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State Child Abuse Death Review Committee


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Title: State Child Abuse Death Review Committee

State Child Abuse Death Review Committee
  • State Child Abuse Death Review Committee
  • Florida Department of Health
  • Michelle Akins, BSW
  • Child Abuse Death Review Quality Improvement

History of Child Abuse Death Review Teams in U.S.
  • 1980s grass roots organization of teams
    throughout the U.S.
  • Early 1990s
  • Following landmark Missouri study of fatal
    abuse deaths, national and state efforts lead to
    models of CDR to improve child abuse reporting
    and services
  • Mid 1990s
  • U.S. Department of Justice, OCAN and American
    Academy of Pediatrics funding of efforts to
    support states national CDR training. MCHB
    begins effort to encourage review of all
    preventable deaths.

History of Child Abuse Death Review Teams in U.S.
  • Late 1990s Most states have some form of CDR,
    but with wide variations in scope process.
  • States form regional support coalitions,
    including South East Coalition and Midwest
    region. These two groups organize
    annual/bi-annual conferences.
  • MCHB promotes efforts to coordinate CDR with
    other review processes, including FIRM, Maternal
    mortality SIDS.
  • Domestic Violence Review starts to organize.
  • MCHB funds the National MCH Resource Center with
    a goal to support expansion of CDR to all
    preventable deaths.

Objectives of Child Abuse Death Review Teams
  • Accurate identification and uniform reporting on
    every child death.
  • Improved investigative systems.
  • Improved services for families and community.
  • Improved communication and linkages among
  • Understanding of risks protective factors in
    child deaths.
  • Changes in legislation, policy and practice, to
    prevent deaths and improve health and safety.

GAO US tracking of child-abuse deaths is flawed
  • America uses flawed methods to tally and analyze
    the deaths of children who have been maltreated,
    and the latest annual estimate of 1,770 such
    fatalities is likely too low, the Government
    Accountability Office says in a new report to
  • Better data, says the GAO, would aid in
    developing strategies that could save many
    children's lives in the future.
  • The GAO report, the subject of a House Human
    Resources subcommittee hearing Tuesday, says
    state agencies and the Department of Health and
    Human Services should broaden the scope of data
    collection, improve coordination, and seek
    uniform definitions of abuse and maltreatment.
  • "We need to do a much better job working together
    at the local, state and national level," said
    Theresa Covington, director of the National
    Center for the Review and Prevention of Child
    Deaths, in testimony prepared for the hearing.
  • In his opening remarks, the chairman of the House
    subcommittee, Rep. Geoff Davis, R-Ky., evoked the
    death of 2-year-old Caylee Anthony, whose mother,
    Casey, was acquitted of murder last week in a
    trial that drew worldwide news coverage.
  • "Sometimes the death of a child from maltreatment
    does not make headlines at all, possibly because
    it is not recorded as a death from maltreatment,"
    Davis said.
  • "It is hard to know which child deaths are more
    tragic those we know about, or those we do
    not," he added. "Our role is to be the voice for
    the voiceless especially those children whose
    deaths are missing from official data today."
  • The main source of nationwide data on
    child-maltreatment deaths is the National Child
    Abuse and Neglect Data System (NCANDS), which
    issues an annual report based on information
    submitted voluntarily by the states. NCANDS'
    latest report, for the 2009 fiscal year,
    estimated that 1,770 children had died from abuse
    or neglect, up from 1,450 in 2005.
  • The GAO notes that many state officials believe
    that increase stems at least in part from new
    procedures and better reporting, rather than a
    surge in abuse of children. But reporting
    standards differ widely from state to state.
  • Some of the problems highlighted by the GAO
  • Nearly half of states included data only from
    child welfare agencies in reporting maltreatment
    deaths to NCANDS. Yet not all children who die
    from maltreatment have had contact with these
    agencies, likely leading to incomplete counts due
    to lack of data from coroners' offices, law
    enforcement agencies and other sources. One study
    cited by the GAO found that maltreatment deaths
    in three states were undercounted by 55 to 75

DAVID CRARY AP National Writer 07/12/11
  • HHS collects some information about maltreatment
    deaths, such as perpetrators' previous abuse of
    children, yet does not report it. And the
    federally funded center for child death review
    does not synthesize or publish the detailed data
    that it collects from states about maltreatment
  • At the local level, lack of medical evidence and
    inconsistent interpretations of maltreatment
    challenge investigators in determining whether a
    child's death is caused by maltreatment. At the
    state level, limited coordination among
    jurisdictions and state agencies, in part due to
    confidentiality or privacy constraints, poses
    challenges for reporting data.
  • According to the GAO, state officials said that
    better data on maltreatment deaths would enable
    them to craft more effective prevention
    strategies comparable to already widespread
    efforts to curtail the problem known as
    shaken-baby syndrome.
  • "As a society, we should be doing everything in
    our collective power to end child deaths and
    near-deaths from maltreatment," the report
    concluded. "The collection and reporting of
    comprehensive data on these tragic situations is
    an important step toward that goal."
  • It recommended that HHS expand the range of data
    that it distributes, while also helping states
    gather more complete and reliable information.
  • HHS, in a formal response, said it agreed with
    the recommendations and was taking steps to
    implement them.
  • Witnesses at Tuesday's hearing, in their prepared
    remarks, acknowledged that state and federal
    budget difficulties complicated any push for more
    funding to curtail child abuse. However, Michael
    Petit of the advocacy group Every Child Matters
    nonetheless called for up to 5 billion in
    additional federal spending.
  • Jane Burstain of the Center for Public Policy
    Priorities, a think tank in Austin, Texas, asked
    politicians to at least maintain current levels
    of spending on programs aimed at preventing
  • "As families struggle and stress levels rise,
    child maltreatment becomes more of a risk," she
    said. "To cut programs that support struggling
    families in tough economic times is the very
    definition of penny wise and pound foolish and is
    a choice our children will pay for with their
  • Dr. Carole Jenny, a pediatrician and child-abuse
    expert at Brown Medical School in Providence,
    R.I., urged federal support for training more
    doctors in child-abuse pediatrics.
  • "When a child does die from abuse or neglect,
    these pediatricians can help police, forensic,
    and social service agencies make the correct
    diagnosis, by doing the appropriate medical work
    up in the hospital and by ruling out conditions
    that mimic abuse or neglect," she said in her
  • Another expert on child welfare, Richard Wexler
    of the National Coalition for Child Protection
    Reform, said the GAO report by detailing the
    inconsistency of child-fatality data
    highlighted the potential flaws in trying to rank
    states in this area.
  • "Phony 'scorecards' claiming state X or Y is
    'worst' when it comes to child abuse deaths
    penalize states that are rigorous in ferreting
    out such deaths and reward states that ignore
    them," Wexler said.

Models Vary
  • State Local Teams Local teams conduct
    intensive case reviews and state boards review
    findings of local teams.
  • State-only teams conduct case reviews of selected
    cases, usually fatal abuse neglect.
  • Local teams review cases independently without
    any state-supported program or board.

Models Vary
  • Almost half of the states review deaths - all
  • Of the limit reviews, 92 exclude deaths from
    natural causes.
  • All review maltreatment.
  • 48 states review deaths through at least age 17.
  • One state to age 15 and one state even reviews up
    to age 24 (New Mexico).
  • States vary greatly on time frames for the review.

Florida the most restrictive State
  • In reviewing Child deaths

Florida Child Abuse Death Review Committee
  • Established by statute in 1999 (Section 383.402)
  • Requires review of the death of a child who
  • died as a result of child abuse or neglect and
  • is verified by Department of Children and

Confidentiality- FS.383.412
  • Any information that reveals the identity of the
    surviving siblings, family members, or others
    living in the home of a deceased child who is the
    subject of review by and which information is
    held by the State Child Abuse Death Review
    Committee or a local committee is confidential
    and exempt from s. 119.07(1) and s. 24(a), Art. I
    of the State Constitution.
  • (b) Information made confidential or exempt from
    s. 119.07(1) and s. 24(a), Art. I of the State
    Constitution that is obtained by the State Child
    Abuse Death Review Committee or a local committee
    shall retain its confidential or exempt status.
  • (3)(a) Portions of meetings of the State Child
    Abuse Death Review Committee or a local committee
    at which information made confidential and exempt
    pursuant to subsection (2) is discussed are
    exempt from s. 286.011 and s. 24(b), Art. I of
    the State Constitution. The closed portion of a
    meeting must be recorded, and no portion of the
    closed meeting may be off the record. The
    recording shall be maintained by the State Child
    Abuse Death Review Committee or a local
  • (b) The recording of a closed portion of a
    meeting is exempt from s. 119.07(1) and s. 24(a),
    Art. I of the State Constitution.

Why reporting is important
  • Child abuse death data is only identified through
    the Dept of Children and Families Florida Abuse
  • No other agencys data specifically identifies
    child abuse deaths
  • We will not know why children die in Florida
  • We will not be able to give an accurate number of
    how many
  • We will not be able to determine what prevention
    efforts are needed

What case qualifies for a Review
  • History- children who had a prior with DCF and a
    verified death
  • Currently- 2004 law was passed after
    recommendation from the State Committee that all
    children who have a verified death
  • This means from 2003 on an average the committee
    reviewed around 35 cases a year

Florida Statistics for 2009
  • 2,638 children died according to Vital Statistics
  • 217,382 reports of abuse and neglect
  • 513 were reports involving child deaths
  • 192 were verified for abuse

Florida Child Deaths
National, Vital Statistics, Hotline calls and
verified for 2009
2004-2009 Verified deaths
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  • 1985-HRS Task force subsequent to the death of
    Cory Greer
  • 1987-Protecting Floridas Children Task Force A
    Blue Print for the next decade
  • 1990_Child Welfare League of America Salary Study
    subsequent to the death of Bradley McGee
  • 1991-Study commission on Child Welfare (Barkett
  • 1995-Governors Panel on Child Protection Issues
    A Review of the Lucas Ciambrone Case
  • 1996_Task force on Family Safety
  • 1997-Governors Child Abuse Task Force
  • 1998-DCF QA Review subsequent to the death of
    Kayla Mckean
  • 1999-District 7 Child Safety Strike Force
  • 2002-Blue Ribbon Task Force (Rylia Wilson)
  • 2002-Jamie Cotter Death Review
  • 2003- I-75 Child Death (Alfonzo Montes)
  • 2005- Hillsborough Kids Inc (Ronnie Parrish)
  • 2009 Gabriel Myers workgroup
  • 2010 Sub-Committee on Safe Families

CADR How does it work?
  • A group of local concerned citizens, agencies,
    professionals get together and review the death
    of the child
  • A belief that environmental, social, economic,
    health and behavioral factors impact the risk,
    manner and investigation of death
  • It is a simple process of sharing data on the
    surface but a complex process of Group
    Thinking and shared responsibility for getting
    it right

What is the purpose
  • Preventing future deaths
  • Preventing further risk to siblings
  • Educating the public
  • Training needs for agencies
  • Legislative changes
  • Policy changes
  • Practice changes

A Public Health Approach
  • Knowing where and how often the occur
  • Understanding who is most at risk and why
  • Creating effective interventions
  • Immunizing other children from harm

Intervention Options
  • Involve othersEngagement
  • Change BehaviorsEducation
  • Change Technology..Engineering
  • Change SystemsEnactment
  • Change Laws..Enforcement

Team Representation Agency Appointments
  • Department of Health
  • Department of Legal Affairs
  • Department of Children and Families
  • Department of Law Enforcement
  • Department of Education
  • Florida Prosecuting Attorneys Association
  • Florida Medical Examiners Commission (must be a
    forensic pathologist)

Team Representation Secretary of Health
  • Pediatrician
  • Public health nurse
  • Childrens mental health professional
  • CPT medical director
  • DCF child protective investigations supervisor
  • Member of a child advocacy organization
  • Private provider of child abuse/neglect
    prevention program
  • Social worker (experience working with victims
    and perpetrators)
  • Paraprofessional (experience in child abuse
  • Law enforcement officer (experienced in
    childrens issues)
  • Florida Coalition Against Domestic Violence

  • Jan-Mar 2010 Quarterly Report
  • Prevention Objective 2.3, Tactic 2.3.3 Healthy
    Start, Fetal and Infant Mortality Review. By 30
    June, 2015, Healthy Start will have secured
    sufficient funding to establish the Fetal and
    Infant Mortality Review process statewide and
    will continue to collaborate in collaboration
    with the State Child Abuse Death Review Team
    regarding mutual strategies to reduce child
  • By 31 December 2010, 100 of the 30 HS
    coalitions will have explored local funding
  • By 29 June 2012, 100 of the HS
    Coalitions will have completed plans for
    collaboration with their CADR Teams.

Local Committees
  • 22 Active Local
  • 2 Inactive

(No Transcript)
Flow chart
Other Review Types
  • Domestic Violence Committee
  • FIMR
  • PAMR

Annual Report 2010

Abuse vs. Neglect 2004-2009
Age of Child at Death
Race and Gender of Child
Relationship of Caretaker
Race of Perpetrator
Age of Perpetrator
Age and Gender of Perpetrator
Types of Child Deaths
  • Physical Injury
  • Murder/Suicides
  • Abandoned Newborns
  • Sexual Assault related
  • Poisoning/Drugs
  • Fire
  • Furniture
  • Firearm
  • Suicide
  • Traffic related
  • Back over
  • Roll over
  • Left in vehicle
  • Drowning
  • Unsafe sleep
  • Medical Neglect
  • Dehydration/malnutrition
  • Neglect-Supervision
  • Animal related

Top 3 Deaths , Findings, and Recommendations
  • Drowning- 59 (31)
  • Physical Abuse- 52 (27)
  • Unsafe sleep environment- 42 (22)

Key Recommendations
  • 1 - Review All Child Deaths - Amend 383.402
    (1), F. S to expand the State Child Abuse Death
    Review Committees authority related to the
    review of child deaths in Florida to have a
    better understanding of why children die in
  • 2 - Fully Fund Healthy Families Florida -
    Support the Department of Children and Families
    2011-12 Legislative Budget Request to restore
    Healthy Families Florida funding to the 2009-10
    funding Level.
  • 3 Prioritize Assessment of Substance Abuse in
    Child Abuse and Neglect Cases Substance abuse,
    the illegal or excessive use of alcohol or drugs,
    should be strongly considered when evaluating and
    investigating all cases of child abuse and
    neglect.  The presence of substance abuse should
    also be given a higher priority in the risk
    assessment activities of child protection
    organizations that come into contact with
    children and their families. 

Priority Issues and Recommendations 
  • Drowning - Children continue to die from drowning
    at an alarming rate as a result of inadequate
  • Recommendation  Implement a systemic approach to
    prevent drowning of children in Florida, with a
    focus on those under 5 years of age.
  • Physical Abuse - An alarming number of infant and
    toddler homicides are attributed to common
    triggers and risk factors for physical abuse.
  • Recommendation  Any entity providing federal or
    state funded services, whether it be child
    protection investigations or case management,
    child care, home visiting or other services,
    should be trained to identify the common triggers
    and risk factors that contribute to child abuse. 
  • Unsafe Sleep Environments - Sudden unexplained
    infant deaths associated with unsafe sleep are
    tragic, but must be investigated thoroughly and
    consistently in order to prevent future infant
  • Recommendation  Improvements in the
    investigation of child deaths and heightened
    public awareness and education should be
    implemented for the prevention of infant
    suffocation deaths related to unsafe sleeping

  • Quality Assurance Review - Understanding the
    thinking and decision-making process of the legal
    decisions made and/or the court action taken
    would assist in educational opportunities
    resulting in better outcomes for children.
  • Recommendation There is a need for a Quality
    Assurance review as it pertains to the legal
    involvement when any child dies as a result of
  • Judicial Involvement - Informing judges,
    magistrates and court staff on the process and
    findings from the child death reviews will assist
    them to recognize key indicators of child
  • Recommendation Increase judicial awareness of
    Child Abuse Death Review Committee findings and
    trends through targeted training initiatives.
  • Public Awareness Campaigns - Research-based
    public awareness campaigns are effective in
    educating the public on strategies and actions
    that work to prevent child abuse and neglect
    before it ever occurs in the first place.
  • Recommendation Enhance targeted public awareness
    campaigns related to child health, safety, and
    welfare, and other mechanisms for preventing
    child deaths.
  • The State Committee believes that implementing
    these recommendations for each priority issue
    will improve the child protection system by
    providing the knowledge, skills, and

  • Accessible and Affordable Childcare - Waiting
    lists for subsidized child care are growing.
    Subsidized child care enables low income parents
    to work, but only 30 of eligible families were
    served 2009-10, leaving more than 90,000 children
    on waiting lists.
  • Recommendation Support The Policy Group for
    Floridas Families and Children to expand child
    care subsidies by 20 annually until all eligible
    children have the opportunity to enroll in a
    child care program or family child care home,
    allowing parents to work.
  • Enhanced Data Collection and Analysis on Economic
    Factors- Without additional data and analysis by
    the State Committee on economic factors present
    in death review cases, a determination of whether
    these factors directly or indirectly contributed
    to these factors is unknown.    
  • Recommendation  Economic factors should be
    considered as a part of the risk assessment and
    documented in the Florida Safe Families Network
    (FSFN) data system so they can be analyzed both
    locally and on a statewide level to determine the
    impact they have on child deaths.
  • Consistency and Communication - Communication
    between agencies and consistent evidence
    gathering protocol are crucial to the child death
    investigation and protection of other remaining
    children that are at risk.
  • Recommendation  Improved consistency,
    communication and coordinated response during
    investigations are needed among the various
    agencies involved in child abuse/neglect and
    child death investigations.
  • Public Awareness Campaigns - Research-based
    public awareness campaigns are effective in
    educating the public on strategies and actions
    that work to prevent child abuse and neglect
    before it ever occurs in the first place.
  • Recommendation Enhance targeted public awareness
    campaigns related to child health, safety, and
    welfare, and other mechanisms for preventing
    child deaths.

The State Committee believes that implementing
these recommendations for each priority issue
will improve the child protection system by
providing the knowledge, skills, and public
awareness needed to reduce tragic child abuse and
neglect deaths.
Wrap up
  • Challenges
  • Lessons learned
  • Experiences

  • The world is not an evil place because of the
    people who are in it, but because of the people
    who refuse to do anything about it!
  • Albert Einstein

We are guilty of many errors and many faults,
but our worst crime is abandoning the children,
neglecting the fountain of life. Many of the
things we need can wait. The child cannot. Right
now is the time we cannot answer Tomorrow his
name is today.
  • Gabriela Mistral (pseudonym of Lucila de María
    del Perpetuo Socorro Godoy Alcayaga), 1945 Nobel
    Laureate for Literature

Thanks for caring for our most precious citizens
  • ?s
  • Michelle Akins, BSW
  • 1701 S 23rd Street
  • Ft. Pierce, Fl 34950
  • 772-467-6012 x 114 office
  • 863-697-3981 Cell
  • Florida State Child Abuse Death Review Committee