Child maltreatment deaths in the U.S. National Child Death Review Case Reporting System

Abstract

Comprehensive reviews of child death are increasingly conducted throughout the world, although limited information is available about how this information is systematically used to prevent future deaths. To address this need, we used cases from 2005 to 2009 in the U.S. National Child Death Review Case Reporting System to compare child and offender characteristics and to link that information with actions taken or recommended by review teams. Child, caretaker, and offender characteristics, and outcomes were compared to team responses, and findings were compared to published case series. Among 49,947 child deaths from 23 states entered into the Case Reporting System during the study period, there were 2,285 cases in which child maltreatment caused or contributed to fatality. Over one-half had neglect identified as the maltreatment, and 30% had abusive head trauma. Several child and offender characteristics were associated with specific maltreatment subtypes, and child death review teams recommended and/or planned several activities in their communities. Case characteristics were similar to those published in other reports of child maltreatment deaths. Teams implemented 109 actions or strategies after their review, and we found that aggregating information from child death reviews offers important insights into understanding and preventing future deaths. The National Child Death Review Case Reporting System contains information about a large population which confirms and expands our knowledge about child maltreatment deaths and which can be used by communities for future action.

Introduction

Child maltreatment (CM) deaths are uncommon sentinel events which offer insight into understanding and preventing abuse and neglect (King, Kiesel, & Simon, 2006). Despite repeated calls for action, at least 3,500 children continue to die from abuse and neglect every year in the industrialized world (UNICEF, 2003, U.S. Advisory Board on Child Abuse and Neglect, 1995). Beyond fatality, deaths from child maltreatment impact living children, families and communities medically, emotionally and economically, contributing to a cycle of violence which has effects far beyond childhood (Anda, Butchart, Felitti, & Brown, 2010).

Low incidence rates, the myriad of potential causes, and our inability to accurately predict CM fatality in infants and young children have made prevention problematic (Jason and Andereck, 1983, Ross et al., 2009). Although certain patterns of death have been identified medically (e.g., abusive head trauma, blunt trauma, asphyxiation, poisoning, neglect; Arbogast et al., 2005, Fujiwara et al., 2009, Kasim et al., 1995, Klevens and Leeb, 2010, Knight and Collins, 2005, Lee and Lathrop, 2010, Ross et al., 2009, Yin, 2011), CM fatality is not solely a medical problem. Professionals in public health, education, criminal justice, and child welfare have increasingly important roles to play in identifying, reporting, investigating, responding to, and preventing child maltreatment fatality (Palusci & Haney, 2010).

It has been consistently estimated that 1–2 per 100,000 U.S. children annually are fatally maltreated (McClain et al., 1993, U.S. Department of Health and Human Services, 2011). In the United Kingdom, similar rates have been reported (Browne & Lynch, 1995). However, there have been persistent concerns about a systematic underascertainment of child maltreatment fatalities (Crume et al., 2002, Ewigman et al., 1993, Tursz et al., 2010, U.S. Government Accountability Office, 2011). In particular, correctly identifying deaths due to neglect is problematic (Asser and Swan, 1998, Knight and Collins, 2005, Palusci et al., 2010a), and children with sudden unexpected death or those with what appear to be unintentional causes on the surface often have preventable risk factors which are substantially similar to those in families with maltreatment (McKenzie et al., 2012, Overpeck et al., 2002, Schnitzer et al., 2011).

Family configuration, child gender, social isolation, lack of support, maternal youth, marital status, poverty, and parenting practices are thought to contribute to increased risk (Brewster et al., 1998, Jenny and Isaac, 2006, Rangel et al., 2010). For example, children residing in households with unrelated adults were significantly more likely to die from inflicted injuries than were children residing with two biologic parents, and increased risk was also elevated with step, foster, and adoptive parents (Schnitzer and Ewigman, 2005, Stiffman et al., 2002). Among newborns, 2.1 per 100,000 in North Carolina were killed or left to die each year, usually by their mothers, many of whom were poor, had no prenatal care, or were adolescents (Herman-Giddens et al., 1999). A review in the United Kingdom identified child age less than 5 years, nonorganic failure to thrive, prior abuse or unexplained injuries, caregiver youth, inexperience, mental illness, drug and alcohol abuse, stress and poverty as risk factors (Browne & Lynch, 1995). In one study from U.S. trauma centers, children with abusive injuries who did not have private insurance were 3.8 times more likely to die after controlling for race, injury severity and Glasgow Coma Scale scores, and although there were more African American deaths, race was not an independent predictor for mortality (Rangel et al., 2010). Higher rates of CM fatality were noted in the U.S. among boys (2.5 per 100,000), infants (18 per 100,000), at the hands of parents (88%), and among those with alcohol and drug abuse and domestic violence. In addition, 12% had received services within five years from child protective services (DHHS, 2011). A prior child protective services (CPS) report of maltreatment has been associated with almost 6 times the risk for death from later injury (Putnam-Hornstein, 2011).

Although community systems such as law enforcement, courts, public health, child welfare, and health care each respond to cases as they arise, they are not designed to accurately ascertain the correct numbers of victims across systems or to address broader issues of risk factors and prevention. Public health surveillance has been suggested as a means to more correctly identify and respond to child maltreatment fatalities (Schloesser et al., 1992, Smith et al., 2011), and several U.S. states began aggregating information about child homicide and linking data across systems (Fujiwara et al., 2009, Klevens and Leeb, 2010, Lyman et al., 2003, U.S. Centers for Disease Control and Prevention, 2011). Local multidisciplinary community reviews of child deaths have been identified as a key source of information for enhanced case identification and response (Bennett et al., 2006, Christian and Sege, 2010, Jenny and Isaac, 2006, National Center for Review and Prevention of Child Deaths, 2010, Onwuachi-Saunders et al., 1999).

Child death review teams (CDRTs) became a well-established process in many states in the last quarter of the 20th century as a mechanism to involve multiple professions in the review of maltreatment deaths (Durfee, Durfee, & West, 2002). Missouri became the first state to have comprehensive legislation for CDRTs and developed standards for investigation, reviews, and reporting. In 2012, all 50 U.S. states, the District of Columbia, and Guam had established review programs. A substantial proportion of all U.S. child deaths, ages 0–18, are now being reviewed (Brixey et al., 2011, Webster et al., 2003). These teams have had some success in better classifying deaths and in developing policies and programs to reduce further deaths and injuries (Douglas and Cunningham, 2008, Hochstadt, 2006, Johnston et al., 2011, Onwuachi-Saunders et al., 1999, Palusci et al., 2010b, Rimsza et al., 2002, Sanders et al., 1999, Schnitzer et al., 2008, Webster et al., 2003). Child death reviews have expanded to other countries and to other specialized reviews of unintentional deaths, perinatal deaths, and reviews for children within the child welfare system (Palusci, 2010, Schnitzer et al., 2011, Sidebotham et al., 2011).

It has been recommended that additional information and support would improve reviews and recommendations made by CDRTs (Wirtz et al., 2011, U.S. Government Accountability Office, 2011). To improve data collection about child maltreatment and non-homicide fatalities from child death reviews, the Maternal and Child Health Bureau of the U.S. Health Resources and Services Administration funded the NCRPCD to create and implement a national data collection system for child death review information. The U.S. National Child Death Review Case Reporting System (NCDR-CRS) is an internet-based data reporting structure that has been used since 2005 among an increasing number of U.S. states (Covington, 2011). A detailed electronic data collection form guides child death review coordinators to enter case-specific information depending on the age, cause, and manner of death with the purpose of providing CDRTs with a simple method for capturing, analyzing, and reporting on the full set of information shared at a child death or serious injury review.

Information is assembled by the CDRT from medical examiners, vital statistics, police and child protection investigations, scene investigations, medical information, and other facts contributed by the team, which the CDRT enters into the form. The form also collects information about the opinions of teams regarding the preventability of deaths and activities recommended, planned, and/or carried out to prevent further deaths. Information entered into the NCDR-CRS is available to local child death review teams and can be aggregated for community-level and state-level reviews, reporting, and policy planning.

The objectives of this study are to (a) describe the case characteristics of child maltreatment deaths in a large U.S. population, (b) systematically assess risk factors and community responses as a result of those reviews, and (c) compare these case characteristics in NCDR-CRS with other published series.