Office of Epidemiology and Research, Division of Research

Advancing Applied MCH Research

(SDAS) A Birth Cohort Analysis of Medically Attended Infant Maltreatment Injuries.

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Project Number: R40 MC 25689
Grantee: University of Southern California
Department/Center: School of Social Work and a Research/Center for Social Services Research
Project Date: 02/01/2013

Final Report


Principal Investigator

Emily Putnam-Hornstein, Ph.D.
Assistant Professor
University Park Campus
Los Angeles, CA  90089-0701
Phone: (213) 740-0811


  • Perinatal/Infancy (0-12 months)


In the United States in 2010, nearly 700,000 children were substantiated as victims of abuse or neglect by child protective services (CPS). Yet, this victimization count almost certainly understates the incidence and public health burden of abuse and neglect. Community data collection efforts indicate that 1.2 million children are "demonstrably harmed or injured" by maltreatment each year; if a more inclusive "endangerment" standard for defining child maltreatment is applied, the number is 3 million. Given the growing body of research documenting the short- and long-term health consequences of childhood abuse and neglect, the failure to identify maltreated children represents a missed opportunity for intervention, treatment, and prevention. The health care system offers clinical settings in which there may be opportunities for enhanced maltreatment identification, particularly for infants who have the highest rates of nonfatal and fatal victimization and yet limited contact with mandated reporters. Although a number of studies have attempted to ascertain the incidence of abuse and neglect encountered by medical providers through International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, previous research has been limited by: (1) a reliance on ICD-9-CM codes specific to maltreatment, despite research indicating an underdiagnosis/underutilization of abuse and neglect codes; (2) analyses restricted to hospitalization data, even though the greatest opportunities for enhanced surveillance may be found among less serious and much more common maltreatment presentations in emergency departments (ED); and (3) the absence of corresponding CPS records that would provide information concerning whether decisions were made to report suspected maltreatment encountered in the health care system. The proposed project overcomes these limitations through the secondary analysis of a linked, longitudinal, and population-based administrative dataset. These data capture the full cohort of children born in California in 2006 (N = 564,676), drawing upon maternal and infant hospital discharge abstracts at birth for sociodemographic and health information and then providing a longitudinal record of ED encounters, hospitalizations, and reports of maltreatment. Using these linked data, we will prospectively characterize the epidemiology of maltreatment from birth through age 1, employing generalized linear models to examine infant and maternal markers for maltreatment risk, and Cox proportional hazards regression models to estimate the likelihood a child is reported to CPS. Specifically, this project has three aims: (1) to utilize ICD-9-CM maltreatment codes in conjunction with newly classified codes "suggestive" of maltreatment to estimate the incidence of abuse and neglect injuries sustained by infants; (2) to examine sociodemographic differences in the likelihood an infant sustains an injury coded as maltreatment or suggestive of maltreatment; and (3) to model variations in the likelihood that a child with an injury identified or suggestive of maltreatment is reported to CPS. Guided by the life course perspective, the proposed research addresses MCHB Strategic Issues 1 and 2 by integrating public health data to improve the health infrastructure and exploring disparities in maltreatment identification and reporting. Additionally, this project addresses Healthy People 2020 objectives IVP-37 and 38 (reduce fatal and non-fatal child maltreatment) by generating knowledge of early childhood maltreatment risk critical to the development of informed prevention, intervention, and treatment responses.


Listed is descending order by year published.

Putnam‐Hornstein E, Schneiderman JU, Cleves MA, Magruder J. A prospective study of sudden unexpected infant death after reported maltreatment. J Pediatr. 2014 Jan;164(1):142‐8.

Putnam‐Hornstein E, Cleves MA, Licht R, & Needell B. Risk of fatal injury in young children following abuse allegations: evidence from a prospective, population‐based study. Am J Public Health. 2013 Oct;103(10):e39‐e44.


Health Disparities, Violence & Abuse

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