title: Abusive head trauma during a time of increased unemployment: a multicenter analysis.
abstract: OBJECTIVE
  To evaluate the rate of abusive head trauma (AHT) in 3 regions of the United States before and during an economic recession and assess whether there is a relationship between the rate of AHT and county-level unemployment rates.
  
  
  METHODS
  Clinical data were collected for AHT cases diagnosed in children younger than 5 years from January 1, 2004 until June 30, 2009, by hospital-based child protection teams within 3 geographic regions. The recession was defined as December 1, 2007 through June 30, 2009. Quarterly unemployment rates were collected for every county in which an AHT case occurred.
  
  
  RESULTS
  During the 5½-year study period, a total of 422 children were diagnosed with AHT in a 74-county region. The overall rate of AHT increased from 8.9 in 100,000 (95% confidence interval [CI]: 7.8-10.0) before the recession to 14.7 in 100,000 (95% CI: 12.5-16.9) during the recession (P < .001). There was no difference in the clinical characteristics of subjects in the prerecession versus recession period. There was no relationship between the rate of AHT and county-level unemployment rates.
  
  
  CONCLUSIONS
  The rate of AHT increased significantly in 3 distinct geographic regions during the 19 months of an economic recession compared with the 47 months before the recession. This finding is consistent with our understanding of the effect of stress on violence. Given the high morbidity and mortality rates for children with AHT, these results are concerning and suggest that prevention efforts might need to be increased significantly during times of economic hardship.
authors.affiliation: Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224, USA. rachel.berger@chp.edu
authors.forename: Rachel P
authors.initials: RP
authors.lastname: Berger
authors.forename: Janet B
authors.initials: JB
authors.lastname: Fromkin
authors.forename: Haley
authors.initials: H
authors.lastname: Stutz
authors.forename: Kathi
authors.initials: K
authors.lastname: Makoroff
authors.forename: Philip V
authors.initials: PV
authors.lastname: Scribano
authors.forename: Kenneth
authors.initials: K
authors.lastname: Feldman
authors.forename: Li Chuan
authors.initials: LC
authors.lastname: Tu
authors.forename: Anthony
authors.initials: A
authors.lastname: Fabio
mesh_terms: D002649:Child Abuse / Q000191:economics / Q000706:statistics & numerical data*; D002675:Child, Preschool; D006259:Craniocerebral Trauma / Q000191:economics / Q000453:epidemiology* / Q000209:etiology; D057172:Economic Recession; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007629:Kentucky; D008297:Male; D010414:Pennsylvania; D016012:Poisson Distribution; D013315:Stress, Psychological; D014478:Unemployment / Q000706:statistics & numerical data*; D014861:Washington