International Journal of Pediatrics
Volume 2020 (2020), Article ID 8169030, 13 pages
https://doi.org/10.1155/2020/8169030

Research Article

Injury Patterns and Demographics in Child and Adolescent Assault Victims Presenting to US Emergency Departments

Randall T. Loder, Samantha Palma, and Maddie Smith

Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

Correspondence should be addressed to Randall T. Loder; rloder@iupui.edu

Received 4 June 2020; Revised 30 September 2020; Accepted 9 October 2020; Published 24 October 2020

Academic Editor: Somashekhar Marutirao Nimbalkar

Copyright © 2020 Randall T. Loder et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Objective. To correlate injury patterns with patient demographics in child and adolescent assault victims. Methods. The National Electronic Injury Surveillance System-All Injury Program data for the years 2005 through 2015 was used. Injuries due to assault were identified and analyzed with SUDAAN 11.0.01™ software to account for the weighted, stratified nature of the data. Results. There were an estimated 4,407,009 ED visits for assault in of age. With increasing age, the percentage of females decreased. Sexual assaults were more common in females (87.4%), and robbery/burglary was more common in males (79.8%). When the perpetrator was a spouse/partner, the assault victim was most commonly female (88.8%), and when a stranger, the assault victim was most commonly male (71.5%). With increasing age, the percentage of sexual assaults decreased while the reason for the assault being unknown increased. The assault occurred in the home in 59.6% of of age, decreasing to 18.7% in those 15 to 19 years of age. The anatomic location was the head/neck in 32.8% of of age, increasing to 60.6% in those 15-19 years old. old had the highest hospital admission rate (8.3%). The main diagnoses were concussion (3.0%), contusion/abrasion (33.3%), fracture (11.5%), laceration (11.5%), internal organ injury (11.5%), puncture (2.8%), and strain/sprain (20.7%). The number of assaults from 2005 to 2015 decreased for all age groups except for old. Conclusions. These data provide a comprehensive overview of child and adolescent assault victims presenting to the ED in the USA and can be used as background data for further study. The decreasing numbers of assaults over the 11 years of the study are encouraging, and challenges still exist in decreasing the number for old.

1. Introduction

Violence and assault are significant public health issues [1]. Although they have been studied in the general population, there are few overall studies of assault in children and adolescents that correlate injury patterns with the demographics of age and gender. Most studies in children and adolescents only address particular anatomic areas (e.g., craniofacial) or singular mechanisms of injury (firearm injuries, sexual assault, and nonaccidental trauma). Barmparas et al. [2] studied children admitted to a trauma center for assault using the National Trauma Data Bank; however, such results are skewed to more serious injuries as these children were seen at a major trauma center. Mollen et al. [3] reviewed youth violence patients presenting to three hospitals in the Philadelphia area, but the study was limited by age (8 to 24 years), as well as urban location. The purpose of this study was to analyze all child/adolescent assault patients in the USA presenting to emergency departments (ED) and correlate the injury patterns with patient demographics by age and gender. Such information will be very useful to all health care providers involved in caring for injured children and adolescents. Understanding injury patterns with their associated demographics will be helpful information for such a health care provider by giving clues to the potential for assault when not immediately divulged by the patient.

2. Materials and Methods

Children and adolescents were defined as of age. The National Electronic Injury Surveillance System- (NEISS-) All Injury Program (AIP) data was used for this study. The NEISS is a stratified, weighted dataset managed by the US Consumer Product Safety Commission (USCPSC) which collects injury data from ~100 hospitals in the United States and its territories having an emergency department (ED). It was initially designed for injuries due to consumer products. However, not all injuries are from consumer products; thus, the USCPSC selected ~65 of these hospitals (actual numbers vary slightly from year to year) to obtain data for all nonfatal injuries, regardless of the association with consumer products. This has been designated the All Injury Program (AIP). This data is in the public domain and housed by the Inter-University Consortium for Political and Social Research (ICPSR). It can be accessed at https://www.icpsr.umich.edu/icpsrweb/ICPSR/search/studies?q=all+injury+program. Use of this publicly available deidentified data was considered exempt by our local Institutional Review Board.

The database includes date of ED visit, gender/race/age of the injured patient, diagnosis, disposition from the ED, incident locale, body part injured, perpetrator and type of assault, reason for assault, causative agent/event of the injury, and hospital size (strata). Detailed descriptions of these variables are given in the appendix. The NEISS-AIP data for the years 2005 through 2015 was used. These years were chosen because 2015 was the last available year at the time the study began in mid-2019, and data before 2005 was coded differently for many variables, making it difficult to combine the years before 2005 with those afterwards. Injuries due to assault were identified using the code INTENT=1 (assault). Race was classified as White, Black, Amerindian (Hispanic and Native American), and Asian [4]. NEISS does not code for Polynesian and Indo-Mediterranean peoples.

2.1. Statistical Analysis

Statistical analyses were performed with SUDAAN 11.0.01™ software (RTI International, Research Triangle Park, North Carolina, 2013) which accounts for the weighted, stratified nature of the data. The estimated number of injuries/ED visits is calculated, along with 95% confidence intervals (CIs) of the estimate. When the actual number of patients () is <20, the estimated number () becomes unstable and should be interpreted with caution; thus, we report both the and . The annual incidence of ED visits for assault was calculated using the US Census Bureau data. Analyses between groups of continuous data were performed with the -test (2 groups) or ANOVA (3 or more groups). Differences between groups of categorical data were analyzed by the test. A was considered to be statistically significant.

3. Results

There were a total of 5,702,369 ED visits in the NEISS-AIP database from 2005 through 2015, for an estimated 337,627,315 patients. Of these estimated 337,627,315 patients, there were an estimated 18,116,132 (14,855,602–22,013,301) due to assault (5.4%). Of these assault patients, an estimated 4,407,009 (4,139,536–4,686,643) were in of age (24.3% of all assault patients).

The average age of these 4,407,009 patients was 14.5 years. Age group distribution was 286,883 (228,316–359,410) (6.5%) (≤4 years), 322,164 (282,865–366,449) (7.3%) (5 to 9 years), 995,807 (922,941–1,072,512) (22.6%) (10 to 14 years), and 2,794,290 (92,693,157–2,892,438) (63.5%) (15 to 19 years old). There were 2,653,938 (60.2%) males and 1,752,659 females (39.8%). Racial composition was known in 3,506,513 patients: White in 1,517,881 (993,044–2089,531) (43.3%), Black in 1,264,225 (974,460–1,586,346) (36.1%), Amerindian in 692,581 (351,002–1,236,046) (19.8%), and Asian in 31,826 (16,831–59,961) (0.9%). Disposition from the ED was known in 4,329,619 patients: 4,110,966 (3,997,537–4,187,175) (94.9%) were treated and released and 281,653 (142,444–332,082) (5.1%) were admitted to the hospital.

3.1. Analyses by Gender

There were differences by gender for all demographic variables (Table 1). With increasing age, the percentage of female patients decreased. Sexual assaults occurred most commonly in females (87.4%), and robbery/burglary most commonly in males (79.8%) (Figure 1(a)) When the perpetrator was a spouse/partner, the assault victim was most commonly female (88.8%); when it was a stranger, the assault victim was most commonly male (71.5%) (Figure 1(b)). When the assault occurred at home, the victim was female in 55.9%, and when on the street, the victim was male in 71.0%. When the injury involved the lower trunk, 70.5% of the victims were female, and when the upper extremity, only 32.8% were female. When the victim was admitted to the hospital, 78.8% were male.

Table 1: General demographics and demographics by gender.

All
Male
Female
% female
value

U95%
L95%
%

U95%
L95%
%

U95%
L95%
%

Average (years)

<10⁻⁴

Age group (years)

    ≤4
10,017
286,857
359,382
228,298
6.5
4,176
119,739
146,910
97,411
4.5
5,841
167,118
210,389
132,084
9.5
58.3
<10⁻⁴

    5 to 9
9,748
322,079
366,420
282,843
7.3
5,287
183,605
212,821
158,027
6.9
4,461
138,475
157,135
121,749
7.9
43.0

    10 to 14
25,031
995,786
1,072,429
922,869
22.6
14,658
604,745
651,433
560,375
22.8
10,373
391,041
426,733
357,538
22.3
39.3

    15 to 19
57,749
2,794,082
2,892,214
2,692,948
63.5
35,430
1,738,937
1,798,125
1,677,950
65.7
22,319
1,055,145
1,099,767
1,009,550
60.2
37.8

Race

    White
27,090
1,517,881
2,089,390
992,977
43.3
15,349
903,556
1,260,861
579,068
42.7
11,741
614,325
830,312
412,866
44.3
40.5
0.015

    Black
40,032
1,264,082
1,592,551
974,043
36.1
23,349
751,445
955,018
570,173
35.5
16,683
512,636
635,124
401,204
36.9
40.6

    Amerindian
12,877
692,488
1,235,612
350,978
19.7
7,853
440,438
779,645
224,087
20.8
5,024
252,050
455,485
127,025
18.2
36.4

    Asian
699
31,826
59,957
16,830
0.9
471
22,587
42,784
11,861
1.1
228
9,239
17,492
4,859
0.7
29.0

Reason

    Altercation
27,268
1,244,983
1,331,674
1,161,579
28.3
17,564
814,419
878,188
753,188
30.7
9,704
430,565
484,961
380,327
24.6
34.6
<10⁻⁴

    Robbery/burglary
1,253
53,672
73,150
39,219
1.2
1,024
42,806
56,529
32,378
1.6
229
10,865
17,702
6,660
0.6
20.2

    Sexual assault
14,810
453,496
583,433
349,884
10.3
2,275
57,234
77,760
41,932
2.2
12,535
396,262
488,116
317,407
22.6
87.4

    Other specified
2,677
87,088
103,114
73,590
2.0
1,607
53,934
66,348
43,790
2.0
1,070
33,154
37,857
28,919
1.9
38.1

    Unknown
56,551
2,558,422
2,685,821
2,428,916
58.1
37,117
1,678,462
1,747,618
1,607,225
63.2
19,434
879,960
936,972
822,873
50.2
34.4

Perpetrator

    Spouse/partner
3,190
168,516
189,043
150,265
3.8
358
18,912
22,824
15,658
0.7
2,832
149,604
164,575
135,831
8.5
88.8
<10⁻⁴

    Parent
8,245
293,505
333,579
257,786
6.7
3,672
132,079
151,540
114,916
5.0
4,573
161,426
179,823
144,770
9.2
55.0

    Other relative
8,660
319,136
350,324
290,835
7.2
3,878
151,728
168,790
136,412
5.7
4,782
167,408
182,101
153,883
9.6
52.5

    Friend/acquaintance
22,655
942,928
1,001,619
886,607
21.4
12,854
568,282
611,202
527,603
21.4
9,801
374,646
394,173
355,790
21.4
39.7

    Multiple
15,281
642,918
763,663
538,486
14.6
9,346
409,989
490,713
340,500
15.4
5,935
232,930
273,415
197,700
13.3
36.2

    Stranger
2,883
113,461
140,570
91,657
2.6
2,023
81,162
99,788
65,818
3.1
860
32,298
41,012
25,414
1.8
28.5

    Other specified
2,303
110,746
120,741
101,792
2.5
1,780
86,635
96,073
78,026
3.3
523
24,111
26,816
21,733
1.4
21.8

    Unknown
39,072
1,801,229
1,911,582
1,693,015
40.9
25,616
1,198,517
1,272,563
1,125,270
45.2
13,456
602,712
644,803
561,902
34.4
33.5

Incident locale

    Unknown
36,784
1,620,207
1,930,530
1,332,996
36.8
22,069
993,134
1,195,334
806,266
37.4
14,715
627,073
739,096
523,344
35.8
38.7
<10⁻⁴

    Home
26,586
1,019,068
1,204,764
854,439
23.1
11,136
449,374
540,076
371,286
16.9
15,450
569,694
659,701
486,538
32.5
55.9

    School/sports
19,195
862,116
943,893
786,137
19.6
12,680
585,871
641,457
533,707
22.1
6,515
276,246
309,520
245,898
15.8
32.0

    Street
9,485
440,176
621,330
307,580
10.0
6,814
312,618
438,165
219,481
11.8
2,671
127,558
186,483
86,231
7.3
29.0

    Other property
10,708
464,533
581,671
368,832
10.5
7,045
312,590
399,683
242,570
11.8
3,663
151,943
185,607
123,913
8.7
32.7

Anatomic location

    Unknown
2,572
87,316
137,045
55,523
2.0
781
25,706
39,278
16,720
1.0
1,791
61,610
100,953
37,156
3.5
70.6
<10⁻⁴

    Head/neck
54,620
2,489,646
2,583,147
2,395,426
56.5
35,868
1,654,719
1,690,028
1,614,125
62.3
18,752
834,927
899,289
770,995
47.6
33.5

    Upper trunk
6,976
308,217
331,817
285,988
7.0
4,521
199,149
218,950
180,999
7.5
2,455
109,068
117,954
100,778
6.2
35.4

    Lower trunk
15,961
520,630
642,923
419,067
11.8
4,411
153,453
178,079
131,901
5.8
11,550
367,177
459,722
289,013
20.9
70.5

    Upper extremity
15,442
700,595
743,834
659,227
15.9
10,316
471,143
643,845
598,728
17.8
5,126
229,451
255,012
206,113
13.1
32.8

    Lower extremity
7,197
300,192
341,511
263,515
6.8
3,851
149,766
172,241
130,043
5.6
3,346
150,426
179,472
125,666
8.6
50.1

Disposition from ED

    Release
94,251
4,110,626
4,186,797
3,997,177
95.0
53,657
2,441,560
2,498,849
2,358,485
93.4
40,594
1,669,065
1,687,753
1,638,350
97.3
40.6
<10⁻⁴

    Admit
6,712
218,603
332,052
142,432
5.0
5,211
172,298
255,374
115,010
6.6
1,501
46,305
77,020
27,617
2.7
21.2

Hospital size

    Small
6,408
779,276
1,096,361
538,927
17.7
3,647
443,477
634,291
301,487
16.7
2,761
335,799
464,104
236,434
19.2
43.1
0.012

    Medium
6,966
887,698
1,234,288
619,568
20.1
4,260
539,925
756,106
373,409
20.3
2,706
347,773
486,363
241,166
19.8
39.2

    Large
17,353
1,535,598
2,189,197
990,162
34.8
10,910
965,666
1,386,151
611,201
36.4
6,443
569,932
804,646
376,471
32.5
37.1

    Very large
41,098
937,644
1,302,590
653,498
21.3
24,827
566,153
802,816
384,821
21.3
16,271
371,490
504,766
265,878
21.2
39.6

    Children’s
30,943
266,381
479,878
144,536
6.0
16,104
138,716
253,982
74,045
5.2
14,839
127,665
227,495
69,581
7.3
47.9

 = actual number of ED visits;  = estimated number of ED visits; L95% = lower 95% confidence interval of the estimate; U95% = upper 95% confidence interval of the estimate. Those categories comprising less than 1% of the variables as described in the appendix are excluded; thus, the percentage sum will not add up to 100.

(a)

(b)

Figure 1: Differences by gender in child and adolescent assault victims. (a) By reason for assault (). (b) By perpetrator of assault ().

3.2. Analyses by Age Groups

The NEISS data is divided into different age groups; for this study, the groups were ≤4 years, 5 to 9 years, 10 to 14 years, and 15 to 19 years old. With increasing age (Table 2), the percentage of sexual assaults decreased while the reason for the assault being unknown increased (Figure 2(a)). Similarly, the perpetrator being a parent decreased with increasing age (Figure 2(b)) while the identity being unknown increased. The home was the incident locale in 59.6% of of age which decreased to 18.7% in those 15 to 19 years of age. Injuries involving the head/neck increased from 32.8% in of age to 60.6% in those 15 to 19 years of age, while lower trunk injuries decreased from 38.9% in to 8.1% in those 15 to 19 years old. While the vast majority of patients in all four groups were discharged from the ED, old had the highest hospital admission rate (8.3%).

Table 2: Demographics by age group.

≤4 years
5 to 9 years
10 to 14 years
15 to 19 years
%
value

L95%
U95%
%

L95%
U95%
%

L95%
U95%
%

L95%
U95%

Sex

    Male
4,176
119,739
111,042
128,627
41.7
5,287
183,605
170,316
196,598
57.0
14,658
604,775
592,393
616,889
60.7
35,430
1,738,937
1,681,758
1,794,918
62.2
<10⁻⁴

    Female
5,841
167,118
158,230
175,815
58.3
4,461
138,475
125,482
151,764
43.0
10,373
391,041
378,897
403,393
39.3
22,319
1,055,145
999,164
1,112,324
37.8

Race

    White
3,652
120,734
85,764
153,782
54.6
2,725
106,686
61,341
158,418
41.5
5,943
320,890
196,764
463,823
39.8
14,749
968,890
647,627
1,316,096
43.7
<10⁻⁴

    Black
2,790
58,623
39,541
82,732
26.5
3,735
90,703
64,761
120,523
35.3
10,987
315,873
241,475
397,159
39.1
22,432
796,637
616,366
996,827
35.9

    Amerindian
1,184
40,819
23,123
67,443
18.4
1,270
56,185
28,640
98,799
21.9
3,187
164,481
78,689
304,750
20.4
7,220
430,248
217,945
769,792
19.4

    Asian
58
1,093
553
2,146
0.5
88
3,515
1,800
6,787
0.0
154
5,627
3,067
10,976
0.7
398
21,369
10,864
41,904
1.0

Reason

    Altercation
533
17,315
13,024
22,893
6.0
1,187
41,309
36,694
46,424
12.8
7,681
308,946
281,813
336,583
31.0
17,853
87,678
819,286
936,367
3.1
<10⁻⁴

    Robbery/burglary
12
338
172
631
0.1
18
616
226
1,675
0.2
198
7,055
4,182
11,950
0.7
1,016
45,392
33,811
60,916
1.6

    Sexual assault
4,441
117,669
99,061
137,216
41.0
3,240
80,435
61,598
102,770
25.0
3,143
89,755
69,607
115,016
9.0
3,986
165,624
125,743
216,837
5.9

    Other specified
957
23,181
19,910
26,967
8.1
490
14,286
11,888
17,139
4.4
578
20,045
16,530
24,198
2.0
651
29,555
22,913
38,282
1.1

    Unknown
4,075
128,333
111,970
145,105
44.7
4,812
185,502
166,752
203,608
57.6
13,395
568,737
537,337
599,575
57.1
34,078
1,669,333
1,590,230
1,746,711
59.7

Perpetrator

    Spouse/partner
17
809
430
1,549
0.3
6
68
32
161
0.0
157
5,368
3,983
7,170
0.5
3,007
162,203
144,465
181,908
5.8
<10⁻⁴

    Parent
2,933
86,586
80,872
92,520
30.2
1,616
53,295
43,589
64,658
16.5
1,829
66,290
57,956
75,681
6.7
1,867
87,334
76,005
100,315
3.1

    Other relative
1,905
49,724
44,696
55,168
17.3
2,115
63,766
58,054
69,877
19.8
2,046
81,267
72,395
91,116
8.2
2,595
124,378
112,330
137,758
4.5

    Unrelated caregiver
302
7,818
6,197
9,869
2.7
73
2,302
1,546
3,447
0.7
44
20
996
2,490
0.0
35
1,468
838
2,235
0.1

    Friend/acquaintance
1,955
53,864
49,946
58,008
18.8
3,504
119,545
105,799
133,956
37.1
8,756
360,802
344,250
377,809
36.2
8,436
408,563
354,037
470,000
14.6

    Multiple
629
15,486
13,168
18,188
5.4
737
22,615
20,361
25,097
7.0
4,080
150,827
120,791
186,714
15.1
9,823
453,753
381,141
537,342
16.2

    Stranger
43
1,234
832
1,807
0.4
55
2,064
1,450
2,932
0.6
415
12,433
10,058
15,335
1.2
2,352
97,008
77,402
121,552
3.5

    Other specified
37
1,649
1,148
2,381
0.6
95
3,297
2,513
4,317
1.0
728
30,247
26,688
34,256
3.0
1,423
75,552
68,181
83,549
2.7

    Unknown
2,179
69,713
63,258
76,598
24.3
1,546
55,083
49,001
61,727
17.1
6,969
286,770
259,607
315,571
28.8
28,199
1,383,384
1,316,949
1,449,957
49.5

Incident locale

    Unknown
2,542
84,218
69,254
100,925
29.4
2,218
74,272
58,054
93,428
23.1
7,268
270,454
220,273
327,222
27.2
24,653
1,187,179
955,647
1,431,235
42.5
<10⁻⁴

    Home
6,445
170,958
155,749
182,687
59.6
4,411
131,254
109,987
153,640
40.7
5,358
193,660
161,022
231,027
19.4
10,356
522,617
426,688
634,304
18.7

    School/sports
671
19,845
15,262
25,676
6.9
2,546
95,004
70,747
123,518
29.5
8,579
377,087
347,935
407,185
37.9
7,399
370,264
314,916
433,394
13.3

    Street
112
3,725
2,238
6,168
1.3
260
9,457
7,216
12,339
2.9
1,690
77,337
51,882
113,721
7.8
7,366
348,235
243,383
489,560
12.5

    Other property
248
8,107
6,053
10,844
2.8
313
12,168
8,698
16,978
3.8
2,134
77,150
60,645
97,689
7.7
7,974
365,657
289,488
458,264
13.1

Anatomic location

    Head/neck
3,043
93,972
78,950
110,364
32.8
3,607
131,804
115,013
149,259
40.9
13,852
567,114
542,914
591,908
57.0
34,026
1,693,398
1,643,043
1,742,799
60.6
<10⁻⁴

    Upper trunk
458
13,063
10,902
15,635
4.6
588
21,683
19,491
24,130
6.7
1,501
65,076
59,748
70,901
6.5
4,382
206,583
189,173
225,220
7.4

    Lower trunk
4,317
111,495
91,430
132,970
38.9
3,251
84,128
66,398
104,639
26.1
3,213
98,207
78,967
121,488
9.9
5,136
225,432
184,144
274,958
8.1

    Upper extremity
586
16,650
13,971
19,795
5.8
1,036
37,670
33,956
41,752
11.7
4,438
184,055
172,673
195,975
18.5
9,374
461,971
432,556
492,913
16.5

    Lower extremity
17,168
33,846
27,971
40,766
11.8
816
33,390
27,674
40,142
10.4
1,501
64,013
56,064
72,993
6.4
3,811
168,324
145,583
194,483
6.0

Disposition from ED

    Release
8,736
259,819
244,976
269,225
91.7
9,409
312,693
306,250
315,844
98.1
23,984
963,933
945,877
973,868
97.8
52,093
2,573,306
2,493,535
2,627,796
94.1
0.0005

    Admit
1,142
23,456
14,050
38,299
8.3
207
6,019
2,868
12,462
1.9
780
21,665
11,729
39,720
2.2
4,408
161,133
106,643
240,904
5.9

Hospital size

    Small
534
65,216
44,610
91,745
22.7
535
65,156
41,205
98,196
20.2
1,495
181,770
120,493
264,686
18.3
3,843
467,014
325,814
653,305
16.7
<10⁻⁴

    Medium
237
31,526
19,795
48,942
11.0
336
43,526
27,030
67,816
13.5
1,504
193,179
125,372
285,597
19.4
4,889
619,468
440,380
844,993
22.2

    Large
1,022
90,183
57,836
130,331
31.4
1,272
111,658
60,148
177,416
34.7
3,856
340,230
195,875
285,597
34.2
11,165
990,152
655,261
1,385,409
35.4

    Very large
2,039
46,684
27,684
74,963
16.3
2,557
58,396
34,021
94,491
18.1
8,722
199,260
121,488
521,604
20.0
27,610
629,400
455,469
845,832
22.5

    Children’s
6,188
53,274
27,311
94,930
18.6
5,049
43,428
22,713
78,093
13.5
9,455
81,368
43,517
309,198
8.2
10,245
88,255
47,503
162,069
3.2

 = actual number of ED visits;  = estimated number of ED visits; L95% = lower 95% confidence interval of the estimate; U95% = upper 95% confidence interval of the estimate. Those categories comprising less than 1% of the variables as described in the appendix are excluded; thus, the percentage sum will not add up to 100.

(a)

(b)

Figure 2: Differences by gender in child and adolescent assault victims. (a) By reason for assault (). (b) By perpetrator of assault ().

3.3. Analyses by Diagnosis

There were seven major diagnoses (Table 3) that accounted for 99.6% of all the injuries. These were concussions (—3.0%), contusion/abrasion (—33.3%), fracture (—11.5%), laceration (—17.3%), internal organ injury (—11.5%), puncture (—2.8%), and strain/sprain (—20.7%). The punctures and lacerations (penetrating trauma) comprised 20.1% of the assaults with blunt trauma comprising the remaining 79.9%. The common penetrating trauma was overwhelmingly in the 15- to 19-year-old age group (76.6% of the lacerations and 79.1% of the punctures were in those 15 to 19 years old). These diagnoses differed markedly by age group (Figure 3(a)) and gender (Figure 3(b)). Strain/sprains were most common in females, and fractures in males.

Table 3: Demographics by major diagnoses.

Concussion
Contusion/abrasion
Fracture
Laceration
Internal organ
Puncture
Strain/sprain
value

L95%
U95%
%

L95%
U95%
%

L95%
U95%
%

L95%
U95%
%

L95%
U95%
%

L95%
U95%
%

L95%
U95%
%

(years)

<10⁻⁴

Age group (years)

<10⁻⁴

    ≤4
21
521
259
1,048
0.4
2,593
86,948
69,164
108,853
6.0
874
19,635
13,197
29,013
3.9
491
16,550
13,414
20,463
2.2
774
22,313
16,894
29,300
4.4
69
3,450
1,466
7,932
2.9
4,886
129,464
102,769
161,714
14.3

    5 to 9
141
4,052
1,113
2,407
3.1
3,037
120,383
105,934
136,576
8.3
506
15,804
12,089
20,601
3.1
1,030
36,397
30,391
43,578
4.8
735
26,130
20,929
32,578
5.2
118
5,793
2,452
13,171
4.8
4,101
111,056
98,876
124,500
12.3

    10 to 14
977
32,386
28,653
36,431
25.0
8,513
382,981
344,797
423,737
26.2
2,983
119,891
109,051
131,465
23.8
3,170
123,542
113,531
134,524
16.3
2,898
118,838
107,770
130,665
23.6
395
15,928
11,669
21,439
13.3
6,020
199,344
184,713
214,864
22.0

    15 to 19
2,055
92,459
87,784
96,805
71.4
16,556
868,838
823,252
913,282
59.5
7,080
348,368
336,168
360,094
69.2
11,961
580,629
566,895
594,709
76.6
6,882
337,023
323,713
349,836
66.8
2,468
95,005
80,830
105,034
79.1
10,595
465,591
430,544
500,445
51.4

Sex

    Male
2,209
88,863
85,458
92,118
68.6
17,187
817,807
799,437
836,067
56.0
9,003
404,347
397,859
410,522
80.1
12,584
584,098
574,357
593,543
77.0
7,258
330,499
319,044
341,591
65.4
2,493
95,855
85,385
104,032
78.1
8,676
321,102
278,833
365,974
35.4
<10⁻⁴

    Female
992
40,717
37,462
44,122
31.4
13,521
641,552
623,293
659,923
44.0
2,463
100,166
93,991
106,654
19.9
4,107
174,229
164,784
183,970
23.0
4,056
175,037
163,945
186,492
34.6
622
26,824
18,647
37,294
21.9
16,973
585,673
540,801
627,942
64.6

Race

    White
1,050
61,213
49,560
71,955
59.1
8,050
509,297
323,501
714,234
42.6
3,268
191,941
134,381
250,850
48.0
3,571
217,560
129,901
324,845
35.3
3,133
181,413
118,947
244,972
48.7
327
15,093
8,837
24,497
16.1
7,541
335,598
224,197
451,099
47.1
<10⁻⁴

    Black
1,055
25,423
16,713
36,749
24.6
12,568
432,994
338,667
537,019
36.3
4,202
131,405
99,596
167,727
32.9
7,469
258,985
205,292
315,976
42.0
3,257
107,107
76,181
144,502
28.8
1,606
51,090
31,864
68,961
54.6
9,629
250,810
183,117
328,001
35.2

    Amerindian
348
15,352
9,262
24,413
14.8
4,082
238,734
110,819
452,710
20.0
1,434
73,738
38,143
130,543
18.4
2,241
132,636
65,844
237,813
21.5
1,537
80,809
82,477
141,447
21.7
391
26,795
13,068
46,598
28.6
2,771
121,803
62,083
219,569
17.1

    Asian
32
1,500
704
3,156
1.4
241
13,146
6,329
27,347
1.1
68
2,741
1,399
5,358
0.7
134
6,756
3,388
13,304
1.1
83
3,195
1,714
5,960
0.9
15
630
300
1,320
0.7
119
3,751
2,278
6,052
0.5

Reason

    Altercation
848
31,990
28,080
36,256
24.7
8,723
433,742
401,212
467,764
29.7
4,422
200,255
181,833
219,047
39.7
6,014
267,732
243,181
293,319
35.3
2,797
117,918
108,136
128,307
23.3
517
22,389
16,402
29,934
18.3
3,875
168,912
146,004
194,520
18.6
<10⁻⁴

    Robbery/burglary
52
1,361
907
1,944
1.1
341
15,701
11,092
22,038
1.1
152
5,910
4,286
8,118
1.2
307
14,770
9,937
21,845
1.9
188
7,810
5,460
11,173
1.5
67
2,335
1,779
3,055
1.9
142
5,464
3,990
7,436
0.6

    Sexual assault
4
109
26
518
0.1
434
14,988
10,508
21,454
1.0
19
542
252
1,160
0.1
111
4,397
2,579
7,509
0.6
24
685
354
1,264
0.1
3
104
25
491
0.1
14,212
432,545
364,102
501,944
47.7

    Other specified
34
1,050
505
2,164
0.8
1,185
39,257
32,109
47,871
2.7
3,334
9,620
7,009
13,111
1.9
180
7,523
5,992
9,406
1.0
242
8,247
6,926
9,808
1.6
126
5,225
2,760
9,692
4.3
480
14,014
11,154
17,593
1.5

    Unknown
2,253
94,483
89,475
99,077
72.9
19,984
954,054
918,015
988,946
65.4
6,512
287,307
269,977
304,014
57.0
10,038
461,959
438,196
484,997
60.9
8,031
369,375
357,471
380,625
73.1
2,374
91,294
85,838
96,193
74.4
6,924
285,213
236,054
339,345
31.5

Perpetrator

    Spouse/partner
76
3,703
2,786
4,898
2.9
1,336
75,153
64,655
87,277
5.1
2,221
11,350
9,177
13,968
2.3
455
22,299
18,660
26,548
2.9
365
18,710
15,824
22,092
3.7
57
3,265
2,306
4,600
2.7
671
33,651
28,385
39,902
3.7
<10⁻⁴

    Parent
87
3,639
2,799
4,717
2.8
3,704
146,722
125,661
170,760
10.1
446
14,696
11,850
18,153
2.9
526
20,384
17,673
23,514
2.7
641
24,273
19,868
29,574
4.8
35
1,567
920
2,662
1.3
2,620
77,860
67,379
89,779
8.6

    Other relative
116
4,948
3,499
6,958
3.8
2,055
98,017
86,255
111,213
6.7
656
25,953
22,389
30,003
5.1
1,490
59,888
53,020
67,584
7.9
606
23,630
20,272
27,502
4.7
99
3,909
2,110
7,140
3.2
3,542
100,251
89,235
112,359
11.1

    Friend/acquaintance
869
32,355
29,285
35,635
25.0
6,835
324,462
308,681
340,789
22.2
2,232
97,439
87,891
107,658
19.3
3,143
135,055
117,798
154,207
17.8
2,477
112,084
101,766
123,151
22.2
350
16,400
9,385
27,382
13.4
6,678
222,728
206,400
239,863
24.6

    Multiple
816
28,528
24,231
33,354
22.0
5,142
232,283
184,625
289,415
15.9
1,548
62,270
56,930
80,075
12.3
2,210
101,729
75,852
134,637
13.4
2,782
114,150
99,390
130,431
22.6
184
8,192
6,784
9,876
6.7
2,548
22,857
79,531
98,031
2.5

    Stranger
75
2,243
1,697
2,954
1.7
464
20,543
16,638
25,249
1.4
294
11,392
8,421
15,329
2.3
506
22,978
19,039
27,686
3.0
284
13,024
10,414
16,329
2.6
445
15,212
10,084
22,426
12.4
806
27,509
19,951
37,725
3.0

    Other specified
7
180
65
505
0.1
576
31,207
27,000
36,049
2.1
1,030
46,843
41,853
52,291
9.3
203
10,145
8,192
12,591
1.3
32
1,476
1,011
2,174
0.3
22
1,634
761
2,429
1.3
427
19,331
15,689
23,760
2.1

    Unknown
1,154
53,975
48,955
59,140
41.7
10,408
525,182
474,478
578,101
36.0
5,002
228,203
215,366
240,881
45.3
8,147
385,365
363,027
407,704
50.8
4,095
197,224
181,541
213,340
39.0
1,917
72,664
60,419
84,047
59.2
8,178
331,872
302,980
361,926
36.6

Incident locale

    Unknown
973
37,540
27,924
48,865
29.0
10,090
486,378
396,979
584,669
33.3
4,781
206,266
168,773
245,772
40.9
6,703
303,689
238,023
374,481
40.0
4,403
205,820
163,797
250,700
40.7
1,009
41,077
28,179
56,359
33.5
8,684
334,006
281,306
390,084
36.8
<10⁻⁴

    Home
404
18,581
15,550
22,080
14.3
8,040
360,952
300,799
428,650
24.7
2,018
83,889
69,133
100,951
16.6
3,071
139,087
109,378
174,687
18.3
1,909
73,122
56,722
93,222
14.5
454
20,018
16,721
23,824
16.3
10,299
312,898
265,981
363,467
34.5

    School/sports
1,070
40,060
36,697
43,578
30.9
6,756
327,984
297,589
360,492
22.5
2,387
108,056
96,161
120,869
21.4
2,871
127,793
109,758
148,139
16.8
2,669
119,812
106,771
133,919
23.7
297
14,400
7,557
26,032
11.7
3,114
122,514
109,004
137,389
13.5

    Street
326
16,993
10,587
26,408
13.1
2,660
142,208
99,245
200,971
9.7
1,045
49,317
32,877
72,612
9.8
2,005
97,382
67,356
139,264
12.8
880
43,006
28,007
64,963
8.5
1,016
32,164
19,665
48,839
26.2
1,535
57,788
37,634
87,693
6.4

    Other property
428
16,407
13,697
19,567
12.7
3,162
141,780
110,483
180,684
9.7
1,236
15,664
45,937
70,242
3.1
2,044
90,119
69,860
115,219
11.9
1,453
63,776
47,218
85,083
12.6
339
15,019
10,845
20,512
12.2
2,016
79,372
63,661
98,484
8.8

Anatomic location

    Unknown
0
0
0
0
0.0
772
28,408
14,449
55,606
1.9
6
188
50
706
0.0
20
668
303
1,593
0.1
0
0
0
0
0.0
11
282
123
675
0.2
1,758
57,573
35,005
93,134
6.3
<10⁻⁴

    Head/neck
3,201
129,580
5,183
8,773
100.0
17,788
864,682
824,024
904,442
59.2
5,583
264,463
253,135
275,473
52.4
12,642
573,946
559,559
587,549
75.7
10,948
491,673
485,475
495,990
97.3
408
17,648
12,317
24,781
14.4
3,890
142,121
124,602
161,602
15.7

    Upper trunk
0
0
0
0
0.0
3,518
165,040
149,743
181,706
11.3
405
15,027
11,900
18,909
3.0
567
24,961
19,873
31,251
3.3
219
8,024
5,308
12,083
1.6
686
27,184
21,677
33,626
22.2
1,514
66,079
53,504
81,345
7.3

    Lower trunk
0
0
0
0
0.0
2,132
99,615
82,023
120,699
6.8
94
3,782
2,773
5,143
0.8
338
14,859
12,212
18,053
2.0
148
5,848
3,792
8,999
1.2
563
21,602
16,145
28,412
17.6
12,596
372,305
305,338
443,180
41.1

    Upper extremity
0
0
0
0
0.0
4,557
220,084
206,079
234,977
15.1
4,553
193,522
180,018
207,197
38.4
2,637
121,514
112,792
130,769
16.0
0
0
0
0
0.0
663
28,567
20,328
38,877
23.3
2,871
130,726
113,810
149,631
14.4

    Lower extremity
0
0
0
0
0.0
1,943
81,653
74,288
89,758
5.6
826
27,540
21,733
34,793
5.5
490
22,571
19,873
25,638
3.0
0
0
0
0
0.0
784
27,396
22,720
32,718
22.3
3,026
138,051
109,095
173,028
15.2

Disposition from ED

    Release
2,909
122,178
116,361
125,441
94.6
29,616
1,411,193
1,386,136
1,423,273
98.4
9,872
456,900
437,159
470,879
91.3
15,821
722,625
713,651
728,787
97.4
9,952
460,606
436,482
475,624
92.6
1,858
80,187
61,549
95,415
66.3
23,717
839,692
805,339
859,951
94.7
<10⁻⁴

    Admit
281
6,984
3,720
12,800
5.4
591
22,691
10,611
47,748
1.6
1,501
43,395
29,417
63,137
8.7
512
19,370
13,208
28,344
2.6
1,175
36,752
21,735
60,877
7.4
1,214
40,805
25,578
59,444
33.7
1,341
46,856
26,596
81,208
5.3

Hospital size

    Small
196
24,037
16,936
33,237
18.5
2,505
303,948
203,890
435,948
20.8
727
88,418
62,628
121,777
17.5
950
115,360
72,894
176,128
15.2
447
54,788
29,372
97,975
10.8
76
9,216
4,932
16,697
7.5
1,472
179,271
125,237
249,204
19.8
<10⁻⁴

    Medium
259
30,923
20,422
44,614
23.9
2,680
337,993
228,847
478,856
23.2
867
109,777
79,067
148,099
21.8
1,236
157,013
100,959
233,093
20.7
724
96,528
62,890
142,361
19.1
97
12,077
5,717
24,045
9.8
1,079
140,281
89,325
212,748
15.5

    Large
457
40,610
29,739
53,335
31.3
5,333
470,519
254,826
754,407
32.2
1,984
175,824
124,248
235,334
34.9
3,188
281,850
147,684
448,436
37.2
2,497
222,527
165,010
283,459
44.0
600
52,913
26,805
82,563
43.1
3,234
286,070
191,165
401,555
31.5

    Very large
1,004
22,977
15,498
33,017
17.7
12,193
278,097
181,852
408,947
19.1
4,404
100,428
73,419
134,131
19.9
7,547
171,618
105,662
262,220
22.6
4,624
10,582
68,704
155,961
2.1
2,014
45,606
24,548
72,172
37.2
9,132
208,948
143,011
293,549
23.0

    Children’s
1,285
11,035
6,336
18,685
8.5
7,999
68,927
37,217
125,078
4.7
3,485
30,075
15,985
55,064
6.0
3,773
32,678
15,246
68,115
4.3
3,023
25,830
15,318
42,921
5.1
328
2,866
1,141
7,079
2.3
10,738
92,284
46,612
173,753
10.2

 = actual number of ED visits;  = estimated number of ED visits; L95% = lower 95% confidence interval of the estimate; U95% = upper 95% confidence interval of the estimate. Those categories comprising less than 1% of the variables as described in the appendix are excluded; thus, the percentage sum will not add up to 100.

(a)

(b)

Figure 3: Diagnosis in child and adolescent assault victims. STSP = strain/sprain; PCT = puncture; Int Org = internal organ injury; LAC = laceration; FX = fracture; CTAB = contusion/abrasion; Conc = Concussion. (a)By age group (). (b) By gender ().

3.4. Changes Over Time

There was a gradual decrease in the number of assaults from 2005 to 2015 for all age groups except for old (Figure 4).

Figure 4: Number of assaults in child and adolescent assault victims over time and by age group. There was a gradual decrease for all age groups except for of age. The number of assaults decreased by 23.7% for old (, ), 54.4% for those 5 to 9 years old (, ), 51.1% for those 10 to 14 years old (, ), and 37.0% for those 15 to 19 years old (, ).

4. Discussion

While there are some similar studies, none have focused on all injured patients who present to the emergency department across a whole country. Most focus on a certain city or county [3, 5, 6], only patients admitted to the hospital [2], or a certain type/cause of injury [7–12]. This study is more expansive, studying all assault victims in children and adolescents, not just those admitted to the hospital or having a particular type of injury, involving a particular anatomic area or encompassing a particular geographic location. In this study, only 5.0% of the patients were admitted to the hospital.

4.1. Literature Comparison

The study most similar to the present one is that of Barmparas et al. [2]. However, they used the National Trauma Data Bank, only studying patients admitted to the hospital. They found a slightly higher median age (16 years vs. 15 years). Both studies noted that most of the assault victims were adolescents. They noted that with increasing age, a greater proportion of their patients were Black and fewer were White. While this trend was also seen in our data until age 15 years, in those aged 15 to 19, there was an increase in the proportion of White patients (Table 2). Amerindian and Asian races demonstrated a consistent proportion across all four age groups. Barmparas et al. [2] found that younger children were more likely to sustain a head injury, while we found that they were more likely to have lower trunk injury. This difference is likely due to the fact that they only studied those admitted to the hospital. In this study, all other age groups were more likely to have a head injury, especially concussions in those 15 to 19 years of age. Additionally, the present study used different classifications for reason of injury. When known, a sexual assault was the most common reason for the assault, except for those 10 to 14 years of age, who were most likely to be injured in an altercation. This also likely explains the fact that most of the injuries in the old involved the lower trunk (sexual assault) as discussed above. We found that adolescents were most likely to be injured in the street, while younger patients were more likely to be injured at home. Children 10 to 14 years of age were most likely to be assaulted at school and by a friend or acquaintance. This finding is consistent with other studies [6, 11] which found that older children and adolescents tended to experience more violent injury further away from home.

The study of Herbert et al. [5] from Cape Town, South Africa, had a younger population while Mollen et al. [3] studied victims of violence limited in the age from 8 to 24 years; however, both noted that most of the injuries were either to the extremities or the head. We found that in old, most of the injuries were to the lower trunk, which has been noted by others to be more serious than other areas of injury [5].

4.2. Our Findings

Most patients in this study were children 15 to 19 years old (64.7%). They were more likely to be male in all age groups except old. As has been previously noted, victims of sexual assault are more likely to be female [13]. In this study, females were more likely to be injured by a partner (8.5% vs. 0.7%) compared to males, but both sexes were more likely to be assaulted by a known person. More importantly, sexual assault accounted for 87.4% of all assaults in females (Table 1). This is likely a low estimate, as many cases of sexual assault are not reported to health care providers [14–18] or police [19]. The perpetrator was unknown in 45.2% of male and 33.5% of female victims (Table 1).

All of the diagnoses (concussions, contusions/abrasions, fractures, lacerations, internal organ injuries, and punctures) were most likely to occur in 15- to 19-year-olds and male patients and least likely to occur in the younger patients. Strains and sprains were the only injuries to occur more often in female patients and have a younger average age of injury presentation. This finding differs from Mollen et al. [3] who found that females were more likely to sustain bruises/abrasions and be injured in an event involving multiple perpetrators. They also noted that older patients were less likely to sustain a fracture [3]. This information may coincide with results from a study of Indianapolis youth [6] which found that there was a significant spike in violent injury events between the ages of 13 and 16. This is in contrast to Mollen et al. [3] who found that females were more likely to sustain bruises/abrasions and be injured by multiple perpetrators. They also found that older patients were less likely to sustain a fracture. The discrepancies between this study and that of Mollen et al. [3] are likely due to the fact that their study was limited to the Philadelphia area, thus not representative of the entire US, as well as limiting the patient age from 8 to 24 years.

Although concussions only accounted for 3.0% of the diagnoses, nearly all occurred in of age. This is likely due to the fact that old also accounted for nearly all of the altercations. Altercations often involve fighting, where exchanges of blows are likely to result in a concussion if delivered to the head. Within the youngest age group (≤ 4 years old), strains/sprains were quite common. These are typically less severe injuries than fractures, concussions, and internal organ injuries. The exact reason why there are more strains/sprains in this age group cannot be stated with certainty. Possible explanations are that, in spite of parents being the most common perpetrator of the assault of the four different age groups, the assault involved lower amounts of energy being delivered to the patient, resulting in a strain/sprain. Also, if the perpetrator was another child, such as in a day care center, a younger child would also likely not be able to deliver adequate injury that would result in a fracture or concussion. However, nearly 50% of the children in the ≤4-year-old age group were assaulted by parents or other relatives. These could also be defined as child abuse, battered child syndrome, or nonaccidental trauma. This leads to the next topic.

4.3. Government and Other Social Factors

All 50 of the states in the US have mandatory reporting of potential or actual child abuse to appropriate legal authorities for certain professionals and groups [20]. These include social workers, teachers/other school personnel, all health care workers, counselors and mental health professions, child care providers, and law enforcement officers. Also, anyone can file a concern for child maltreatment with appropriate authorities, and in 18 states, it is law that any person who suspects child abuse or neglect is required to report such concerns [20]. Most states have a toll-free number to call to report suspected abuse. Child Welfare Information Gateway, a service of the Children’s Bureau (https://www.childwelfare.gov), provides a list of state child abuse reporting numbers. Another source on how and where to file a report of suspected child abuse and neglect is the National Child Abuse Hotline and can be reached 7 days a week, 24 hours a day, at its toll-free number, 1.800.4-A-CHILD (1.800.422.4453).

Once such a report has been filed, then each state’s Child Protective Services agency follows its own investigation algorithm. The Child Protective Services response is often differential [21]. In serious cases, the state will take legal custody of the child and place them into foster care. In less serious cases, they will use community agencies to support families who are considered lower risk, recognizing that variations in families’ needs and strengths require different approaches. In-home services play an important role in safety and permanence for the majority of families that receive a report of child maltreatment [22].

There is now an even stronger push to keep children in their own home when possible. The 2018 signing of the Family First Prevention Services Act (H.R. 1892) [23] redirects federal funds to provide services to keep children safely with their families and out of foster care, and when foster care is needed, it allows federal reimbursement for care in family-based settings and certain residential treatment programs for children with emotional and behavioral disturbance requiring special treatment. As the data used in this was collected before the implementation of this law, further research and follow-up will be needed to assess its impact on the incidence of child maltreatment occurring in their own home.

4.4. Limitations

There are certain limitations to this study. One potential limitation is the accuracy of the NEISS data. However, two studies have demonstrated over 90% accuracy [24, 25]. The NEISS only identifies individuals who sought care in an ED. It does not include those who might have been treated in urgent care centers, physician offices, and other non-ED venues or those persons who did not seek medical care, and therefore, the assault was never reported to any agency collecting such data. Another limitation is injury severity. The only proxy of injury severity with NEISS data is disposition from the ED as being treated and released or admitted to the hospital. The NEISS-AIP does not include fatal injuries nor does it record the Injury Severity Score. Finally, the race was not known in 20.4% of the patients; this is due to either the patient refusing to divulge such information or it not being collected on the medical record so that the NEISS coders could include it. However, acknowledging these limitations, we noted many interesting findings as described above.

5. Conclusion

These data provide a comprehensive overview of child and adolescent assault victims presenting to the ED in the USA. They can be used as background data for further study. The decreasing numbers of assaults over the 11 years of the study are encouraging, but there still exist challenges in decreasing the number for old.

Appendix

A. NEISS Definitions [26]

A.1 Assault

Assault is defined as injury from an act of violence where physical force by one or more persons is used with the intent of causing harm, injury, or death to another person or an intentional poisoning by another person. This category includes perpetrators as well as intended and unintended victims of violent acts (e.g., innocent bystanders). This category excludes unintentional shooting victims (other than those occurring during an act of violence), unintentional drug overdoses, and children or teenagers “horsing” around.

A.2 Hospital Strata

Four are based on size (the total number of ED visits reported by the hospital, which are small (0–16,830), medium (16,831–21,850), large (28,151–41,130), and very large (>41,130)), and one includes children’s hospitals of all sizes. The actual age is also categorized into 18 different groups in 5-year increments with the last group including all years old. The injured body part is classified into five major locations (head/neck, upper trunk, lower trunk, upper extremity, and lower extremity).

A.3 Incident Locale

This is categorized into home/apartment/mobile, school/sports, street, other property, farm, and unknown. Other property consists of stores, office buildings, restaurants, churches, hotel/motels, hospital/nursing homes, adult day care facility, fraternity/sorority houses, theaters, sidewalks, and parking lots/garages.

A.4 Perpetrator

This is categorized into spouse/partner, parent, other relative, unrelated caregiver, friend/acquaintance, official authorities, multiple perpetrators, stranger, other specified, and unknown.

A.5 Reason for Assault

This is categorized into altercation, robbery/burglary, drug-related, sexual assault, gang-related, other specified, and unknown.

A.6 Causative Agent of Injury

This is categorized into motor vehicle occupant, motorcyclist, pedal cyclist, pedestrian, other transport, fall, struck by/against, cut/pierced, overexertion, fire/burn, poisoning, inhalation/suffocation, drowning/near drowning, machinery, foreign body, dog bite, other bite/sting, firearm gunshot, BB/pellet gunshot, and natural/environmental causes.

Data Availability

The raw data is in the public domain and housed by the Inter-University Consortium for Political and Social Research (ICPSR). It can be accessed at https://www.icpsr.umich.edu/icpsrweb/ICPSR/search/studies?q=all+injury+program. The refined data are available from the corresponding author upon request.

Conflicts of Interest

The authors declare that there are no conflicts of interest.

Authors’ Contributions

RTL conceived and designed the study. RTL, SP, and MS collected and analyzed the data. RTL performed the statistical analyses. RTL, SP, and MS prepared the original manuscript. RTL, SP, and MS participated in manuscript reviews and approved the final manuscript.

Acknowledgments

This study was supported in part by the Garceau Professorship Endowment and Rapp Pediatric Orthopaedic Research Fund, Riley Children’s Foundation.

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