Child Fatality Review in Georgia: Reported Trends and Prevention Opportunities--Arleymah Gray, MPH

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Successful injury prevention efforts depend on high quality data to better understand the circumstances of the injury/fatality events. Child Fatality Review in Georgia is a great source for these data, and the local Child Fatality Review committees are key in implementing prevention efforts. This workshop will offer data from reviewed child deaths, reported trends over time, and present opportunities for targeted prevention efforts.

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  • The most reported causes of child deaths are: sleep-related infant deaths (including SIDS/SUID/asphyxia), motor vehicle-related, and medical
  • These are the common terms that we use to discuss “sleep-related infant deaths”. Ask the audience if they have heard of these terms, and make sure all know the difference between them. Stress that the issue of “sleep-related death” encompasses all of the scenarios, and the prevention efforts are all essentially the same
  • This environment is considered the “Best sleep” for CFR. If the infant dies in this environment (i.e. on the back ,in a crib, no risk factors on or near the child”, we would classify this a “SIDS” death. However, most CFR reported infant deaths do not look like this; only a handful each year.
  • Ask the audience to decide if these are safe sleep environments and why (or why not).Wedges and sleep positioners are not recommended, per AAP guidelines (and explain why – that babies sometimes roll within them and then suffocate because they can’t roll back to a face-up position).Blankets are not recommended, per AAP guidelines, because of the risk that the child will roll down into the blanket space and suffocate. This is a new change in the October 2011 guidelines, because they used to recommend a tucked blanket and now they don’t want any blanket. Also a rule for all childcare centers – no blankets period. **In the AAP technical report, that was issued along with the recommendations, they do still allow for the “feet to foot” and use of light weight, tucked blanket, but as a last resort if blanket sleeper is not available and room is cold.**
  • Ask the audience if they know of these trends. These are common in Georgia, and all over the country. There are no proven reasons why, but many theories…2-4 months of age is when many infants are developing faster in the brain and so could miss a step in the breathing systems, and they are also crying more so parents may sleep with them to soothe (this is the peak age for shaking/abusive head trauma as well)Cold months are usually when more blankets are used and bedsharing happen, and also more toxins in home air b/c people don’t open their windows or use fans to circulate the air
  • These quotes are take directly from African-American mothers who were involved in a research project in Washington, DC. (I think around 2009). Ask the audience how they would respond to a parent who said this, and what they would say to encourage the parent to change their behavior. Encourage multiple responses
  • $75 on eBay
  • SIDS rates have decreased since “BTS” because fewer medical examiners are using the terminology, as well as fewer infants tummy sleeping
  • A simple image of a baby (of indiscriminate race/ethnicity) alone, clearly on its back and in a crib or obviously enclosed area without any objects in the sleep environment.Safe To Sleep is the new expanded campaign name—the words feel like a natural evolution from Back To Sleep (as target audience members told us).Target audience members wanted a logo whose “look and feel” mirrors the broader safe sleep recommendations.
  • 9 page booklet – General audience Hispanic African American Native American / Alaskan
  • Campaign website launch – OctoberVideo on safe infant sleep – OctoberUpdate other campaign materials FY13
  • Babies who sleep on their backs every time, for naps and at night, are much less likely to die of SIDS than babies who sleep on their stomach or sides. The baby’s sleep area should be a safety approved crib, bassinet or portable play area. if the recommended sleep products are not available alternative firm sleep surfaces like dresser drawer, laundry basket, wash tub with no loose blankets can be used. Babies who sleep on a soft surface, such as an adult mattress, or under a soft surface, such as a blanket or quilt, are more likely to die of SIDS and other sleep-related causes of infant death.
  • From the Associated Press, Feb 29,2012-Automakers are also concerned that the cumulative effect of federal safety regulations is driving up the average price of a new car, which is now about $25,000, she said.About 45 percent of 2012 model cars have rearview cameras as standard equipment, according to KidsAndCars.org, a safety group that championed the passage of the 2008 law. The cameras are an option on an additional 23 percent of models.
  • Child Fatality Review in Georgia: Reported Trends and Prevention Opportunities--Arleymah Gray, MPH

    1. 1. 2nd Annual Conference September 4, 2013
    2. 2. Child Fatality Review in Georgia Reported Trends and Prevention Opportunities
    3. 3. Child Fatality Review: What We Do • To serve Georgia’s children by: – promoting more accurate identification and reporting of child fatalities, – evaluating the prevalence and circumstances of both child abuse cases and child fatality investigations, and – monitoring the implementation and impact of the statewide child injury prevention plan in order to prevent and reduce incidents of child abuse and fatalities in the state • The most important reason to review child fatalities in Georgia is to identify factors that can improve the health and safety of children, and to prevent other children from dying
    4. 4. Reviewed Deaths, 2005-2011 623 594 681 571 518 594 495 0 100 200 300 400 500 600 700 800 2005 2006 2007 2008 2009 2010 2011
    5. 5. All Reviewed, 2011 (N=495) 2 3 5 5 8 8 15 16 19 28 59 85 87 155 0 50 100 150 200 Other (Weather-related)0.4% Unintentional Firearm 0.6% Exposure 1.0% Fall/Crush 1.0% Asphyxia/Suffocation 1.6% Poison 1.6% Fire 3.0% Undetermined 3.2% Suicide 3.8% Drowning 5.7% Homicide 11.9% Medical 17.2% Motor Vehicle-Related 17.6% Sleep-Related Infant Deaths…
    6. 6. CFR Definition of “preventable” • The definition of “preventable” for CFR in Georgia states that a child’s death is preventable if the community or an individual could reasonably have done something AT ANY POINT PRIOR TO THE DEATH that COULD have changed the circumstances that led to the death. • We often think that injury events are random "accidents.” However, most injuries to children are predictable, understandable, and therefore preventable.
    7. 7. Preventability, Reviewed Deaths, 2011 CAUSE Missing/Blank No, Probably Not Yes, Probably Team could not determine % Preventable* All Unintentional 2 18 134 10 88.2% SIDS -- 6 -- 2 n/a Sleep-Related Asphyxia 1 2 21 4 91.3% SUID 6 15 61 26 80.3% Homicide 4 5 48 3 90.6% Suicide -- 3 16 -- 84.2% Undetermined -- 4 3 7 n/a Medical 9 49 17 19 25.8%
    8. 8. 2011 Prevention Recommendations • Committees can choose multiple recommendation areas in each death, because there are many ways that prevention efforts can be delivered to parents, caregivers, communities, providers, and policymakers. • In 2011, there were 104 deaths (21%) where the committees made a prevention recommendation for at least one area (e.g. education, law/policy, environment, etc). In 391 cases, the committee did not recommend any preventive action.
    9. 9. 2011 Prevention Recommendations • Of the 227 “education” recommendations, committees most often suggested media campaigns, school programs, parent education, and community safety projects • Of the 12 “law” recommendations, committees most often identified enforcing existing laws and ordinances • Of the six “agency” recommendations, committees most often identified revising policies, creating new programs, and expanding services
    10. 10. Important Terms • SIDS – Sudden Infant Death Syndrome • SUID – Sudden Unexplained Infant Death • Sleep-related Asphyxia • Accidental Suffocation or Strangulation in Bed (ASSB) • Unknown/Undetermined
    11. 11. SIDS • sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history
    12. 12. Safe Sleep Environment
    13. 13. SUID • Infant deaths reported to medical examiners and coroners that: – Occur suddenly and unexpectedly – Have no obvious cause (and/or manner) of death prior to investigation – After investigation, risk factors are identified that COULD HAVE contributed to the death, but are not conclusive to have CAUSED the death
    14. 14. Safe or Unsafe?
    15. 15. Common Patterns • Most sleep-related deaths occur when the infant is between two and four months of age • More sleep-related deaths occur in the colder months • More males die from sleep-related deaths than females • African-American infants have a 2-3 times greater risk of dying from unsafe sleep than Caucasian infants • Back sleeping is the safest sleep position for infants under one year of age • About 75% of infants who die suddenly and unexpectedly die while they are sleeping in the same place (couch, futon, or bed) as another person • SIDS is not the same as suffocation/asphyxia, but both can happen when the infant is asleep
    16. 16. Month of Death for Reviewed Sleep- Related Deaths, 2006-2011 (N=1,094) 106 94 97 100 93 76 80 84 82 79 105 98 0 20 40 60 80 100 120
    17. 17. Sleep-Related Deaths by Location, 2011 (N=155) 1 2 2 3 4 5 14 19 25 80 0 20 40 60 80 100 Stroller Floor Carseat Chair Playpen Other Bassinette Couch Crib Adult bed
    18. 18. 61% 39% Sharing Alone 2011 Sleep-Related Deaths by Bedsharing status (N=152)
    19. 19. Common Issues with Bedsharing • “I’m gone all day at work and I want her close to me at night so I can cuddle with her in bed” • “I want to keep breastfeeding whenever she needs me, but I don’t want to get up and walk back and forth to her crib all night either” **https://www.childwelfare.gov/pubs/guide2013/bonding.pdf**
    20. 20. “ Cribs for Kids” Pack and Play
    21. 21. Cribs for Kids “Safe Sleep Survival Kit” -Graco pack and play -crib sheet with safe sleep message -Halo sleep sack -newborn pacifier -safe sleep magnet
    22. 22. Position Placed to Sleep, when known, 2009-2011 (N=432) 212 144 76 94 0 50 100 150 200 250 Placed on Back (Supine) Placed on Stomach (Prone) Placed on Side Unknown
    23. 23. Upper Respiratory Anatomy: Baby in Back Sleeping Position
    24. 24. Upper Respiratory Anatomy: Baby in Stomach Sleeping Position
    25. 25. Sleep Position Source: NICHD Household Survey SIDS Rate Source: National Center for Health Statistics, CDC National SIDS Rate and Sleep Position, 1988-2008 1.4 1.39 1.3 1.3 1.2 1.17 1.03 0.87 0.74 0.77 0.720.670.620.560.570.530.560.540.550.570.55 13 17 26.9 38.635.3 53.1 55.7 64.466.6 71.671.172.870.172.275.7 70.372.1 0 50 100 0 0.5 1 1.5 PercentBackSleeping SIDSRate Year Pre-AAP recommendation Post-AAP BTS Campaign
    26. 26. MODIFIABLE RISK FACTORS • What are some “modifiable risk factors” for sleep-related deaths? – What are some things we can change – environment, engineering, behaviors – that might reduce the chances of an infant dying during sleep?
    27. 27. American Academy of Pediatrics (AAP) • AAP’s new safe sleep recommendations were published in November 2011 • Recommendations target the creation of a safe sleeping environment for infants to prevent infant sleep death from a variety of causes • The recommendations are divided into 3 levels. – Level A – based on good, consistent scientific evidence – Level B – based on limited, inconsistent scientific evidence – Level C – based on consensus and expert opinion
    28. 28. 2011 AAP Recommendations: Level A (based on consistent scientific evidence) –Always place baby on back for every sleep time –Use a firm sleep surface covered with fitted sheet –Room sharing without bed sharing –Keep soft objects and loose bedding out of baby’s sleep area, including bumpers –Pregnant women should receive regular prenatal care
    29. 29. 2011 AAP Recommendations: Level B (based on inconsistent scientific evidence) • Avoid smoking exposure during pregnancy and after birth • Avoid alcohol and illicit drug use during pregnancy and after birth • Breastfeed baby • Consider giving a pacifier at nap time and bed time • Avoid overheating
    30. 30. 2011 AAP Recommendations: Level C (based on consensus and expert opinion) • Infants should get well-baby check-ups and vaccines • Avoid commercial devices marketed to reduce SIDS • Do not use home breathing and heart monitors to reduce SIDS • Give supervised tummy time AAP Pediatrics, Vol. 128, # 5, November 2011
    31. 31. New Safe to Sleep Campaign Logo (**changed from “Back to Sleep”**) English Spanish
    32. 32. Safe to Sleep Campaign Materials The expanded “Safe to Sleep” campaign builds on the success and reach of the “Back to Sleep” campaign. In addition to strategies for reducing the risk of SIDS, “Safe to Sleep” also describes actions that parents and caregivers can take to reduce the risk of other sleep-related causes of infant death, such as suffocation.
    33. 33. Safe to Sleep Campaign Materials
    34. 34. Safe To Sleep Campaign The campaign’s main messages are: 1. Babies sleep safest on their backs. 2. Create a separate sleep area for your baby. 3. Sleep surface matters. Use a firm surface, covered by a fitted sheet. Remove all bumpers, loose bedding, soft objects and toys. ** http://www.nichd.nih.gov/SIDS**
    35. 35. MOTOR VEHICLE RELATED DEATHS
    36. 36. Motor Vehicle-related deaths by Position, 2011 (N=87) 26 21 17 12 6 3 2 0 5 10 15 20 25 30 Back Seat Passenger Pedestrian Driver Front Seat Passenger Passenger - Unknown position Other Bicyclist
    37. 37. Motor Vehicle-Related Deaths •Of 15-17 year old MV- related deaths: •46% of those were operating the vehicle •29% were passengers •Less than 20% of those driving were under influence (DUI) 5% 17% 13% 18% 46% Percentage of Deaths by Age, Motor Vehicle 2004-2008 Infants 1-4 years 5-9 years 10-14 years 15-17 years
    38. 38. Common Patterns • Child restraint systems (i.e. car seats) are often used incorrectly – studies suggest up to 80% • Restraint use among young children often depends upon the driver’s seat belt use. Almost 40% of children riding with unbelted drivers are also not restrained appropriately • Approximately 39% of backover deaths occurred at home in the driveway, an apartment parking lot or in a townhome complex • Sports utility vehicles and trucks are involved in more backovers than cars • Of reviewed toddler Motor Vehicle-related deaths in Georgia, 42% of victims were pedestrians – Driveways – Playing in yard, darting out – Walking in roadways
    39. 39. MODIFIABLE RISK FACTORS • What are some “modifiable risk factors” for motor vehicle deaths? – What are some things we can change – environment, engineering, behaviors – that might reduce the chances of someone being hurt or killed by a vehicle?
    40. 40. Prevention Together • Rules aimed at helping drivers avoid unintentionally backing over children, already overdue, are being delayed again following complaints from automakers that requiring rearview video cameras systems on new cars and trucks would be too expensive. • The new rear visibility standard was required by a law that Congress passed in 2008 in response to dozens of accidents in which children were backed over. At issue in particular were blind zones in large sport utility vehicles and pickups. • More than a year ago, the National Highway Traffic Safety Administration proposed requiring improved driver rear visibility in new vehicles, a standard that in most cases would necessitate rear- mounted video cameras with in-vehicle display screens. The regulations were to be phased in, applying to all cars and light trucks by the 2014 model year.
    41. 41. MEDICAL DEATHS
    42. 42. Medical Deaths by Age of Decedent, 2011 (N=85) AGE NUMBER PERCENT Infant 31 35.6 1 to 4 16 18.4 5 to 9 10 11.5 10 to 14 12 13.8 15 to 17 16 18.4
    43. 43. 2010 Reviewed Medical Deaths, All Ages 1 1 3 4 4 5 8 8 15 20 30 0 5 10 15 20 25 30 35 Malnutrition/dehydration Unknown Asthma Neurological/seizure disorder Prematurity Undetermined medical cause Congenital anomaly Other infection Pneumonia Cardiovascular Other medical condition
    44. 44. MODIFIABLE RISK FACTORS • What are some “modifiable risk factors” for medical deaths? – What are some things we can change – environment, engineering, behaviors – that might reduce the chances of someone dying from an illness or disease?
    45. 45. Prevention Together • The Urban Health Program in the department of pediatrics at Emory University School of Medicine recently announced funding for 18 planning grants throughout Georgia, to stimulate development, collaboration, and community discussion to expand the number of school-based health centers. The grants are funded by a $3 million gift from the Zeist Foundation aimed to help improve outcomes for at-risk children in metro Atlanta and throughout the state over the next five years. – There are 2,000 school-based health clinics in the nation. School-based health centers are located in schools or on school grounds, and they employ a multidisciplinary team of providers to care for children. They also provide clinical services through a qualified health provider such as a hospital, health department, or medical practices. Florida has 245, California has 160, Louisiana has 64, Mississippi has 31, and Georgia has only two in the entire state. – The 2009 Kids Count Data Book ranked Georgia children 42nd in the nation for well being. More than 300,000 of the state’s children are uninsured with very limited access to routine healthcare.
    46. 46. HOMICIDE DEATHS
    47. 47. Demographics (Age) of Reviewed Homicide Deaths, 2011 (N=60) Infant 14 24% 1 to 4 17 28% 5 to 9 6 10% 10 to 14 9 15% 15 to 17 14 23%
    48. 48. Reviewed Homicide Deaths, by Mechanism, 2011 (N = 60) 7 1 1 1 2 3 3 7 14 21 0 5 10 15 20 25 Unknown Choking Deprivation Exposure Drowning Fire Poison Knife Blunt Force Trauma Firearm Number of Deaths
    49. 49. MODIFIABLE RISK FACTORS • What are some “modifiable risk factors” for homicide deaths? – What are some things we can change – environment, engineering, behaviors – that might reduce the chances of someone being hurt or killed by someone else?
    50. 50. Prevention Together • Chicago’s CeaseFire uses a public health model to stop shootings and killings. CeaseFire is a unique, interdisciplinary, public health approach to violence prevention. Violence is a learned behavior that can be prevented using disease control methods. Using proven public health techniques, the model prevents violence through a three-prong approach: – Identification & detection – Interruption, Intervention, & risk reduction – Changing behavior and norms • The award-winning film “The Interrupters” (released in 2012) shows how three CeaseFire workers are changing their community landscape and reducing violence and homicide. Watch it free on Frontline (www.pbs.org)
    51. 51. SUICIDE DEATHS
    52. 52. Demographics (Race/Gender) of Reviewed Suicide Deaths, 2011 (N=19) White Male 12 White Female 2 African- American Male 2 African- American Female 2 Asian Male 1
    53. 53. Reported Risk Factors, 2011 (**multiple risk factors could be selected for each individual case**) 7 7 5 5 4 4 4 3 2 0 1 2 3 4 5 6 7 8
    54. 54. MODIFIABLE RISK FACTORS • What are some “modifiable risk factors” for suicide deaths? – What are some things we can change – environment, engineering, behaviors – that might reduce the chances of someone trying to hurt or kill themselves?
    55. 55. Prevention Together • The Sources of Strength (SOS) Program is provided as part of the Garrett Lee Smith grant youth suicide prevention activities out of the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD).
    56. 56. Sources of Strength (SOS) • Comparing the Department of Education (DOE) Student Health Surveys for the Middle Schools in Houston and Emanuel Counties that have Sources of Strength Teams (three schools/ 750 students sampled) with those that don't (seven schools/ 2,300 students sampled) after implementing the program: – The schools that have SOS showed a decrease in the number of students reporting that they have seriously considered suicide in the past year by 42% compared to an 8% decrease in the schools without SOS – In the schools that have SOS, self-reports of annual suicide attempts showed a 21% drop compared to a 16% drop in those schools without SOS
    57. 57. Sources of Strength (SOS) • After three months of participation in SOS, 88 Middle School and High School students completed follow-up surveys indicating that: – 99% believed there was an adult at school that could be trusted to help suicidal students (an increase from 83%) – 98% would tell an adult about a suicidal friend even if asked to keep it secret (an increase from 88%) – 74% would go to an adult at school if they had a problem (an increase from 64%)
    58. 58. Prevention Strategies in Georgia • Promoting Protective Factors – Protective factors are conditions that buffer a person from exposure to risk by either reducing the impact of the risks or changing the way that one respond to risks • Reducing Risk Factors – Risk factors are conditions that increase the likelihood of a person becoming involved in problem behavior or developing a disease or injury (e.g., smoking increases the chance of developing lung cancer)
    59. 59. Richmond County – Fatality Trends • 131 child deaths reported to CFR since 2006 – 34 child deaths from 2010-2011 – of those, 16 were infants (47%) – the most frequent causes overall were: • homicides (N=9) • sleep-related (SIDS/SUID/asphyxia) (N=12)
    60. 60. Richmond County- Prevention Efforts • Augusta Safe Kids provides outreach and education to Richmond and neighboring counties for safe sleep, motor vehicle, drowning, and other child injury/death issues • Applying for grants that will support their “Cribs for Kids” education programs • Presented local safe sleep educational activities at the National Cribs for Kids Conference in June 2013 (Pittsburgh, PA)
    61. 61. Floyd County – Fatality Trends • Floyd County CFR reported on 63 child deaths since 2006 • 18 child deaths in 2010-2011 (10 were infants – 56%) – Of those 18, six were determined to be “probably preventable”
    62. 62. Floyd County - Prevention Efforts • The Floyd County CFR Team addressed infant sleep-related deaths in 2012, with support from a grant/donation that was received through a former 501 organization in Rome called TASK – the Alliance to Support Kids • The prevention effort was to provide co-sleepers and cuddle nests to mothers that rated on their scale as “in need” of them and would possibly sleep in the same bed with their infant – The funds allowed for service of up to 200 families, and the company even gave extra due to the team’s passion and concern with this issue • The team has given the co-sleepers through the Floyd County Family Resource Center, Floyd Medical Center-Pediatrics and through TASK during the calendar year of 2012 – The team will monitor sleep-related deaths in 2013 to see if there is any drop in bed sharing deaths
    63. 63. Gwinnett County – Fatality Trends • 241 deaths reported to CFR since 2006 – 67 reported from 2010-2011 – Of those 67, 19 were infants (28%) • Of those 67 deaths reported, 31 were unintentional injuries: – 19 motor vehicle deaths (28%) – eight drowning deaths (12%) – two fire deaths (3%)
    64. 64. Gwinnett County – Prevention Efforts • In 2012, the Gwinnett CFR team looked at their data and evaluated the areas that needed the most attention on prevention. From that review, they noted the areas were: safe sleep, motor vehicle deaths, and suicide prevention. – The team members attended training webinars to better understand suicide and are looking to get prevention programs implemented in the near future. – They also addressed the need to reduce motor vehicle deaths and will be working with local law enforcement and the schools to get prevention methods in place. – Gwinnett has also created new educational literature regarding infant safe sleep habits. • They have used their partnership with Safe Kids Gwinnett to help get the information about Safe Sleep out to the community through the DA's Office, Law Enforcement, and in local hospitals and shelters.
    65. 65. Brooks County – Fatality Trends • Brooks County CFR has reported on six child deaths since 2007 • The most recent CFR report was in 2010 (a sleep-related infant death case)
    66. 66. Brooks County - Prevention Efforts • In December 2012, the CFR team decided to continue with their current programs of educating the community on infant death prevention with the most up-to-date educational materials available • The VWAP and DFCS Director are members of the Brooks County Family Connections strategic planning committee – Family Connections is the organization where all of the community agencies, groups and programs partner together to provide educational programs to improve quality of life for the children in Brooks County • The BCFC Strategic Planning Committee is currently working on plans for Teen Maze to be held the last week in October. – This event will cover several other educational programs for child death prevention (i.e.: texting and driving, drinking and driving, teen pregnancy, dating violence, etc) • They will continue to work closely with all of their community organizations to support any additional programs as requested for child death prevention
    67. 67. Cherokee County – Fatality Trends • 67 deaths reported to CFR since 2006 – 22 deaths from 2010-2011 – Of those 22, 6 were infants (27%) • Most common causes of deaths reported: – Medical issues (5; 23%) – Motor vehicle (4; 18%) – Suicide (3; 14%)
    68. 68. Cherokee County – Prevention Efforts • In August 2012, the Cherokee County CFR committee participated in the Night Out Against Crime Community Prevention night sponsored by the Woodstock Police Department. • The majority of their table was dedicated to sleep-related infant death prevention and abusive head trauma prevention. – They had free education materials on safe infant sleep and information on the number of sleep-rated deaths in our county over the past seven years. – There was a laptop continuously playing Dr. Randall Alexander’s “Abusive Head Trauma” video that explains what AHT is and the internal effects on a baby. They had free educational materials on shaken baby syndrome and dealing appropriately with a crying baby. – They also provided free materials on teen suicide, online predators, teen depression, bullying, teenage dating violence, and general child abuse prevention. • In 2012, we also made these free materials available in the lobby of the Office of the District Attorney, and in January 2013, we expanded to place these free materials in the Juvenile Court Offices.
    69. 69. Thank You! Arleymah Gray, MPH Child Fatality Prevention Specialist Georgia Office of the Child Advocate agray@oca.ga.gov 404-232-1310
    70. 70. This project was supported in part by the Governor’s Office for Children and Families through the U.S. Department of Health and Human Services, Administration for Children and Families, Community Based Child Abuse Prevention and Treatment Act (CFDA 93.590). Points of view or opinions stated in this document are those of the author(s) and do not necessarily represent the official position or policies of the Governor’s Office for Children and Families or the U.S. Department of Health and Human Services, Administration for Children and Families, Community Based Child Abuse Prevention and Treatment Act (CFDA 93.590).

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