1. WORKING TOGETHER TO PREVENT CHILD FATALITIES: COLLABORATION AMONG REVIEW TEAMS, CHILD WELFARE AGENCIES, AND COMMUNITIES David P. Kelly, J.D., M.A. Administration for Children and Families, Childrens Bureau Ying-Ying Yuan, Ph.D. Walter R. McDonald & Associates, Inc. Teri Covington, M.P.H. National Center for the Review and Prevention of Child Deaths Liz Oppenheim, J.D. Walter R. McDonald & Associates, Inc.

2. Examining Child Fatality Reviews and Cross- System Fatality Reviews to Promote the Safety of Children and Youth at Risk Funded by the Administration on Children, Youth and Families, Childrens Bureau 9/26/2011 through 9/25/2012 Contract Number: HHSP23320095656WC Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 2

3. Overview of Presentation Study Purpose Identify promising practices for fatality reviews and furthering collaboration among reviews Methods Literature Review Review of Recommendations and Outcomes Site Visits/Telephone Interviews National Meeting What Do Fatality Statistics Tell Us? Fatality Review Structures & Processes Fatality Review Recommendations Summary Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 3

4. What Do Fatality Statistics Tell Us? Several data sources for national statistics Vital Statistics National Resource Center for the Review and Prevention of Child Deaths National Child Abuse and Neglect Data System (NCANDS) Children younger than 1 and 1-4 are at highest risk Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 4

5. Child Mortality Has Decreased Dramatically for 1- 4 Year Olds 1 Overall death rate has consistently downward trend 1,419 deaths per 100,000 in 1907 28.6 deaths per 100,000 in 2007 Homicide rate increased between 1970-2007 by 26% (points in time) Homicide percentages increased from 2% to 8% Racial/ethnic, socioeconomic and geographic disparities continue Black children 50% higher mortality risk than White counterparts and socioeconomic disparities increasing 1 Singh G.K. (2010). Child Mortality in the United States, 1935-2007: Large Racial and Socioeconomic Disparities Have Persisted Over Time. A 75th Anniversary Publication. Health Resources and Services Administration, Maternal and Child Health Bureau. Rockville, MD: US Department of Health and Human Services. Available from: http://www.hrsa.gov/healthit/images/mchb_child_mortality_pub.pdf Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 5

6. Leading Causes of Death for 1- 4 Year Olds, 2007 (Singh, 2010) Unintentional injuries: 34% 1/3 of these relate to motor vehicle accidents Birth defects: 12% Homicides: 8% Diseases: Cancer: 8% Heart Disease: 4% Less than 2% Pneumonia: 2% Septicemia: 2% Perinatal conditions: <2% Benign Neoplasms: 1% COPD: 1% Other causes: 27% Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 6 Infant mortality rate is at an all time low: 6.39 infants deaths per 1,000 live births

7. Background on a Review of Selected Records NCDR-CRS 34,000 records of deaths of children between 0-5 years of age were reviewed from 36 States A subset of the 49,000 records (2008-2011) Using a very broad definition of CAN related, 13% or 4,500 deaths were CAN-related The data are from 36 States but may not be all deaths in all years from each State. Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 7

8. Causes of Death Related to CAN More than half of deaths from assault or drowning had a relationship to CAN 78% of deaths from assault (including use of weapons) 53% of deaths from drowning A third to a fifth of deaths from burns, asphxia, and motor vehicles were considered CAN related 33% of deaths from fire and burns 25% of deaths from asphxia 20% of deaths from motor vehicles Smaller percentages for other causes of death 11% from SIDS 2% from perinatal causes (prematurity, LBW etc.) Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 8

9. CHILD MALTREAT- MENT FATALITY RATES, NCANDS, 2002–2010 Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 9 The National Child Abuse and Neglect Data System: collects data from all States on the CPS investigation or assessment of alleged maltreatment, including deaths 11,600 fatalities are in the case level database from 2002-2012. The majority of the information is provided at the case level, but many States report on additional deaths. NCANDS

10. Child Maltreatment Fatalities, NCANDS Number of child fatalities due to maltreatment has fluctuated during the past 5 years; since 2007 on a decrease Explanations included system improvements that reduced case backlog and successful prevention programs. Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 10

11. Child Maltreatment Fatalities by Age, NCANDS,2010 N=44 States (unique count) Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 11

12. Race of 0 and 1-4 Fatality Cohorts Race of Age, 0 Race of Age, 1-4 Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 12

13. Maltreatment Types of 0 and 1-4 Fatality Cohorts, NCANDS, 2010 Maltreatment Types of Age, 0 Maltreatment Types of Age, 1-4 Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 13

14. Perpetrator Relationship of 0 and 1-4 Fatality Cohorts Perpetrator Relationship Age, 0 Perpetrator Relationship Age,1-4 Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 14

15. Summary Child fatalities due to abuse and neglect can be understood within a context of all deaths of young children Social and community decisions contribute to the definitions of child abuse and neglect deaths We seek to reduce child fatalities through Better identification of causes and factors leading to death More targeted prevention programs Involvement of all sectors of society Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 15

16. Fatality Review Structures & Processes The web of reviews Shared perspectives Fatality review structures and processes Collaboration for improving administration and processes Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 16

17. The Web of Reviews 50 States and the District of Columbia have an active CDR program (at the State and/or local or regional level) 17 States use their CDR team as the citizen review panel for review of fatalities Many child welfare agencies conduct internal child fatality reviews 200 Fetal and Infant Mortality Review (FIMR) programs in 40 States 144 Domestic Violence Fatality Review (DVFR) teams at the State and local level Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 17 Background

18. Fatalities/ Near Fatalities Foster Care Adoption Prevention Child Death Review Fatality Review CRP State/Local/ Regional CDR Internal Agency DVR FIMR Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 18 The Web of Reviews

19. Shared Perspectives Deaths and serious injuries are sentinel events: markers for the health and safety of people. Environmental, social, economic, health and behavioral factors impact the death or injury. These factors are so multidimensional that responsibility for a death or injury doesnt belong to any one agency or organization. Reviews focus on what went wrong and how can we fix it, not who is at fault and who should we blame. The best reviews are multi-disciplinary. Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 19

20. Fatality Review Structures & Processes Membership All are multidisciplinary May not always have all the needed representatives Administrative Homes Many different administrative homes Data collection All team processes include data collection activities For some teams, legislation provides access to needed information Some teams rely on information brought to reviews by team members Some teams conduct interviews with family members Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 20

21. Benefits of Collaboration Legislative support More cases More information More knowledge about agencies Existing multidisciplinary team More resources Near fatalities Access to citizen participation Coordinated prevention Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 21

22. Strategies for Collaboration Administrative home Membership Case identification Data collection Joint meetings Cross pollination/communication Identification of cross-cutting issues Joint training Develop joint recommendations Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 22

23. Fatality Review Recommendations Findings Types of recommendations made Implementation of recommendations Results Writing effective recommendations Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 23

24. Prevalence and Types of Recommendations Most of the recommendations were for: increasing public awareness and education improving policies and legislation strengthening organizational capacity Agency, persons, or organizations often not identified Many global statements indicating that parents should make specific changes in behavior or that communities should provide particular supports or services Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 24

25. Prevalence and Types of Recommendations No mention of collaboration to enhance injury prevention CDR and FIMR teams made recommendations regarding SIDS DVFR teams acknowledged the impact of DV on children All teams acknowledged that collaboration among many agencies and providers was necessary in order to effectively implement recommendations Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 25

26. Prevalence and Types of Recommendations CAN Related Recommendations 78.8 % of the recommendations pertained to some type of educational activity 28.5 % of the recommendations were for parent education Non-CAN Related Recommendations 78.8 % of the recommendations pertained to some type of educational activity 27.5 % of the recommendations were for parent education Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 26

27. Commitment to prevention Each team member must commit to use review information to educate their own agencies and advocate for needed changes Dissemination strategies Disseminate reports far and wide Select the right messenger(s) Work with the media Make in-person presentations Increasing Likelihood of Implementation Include people with authority to effect change Conduct advocacy with legislators and elected officials Implement a separate Community Action Team (CAT) Develop memoranda of understanding regarding next steps Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 27 Implementation of Recommendations

28. Results of Fatality Review Team Recommendations Improved interagency communication Numerous strategies to promote public awareness and education Prevention strategies focused on high risk populations Strengthened organizational capacity Changes in policy and legislation Improved service delivery Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 28

29. Writing Effective Recommendations Assessment of the Problem Describe particular risks or protective factors Include information on best and promising practices Discuss current efforts, resources, and capacity Process Develop or review recommendations with agencies identified to implement them Prioritize recommendations Recommendation Discuss the primary outcome sought Tie recommendations to specific findings Indentify the agency, persons, or organizations Identify target population Include detailed plan of action Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 29

30. Strategies for Collaboration Develop an integrated database of fatality review findings and recommendations Assessing risk factors Identify shared prevention strategies Develop joint training Share information about best and promising practices Hold joint meetings to create/share findings and recommendations Develop joint reports Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 30

31. Summary A lot of time, effort, and hard work is being dedicated to conducting fatality reviews. There are a number of creative and effective strategies in place for effective review meetings and collaboration among reviews. Many of the recommendations of fatality review teams have resulted in increased public awareness and education. Improvements in organizational capacity, improved practice and policy, and new legislation. There is a lot to learn from one another about improving review processes, recommendations and outcomes. Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 31

32. Resource Center Websites National Center on Substance Abuse and Child Welfare http://www.ncsacw.samsha.gov National Child Welfare Resource Center for Organizational Improvement http://muskie.usm.maine.edu/helpkids/index.htm National Child Welfare Workforce Institute http://www.ncwwi.org/ National Domestic Violence Fatality Review Initiative http://www.ndvfri.org/ Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 32

33. Resource Center Websites (continued) National Fetal and Infant Mortality Review Program http://www.nfimr.org National Resource Center for Child Protective Services http://www.acf.hhs.gov/programs/cb/tta/neccps.htm National Center for the Review and Prevention of Child Fatalities http://childdeathreview.org/ National Citizens Review Panel Virtual Community http://www.uky.edu/SocialWork/crp/ Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 33

34. Contact Information David P. Kelly, J.D., M.A. David.Kelly@ACF.hhs.gov Ying-Ying Yuan, Ph.D. yyyuan@wrma.com Teri Covington, M.P.H. tcovingt@mphi.org Liz Oppenheim, J.D. loppenheim@wrma.com Working Together to Prevent Child Fatalities: Collaboration Among Review Teams, Child Welfare Agencies, and Communities 34