Helping us better understand child maltreatment fatalities. Vincent J. Palusci MD MS, New York University, School of Medicine. USA Theresa M. Covington, MPH, National Center for CHild Death Review, Washington DC, USA

1. Child Death Review and the U.S. National
Child Death Review Case Reporting System:
Helping us better understand child
maltreatment fatalities
Vincent J. Palusci, MD MS
New York University School of Medicine
New York City, New York, USA
Theresa M. Covington, MPH
National Center for Child Death Review
Washington, DC, USA

2. Objectives
1. Describe the child death review process in
the U.S.
2. Explain the development and use of the
National Child Death Review Case Reporting
System (CDR-CRS)
3. Report aggregate information from these
reviews to inform our understanding and
response to how and why children die from
child maltreatment (CM) in the U.S.

3. Agenda
• Ms. Covington will review the history and
implementation of child death review as used
in the U.S. and the development of the
National Child Death Review Case Reporting
System
• Dr. Palusci will review results from the NCDR-
CRS which highlight risk and protective factors
associated with how and why children die
from maltreatment in the U.S.

4. Background
• Reviewing the facts surrounding the death of child
offers a chance to improve the lives of other children
and families.
• Investigations of child maltreatment deaths involve
several community systems which can act on this
information to prevent additional deaths.
• Child death reviews (CDRs) are increasingly being
used throughout the world for several purposes.
• In the United States, the National Child Death Review
Case Reporting System (NCDR-CRS) contains
information from more than 100,000 reviews.

5. Child Death Review:
Intensive case reviews
conducted by teams of
professionals, from many
disciplines, in order to:
• Improve investigations
• Improve diagnosis of cause of death
• Improve services to families
• Improve agency systems
• PREVENT DEATHS

6. •Medical Examiner/ Coroner
•Law Enforcement
•Child Protective Services
•Public Health
•Prosecutor
•Pediatrician or Other
Health Care Provider
Core Team Members

7. Other Team Members
•EMS
•Community Hospital
•Community Mental Health
•Juvenile Division of court
•Schools
•Child Care Licensing
•Clergy
•Advocacy Centers
•SIDS Services
•Domestic Violence
•Tribal councils
•Ad Hoc

8. • All 50 states have well established CDR programs.
• State laws mandate/support CDR in 39 states.
• 23 based in State Health Departments; 20 in Social
Services.
• 37 states have community teams & state boards.
• Half review all causes; all review to age 18.
• Most are funded with federal maternal and child health
or child protection dollars.
• 44 use the national CDR Case Reporting System.
CDR in the United States

9. Is as hard as climbing all of the Munros
or the
•Corbetts
•Grahams
•Donalds
•….and even the Marilyns
Taking Action from the Reviews

10. The Marilyns: Improving the
Investigation

11. The Donalds: Improving Services

12. The Grahams:
Improving Agency Systems

13. Preventing Deaths
The Munros: Preventing Deaths

14. Low Birth WeightPoverty
Racism
Poor Access
to Prenatal Care
Education
Family Support
Genetics
Nutrition
Stress
Smoking
Substance Use
Tobacco
Inadequate housing
Unemployment
Death
Provider Bias
Sleep Place
Supervision
Identify the Risk Factors
bedding

15. National Child Death Review
Case Reporting System
• Built by National Center in 2002-04 with extensive input from
state and local users.
Data is entered on the web and stored on servers at Center’s
parent agency.
• 1600 plus data elements
• Teams own their data and can retrieve and analyze their data.
• National Center can download de-identified data for study.
• Child maltreatment data collected since 2005
• 44 of 50 states voluntarily participating in system but they
have joined over years since 2005.

16. Records in the NCDR-CRS
Total records 153,000
Records related to child deaths 144,000
Complete records, 2005-2009 45,974
Complete records, CM deaths,
reviewed 2005-2009 (23 states) 2,285
Cause/Contributor to death:
Abuse only-1,077 Neglect only-995 Both-85

17. Database information about CM
Child factors
Age
Gender
Race
Hispanic ethnicity
Housing
conditions/homelessness
Medical insurance
Disability
Substance exposure/abuse
School problems
Prior maltreatment
Prior foster care
Triggers
Perinatal/prenatal issues
Medical history
Caretaker/Supervisor/Offender factors
Age
Gender
Race
Hispanic ethnicity
Employment
Income/poverty
Education
Language
Immigration
Social services received
Alcohol/Substance abuse
Physical/mental disability
History of maltreatment as a child
Criminal justice involvement
Prior CPS involvement
Other family violence

18. Database information about CM
Investigation
Scene investigation
Autopsy details
CPS actions
Law enforcement actions
Criminal charges
Court outcomes
Cause/manner of death
Team Review
Services planned/provided
Level of preventability
Acts causing death
Acts contributing to death
Changes in policy/procedure
Prevention programs

19. Results
• Using preliminary data for 101,501 child deaths
reviewed in 23 U.S. States, there were 2,285 cases in
which child abuse or neglect caused or contributed
to fatality or near-fatality.
• Among fatalities, over 70% had physical abuse
identified during child death review, with 40% having
abusive head trauma (almost one-half of which were
labeled as shaken baby syndrome).
• CDR teams identified additional abuse and neglect,
triggers, and perpetrator characteristics among these
deaths.

20. Review determinations of
abuse and neglect by year
2005 2006 2007 2008 2009
Act causing to CM death:
Abuse 128 198 205 277 307
Neglect 31 54 93 98 110
Act contributing to CM death
Abuse * 20 25 32 38
Neglect 118 126 144 223 179
Total unique cases 274 374 448 595 594
U.S. states reporting 12 17 17 21 21
*cell n<6

21. Physical Abuse
CM type CM caused CM contributed Total
(1,503) (907) (2,285)
Physical Abuse 1,103 186 1,178
Abusive head trauma 658 107 693
-Shaken baby 295 46 313
-Head impact 159 26 167
-Retinal bleeding 366 51 383
Chronic battering 109 34 114
Beating or kicking 279 58 289
Scalding/Burning 36 7 37
Munchausen by proxy * * *
*cell N<6

22. Events Triggering Physical Abuse
Event trigger CM caused CM contributed Total
(1,503) (907) (2,285)
Physical Abuse 1,103 186 1,178
Crying 241 32 245
Toilet training 46 11 47
Disobedience 61 17 65
Feeding problem 28 * 28
Domestic arguments 61 7 63
*cell n<6

23. Other CM Types
CM type CM caused CM contributed Total
(1,503) (907) (2,285)
Sexual Abuse 26 6 30
Emotional Maltreatment 20 22 38
Emotional Abuse 11 8 17
Emotional Neglect 9 14 21
Neglect
Failure to protect from harm 300 496 741
Failure to provide necessities 78 90 158
Failure to provide food 55 40 86
Failure to provide shelter 14 7 21
Failure to seek/follow treatment 104 240 311
Abandonment 23 14 35

24. Case Outcomes
PA SA PM NEG
Total number 1,178 30 38 1,130
CDRT determination as preventable 962+ 30+ 35 804
Manner of death: Natural 20+ * * 234
Accident 16+ *+ * 415
Suicide * * 10+ 20
Homicide 1,069+ 28 22+ 201
Undetermined 56+ 5 *+ 243
CPS substantiated/indicated 486+ 12 15+ 308
Criminal charges filed/pending 766+ 18 18+ 292
Criminal conviction/Plea 244+ 16 15+ 83
*cell n<6; +Comparison with neglect: P<0.05

25. Results
• CM deaths were more likely than non-CM deaths
among older children, girls, certain racial and ethnic
groups, in the parents home, in families with public
or no health insurance, or with those who received
no prenatal care, had mothers who used drugs or
alcohol during pregnancy, were exposed to domestic
violence or who refused prenatal services.
• Comparisons with other specific causes of death also
reveal other factors associated with CM deaths.

26. Significant Risk Factors
Compared with Neglect, each of the following factors
significantly increased with CM type:
• Physical Abuse
– Younger child or infancy, young parents, employment,
other Domestic Violence
• Sexual Abuse
– Older child, girls, employment, English speaking
• Psychological Maltreatment
– Older child, prior maltreatment, prior foster care, biologic
parents

27. Significant Protective Factors
Compared with Neglect, each of the following factors
significantly decreased with CM type:
• Physical Abuse
– Hawaiian-Pacific Islander, American Indian-Native Alaskan,
Medicaid, prior disability or chronic illness, overcrowded
residence, history of substance abuse
• Sexual Abuse
– Younger child, boys, prior maltreatment, prior foster care,
employment, history of substance abuse
• Psychological Maltreatment
– None

28. Potential Actions after Review
• Education
– Media campaign, School Program, Community safety Project,
Provider education, Parent Education, Public Forum
• Agency
– New/revised policy, new program, new services, expanded
services
• Legal
– New or amended law or ordinance, enforcement of law or
ordinance
• Environment
– Modify consumer product, modify a public space
• Other
– Short-term, long-term, local, state, national

29. Actions Taken After Review
PA SA PM NEG
Total reviews 1,178 30 38 1,130
Total actions taken (% cases) (14) (30) (39) (25)
Education 143 * * 170
Agency 76 * * 61
Legal 29 * * 24
Environment * * * 7
Other 16 * * 20
*cell n<6

30. Conclusions
• While the NCDR-CRS has not been implemented by
all U.S. states and is not nationally representative, it
does highlight a large population of CM deaths with
modifiable risk factors which can be used by
communities for future action.
• Deaths and near fatalities from causes other than
CM often have similar risk profiles which can also be
addressed.
• Aggregating information from child death reviews
offers important insights into preventing future
deaths.

31. Thank You! Questions?
Theresa M. Covington, MPH Vincent J. Palusci, MD MS
Public Health Institute NYU School of Medicine
Okemos, Michigan, USA New York, New York, USA
tcovingt@mphi.org Vincent.Palusci@nyumc.org