent to or lower than White
children
qualifications and limitations
• ecological analysis
– racial bias unlikely to operate on such a large scale as to explain observed
disparities
• method for determining how many injury deaths
are preventable
– relied on a rate of death that was achieved, findings held under alternative
specifications
• baseline rates of random deaths may differ due to
non-parental risk factors
– excluded transportation-related deaths, findings held
• variation in the timeliness and/or quality of medical
interventions to prevent death
– research suggests most injury fatality victims are declared dead prior to
arrival at ER/hospital
conclusions?
• to date, efforts to reduce racial disparities have been
oriented around an understanding that the
overrepresentation of Black and Native American
children among victims of maltreatment originated
from CPS system and worker bias
• efforts to reduce racial disparities will continue to
fall short if intervention strategies ignore the social
and economic factors that place some children at far
greater risk of abuse and neglect than others
eputnamhornstein@berkeley.edu
http://cssr.berkeley.edu/cwscmsreports/
Thank you to my colleagues at the Center for
Social Services Research and the
California Department of Social Services
Support for this and other child maltreatment/mortality research
was provided by the HF Guggenheim Foundation. Ongoing
support for research arising from the California Performance
Indicators Project is generously provided by the California
Department of Social Services and the Stuart Foundation.