DOCUMENT RESUME

ED 393 570 PS 024 030

TITLE A Nation's Shame: Fatal Child Abuse and Neglect in

the United States. A Report of the U.S. Advisory

Board on Child Abuse and Neglect. Fifth Report.

INSTITUTION United States Advisory Board on Child Abuse and

Neglect, Washington, DC.

SPONS AGENCY Administration for Children, Youth, and Families

(DHHS), Washington, D.C.

PUB DATE Apr 95

NOTE 294p.; The Executive Summary contained in this report

has been separately published as a 41 page document,

see PS 024 031.

PUB TYPE Reports Research/Technical (143)

Tests/Evaluation Instruments (160)

EIIRS PRICE MF01/PC12 Plus Postage.

DEZCRIPTORS Agency Cooperation; Change Strategies; Chi Abuse;

Child Caregivers; Child Health; *Child Neglect; Child

Welfare; Community Involvement; *Death; Family

Programs; Homicide; Integrated Services;

Investigations; Law Enforcement; Parents;

*Prevention; Program Improvement; Social Problems;

*Social Services; State Legislation; Training; *Young

Children

IDENTIFIERS Autopsies; Cause of Death; Child Abuse Prevention and

Treatment Act; Child Safety; Family Preservation

Services; Family Support

ABSTRACT

The U.S. Advisory Board on Child Abuse and Neglect

was established under the Child Abuse Prevention and Treatment Act

(CAPTA). In its annual reports, the Board is charged with evaluating

the nation's efforts to accomplish the purpose of CAPTA and to

propose recommendations about ways those efforts can be improved.

Noting that every day, five young children die from abuse or neglect

at the hands of their parents or caregivers, this report examines

existing efforts and opportunities that aid in understanding and

preventing child abuse and neglect fatalities. The report also

provides a close look at system-wide weaknesses and obstacles, and

lack of resources and commitment by policymakers to take action that

could save children's lives. The first chapter of the report explores

the lack of knowledge over the scope and nature of child abuse and

neglect fatalities, attempting to quantify the problem. Chapter 2

examines the need for better investigation and prosecution and for

major efforts to improve and train front-line professionals. Chapter

3 discusses the encouraging emergence of Child Death Review Teams.

Chapter 4 examines the need for more aggressive efforts to protect

children and to facilitate community-based family services and

primary prevention efforts to help families live safe and healthy

lives. The report offers 26 recommendations for addressing

deep-seated problems within the law enforcement, child protection,

health agency, and court branches that constitute the

child-protection system. These recommendations include: (1)

establishing a national commitment to addressing the problem of abuse

and neglect fatalities; (2) increasing the number of professionals

qualified to identify and investigate such fatalities; (3) enacting

legislation establishing child autopsy protocols; (4) enacting model
legislation to address confidentiality; (5) including the religious

community in prevention efforts; (6) adopting child safety as the

goal of family programs and policy; (7) using family support funding

for prevention; and (8) adopting regulatory measures to reduce

environmental dangers for children. The report's five appendices

include, a list of participants in the board's previous congressional

hearings and workshops, a roview of child fatalities research and

literature, and a sample death certificate. (En!)

***********************************************************************

* Reproductions supplied by EDRS are the best that can be made *

* from the original document. * ***********************************************************************
U.S. DEPARTMENT

OF HEALTH

AND HUMAN

SERVICES

Administration for

Children and

Families

A Nation's Shame:

Fatal Child Abuse and

Neglect in the

United States

U S. DEPARTMENT OF EDUCATION

Office of Educatonal Researce and Improvement EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC)

Kihis document has been reproduced as

received from the person or organization

originating it.

0 Minor changes have been made to

improve reproduction quality

. . . . Points of view or opinions stated in this

document do not necessarily represent

official OERI position or policy.

A Report of the U.S.

Advisory Board on Child

Abuse and Neglect

',coy rNOV AVAII ARI
The views expressed in this report are those of the members of the

U.S. Advisory Board on Child Abuse and Neglect and do not necessarily reflect the views

of any part of the U.S. Department of Health and Human Services.

This document may be reproduced without permission.

For information regarding this report, A Nation's Shame: Fatal Child Abuse and

Neglect in the United States

contact:

THE NATIONAL CLEARINGHOUSE ON CHILD ABUSE AND NEGLECT

IN,FORMATION:

1 (800) 394-3366

(703) 385-7565

THE FOLLOWING BOARD PUBLICATIONS ARE ALSO AVAILABLE FROM

THE NATIONAL CLEARINGHOUSE ON CHILD ABUSE AND NEGLECT:

Child Abuse and Neglect: Critical First Steps in Response to a National Emergency

(August, 1990)

Creating Caring Communities: Blueprint for an Effective Federal Policy on Child Abuse

and Neglect

(September, 1991)

The Continuing Child Protection Emergency: A Challenge to the Nation

(April, 1993)

Neighbor:v Helping Neighbors: A New National Strategy for the Protection olChildren

(September, 1993)

U. S. ADVISORY BOARD ON CHILD ABUSE AND NEGLECT

200 Independence Avenue, S.W.

Washington, DC 20201

(202) 690-8137

3
Department of Health and Human Services

Administration for Children and Families

A NATION'S SHAME:

FATAL CHILD ABUSE AND NEGLECT

IN THE UNITED STATES

A Report of the

U.S. Advisory Board on Child Abuse and Neglect

Fifth Report

U.S. Advisory Board on Child Abuse and Neglect

April 1995

4
MEMBERS OF THE U.S. ADVISORY BOARD ON CHILD ABUSE AND NEGLECT

Deanne Tilton Durfee, Chairperson

California

Yvonne M. Chase, Vice-Chairperson

Alaska

Randell C. Alexander

Iowa

Jane Nady Burnley

Virginia

Frances E. Jemmott

California

Enid A. Borden

Virginia

Nancy Hoit

Massachusetts

Murray Levine

New York

Elba Montalvo J. Tom Morgan

New York Georgia

Lawrence F. Potts Prince Preyer, Jr.

Texas Alabama

Michael S. Wald

Washington, DC

John Wilson

Washington, DC

Michael W. Weber

Minnesota

Preston Bruce, Executive Director

Washington, DC
"A simple child,

That lightly draws its breath,

And feels its life in every limb,

What should it know of death?"

William Wordsworth

6
Table of Contents

Table of Contents

DEDICATION vii

FOREWORD xv

MISSION AND COMPOSITION OF THE U.S. ADVISORY

BOARD ON CHILD ABUSE AND NEGLECT xxi

EXECUTIVE SUMMARY xxiii

Background xxiii

Chapter One: Quantifying the Problem xxviii

Chapter Two: Government and Individual Responsibility xxix

Chapter Three: The Need for Child Death Review Teams xxxi

Chapter Four: Toward a Better Future xxxiii

Part One: Family Services, Intervention, and Preservation x.xxiii

Part Two: Fatality Prevention xxxiv

Conclusion xxxvi

Summarized Recommendations xxxvii

References xliv

BODY OF REPORT

Preface 1 Introduction 5

1.. Chapter One: Defining the Scope and Nature of Fatal Abuse and

Neglect 7

Understanding the Problem 7

What Do the Data Tell Us? 1 1

What Differentiates Abuse from Neglect Fatalities? 1 1

Who Is Committing These Acts? 1 3

What Are the Causes of Death? 1 5

Which Children Are Likely to Die? 1 6

What Happens to the Survivors? 1 6

Current Issues: Official Underreporting, Definitionsthat Obscure

i

U.S. Advisor) ooard on Child Abuse and Neglect

7
ii

Table of Contents

Abuse-Related Causes, and Poor Case-Level Data 18

Official Underreporting 18

The Annual Survey by the National Committee to Prevent Child

Abuse 19

The Federal Bureau of Investigation's Uniform Crime Report 20

The National Center for Health Statistics, Vital Statistics 21

Unclear Definitions and Poor Case-Level Data 23

Insufficient Data Collection on Individual Cases 24

Highly Inadequate Research Efforts 24

Strategies for Improvement 26

Seeking Common Definitions and Data Elements 26

Use of Estimation Models by the Centers for Disease Control and

Prevention 26

Sending a Clear Public Message 27

A New Effort by the National Child Abuse and Neglect Data System 28

Greatly Expanded Research Efforts 28

The Emergence of Child Death Review Teams 29

Chapter One Recommendations 30

Chapter One References

Chapter Two Addressing Shared Responsibility: Case

Investigation and Prosecution

33

39

Case Investigation and Prosecution 39

The Child Protection System of Mandated Reporters and

Agencies 40

The Role of Child Protective Services 42

The Role of Prosecution 43

A Struggle for States 43

Provision of Available and Necessary Medical Care to Children 45

Current Issues: Training Weaknesses 49

Physicians and Hospital Personnel are Unaware of Abuse Clues 50

Few Medical Examiners or Coroners Know How to Detect Child

Abuse and Neglect 51

Police Often are Not Trained to Detect or Deal with Serious and

Fatal Child Abuse

U.S. Advisory Board on Child Abuse and Neglect

53
Table of Contents

Child Protection Workers are Often Inexperienced, Undertrained, or

Overextended 55

Multiple Problems Deter the Prosecution of Perpetrators 57

Strategies for Improvement: Expanding the Expertise 59

Broad New Training for All Front-line Workers 59

Increased Use of Immediate-Response Joint Criminal Investigations 61

Hospital SCAN Teams and Other Hospital Ef torts 63

Mandated Autopsies 64

Enhanced Prosecution and Evidence Gathering 66

Chapter Two Recommendations 67

Chapter Two References 72

Chapter Three The Need for a Nationwide System of Child Death

Review Teams 75

The History of Child Death Review Teams 77

A Rich Source for Understanding 78

How Teams Operate 83

Local Team 83

Statewide Teams 84

State of the Art Models 87

The Missouri Model 87

The Colorado Model 88

The California Model 89

Strategies for Improvement 90

Toward National Leadership 90

Confronting Confidentiality Obstacles 92

Better Team Design and Support 92

Helping Surviving Victims 97

Chapter Three Recommendations 99

Chapter Three References 103

iii

U.S. Advisory Board on Child Abuse and Neglect

Co
iv

I

Table of Contents

=1,

Chapter Four Toward a Better Future: Services and Interventions

for Children and Families and Fatality Prevention 107

Part One: Services and Interventions 107

Current Issues 110

Inadequate Services and Decision-Making 110

Confusion Over and Misapplication of Family Preservation Services. 111

Inappropriate Placements 113

Strategies for Improvement 116

Intensive Family Preservation Services 116

Expedited Decisions on Permanence 119

Part Two: Fatality Prevention 121

Who is at Fault? 121

Addressing the Perpetrators 123

Understanding Domestic Violence 124

The Challenge of Helping Hard-Hit Communities 125

The Problem of Overselling Prevention Efforts That May Not

Work 126

Strategies for Improvement: Casting a Wider Net 128

Broadly Expanded Voluntary Home Visiting 128

Reaching New Parents 130

Creating a Caring Community 131

Increasing Emphasis on Family Support Services 134

Reaching Fathers and Other Males 134

Getting the Private and Non-Profit Sectors Involved in Prevention 135

Reducing Preventable Deaths from Household Ha72rds 136

Chapter Four Recommendations 138

Conclusion : The Challenge 146

Chapter Four References 147

Epilogue 151

U.S. Advisory Board on Child Abuse and Neglect

1 6
Table of Contents

Appendices

Appendix A List of U.S. Advisory Board Members 155

Appendix B Participants of 1992, 1993, & 1C94 Hearings and

Workshops 159

Appendix C Review of Child Fatalities Research and Literature 179

Appendix D Map & List of Child Death Review Team Contacts 205

Appendix E Sample Death Certificate 247

The children's artwork for this report has been provided by ICAN/ICAN Associates, Los

Angeles County, from their Child Abuse Prevention Month Poster Art Contest.

U.S. Advisory Board on Child Abuse and Neglect

1 1
Dedication

DEDICATION

This report is dedicated to the children on the following list andthe thousands not named here,

who have died at the hands of parents or caretakers. The names are taken from newspaper

articles published throughout the ct untry.

Sources: New York Times, Chicago Tribune, Houston Post, Denver Post, San Francisco

Chronicle, Los Angeles Times, Boston Globe, Atlanta Constitution-Journal, Philadelphia Inquirer,

Miami Herald, Detroit Free Press, Washington Post.

tt'

kr)

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..SktP .K6 cirl; tA Nioeseckse.

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1.4

1414

(tr

U.S. Advisory Board on Child Abuse and Neglect

Joann 6th Grade

Fair Avenue School

vii

12 BEST COPY AVAliAbiz
Dedication

Name Age Cause of Death Date Location

Michael A. Lazas, 2 years Suffocation. 1/93 Maryland

Jr.

Davi 4 Welch 3 years Severely beaten. 1/93 Florida

Baby Boy Braz 2 months Manner unspecifie& 1/93 California

Franciscb Lopaz 2-1/2 years Died from 103 body wounds. 1993 Illinois

Unnamed Newborn Buried alive. 2/16/93 New York

Baby Rodriguez 5 months Severely beaten. 2/15/93 Texas

Twin Girl

Amy Lynn Mitich 2 months Suffocation. 2/25/93 Florida

Jamie! Neal 3 years Severely battered and

burned with a stun gun.

2/28/93 Michigan

Baby Boy Jones Infant Manner of death

unspecifie&

2/93 Colorado

Samantha Jo 4 years Severely beaten. 2/93 Illinois

Haight

Tommy Eken 3 months Manner of death

unspecified

2/93 Illinois

Ditaya Douglas 2 years Death by scalding. 3/20/93 New York

Shayne Bryant 4 years Scalded and beaten. 3/93 New York

Keeyan Pinnick I year Death by scalding. 4/2/93 Illinois

Jose Manuel 2 years Burned to death. 4/2/93 Florida

Garcia

Lauren Jandree Toddler Severely beaten. 4/3/93 Texas

Saraphina S months Shaken to death. 4/93 Illinois

Johnson

Tiffany Guzman 1 year Smothered to end crying. 4/93 Texas

U.S. Advisory Board on Child Abuse and Neglect
Dedication

Name Age Cause of Death Date Location

Brittany Harris 2 years Manner of death

unspecified

4/93 Texas

Devon Phillips 5 years Stabbed to death. 4/93 District of

Columbia

Thomas Owenby 10 months Starved to death. 4/93 District of

Columbia

Thomas McNeil 10 months Starved to death. 4/93 District of

Columbia

Joseph Wallace 3 years Forcibly hung by neck. 4/93 Illinois

Donnell Robinson 2 years Fatally shaken. 5/4/93 Virginia

Tish Phipps Toddler Severely beaten. 5/8/93 Texas

Ryan Plintpton 6 months Massive head injuries. 5/93 Illinois

Ariel Hill 5 months Scalded to death. 5/12/93 Illinois

Jasmine Kent 2 years Severely beaten. 5/21/93 Illinois

A.J. Schwarz 10 years Found battered and floating

in family pooL

5/23/93 Florida

Donnell Shaw 2 years Massive head injuries. 5/26/93 Florida

Brandon Jones 9 months Massive head injuries. 5/93 Florida

Jermey Booze 2-1/2 years Massive head injuries. 5/93 Florida

Robert Earl 2 years Fatally shaken. 5/93 Florida

Jefferson

Myowsha 1 year Severely beaten. 5/93 Illinois

Holoman

Lindsay Creason 3 weeks old Smothered to end crying. 6193 Colorado

Adrain Adam Bell 3 years Severely beaten. 7/93 &strict of

Columbia

U.S. Advisory Board on Child Abuse and Neglect

ix

14
Dedication

Name Age Cause of Death Date Location

Clayton Miracle 3 years Severely beaten by foster

parents.

8/11/93 Georgia

Robert Ward 8 years Severely beaten. 9/93 District of

Spencer Columbia

Cody James 19 months Forced Valium overdose. 1993 Colorado

Tiara!, Bowers 2 years Chronically battered to

death.

7/93 Illinois

Cimantha 10 days Dropped two stories. 7/93 Illinois

Shepeard

Latoya Harris 8 years Found entombed in cement. 7/93 California

Jeremy A rans 3 months Massive head injuries. 8/4/93 Illinois

Kevin Kreith 3 years Severely beaten. 8/93 Illinois

Michael Cecil 2 years Chronically battered to

death.

8/15/93 Illinois

Saleem Broom 1 year Starved to death. 8/21/93 New York

Denise Rome 2 years Manner of death

unspecified

9/2/93 Ohio

Louis Murphy 2 years Severely beaten. 9/1 7/93 Texas

Anonymous

Toddler

3 years Severely beaten after crying

over fear of dark.

9/93 California

Corey Sparks 2 years Severely beaten. 10/93 Illinois

Brittany Scott 5 years Massive head injuries. 10/93 Michigan

Jonathan Boylan 6 months Massive head injuries and

choked

10/13/93 Florida

Kayla Basante 8 months Choked with blanket. 11/93 Florida

Cecilia Marie 2 years Fatally beaten. 11/93 District of

Rushing Columbia

U.S. Advisory Board on Child Abuse and Neglect

1 5
Dedication

Name Age Cause of Death Date Location

Tommy Bush 4 years Severely beaten. 11/2193 Florida

Richard Spells 4 months Massive head injuries. 11/9/93 Illinois

Kieran Dunne 10 months Severely beaten. 11/9/93 or New York

11/10/93

Tonya Heddins 2 months Forcibly suffocated

following chronic abuse.

11/10/93 Illinois

Baby Girl Glover 5 months Severely beaten. 1993 Colorado

Shawna Reeder 15 months Manner of death

unspecified

11/93 New York

Latisha Lawrence 15 months Manner of death

unspecified

11/93 New York

Baby Girl Casares Infant Manner of death

unspedfied

12/3/93 California

Unidentified girl 17 months Beaten all over body. 12/24/93 Florida

Richard Jones 1-1/2 years Severe intoxkation. 12/25/93 Connecticut

Michael Marshall Infant Severely beaten. 12/93 Illinois

III

Joseph M. Harvey 3 years Fatally scalded in bathtub. 12/93 Maryland

Christopher Flye 6 years Severely abused 1993 Maryland

Danny Carter, Jr. 2 years Severely beaten after

bedwetting.

1993 Virginia

TeSean J. Bond 2 months Force fed fatal amounts of 1994 District of

Epsom salts and liquid

antacids.

Columbia

Roosevelt Bryan 5 months Fatally shaken. 1/1/94 Illinois

Bell

Baby Girl 3 months Starved to death. 1/94 Illinois

Buchanan

U.S. Advisory Board on Child Abuse and Neglect

xi

:16
'di

Dedication

Name Age Cause of Death Date Location

Baby Williams 2 years Fatally scalded 1/13/94 Texas

Kelly Jackson 4 months Fatally shaken. 1/20/94 Illinois

Jimmie Williams 2 years Severely beaten after

bedwetting.

1994 Illinois

Erick Stark 16 months Chronically battered 1994 Illinois

Jackie Wright 7 years Bludgeoned to death. 2/94 Maryland

Tenicha Nixon 8 months Severely battered for crying. 3/22/94 Florida

Carol Jean Waters Toddler Fatally beaten. 3/26/94 Florida

Jasmine Buice 1-1/2 years Severely beaten. 3/9/94 Texas

Jodi Santillo 3 years Massive head injuries. 4/7/94 Florida

Baby girl Wright 2 years Bitten and severely beaten. 4/14/94 Florida

Daryl Bell, Jr. 2 years Severely beaten after

wetting pants.

4/94 Illinois

Andre Roberts 1 year Severely beaten. 4/94 Illinois

Tyesha Dixon 1 year Starved and beaten. 4/2/94 Texas

Raychell Ortiz 4 years Killed and tossed in river. 5/4/94 New York

Unidentified 3 years Beaten with towel rack 5/29/94 Florida

Michael Scott 1 month Massive head injuries. 5/30/94 Florida

Richman

Corey D. Taylor 3 years Pushed into Anacostia River

and drowned

5/94 District of

Columbia

Charles Sanborn 10 years Chronically battered 6/94 Illinois

Baby boy Day Toddler Manner of death

unspeced

6/2/94 Florida

Baby Boy Adams 14 months Scalded and beaten. 6/18/94 California

U.S. Advisory Board on Child Abuse and Neglect

1 t

1
Dedication

Name

1=1111. Age Cause of Death Date Location

Anaberta James 8 months Manner of death

unspecified

6/19/94 Texas

Eric Dunphy 2 years Severely beaten and stuffed

into a Christmas ornament

box.

8/94 Rhode Island

Christina Holt 7 years Beaten to death. 9/94 Florida

Dayton Boyton 5 months Injuries unspecified 10/94 Florida

Damian Grant 2 years Fatally beaten. 10/21/94 Florida

Sasha Gibbons 4 years Suffocated 11/23/94 Florida

Unidentified baby

girl

? Head injuries from being

tossed in air.

12/1/94 Florida

Rafael Jose 8 years Stabbed in heart. 12/10/94 Florida

Anthony Dorch 1-1/2 months Severely battered 12/13/94 Florida

Tiffany Greenfield 4 months Fatally shaken. 12/21/94 Florida

Joey Fajardo 3 weeks Fatally shaken. 12/24/94 Florida

Baby boy Thorpe 4 months Found in plastic bag in

vacant lot.

1/95 Florida

Jonathan Austin 5 weeks Fatally beaten. 1/8/95 Pennsylvania

Felicia Brown 1-1/2 years Beaten with shoe heel. 2/95 Michigan

U.S. Advisory Board on Child Abuse and Neglect

1 cu
Foreword

FOREWORD

by Deanne Tilton Durfee

Chairperson, U.S. Advisory Board on Child Abuse and Neglect

OUR CHALLENGE

The U.S. Advisory Board on Child Abuse and Neglect began the

daunting task of confronting the most extreme and tragic consequences

of child maltreatment over 2 years ago. This has clearly been the most

challenging and the most comprehensive process this Board has yet

undertaken. Our study, discussions, review of material, and testimony

from multiple States have revealed a problem far greater than previously

realized. We also have been the beneficiaries of far greater insight into

the strengths and weaknesses of the broader community-and

government-based child protection systems.

The cruel realization that parents and caretakers can kill their own

children has been difficult for our Nation to face. Indeed, many who

make policies, direct programs, and deliver services to children and

families have found it difficult to accept. Yet, this is reality.

For so many who question the importance of providing preventive

services to high risk families, especially those with small children, let this

report serve as a reminder of what the tragic outcome of indifference may

be. For those who believe that the child protection system is overly

intrusive, let us recall how we might have wished there had been a

meaningful intervention before the death of a helpless young victim. Let

us also ask how a strong community support systemfriends, family,

neighborscould have helped assure the safety of a preschool child who

was never seen outside the home until autopsy.

U.S. Advisory Board on Child Abuse And Neglect

1 3

XV
Foreword

xvi

Serving as a member of the U.S. Advisory Board on Child Abuse

and Neglect has been a consuming experience. This report, which has

required confronting the unnecessary loss of helpless children's lives, has

profoundly drawn on the personal and psychological energies of Board

members and staff. Yet, by reviewing child deaths, we have been able to

expand our appreciation and understanding of the importance of children's

lives.

The future work of this Board will benefit greatly from the wealth

of information gained through this process. The issues related to child

abuse fatalitiesaccountability, professional qualifications, interagency

collaboration, information sharing, and preventionall sit at the

foundation of our entire child protection system.

The Board heard the perspectives of true heroes; professionals,

volunteers, and concerned citizens from diverse communities across the

Nation. These are some of the most brilliant, dedicated, and insightful

individuals we could have the privilege to meet.

We have been motivated by a belief that the purpose of life is to

matter, to count, to have it make some difference that we lived at all.

Having experienced the pain of children, we seek to honor them and

confirm that their brief lives did matter, each and every one of them. By

better understanding child abuse and neglect fatalities, and how such

tragedies could be prevented, we are given a great opportunity to ensure

that it did make a difference that these children lived at all.

ACKNOWLEDGMENTS

The Board members, staff, and others involved in the development

of this report have invested their hearts, minds, time, and energy to making

a difference in the lives of children and families in America.

U.S. Advisory Board on Child Abuse And Neglect
Foreword

It has been a profound honor to serve as Chair of this prestigious

Board for the past 2 years. I came into this position following in the

footsteps of two of the most highly respected professionals in this field,

Richard Krugman and Howard Davidson, our Board's first two Chairs.

We all owe much to their leadership and the standards and direction they

set for our work. Other previous members of the Board who participated

in the initial stages of the development of this report also deserve

recognition. They should feel justifiable credit for their role in laying the

groundwork for this report.

Special recognition must be given to the Vice-Chairof the Board

Yvonne Chase, who provided direction, advice, and leadership in all

aspects of the Board's work. She also provided me with invaluable

personal support. During the process of developing this report on child

maltreatment fatalities, Yvonne took leadership in organizing meetings,

symposia, and hearings on cultural diversity in partnership with the People

of Color Leadership Institute (POCLI). These forums produced unique

and enlightening dialogue and constitute an important foundation for

future Board reports.

MI members of the Board deserve credit for their dedication to

protecting children and serving families and for their important

contributions to this report. Special recognition was earned by the

members of the Board's Executive Committee, Randy Alexander, Jane

Burnley, J. Tom Morgan, and Michael Weber, for their additional

investment of time and energy. This included frequent conference calls,

special meetings, repeated editing, and responsibility for developing

sections of the draft report. Enid Borden, former member of the

Executive Committee, continued to share her considerable creativity with

the written word, and Murray Levine brought us awealth of talent in

research and evaluation.

U.S. Advisory Board on Child Abuse And Neglect

21

xvii
Foreword

The Executive Director of the Board, Preston Bruce, has been our

ambassador, our source of moral support, and one of the kindest and most

caring individuals I have had the pleasure to know. Preston brings a

strong heritage of distinguished public service to his work. Sadly,

Preston's father passed away only a few months before this report could be

completed. There is no doubt he would have been very proud of his son.

Our Board met with tremendous good fortune when we contracted

with Laurel Consulting Group, a professional management services firm

that exceeded all of our expectations for both quality and quantity of work.

We owe special thanks to Conrad Kenley, President of LCG, whose mind

and management skills are unparalleled, and to Anne Marie Finn, policy

analyst, whose intelligence, good nature, and ability to absorb and

translate masses of information proved invaluable. Conrad and Anne

Marie, joined by other outstanding LCG staff, worked into nights and

weekends to assure that this report was of high quality and completed on

time.

Jill Stewart a widely respected newspaper and magazine writer,

provided our Board with the gift of her notable journalistic talent. She

was the individual who brought together the masses of information

presented to us from testimony;local State and Federal reports; journal

articles, news reports and literally thousands of pages of transcripts from

hearings, symposia and meetings. Her organization, creative mind,

writing skills, and a deep personal concern for the children about whom

she was writing made her an invaluable member ofour "team."

Penny Weiss, ICAN Assistant Director, and Mitch Mason, ICAN

Program Analyst, deserve a great deal of credit for lending their

considerable talents to many aspects of this report, and for their patience

with me during my term as Chairperson.

U.S. Advisory Board on Child Abuse And Neglect
Foreword

Finally, I most sincerely thank Michael Durfee, my hero and best

friend. He has provided me with unrelenting encouragement and moral

support, even when I have found myself tired and rather intolerable.

Moreover, he is more responsible than anyone I know for moving this

country toward a better system of accountability for the serious and fatal

abuse of children.

The Board also wishes to acknowledge the important contributions

of the following individuals and organizations in the development of this

report:

Jose Alfaro, Director of Research, Children's Aid Society and Donya

Witherspoon, Attorney at Law for lending their expertise to the task of

summarizing expert testimony taken by the Board inNew York City

and Los Angeles.

Sharon Smolick Director of Family Violence Program, Bedford Hills

Correctional Facility for her cooperation in allowing Board members

access to the women who shared their stories with us.

Cheryl Compaan and Jennifer Freeman at the State University of New

York for additional bibliographic research.

All of the Department of Health and Human Services Regional staff

for their logistical support and input in public hearings and forums.

and, finally, the Board would like to thank Cathie O'Donnell from

Circle Solutions Inc. for editing this report.

U.S. Advisory Board on Child Abuse And Neglect

six
Mission and Composition of the Advisory Board

MISSION AND COMPOSITION OF

THE U.S. ADVISORY BOARD ON CHILD ABUSE AND

NEGLECT

The U.S. Advisory Board on Child Abuse and Neglect was

established under 100-294, Section 102, of the Child Abuse Prevention

and Treatment Act (CAPTA), amendments of 1988. It consists of 15

members appointed by the Secretary of Health and Human Services

(DHHS). Members represent a wide range of legislatively mandated

disciplines, as well as various regions of the country and di verse personal

perspectives. The name, title, and address of each Board member are

listed in Appendix A.

Explicit provisions of CAPTA require the Board to prepare an

annual report to the Secretary of DHIIS, appropriate committees of

Congress, and the Director of the National Center on Child Abuse and

Neglect (NCCAN). In its reports, the Board is charged with evaluating the

Nation's efforts to accomplish the purpose of CAPTA and to propose

recommendations about ways those efforts can be improved.

In its first report in 1990, the Board concluded that the problem of

child maltreatment in the United States had escalated to the level of a

national emergency based on the alarming increase in the number of abuse

and neglect reports and the negative consequences for society, especially

for children. It recommended 31 critical steps to address this national

emergency, directed to all levels of government, all professional

disciplines and each citizen. One recommendation called for an effort to

bring agencies together at local, State, and Federal levels to address fatal

child abuse and neglect.

2 4

U.S. Advisory Board on Child Abuse and Neglect xxi
Mission and Composition of the Advisory Board

In its second report in 1991, the Board urged funding, structural

reforms, and action at the Federal level to bring critically needed

preventive services to communities. Key among its recommendations was

the implementation of universal voluntary neonatal home visiting

programs as a means of early prevention of abuse and neglect. The third

report, in 1992, was devoted largely to recording Board activities and

positions issued that year.

Building on the community-based preventive philosophy of its

1991 report, in 1993 the Board described the steps that must be taken to

create a comprehensive new neighborhood-based prevention strategy in

which government, front-line professionals, neighbors, families, and

friends all play a role.

This report reflects a response to the Board's longstanding concern

for cii;ldren who die at the hands of their parents or caretakers. Members

of Congress shared this concern, and in 1992 congressional hearings were

held, resulting in a mandate to the Board to issue a report on the nature

and extent of child abuse and neglect fatalities and how these tragic deaths

might be prevented.

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

EXECUTIVE SUMMARY

Background

In 1991, a riveting PBS documentary told the story of the

brutal death of malnourished 5- year-old-Adam Mann, beaten to death

on March 3, 1990, by his stepfather, Rufus Chisolm, with participation

by his mother, Michelle Mann (Langer, 1991). Many professionals

had missed a series of red flags that Adam was in serious danger. The

autopsy of Adam revealed over 100 injuries on his body. Following

the autopsy, the cause of death was listed as a broken skull, broken

ribs, and a split liver. At one time or another, nearly every bone in his

body had been broken. In addition, there was no food in his stomach.

Adam's stepfather and mother were imprisoned and Adam's siblings

were placed in foster care. The story of this child's death, as well as

compelling testimony regarding hundreds of child abuse fatalities,

prompted Congress to ask the U.S. Advisory Board on Child Abuse

and Neglect (ABCAN) to recommend:

a national policy to reduce and ultimately prevent such

fatalities,

changes to achieve an effective Federal role on the

implementation of the policy, and

changes needed to improve data collection about child

abuse and neglect fatalities.

Since Adam's death, some 10,000 children have died at the hands of

their parents or caretakers.

Conservative estimates indicate that almost 2,000 infants and

young children die from abuse or neglect by parents or caretakers each

year, or 5 children every day. The vast majority are under 4 years old,

U.S. Advisory Board on Child Abuse and Neglect

2,000 children die

from abuse or

neglect each year...or

5 children every day.
Executive Summary

Homicide rates

among children age

4 and under have

hit a 40-year high.

xxiv

an age when they are most vulnerable to physical attacks and to

dangers created by lack of supervision and severe neglect, and are

isolated from teachers or others who might intervene to protect them.

According to the Population Reference Bureau, death rates among

children age 4 and under who die from homicide have hit a 40-year

high (Mackellar & Yanagishita, 1995; Baltimore Sun, 1995). Violence

towards very young children has reached the level of a public health

crisis and is similar in scope to the destruction of teenagers by street

gunfire.

Leading Causes of Trauma Death Age Four and Under

Falls Choking on F. Suffocation Drowning Fires Motor V Child Abuse N21411 0 200 400 600 BOO 1.000 1200 1.400 1.600 1.000 Deaths Per Year

Sour°, National Safety Counol Child Muse and

Neglect deaths from Centers for Disease Control and Prevention Yet the American public, as well as many government leaders

and policymakers at the local, State, and Federal levels continue to

regard these deaths as if they are rare and tragic curiosities. We hope

to dispel this notion, which we b. .;ve impedes any meaningful

solution. McClain's research at the Centers for Disease Control and

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

Prevention (CDC) suggests that abuse and neglect kills 5.4 out of

every 100,000 children age 4 and under (McClain et al, 1993;

McClain, 1995). However, due to the misclassification of child

deaths, McClain believes that a second conservative estimate can be as

high as 11.6 per 100,000 children age 4 and under (McClain, 1995).

This is a shocking rate compared with deaths among teenagers from

gunshot wounds and deaths among

children age 15 and under from auto

accidentsneither of .which are

downplayed as "rare" events. As

shown, abuse and neglect has

become one of the biggest threats to

the lives of infants and small

children in America. Deaths from

ChN ANN

Ffoillios AM

Serious DenabIlldes 19,090

Sodom Injury141,700

Substandited

Incidence of

abuse and neglect of children age 4 ChNd Abuse and Negiset 9112117 and under outnumber those from Reports of

Child Abuse

and *pied- falls, choking on food, suffocation, 29 ISIlion,

Involving 1.9 Mon drowning, residential fires, and Childnen motor vehicle accidents.

It is particularly difficult to Sources: U.S. Advisory Board on Child Abuse and Neglect; Baladerian, Verbal

testimony, 1994; NCCAN, 1991; National Committee to Prevent Child Abuse

accept the alarming levels of abuse

and neglect deaths in the 1990's, given that death rates among infants

and young children from all other major causes are steadily declining.

Yet fatalities are not the entire story. The misery caused by

near-fatal abuse and neglect ripples through this country, each year

leaving 18,000 permanently disabled children (Baladerian, 1991), tens

of thousands of victims overwhelmed by lifelong psychological

trauma, thousands of traumatized siblings and family members, and

thousands of near-death survivors who, as adults, continue to bear the

rl r

XXV

U.S. Advisory Board on Child Abuse and Neglect

BEST COPY AVAILABLE
Executive Summary

...141,700 infants and

children were

seriously injured due

to abuse or neglect in

1990 alone.

xxvi

physical and psychological scars. Some may turn to crime or domestic

violence or become abusers themselves.

Near-fatal injury is nearly as appalling in its

destruction as the toll of dead children. Many children with head

injuries known to be caused by abusive caretakers are left with lifelong

cerebral palsy (Diamond & Jaudes, 1983). The National Center on

Child Abuse and Neglect (NCCAN) estimates that 141,700 infants and

children were seriously injured due to abuse or neglect in 1990 alone

(1991). The National Research Council (NRC) points out that, beyond

these human costs, "the future lost productivity of severely abused

children is $658 million to $1.3. billion, if their impairments limit their

potential earnings by only five to ten percent" (NRC, 1993, p. 40).

Each year we learn more about which children have died and

which parents and caretakers are responsible. We know that a

disproportionate number of victims come from low-income families

with multiple problems. However, children of middle-and-high

income families also die at the hands of their parents or caretakers.

Such was the case of Lisa Steinberg who died in 1987 under the care

of Joel Steinberg and Hedda Nussbaum, an upper middle-class wlilte

couple. In addition, research suggests that males cause most physical

abuse fatalities, and that mothers are held responsible for most deaths

caused by severe neglect. Furthermore, abuse and neglect deaths are

not limited to inner cities. Such deaths occur in many communities,

including isolated rural areas.

What we must ask is why. Must 2,000 babies and small

children die at the hands of their parents or caretakers in 1995? What

events lead up to these tragic deaths? What goes on in the minds of

parents or caretakers that cause them to abandon their protective roles

and lash out at or severely neglect tiny, helpless children? Angry

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

Americans asked this question of Rufus Chisolm and Michelle Mann,

as well as Joel Steinberg, who beat their children to death. But these

are questions that cannot be answeredor addresseduntil this

Nation chooses to tackle this long-ignored crisis in a meaningful way.

How Can We Address This Devastating Crisis?

This report offers a discussion of the existing efforts and

opportunities that show promise in helping us to understand and

prevent child abuse and neglect fatalities. These efforts emerge from

motivated individuals and agencies that have assumed strong

leadership roles in the response to and prevention of child abuse and

neglect fatalities. In addition, many communities have established

neighborhood support systems to prevent child abuse and neglect.

This report also provides a close look at systemwide

weaknesses and obstacles, and a lack of resources and commitment by

policymakers to take action that could save children's lives. Thus, we

wish to send a wake-up call to those who may minimize this crisis and

to those who do not know this crisis exists.

We offer 26 Recommendations for addressing deep-seated

problems within the law enforcement, child protection and health

agencies and courts that comprise the country's child protection

system. Our Recommendations are addressed to Congress, States,

public policymakers, and all citizens.

The four chapters of the report address: (1.) the lack of

knowledge over the scope and nature of child abuse and neglect

fatalities, (2.) the need for better investigation and prosecution and for

major efforts to improve and train front-line professionals, (3.) the

encouraging emergence of Child Death Review Teams, (4.) the need

for more aggressive efforts to protect children and facilitate

xxvii

U.S. Advisory Board on Child Abuse and Neglect

3
Executive Summary

...85 percent of

childhood deaths

from abuse and

neglect are

systematically

misidentified.

"The germ theory of

disease is at least a

century old and 1 glen

say that we're at about

the year 1930 in terms of

our understanding of

child maltreatment. We

are still arguing about

whether a case is

maltreatment or not, just

as we once argued is

this an infectious disease

or not?Dr. Bernard

Ewigman, University of

Missouri, Department of

Medicine, New York

Focus groups, 1994

community-based family services and primary prevention efforts to

help families live safe and healthy lives.

Chapter One: Quantifying the Problem

Our society has, in this century, kept a watchful eye on

virtually every cause of child death, using what we have learned to

quantify the scope and nature of threats to children's health and safety

and then to design prevention efforts. These efforts have included the

war on polio and, more recently, the massive investment in

automobile safety seats for children younger than age 4. But when it

comes to deaths of infants and small children due to physical abuse or

severe neglect, few resources have been expended to understand this

phenomenon. Its scope and very nature remain essentially unknown.

It has been estimated that 85 percent of childhood deaths from

abuse and neglect are systematically misidentified as accidental,

disease related, or due to other causes (NRC, 1993; McClain et al,

1993; Ewigman et al, 1993). This arises from poor medical diagnoses,

incomplete investigations, and widespread flaws in the way deaths are

recorded on death certificates, in crime reports, and by the child

protection system.

As a result of this misclassification and misdiagnosis, we do

not have a reliable source to determine accurately why or exactly how

many children die from abuse and neglect. Each national information

system is incomplete as a source of comprehensive information on

child abuse and neglect deaths. Vital Statistics, the FBI's Uniform

Crime Rep,ets, and State child abuse indices each track just one

limited part of the picture.

31

U.S. Advisory Board on Child Abuse and Nealect
7 Executive Summary

In Chapter One, our Recommendations address this widespread

lack of knowledge that badly hampers our ability to prevent fatal child

abuse and neglect. Significantly reducing fatal child abuse and neglect

and the attendant broad social, economic, and personal costs of severe

abuse and neglect among survivors requires the highest level of

attention, a far more sophisticated understanding of the problem, and a

much greater commitment of our resources.

Chapter Two: Government and Individual Responsibility

The systems created in the United States to ensure that adult

homicides are thoroughly investigated were never developed for

children who die due to abuse and neglect by parents or caretakers. In

times past, children were often seen as property. Many police,

prosecutors, and judges viewed such deaths as a strictly social

problem, not a criminal issue. Today, systemic failures created by

those attitudes linger on. The question of who harmed a child is often

never asked or answered, and in too many cases perpetrators have gone

undetected to harm or kill other children.

Even if a fatality is recognized by the system and an

investigation is launched, the criminal justice system may respond

poorly. Prosecutors often reduce child homicides, including those of a

heinous nature, to lesser crimes or do not charge perpetrators at all.

Prosecutors are hampered in part by murder statutes that do not fit

many child fatalities. Cases are difficult to prove in court because

most prosecutors have little training in child abuse and neglect,

insufficient evidence is gathered, and autopsies are rarely performed

by medical examiners with sufficient pediatric expertise. These

problems in prosecuting cases are exacerbated by the fact that

32

U.S. Advisory Board on Child Abuse and Neglect

These problems in

prosecuting cases are

exacerbated by the fact

that witnesses are rare

because most deaths

occur in the privacy of

the home...
Executive Summary

Over half the

children who die

are from families

who have never

been investigated

by CPS.

XXX

witnesses are rare because most deaths occur in the privacy of the

home, and some jury members cannot believe that any parent or

caretaker would commit such acts upon a child.

Many of the key agencies involved still do not fully exercise

their roles in investigating abuse and neglect or in assuring a child's

safety. For example, a coroner may label a case of inflicted

suffocation as "Sudden Infant Death Syndrome" to protect a family's

reputation. The breakdown can be seen in the numbers of mandated

reporters who do not alert child protective service (CPS) agencies

when they recognize a child as abused or neglected. Zellman &

Anther (1990) found that 22 percent of mandated reporters, including

pediatricians, school principals, therapists, and day care operators, do

not report suspected cases of abuse. They cited a lack of hard evidence

of abuse and neglectwhich is not required to make a reportand

their belief that "I can do better than the system." They are often

breaking State law.

Such practices among those who could be saving children's

lives are extremely significant when one considers how many children

die before their families are reported to a CPS agency. Over half the

children who die from abuse and neglect nationwide are from families

who have never been investigated by CPS. Yet, thousands of children

who died in the past decade were known to at least one professional or

agency that might have intervened to save their lives.

The lack of specialized training among those who deal with

high-risk families is the single biggest impediment to improving the

system in two critical areas: saving children by recognizing lifethreatening abuse or neglect and establishing how and why a child has

died. It is clear that most police, medical examiners, health

practitioners, and CPS workers do not have the level of expertise

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

needed to protect children from serious child abuse and neglect. We

believe a concerted new training effort is needed.

States have struggled to address problems within the judicial

system, noncompliance by mandated reporters, and systemwide

training inadequacies. In the face of such basic, deep-rooted problems,

it is not hard to see why the system appears to be in disarray when yet

another tragic death of a child is made public in 'the media. We believe

it is time for physicians, hospitals, police, prosecutors, teachers,

therapists, the clergy, and communities at large to become active

participants in a comprehensive child protection system and to bear

greater responsibility for the safety of children.

In Chapter Two, our Recommendations further our philosophy

of better educating professionals to identify and investigate abuse and

neglect and to hold perpetrators responsible for child deaths.

Chapter Three: The Need For Child Death Review Teams

Our understanding of fatal child abuse and neglect is hampered

by a vast societal lack of awareness combined with avoidance of the

issue. In the 33 years since Dr. C. Henry Kempe first described the

Battered Child Syndrome, more children have died from child abuse

and neglect than from urban gang wars, AIDS, polio, or measles; yet

the contrast in public attention and commitment of resources is vast.

An encouraging new development is the emergence of

multiagency/multidisciplinary Child Death Review Teams, a

phenomenon still so new and evolving that the very existence of the

teams is not yet widely known to the public or national media.

Already, Child Death Review Teams have become one of our richest

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

Child Death Review

Teams appear to

offer the greatest

hope of defining the

underlying nature

and scope of

fatalities from child

abuse and neglect.

sources for understanding this quiet crisis. On a regular basis, teams

must grapple with systemwide flaws and outmoded policies that often

work to prevent authorities from recognizing and properly responding

to deaths due to abuse and neglect. Experts from multiple agencies

and disciplines serve as members of the teams. These teams review

cases of child deaths and facilitate appropriate follow up. Such

followup includes assuring that services are provided to surviving

family members, providing information to assist in the prosecution of

perpetrators, and developing recommendations to improve child

protection and community support systems. In addition, teams can

assist in identifying weaknesses in the child protection system and

determining avenues for prevention efforts and improved training of

front-line workers.

State-level teams may review individual cases, or in larger

States, provide support and accountability for local teams. Welldesigned, properly organized Child Death Review Teams appear to

offer the greatest hope of defining the underlying nature and scope of

fatalities due to child abuse and neglect.

In Chapter Three, our Recommendations emphasize the critical

importance of Child Death Review Teams in assessing child fatalities,

pinpointing system flaws, and promoting prevention services.

Diverting even a small fraction of our national attention and resources

to an integrated and comprehensive approach to the defense of

children's lives is a monumental task that should begin with the broad

use of Child Death Review Teams.

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

Chapter Four: Toward a Better Future

Part One: Family Services, Intervention, and Family Preservation

Child welfare and law enforcement agencies have an explicit

statutory mandate to intervene to protect children when the family

does not provide that protection. However, if the system is going to

save children, this responsibility must be greatly broadened and seen

as a collaboration among law enforcement, social service, public

health, and education systems. The final critical component to this

broader system must be neighbors, extended family, friends, and local

agencies in every community. The child's safety and well-being must

be a priority in all child and family programs.

Unfortunately, in many States, laws and policies regarding

child protection and case management are inadequate or conflicting.

The roles of all child protection agencies, especially with regard to

emergency measures and followup investigations with parents, may be

poorly defined. Moreover, most citizens do not feel a sense of

responsibility for protecting the children in their neighborhoods.

Hundreds of thousands of families in which child abuse or

neglect is confirmed do not even receive basic services to ameliorate

the negative effects of such maltreatment (McCurdy & Daro, 1992).

The cases are merely monitored and closed. In addition, decisions by

front-line workers are often not responsive to a family's needs. These

decisions are affected by limited funds and restrictive eligibility

requirements.

The recent legislation creating the 5-year, $1 billion Family

Preservation and Family Support Program has given States and

counties a tremendous opportunity to shift from this crisis-driven

U.S. Advisory Board on Child Abuse and Neglect

Hundreds of thousands

offamilies in which

child abuse or neglect is

confirmed do not even

receive basic services.

3 11
Executive Summary

The media can play

a key role in sending

accurate and

influential messages.

xxxiv

response system toward one that reduces the core family problems that

we believe lead to abuse and neglect fatalities.

It is the strong belief of this Board that this legislation should

serve as a catalyst for the growth of an integrated, prevention-oriented,

community-based system of support for families and children.

Part Two: Fatality Prevention

There is probably no greater area of public debate in the child

welfare field than the issue of how society should prevent fatalities at

the hands of parents and caretakers. Invariably, when the death of a

small child is reported in the media, well-meaning journalists and

policymakers blame the CPS worker who appeared to know a child

was living under dangerous conditions and yet failed to rescue that

child.

We, as a society, want swift action and clear-cut policies. We

condemn what appears to be the failure of the system and the "passing

of the buck." However, this Board is convinced that the public debate

over who "made a mistake" that led to a child's death focuses on the

wrong issues. The best chance we have for reducing these deaths is by

beginning to ask the right questions and focusing on the right issues.

The media can play a key role in sending accurate and influential

messages that could reduce serious and fatal child abuse and neglect

not only to parents, but to all citizens.

The truth is that, except in obvious cases of imminent danger,

no single agency or individual in the multiagency system of child

protection workers, police, physicians, and courts has the ability to

foresee serious abuse or neglect that can cause a child's death. In

many ways, we are as ignorant about abuse and neglect fatalities today

as we were about child sexual abuse in the 1970's. Many thousands of

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

infants and small children today live in what the literature refers to as

"high-risk" families. In 1993, 500,00 to 650,000 parents and children

were living in the streets either temporarily or permanently (personal

communication, Debbie Chang, National Alliance to End

Homelessness); 3.3 to 10 million households with children contained a

violent male with a history of domestic abuse (Schecter & Edleson,

1994); and 11 million parents with children were abusing drugs and

alcohol (personal communication, Narconon, U.S. Drug Education

Division). Each of these factors is considered a risk factor for child

abuse and neglect.

The minimal research conducted in this area has not identified

specific behaviors that can single out parents whose action or inaction

might end a child's life. Currently, the best predictor of future abuse

is a pattern of past abuse.

This Board is urging Congress, the States, and policymakers to

greatly improve the existing primary prevention efforts. In providing a

comprehensive, early safety net for all children, we hope to influence

the lives of many families, and thus identify and protect those

unknown innocents who need our help the most.

Our design for primary prevention stresses child and family

well-being in a healthier, more active, community-based setting. We

are building upon our 1991 and 1993 Board reports, which urged the

creation of a neighborhood-based, community system to serve families

and the inclusion of neighbors, family, and friends in assuring the

safety and well-being of children. This should include informal family

and neighborhood support, assistance with difficult parenting issues

via community-based programs, and crisis intervention services. It is

our belief that, given such support, more parents and caretakers will

Currently, the best

predictor offuture

abuse is a pattern of

past abuse.

U.S. Advisory Board on Child Abuse and Neglect

33
Executive Summary

xxxvi

welcome a helping hand when it is needed and will raise their children

in safety.

However, this Board also rccognizes that some parents and

caretakers, even with supportive services, cannot provide a safe home

environment for their children. Therefore, it is imperative that, when

necessary, a child's safety and well-being must be protected through

prompt removal from the home and by expedited termination of

parental rights (TPR) actions by the juvenile courts. We strongly

believe that any child who suffers abuse or lives in a severely abusive

family deserves r-..rmanent placement with a family who is willing to

nurture and care for that child.

In Chapter Four, we pinpoint the populations at greatest risk for

becoming victims of fatal abuse and neglectvery young childrenas

well as those at greatest risk for becoming perpetratorsmale

caretakers and parents of toddlers and infants. This Board emp:lasizes

the great need for public awareness campaigns. In addition, we urge

that when a family completely fails a child, the child be given a second

chance with a new life and a new family in an expeditious manner.

Conclusion: The Challenge

ABCAN hopes that this report will awaken America to the

national shame of child maltreatment-related fatalities and will

galvanize all Americans to act now to prevent these tragedies.

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

SUMMARIZED RECOMMENDATIONS

OF THE

U. S. ADVISORY BOARD ON CHILD ABUSE AND NEGLECT

Recommendation 1: Our Nation must establish a national

commitment at the highest levels to understand the scope and

nature of fatal child abuse and neglect.

We urge the U.S. Attorney General and the Secretary of Health

and Human Services to devote existing resources and expertise to

address the lack of knowledge regarding the true nature and extent of

fatal child abuse and neglect in America.

Recommendation 2: Federal and State agencies must significantly

increase research efforts on serious and fatal child abuse and

neglect.

Research is needed to address the serious gaps in information

on issues such as the effects of poverty, race, domestic violence, and

substance abuse in serious and fatal child abuse and neglect, as well as

the effectiveness of current services in preventing serious and fatal

injury.

Recommendation 3: The supply of professionals qualified to

identify and investigate child abuse and neglect fatalities should be

increased.

The leadership of the Department of Health and Human

Services and the Department of Justice should work with professional

associations to develop a national strategy to address the dramatic lack

of medical, law enforcement, legal and social service professionals

qualified to identify and investigate child abuse and neglect fatalities.

Recommeldation 4: There must be a major enhancement of joint

training by government agencies and professional organizations

on the identification and investigation of serious and fatal child

abuse and neglect.

The Secretary of I lealth and Human Services and tl U.S.

Attorney General should utilize funds to improve multidiF plinary

training in all disciplines charged with identifying and investigating

U.S. Advisory Board on Child Abuse and Neglect

4 0
Executive Summary

child abuse and neglect fatalities, with an emphasis on crosstraining

where possible. This effort should be tailored to a broad audience

including child welfare workers, law enforcement officers,

prosecutors, mental health practitioners, physicians, paramedics,

emergency medical technicians, and others who might work in a frontline capacity.

Recommendation 5: States, military branches, and Indian Nations

should implement joint criminal investigation teams in cases of

fatal child abuse and neglect.

All States should create criminal investigation teams eithei

the local or regional level to investigate any "unexpected child death."

Each team should include, at a minimum, a medical examiner, law

enforcement officer, CPS worker and prosecutor. These teams should

investigate all unexpected child deaths. Military branches and Indian

Nations should work with Federal and State law enforcement and

health authorities to establish such teams.

Recommendation 6: States and the Joint Comuission on

Accreditation of Health Care Organizations should adopt

requirements to assure that all hospitals with pediatric services

have Suspected Child Abuse and Neglect (SCAN) teams.

Any hospital with a pediatric unit should be required by the

State, military branch, or Indian Nation, which oversees its

certification, to have a SCAN team. SCAN teams should include a

physician, social worker, and nurse specially trained to recognize,

treat, report, and consult on suspected child abuse and neglect cases.

Recommendation 7: All states should enact legislation

establishing child autopsy protocols. Federal funding for

autopsies of children who die unexpectedly should be available

under Medicaid.

Autopsies should be required at a minimum when any child's

death is suspected as being a homicide or suicide, the child was not

under supervision of medical personnel at time of death, or the cause

of death is not readily determinable.

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

Recommendation 8: States should take steps to ensure that all

children have access to available, necessary medical care when

they are at risk of serious injury or death.

All states should ensure that child abuse laws include the

provision that parents must provide medical care when such care is

available and necessary to protect the child from death or serious harm.

Failure to do so is reportable under child abuse and neglect reporting

law.

States should ensure that all health care providers, including

spiritual healers who receive healthcare reimbursement, are listed as

mandatory reporters of child abuse and neglect, thereby involving such

providers in training activities that are conducted for mandatory

reporters.

Recommendation 9: States should enact "felony murder or

homicide by child abuse" statutes for child abuse and neglect.

States that currently define child abuse as a misdemeanor should

establish laws to define child abuse and neglect as felonies.

Felony murder or homicide by child abuse and neglect statutes

in all States should specifically include child abuse or neglect as one of

the underlying felonies, as currently is the case in 21 States.

Recommendation 10: The Secretary of Health and Human

Services and the U. S. Attorney General should work together to

assure there is an ongoing national focus on fatal child abuse and

neglect and to oversee aa ongoing process to support the national

system of local, State, and Federal child abuse and neglect fatality

review efforts.

A national structure is needed to incorporate the knowledge of

the teams, establish a mechanism for disseminating that knowledge,

and facilitate development of a national perspective to prevent child

abuse and neglect fatalities. This can be accomplished through the

designation of individuals within the Department of Health and Human

Services and the Department of Justice who would assume ongoing

responsibility to support the process and the semi-annual convening of

experts from throughout the country to review and analyze relevant

data, share information, track national trends, and develop

recommendations.

U.S. Advisory Board on Child Abuse and Ne lect

4 2
Executive Summary

xl

Recommendation 11: A national-level effort should ensure that

services and training materials on fatal child abuse and neglect are

made available to all states.

Federal resources must be allocated to provide a far more

meaningful level of expertise, technical assistance, and resources to

professionals and agencies who need it. The Secretary of Health and

Human Services and the Attorney General should oversee this

interdisciplinary effort.

Recommendation 12: All States should have State level Child

Death Review Teams. Such teams should also be established

within the military branches, Indian Nations and territories,

These multidisciplinary/multiagency child death review teams

should include participation from criminal justice, health, social

services, and other relevant agencies and individuals. The teams

should provide support to local teams and publish an annual report that

summarizes local case findings and provides recommendations for

systemwide improvement in services to prevent fatal abuse and

neglect.

Recommendation 13: Child Death Review Teams should be

established at the local or regional level within states.

Local multidisciplinary/multiagency teams are the core of the

child death review system. They conduct individual case review,

assist with case management, and suggest followup and systems

improvements. Regional teams may be effective in multicounty rural

areas or in areas that border other nations. Such regional teams are

also effective in key population centers and regions where counties

may benefit from sharing information and statistics.

Recommendation 14: Model legislation should be enacted to

address confidentiality.

Information sharing is critical to the effective functioning of

Child Death Review Teams. Federal regulations should assure

immunity from legal sanctions for agencies and team members who

share information in the course of the team's work and protect such

information from judicial discovery. States should enact legislation to

clarify their ability to share information among law enforcement, CPS,

mental health, and health agencies.

U.S. Advisory Board on Child Abuse and Neglect
Executive Summary

Recommendation 15: States and communities should assure that

the religious community is included in efforts to prevent child

abuse and neglect fatalities.

The religious community should be an active participant in

State and local efforts to prevent serious and fatal child abuse and

neglect. Members of the clergy should also be recognized as a vital

resource in the provision of personal support, spiritual guidance, and

counseling to surviving siblings and other family members who

survive fatal child abuse and neglect.

Recommendation 16: All child and family programs must adopt

child safety as a major priority.

Family, child welfare, health, mental health, and education

programs must adopt children's safety as a major priority and

explicitly assess the child's safety while providing services. Goals

must also include the child's overall well-being and development and

the preservation of the family.

Recommendation 17: All relevant State and Federal legislation

must explicitly identify child safety as a goal.

Congress and State legislatures must explicitly identify child

safety as a major goal. This goal must be statutorily presented as

consistent with other public policy goals, such as family preservation

and permanence for children.

Recommendation 18: The decision to remove children from their

homes or initiate family preservation services should be made by a

team.

Child protection and law enforcement agencies should use

multidisciplinary team assessment and decision making whenever

possible.

Recommendation 19: Family preservation services should be

available in every jurisdiction.

Intensive family preservation seNices should be available in

every jurisdiction as an option.

xli

U.S. Advisory Board on Child Abuse and Neglect

4 4
Executive Summary

Recommendation 20: States should use guidelines when

considering family preservation services.

Until the completion of needed research on the families most

likely to be helped by family preservation services, States should use

guidelines focusing on the safety and well-being of children in

determining whether such services are the appropriate option for a

specific family.

Recommendation 21: An array of primary prevention services

and supports, including home visiting, must be made available to

all families.

Primary prevention means helping families before an incident

of abuse or neglect occurs. Because it is impossible to predict which

families will kill their children, the most effective prevention is to

support parents in being effective and nurturing, to provide treatment

services when family problems do arise, and to respond quickly and

appropriately when abuse or neglect is identified.

Recommendation 22: Family support services funding should be

used for prevention programs aimed at families with infants and

toddlers.

Because most children die from abuse or neglect before age 4,

available Family Support funds and other prevention funds should be

used to significantly increase the emphasis on mothers, fathers, and

other caretakers of infants, toddlers, and preschoolers.

Recommendation 23: State and local agencies should design

prevention programs for men. Programs should integrate services

on child abuse and domestic violence and address the need for

interagency training.

Specific strategies must reach men and alert women to the

potential role of men in abuse. These strategies should be funded via

Federal Family Preservation and Support monies, as well as public and

private sources at the state and local levels. Because of the correlation

and frequent coexistence of domestic violence and child abuse,

programs must address all forms of family violence, especially when

children are in the home.

U.S. Advisory Board on Child Abuse and Neglect

Ir.

4 .)
Executive Summary

Recommendation 24: Expedited TPR should be developed in

State.

When voluntary TPR is not an option, CPS agencies, States,

and the juvenile courts should develop ways to expedite court TPR and

placement with a permanent family in situations when a child cannot

safely remain with or return to parental custody.

Recommendation 25: A broad public prevention campaign should

be developed to address serious and fatal child abuse and neglect.

Well constructed campaigns can help educate parents about the

triggers associated with serious injury and deaths of infants and

children and suggest alternative means to cope with such problems.

Such campaigns can also substantially increase public awareness about

how to report abuse and how to prevent harm to children. The media

should play a major role in this effort because of its unique ability to

reach into homes of millions of people, including those who need help

and those who might help others.

Recommendation 26: Regulatory measures should be adopted to

reduce environmental dangers.

Regulations and codes should be enacted to end preventable

child fatalities and serious injuries from household hazards and

environmental dangers.

U.S. Advisory Board on Child Abuse and Neglect 74
Executive Summary

xliv

REFERENCES

Baladerian, N. J. (1991). Abuse Causes Disabilities. Disability

and the Family. Culver City, California: SPECTRUM Institute.

Chang, D.. (1995). [National Alliance to End Homelessness]

(Jill Stewart).

Diamond, L. J., & Jaudes, P. K. (1983, April). Child abuse in

cerebral-palsied population. Developmental Medicine and Child

Neurology, pp. 169-174.

Durfee, M., Gellert, G., & Tilton Durfee, D. (1992). Origins

and clinical relevance of child death review teams. Journal of the

American Medical Association, 23 7, 3172-3175.

Ewigman, B., Kivlahan, C., & Land, G. (1993). The Missouri

Child Fatality Study: Underreporting of Maltreatment Fatalities

Among Children Younger Than Five Years of Age, 1983 Through

1986. Pediatrics, 91, 330-337.

Knight Ridder New Service. (1995, February 2). U.S. Murder

rate for children soars. Baltimore Sun, p. 12A.

Langer, C. (1991). Who Killed Adam Mann? [Public

Broadcasting Service, Frontline].

Mackellar, F. L., & Yanagishita, M. (1995, February).

Homicide in the United States: Who is at risk? (Vol. 21). Washington,

DC: Population Reference Bureau.

McClain, P. (1995, March 21). [Centers for Disease Control

and Prevention] ( Anne Marie Finn). Atlanta, Georgia.

McClain, P., Sacks, J., & Frohlke, R. (1993). Estimates of Fatal

Child Abuse and Neglect, United States, 1979 Through 1988.

Pediatrics, 91, 338-343.

McCurdy, K., & Daro, D. (1994). Current Trends in Child

Abuse Reporting and Fatalities: The Results of the 1993 Annual Fifty

State Survey. National Center on Child Abuse Prevention Research.

Chicago: National Committee to Prevent Child Abuse.

U.S. Advisory Board on Child Abuse and Neglect

47
Executive Summary

McCurdy, K., & Daro, D. (1992). Current Trends in Child

Abuse Reporting and Fatalities: The Results of the 1991 Annual Fifty

State Survey. Chicago: National Center on Child Abuse and Prevention

Research.

Narconon. (1995). [U.S. Drug Education Division] ( Jill

Stewart).

National Center on Child Abuse and Neglect. (1991). National

Incidence and Prevalence of Child Abuse and Neglect: The 1988

Revised Report (NIS-2) [Westat.]. Washington, DC: Department of

Health and Human Services.

National Research Council. (1993). Understanding Child

Abuse and Neglect. Washington, DC: National Academy of Sciences.

Schecter, S., & Edleson, J. L. (1994, June 8-10). In the Best

Interest of Women and Children: A Call for Collaboration Between

Child Welfare and Domestic Violence Constituencies. Wingspread.

Racine, Wisconsin.

Zellman, G., & Anther, S. (1990, Winter). Mandated reporters

and CPS: A study in frustration; misunderstanding, and

miscommunication threaten the system. Public Welfare, 48.. 30-37.

xlv

U.S. Advisory Board on Child Abuse and Neglect

4 8
Preface

PREFACE

We have all seen the stories in the newspapers and on the evening

news. A mother kills her children. A teenager, babysitting for young

nieces and nephews, gets angry and throws a child against a wall. A father

who cannot handle a child's crying lashes out with his fists in frustration.

While it seems that society should feel its greatest sense of shame

when a child dies from abuse or neglect, instead our overwhelming

reactions are outrage, shock, disbelief, and sometimes denial. Because

most of us do not understand how a parent or caretaker could bring him or

herself to kill a child, we feel paralyzed and powerless to prevent future

deaths. The U.S. Advisory Board on Child Abuse and Neglect (ABCAN)

believes that in order to change this situation, Americans need to hear the

truth about fatal child abuse and neglect.

Americans need to hear about tens of thousands of children hurt or

killed by their parents or caretakers each year. They need to hear about

parents who know too little about child rearing and about households that

exist in an atmosphere of stress and isolation. They need to hear about a

child protection system able to provide only minimal attention or support

to parents until after abuse occurs. They need to hear about a system that

places too 1 i ttle emphasis on acting to save a child before he or she is

irreparably harmed and that places too much emphasis on intervening after

a crisis has reached a tragic peak. In short, they need to hear about

devastating tragedies that could and must be prevented.

ABCAN believes that fatal child maltreatment is not one of life's

deadly inevitabilities. Nor is it just one of a long litany of social problems

taking its place in line behind many others. It is an crisis that needs to be

treated with the seriousness of any major health threat.

U.S. Advisory Board on Child Abuse and Neglect
Preface

2

The incidence of fatal child abuse is greater than most of us realize.

Last year some 2,000 children died in America at the hands of their

parents or caretakers. Some approximate that more than 18,000 children

suffered permanent disabilities from abuse or neglect while 141,700

sustained serious or near-fatal injuries. Yet these estimates probably

underrepresent the true extent of the problem. Until we develop more

comprehensive and sophisticated data, our efforts to understand and

prevent child maltreatment-related deaths will be severely handicapped.

With an improved understanding of the magnitude of fatal abuse and

neglect, it will become possible to better understand this tragedy and take

steps that will keep children who are at risk of abuse from becoming the

subject of newspaper headlines.

ABCAN has conducted a 2-year study on child abuse related

fatalities, traveling to 10 States to hear the public and experts in many

professions provide information on this phenomenon. One of the most

instructive events was the Board's visit to the Bedford Hills Correctional

Facility in New York where we heard disturbing testimony from Women

incarcerated for abusing or killing their children. From them we learned

important lessons about the pain and abuse they suffered as children and

how it affected their behavior as parents.

The information gathering process was a valuable experience. We

learned that the children most vulnerable to serious or fatal abuse and

neglect are those whose parents or other caretakers are ill-equipped to care

for them, who live in social isolation and poverty, and who are virtually

invisible to the larger community and to the educational and child

protective services systems. They tend to live in environments

that have few supports for parents. They may not know their neighbors

well enough to ask for help. It is disturbingly common for trial testimony

U.S. Advisory Board on Child Abuse and Neglect

5 0
Preface

in child abuse cases to reveal that family, neighbors, and even health care

professionals suspected abuse but took no action.

This is not to absolve parents for their actions. On the contrary,

serious or fatal maltreatment of a child should carry the same criminal

weight as comparable crimes against adults. But neither can the larger

community be absolved from its responsibility for supporting parents and

for protecting children.

Our greatest priority must be to help children and families before

harm occurs. Breaking a household's isolation with appropriate

preventive services, such as voluntary home visitation, respite day care or

parenting education and support. can change an environment that is unsafe

for a child. When prevention does not appear to work, then intervention

on behalf of threatened children must be swift, professional, coordinated,

and if necessary, permanent.

In both prevention and intervention, there is far more work that

needs to be done. Our review has revealed serious gaps in data collection,

support services for families, professional practice, and coordination and

accountability among systems. Improvement in these areas can lead to

better strategies and programs and will save lives.

There is so much more that we, as a nation, can and should be

doing. We can strive to collect accurate and complete data on the number

of children killed and injured every year. We can intervene in high-risk

circumstances. We can expand basic support systems for families from

the prenatal period all the way through the child's development. We can

do a better job of sharing information among agencies to ensure that no

child is seriously hurt or killed simply because one arm of the system did

not communicate with the other.

While this Board is well aware of the current political trend toward

consolidating child welfare and child abuse programs, giving more latitude

U.S. Advisory Board on Child Abuse and Neglect
Preface

to States to determine what services are provided and to whom, we believe

that our Nation's response to the seriousness of children's deaths demands

a strong local, State, and national focus. The majority of this report's

recommendations require no new funds or bureaucracies, but would make

a great difference in preventing child abuse and neglect and the loss of

children's lives. Even where additional resources are needed, we can think

of no better use for our dollars than to stop children from dying.

Anthony

New School for Child Development Special Education

Division

4

ktitt Nurarts

U.S. Advisory Board on Child Abuse and Neglect
Introduction

"A simple child,

That lightly draws its breath,

And feels its life in every limb,

What should it know of death?"

William Wordsworth

INTRODUCTION

In 1991, a riveting PBS documentary told the story of the brutal

death of 5-year-old Adam Mann, beaten to death on March 3, 1990, by

his stepfather, Rufus Chisolm, with participation by his mother,

Michelle Mann. Many professionals had missed a series of signs that

Adam was in serious danger. The autopsy demonstrated the cruelty

Adam experienced in his short life. Over 100 injuries were observed

on his body. The cause of death was listed as a broken skull, broken

ribs, and a split liver. At one time or another, every bone in his body

had been broken. There was no food in his stomach at the time of

death. Adam's stepfather and mother were imprisoned, and Adam's

siblings were placed in foster care.

The story of Adam Mann's death, as well as compelling

testimony regarding other child abuse fatalities, prompted Congress to

ask the U.S. Advisory Board on Child Abuse and Neglect (ABLAN) to

prepare a report on child maltreatment-related fatalities. The report

was to contain the Board's recommendations for:

a national policy to reduce and ultimately prevent such

fatalities,

U.S. Advisory Board on Child Abuse and Neglect

0 ;3

5
6

Introduction

changes needed to achieve an effective Federal role in the

implementation of the policy,

changes needed to improve data collection about child

abuse and neglect fatalities.

Given this important charge, the Board held an extensive series

of hearings, workshops, and public forums, drawing upon the

knowledge and experience of scholars, social work professionals,

physicians, nurses, lawyers, teachers, child advocates, convicted child

abusers and others with an interest in this topic. The information

gained from this process is presented in this report, along with the

Board's considered recommendations for actions that could reduce the

number of child fatalities in the United States.

Thus, the Board presents this report in response to public

concern, a congressional mandate, and ;ts own longstanding belief that

addressing child fatalities is a moral and ethical imperative to provide

a critical perspective into the tragic lives of millions of other abused

and neglected children. The Board hopes that its work, in some small

way, will serve as a memorial to Adam Mann and to the thousands of

fatally victimized children who cannot speak for themselves.

U.S Advisory Board on Child Abuse and Neglect
Chapter One

Must I light a candle to my shame?

William Shakespeare

Merchant of Venice

CHAPTER ONE

DEFINING THE SCOPE AND NATURE OF FATAL

ABUSE AND NEGLECT

UNDERSTANDING THE PROBLEM

Our society has, in this century, kept a watchful eye on untimely

child deaths due to everything from car crashes to contagious disease to

poisonings. One can find out exactly how many children under the age of

18 died from gunshots by strangers in 1993 (FBI, 1994) and precisely how

many children died from measles in 1970 (CDC, 1971). Last year, the

Centers for Disease Control and Prevention (CDC) even began collecting

information on child deaths due to accidents involving soccer goal-posts

(personal communication, 1995).

Such detailed information has been used to identify the scope

and nature of threats to children's health and safety and then to design

prevention efforts that save lives, for example, the war on polio and the

massive expenditures since 1983 on automobile safety seats for

children.

But when it comes to deaths of infants and small children due to

physical assault or severe neglect at the hands of parents or caretakers,

society has responded in a strangely muffled, seemingly disinterested,

way. Little money has been spent to understand this tragic phenomenon.

Abused children

died nearly three

times more often

than children

hospitalized from

auto crashes.

"You can call the Centers for

Disease Control and Prevention

and find the number of children

who had a brown recluse spider

bite last year, but you certainly

can't get correct information on

child abuse and neglect or

fatalities." Dr. Barbara

Bonner, Center on Child Abuse

and Neglect, University of

Oklahoma, Oregon public

hearing, 1993

7

U. S. Advisory Board on Child Abuse And Neglect

t.)
Chapter One

"I was invited to the first

national symposium on child

maltreatment fatalities and

was asked to bring data

from my State. I called Vital

Statistics, and they had six

deaths due to abuse and

neglect in the State. I

thought, 'Boy, that's

unusual. I know about more

deaths than that myself

Dr. Colleen Kivlahan,

Medical Director,

Department of Health,

Jefferson City, Missouri

8

The true numbers and exact nature of the problem remain unknown, and

the troubling fact of abuse or neglect often remains a terrible secret that is

buried with the child. According to the General Accounting Office,

Federal agencies spent only $5.7 million on research primarily relevant to

child physical abuse, sexual abuse, and neglect in fiscal year 1989, and

only a small fraction went to fatality research (Westover, 1990).

Childhood mortality rates were dramatically reduced in the United

States by the success of sanitation measures early in the century, the

development of antibiotics and immunizations, and strides in saving

premature infants. However, no such societal investment of time and

study has been made to reduce child fatalities from abuse and neglect.

According to the Population Reference Bureau, death rates among children

age 4 and under who die from homicidethe vast major:1y of which is

committed by parents and caretakershave hit a 40-year high (Mackeller

& Yanagishita, 1995). Phil McClain of the Centers for Disease Control

and Prevention believes that abuse and neglect kills 5.4 out of every

100,000 children age 4 and under (McClain et al, 1993; McClain, 1995).

However, due to misclassification of child deaths, McClain believes that a

second conservative estimate can be as high as 11.6 per 100,000 children

age 4 and under (McClain, 1995). In comparison, the overall U.S. murder

rate is 10 per 100,000 (Mackeller & Yanagishita, 1995).

Even these unacceptably high death rates may be underestimated.

In its extensive 1993 review of the lagging efforts to understand child

abuse and neglect, the National Research Council (NRC) of the National

Academy of Sciences noted that recent research suggests 85 percent of

child abuse and neglect deaths have been systematically misidentificd

(NRC, 1993; McClain et al, 1993; Ewigman et al, 1993). Of the cases

studied, 38 percent were listed as accidents, 15 percent were listed as

"homicides" with no indication that a parent or caretaker was the

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

perpetrator, 15 percent were listed as Sudden Infant Death Syndrome

(SIDS), 9 percent were listed as natural and 7 percent were listed as

undetermined intentionality (NRC, 1993). This misidentification is due to

poor medical diagnoses, incomplete police and child protection

investigations, inaccurate or incomplete crime reports and flaws in the way

the cause of death is recorded on death certificates (McClain et al, 1993;

Ewigman et al, 1993).

As a result of these systemic problems, as well as the paucity of

funding and lack of leadership to correct them, agencies that collect and

monitor information on child abuse and neglect do not know how, why, or

which children are dying. In 1993, the National Committee to Prevent

Child Abuse (NCPCA) reported 1,299 known deaths by abuse and neglect

(McCurdy & Daro, 1994). In 1992, the National Child Abuse and Neglect

Data System (NCANDS), operated by the National Center on Child Abuse

and Neglect (NCCAN), reported 1,068 deaths in 42 States (NCCAN,

1994). Yet the Federal Bureau of Investigation's (FBI) Uniform Crime

Report (UCR) for 1992 listed only 788 murder victims under age 9 (1994).

It appears the most realistic estimate of annual child deaths from

abuse and neglect, known and unknown, is about 2,000, or some 5

children every day. However, some experts believe the deaths may

number 5,000 annually (Ryan Rainey, National Center for the Prosecution

of Child Abuse, 1994 testimony).

What accounts for this broad-based ignorance of the extent of child

maltreatment-related fatalities, an issue that should be of paramount

interest to a country that deeply values its children? It is caused in part by

incomplete data collection, inconsistent handling and tracking of cases,

and little accountability among the law enforcement, medical, and child

protection agencies responsible for investigating child deaths. It is equally

related to unresolved differences in terminology used to describe ie

"De: meting on your role

child protective services, law

enforcement, or medicine

your view of child abuse

fatalities is quite different.

We have to combine these

views to get the full

picture."Jane Burnley,

ABCAN Board member, New

York workshop, June 16,

1994

9

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

...understanding these

fatalities is critical to

developing a sound

preventive response.

10

manner and cause of death; outmoded investigation and reporting practices

by coroners, medical examiners, hospitals, and health agencies; and,

finally, by the failure of any powerfiil leader or group to take on this crisis.

Public concern over this crisis is growing, in large part due to

intense media coverage. Documentaries such as Who Killed Adam Mann?

and media reports such as Gannett News Service's 1990 Pulitzer Prizewinning expose Getting Away With Murder and the Chicago Tribune's

1994 Pulitzer finalist Killing Our Children, do much to awaken the public

to the horror of child deaths from maltreatment.

The American Professional Society on the Abuse of Children

(APSAC), NCPCA, NCCAN, and Child Death Review Teams in 45 States

are compiling and analyzing information on child fatalities. Their efforts

to understand how many children die from abuse or neglect, and the

manner and exact cause of death, are not simply about counting bodies.

This Board agrees with extensive testimony presented to it in 1993 and

1994 from experts in dozens of disciplines, who made it clear that

understanding the scope and nature of these fatalities is critical to

developing a sound preventive response. Until we do understand, efforts

to battle this threat to children will continue to rely on isolated decision

making and fragile assumptions.

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

WHAT DO THE DATA TELL US?

Until recently, we were largely uninformed about the nature of child

abuse and neglect deaths. The sometimes simplistic explanation inherent

in the "Battered Child Syndrome" has gradually been replaced by a more

sophisticated understanding gained through basic research and analysis of

slowly improving data. We have learned a great deal about the differences

between abuse and neglect fatalities, about who is most likely to be

responsible for such deaths, what causes are indicative of maltreatmentrelated fatalities, which children are most likely to be the victims, and

what happens to the survivors of near fatal maltreatment.

What Differentiates Abuse from Neglect Fatalities?

The data have demonstrated that abuse and neglect fatalities are

two distinct maltreatment categories, requiring dramatically different

prevention and treatment strategies. But neither category is yet fully

understood. We have only recently begun an attempt to distinguish, for

example, between "supervision neglect" deaths that involve critical

moments in which the parent or caretaker is absent and the child is killed

by a suddenly arising danger, and "chronic neglect" deaths caused by

slowly building problems (Zuravin, 1991; Colorado Child Fatality Review

Committee, 1993; Ewigman et al, 1993). With regard to the former, better

public education and parenting training can serve to awaken parents and

caretakers to the hidden, subtle dangers an unsupervised child faces.

On the other hand, ways to prevent the negative outcomes of

chronic neglect, whether intentional or unintentional, are less well

understood. Some experts believe that one promising method is to have "a

second set of eyes" in the home, provided by programs such as voluntary

home visiting by professionals or paraprofessionals or intensive, long-term

U. S. Advisory Board on Child Abuse And Neglect

3
Chapter One

...some attacks begin

with battering a

spouse, then escalate

to include di,.

children.

12

monitoring of high-need families and their children by service agencies.

This has inspired such efforts as Healthy Families America, a project of

the NCPCA. This program holds promise, but will require several years to

show verifiable results.

Many experts testified before this Board that child physical abuse

deaths are the most difficult to reduce since they are the most baffling.

But some answers are being provided by new research and analysis of data

emerging from Child Death Review Teams. Teams in States such as

Colorado and Oregon have identified specific "triggers" that occur just

before many fatal parental assaults on infants and young children. These

include a baby's inconsolable crying, feeding difficulties, a toddler's failed

toilet training, and highly exaggerated parental perceptions of acts of

"disobedience."

In addition, some rage-based assaults are set off by stimuli other

than the child. In the 1994 case of 5-month-old Roosevelt Bell in

Chicago, the trigger was the outcome of a televised ball game.

Roosevelt's father became so furious when his team lost that he beat the

child to death (Martin, 1994). Domestic violence is another factor in

abuse deaths. Preliminary research and early data suggest that some child

abuse begins with the battering of a spouse, then escalates to include the

children. The American Bar Association (ABA) reported that "children in

homes plagued by domestic violence may themselves be abused within

those homes at a rate much higher than the national average for child

abuse ... overiap between households with both domestic violence and

child abuse range from 40 to 60 percent" (1994, p. 18).

Identifying and understanding these patterns is critical to designing

strategies to reduce such attacks. While specific "trigger" events are being

identified, their causes and means of prevention have received very little

attention, in part due to the scarcity of Federal and private funds devoted

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

to physical abuse and neglect-related fatalities. We still do not know why

some parents and caretakers respond with extreme violence to natural

events in a child's life while other parents, suffering the same stresses,

accept routine child-rearing challenges without resorting to violence

(Levine et al, 1994; Levine et al, 1995).

Who Is Committing These Acts?

What sort of parent would attack or severely neglect a child in a

manner that leads to death? In recent years we have learned that the

average abusive parent is in his or her mid-20's, lives near or below the

poverty level, often has not finished high school, is depressed and unable

to cope with stress, and has experienced violence first hand. However, no

single profile fits every case, and there are many exceptions to the

"average."

One of the most interesting new findings that demonstrates the

critical importance of better information is that most physical abuse

fatalities are caused by enraged or extremely stressed fathers and other

male caretakers (Levine et al, 1994; Levine et al, 1995). These men

primarily assault infants and very small children by beating their heads

and bodies, shaking them violently, intentionally suffocating them,

immersing them in scalding water, and performing other brutal acts.

Such findings have turned a common assumption upside-down:

that mothers are the culprit in most abuse and neglect deaths. In fact, the

adult most dangerous to an infant or small child is maleincluding birth

fathers, stepfathers, and boyfriends. Studies show that mothers are most

often held responsible for child neglect deaths from causes such as bathtub

drowning, fires started by unsupervised children, dehydration, and

starvation (Margolin, 1990). However, the supposition that the female is

generally responsible can lead to unfair assignment of blame when a

...most physical abuse

fatalities are caused by

enraged or extremely

stressed fathers or

other male caretakers.

13

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

14

mother is held accountable for a neglect death even when the father was

the parent in charge of the child. Clearly, these findings demonstrate a

serious need for rethinking the design of prevention and treatment

strategies that now focus primarily on females.

Another long-held belief contradicted by recent data is that fatal

abuse and neglect are largely perpetrated by teenage or young single

parents living alone. In fact, six studies undertaken since 1988 agree that

the typical perpetrator is in his or her midtwenties, although many of them

first became parents while teenagers. Moreover, most perpetrators are not

raising their children alone. Bonner was surprised when her own study

revealed that 60 percent of the children were killed while living with both

biological parents (verbal testimony, 1994). Alfaro (1988) suggests that

the majority of deaths occur in two-adult families where a male is present.

Ewigman's 1993 Missouri study showed that married couples represented

half of the perpetrators of abuse and neglect deaths.

Researchers have not identified a consistent set or cluster of

personality traits that characterize extremely abusive and neglectful

parents. Professionals who deal with such families report that many

parents involved in fatal abuse and neglect are substance abusers with

histories of child or spousal abuse or other violence. But little reliable

data exist in this area and the scientific literature is lacking, (NRC, 1993)

possibly indicating how little attempt is made by authorities to record

evidence of substance abuse or other problems during child abuse and

neglect investigations.

It has been long assumed that many parents involved in fatal abuse

and neglect are affected by combinations of behavioral, emotional, and

cognitive difficulties. Consistent with several decades of research, a

recent study found that diagnosed mental illness is a factor in only a small

percentage of child maltreatment cases (DePanfilis & Salus, 1992). While

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

the extent to which intent figures into child fatalities is not known, two

recent studies reveal that many fatal injuries must result from very violent

attacks, suggesting that many parents are conscious of the damage they are

inflicting (Kantor & Williams, 1993). Dr. Randell Alexander (1993)

argues that while death caused by child abuse is often a matter of chance,

the extreme force needed to inflict such damage on a child should have

deterred any reasonable parent from such behavior.

What Are the Causes of Death?

Whatever the stimuli that lead to parents and caretakers killing

children, fatal injuries from maltreatment follow a startling pattern of

similarity. A study of child deaths in Oklahoma revealed that 29 percent

of the children who die from abuse or neglect succumb to severe head

traumaa figure that has been replicated in studies by Colorado, Oregon,

Los Angeles County, and other Child Death Review teams (Bonner &

Thigpen, 1993). Similarly Shaken Baby Syndrome, an act so lethal that

20 to 25 percent of its victims die and that most survivors suffer brain

damage resulting in lifelong cerebral palsy, visual detects, or cognitive

impairment (Levitt et al, 1994), repeatedly appears as the cause of about

10-12 percent of all abuse and neglect deaths (Bonner & Thigpen, 1993;

Colorado Fatality Review Committee, 1993). In a 34-State study of 216

fatal cases of Shaken Baby Syndrome, most perpetrators were men who

became furious over a baby's crying (Showers, 1994). This is consistent

with other evidence pointing to males acting out their frustration and rage

by assaulting a child.

Assaults upon a child's abdomen, thorax, or both, while less

common than head battering or severe shaking, leave such extensive

internal damage that victims suffer a 40 to 50 percent fatality rate

(Cooper et al, 1988; Sivit et al, 1989). Although less frequent, small

Shaken Baby

syndrome is so lethal

that 20 to 25 percent

of its victims die, and

most survivors suffer

brain damage.

15

U. S. Advisory Board on Child Abuse And Neglect

6 3
Chapter One

16

children also die from intentional or preventable scalding, suffocation,

drowning, and poisoning. These deaths may be related either to abuse or

neglect.

Which Children Are Likely to Die?

Understanding which children die allows us to focus prevention

and treatment where it will do the greatest good. Several new studies

found that only 10 percent of child abuse fatality victims were older than

age 4; most victims were under the age of 2 and 41 percent were under the

age of 1 (McClain et al, 1993; Levine et al, 1994; Levine et al, 1995).

Recent research also indicates that very young girls and boys are at equal

risk of dying of the effects of maltreatment. Parents of very young

children and infants, a group that has not received adequate attention in

research, prevention, and treatment efforts or in legislation designed to

address abuse and neglect, are clearly emerging as the critical population

on which to focus.

Much remains unknown, however. For example, some earlier

studies found that many of the youngest children who die from beatings

had no previous signs of battering, suggesting that the attack upon them

was the first incident (Abel, 1986). This implies that prevention of such

deaths is highly problematic. Nonethe'.;s:), more recent studies

demonstrate that many infants suffer numerous beatings before dying,

indicating that they may have been seen by an official, family member, or

neighbor who might have intervened to save them (Alexander et al, 1990).

What Happens to the Survivors?

One of the most alarming outcomes of life-threatening abuse and

neglect by parents is the legacy of damaged and disabled children alive

today who survived medical emergencies that would have killed other

U. S. Advisory Board on Child Abuse And Neglect

64
Chapter One

children. We are only now getting an early picture about the human costs

of near-fatal abuse and neglect. NCCAN (1991) indicates that 141,700

children have suffered serious injury as a result of child abuse and neglect.

Nora J. Baladerian, after extensive review of the literature on

disabilities caused by abuse, testified before this Board that the large

population of children seriously injured and permanently disabled by

abuse and neglect are "the survivors of the cadre of child abuse fatality

near-misses," a view supported by Dr. Richard Gelles (verbal testimony,

1994). If one agrees with this view, luck plays a major role in determining

which children live and which die.

Baladerian (1991) estimates that at least 18,000 children per

year are permanently disabled by abuse or neglect, suffer mental

retardation or sensory and motor impairments, and often require lifelong

services at great cost. She suggests that at least ten times as many

children survive severe abuse as die from it, and that a staggering 9.5 to

28 percent of all disabled persons in the United States may have been

made so by child abuse and neglect (1991, p. 14).

However, there are no rigorous scientific findings on such

disabilities (NRC, 1993). It is unknown, for example, how many of the

90,000 Americans left with brain damage from head injuries each year

were made so by severe child abuse or neglect (Guzman, personal

communication, 1995). Of children with head injuries known to be caused

by abusive caretakers, however, it is known that many are left with

lifelong cerebral palsy (Diamond & Jaudes, 1983).

Beyond the terrible human costs, Baladerian estimates that society

spends an average of $20,000 per year for services throughout the life of

each child with an acquired disability (Baladerian, written testimony,

1993). Clearly the millions now being spent to care for victims would be

far better and more humanely spent developing services and strategies to

...an estimated 18,000

children per year are

permanently disabled

by abuse or neglect.

17

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

18

prevent and reduce injuries. More extensive data and research on severe

injuries and disabilities caused by abuse and neglect would help address

this situation.

CURRENT ISSUES: OFFICIAL UNDERREPORTING,

DEFINITIONS THAT OBSCURE ABUSE-RELATED CAUSES,

AND POOR CASE-LEVEL DATA

New findings strongly suggest that policies, programs, and funding

can be tailored to avoid efforts that target the wrong problems or

populations and instead focus on those who need it most. But far more

information is needed to mount an effective response. To acquire such

information, a cohesive system to identify and investigate child abuse and

neglect deaths, as well as to collect and interpret the resulting data, must

be established.

Establishing a cohesive system is complicated by the fact that no

identifiable entity is responsible for addressing child fatalities by abuse

and neglect. For these children there is no equivalent of the March of

Dimes or Mothers Against Drunk Driving. Attempts to understand the

scope and nature of the problem still focus primarily on the most obvious

deathsthose already identified as fatal abuse or neglect cases by law

enforcement, child protection workers, or health authorities. Yet each of

these three groups knows and tracks only one part of the child fatality

picture. Since no one agency or source is sufficient to address this issue, a

new, more comprehensive source must be developed.

Official Underreporting

Underreporting is a major obstacle to understanding fatal abuse

U. S. Advisory Board on Child Abucc And Neglect
Chapter One

and neglect. In Missouri, an exhaustive review of all child deaths by

researchers and Child Death Review Teams, combined with broad

government-led efforts to correct underreporting, has produced startling

results in the past 2 years. The State has seen a doubling in child

homicides recognized and coded on death certificates, a doubling in child

abuse and neglect fatalities identified as such by the Division of Family

Services, and a tripling in prosecutions of perpetrators (Ewigman, verbal

testimony, 1994).

Missouri found underreporting at many levels. In 121 cases of

verified fatal maltreatment among children age 4 and under, only 47.9

percent were given the necessary ICD-9 (International Classification of

Diseases) code on the death certificate by a coroner, indicating abuse or

neglect. The Division of Family Services substantiated only 79.3 percent

of the cases as abuse or neglect fatalities, and the FBI's UCR recognized

only 38.8 percent as homicides (Ewigman et al, 1993).

Child abuse and neglect fatalities are drastically underreported

because of inadequate investigations, lack of information sharing between

investigators and agencies, and outdated reporting systems that fail to

capture maltreatment as the official cause of death. Moreover, each

national source of information on child abuse and neglect deaths is

renderM incomplete by its own design. We describe these sources and

their problems below.

The Annual Survey by the National Committee to Prevent Child

Abuse

The NCPCA, a nonprofit organization, deserves tremendous credit

as the pioneer that first released annual national figures on child abuse and

neglect fatalities in 1986. The NCPCA's data are the most frequently

quoted by the media and policymakers. The survey is conducted at

Child abuse and

neglect fatalities

are drastically

underreported.

19

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

"During our survey. I talked

to a person in a State that's

pretty good at data

collection, and he said 1

could call on a different day

of-the week and ask him how

mum, child abuse and

neglect deaths there were,

and it would be a different

number. There are major

problems." Karen

McCurdy, Principal Analyst,

NCPCA, New York Focus

group, 1994

20

NCPCA expense and gathers data via a 50-state telephone and written

survey usually answered by each State's NCCAN liaison. Although in

recent years the method of collecting information has become more

rigorous, the data analysis is still a voluntary, private effort that doesnot

give the full picture.

In 1993, with 37 States responding, the NCPCA reported 786

deaths known to child protective service (CPS) agencies and confirmed as

due to abuse or neglect. The NCPCA estimates that all 50 States are

actually aware of about 1,300 children who have died from abuse or

neglect (McCurdy & Daro, 1994). It also estimates that about 40 percent

of deaths are due to neglect, 55 percent to physical abuse, and 5 percent to

both. The effort by the NCPCA is extremely important because it

represents the most extensive, long-term attempt to gather aggregate

information on child abuse and neglect fatalities.

The Federal Bureau of Investigation's Uniform Crime Repod

Another currently problematic source of data is the UCR, which is

compiled by the FBI using information from State law enforcement

agencies. Although the FBI receives data on child homicides by age,

gender, and victim relationship to perpetrator, its published reports do not

link these elements, to distinguish child homicides by caretakers. In

addition, certain key data, such as whether the perpetrator was a boyfriend

of the mother, are not included.

Nationwide implementation of the new National Incident-Based

Reporting System (NIBRS) will permit an analysis of case specific data

(e.g., linking the victim's age and relationship to the perpetrator). Even

after NIBRS is more widely used, howl.wer, the UCR may still not contain

enough information to assess abuse and neglect fatalities completely,

because States have different definitions of child homicide and many

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

fatalities are not identified as child abuse homicides. This is likely to

distort which cases are reported to UCR. Moreover, some jurisdictions

provide information to the FBI only when an arrest is made. Since arrests

are often not made in child maltreatment cases, data from such cases may

not be included.

The National Center for Health Statistics, Vital Statistics

A RECENT CASE:

The widely publicized Waneta E. Hoyt case in Newark Valley,

N.Y., involved the loss of five babies in one family to Sudden Infant

Death Syndrome. At the time of the deaths from 1964 to 1971, the Hoyts

received much sympathy from the public and medical experts.

Researchers published a seminal article theorizing that the five cases were

inherited SIDS, which led to a recommendation of apnea monitors for

some families. In 1992, however, a district attorney who had long been

bothered by the case reopened the investigation. The District Attorney

(D.A.) and state detectives gathered enough autopsy slides and notes from

the original investigation to charge Mrs. Hoyt with smothering her

children. The five deaths are still listed by Vital Statistics as SIDS. and

there is little chance the death certificates will be corrected. Medical

experts say the chances of three SIDS in one family are nearly one in a

billion, the chances of five are virtually impossible. New York Times,

March 25 & 28, 1994, and Dr. Michael Baden, New York State Police

Medical Examiner's Office, New York Workshop, 1994.

Vital statistics are collected by states from death certificates and

then compiled and distributed by the National Center for Health Statistics.

Death certificates are completed by coroners, medical examiners, or

physicians who had been attending the deceased patient. Coroners and

medical examiners are expected to note the cause of death (e.g., head

trauma, pneumonia) and the manner of death (e.g., homicide, suicide,

accident, natural, or undetermined). They may also include brief

21

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

"Death certificates should

include a check-off box to

indicate child abuse and

neglect as a cause of death.

Harry Wilson, M.D.

Denver Focus Group, 1993

Misdiagnosis is

common in many

States. Determination

of the cause of a

child's death is made

by coroners, who

o,:ten have little or no

medical training.

22

narratives for clarification. If the investigation and autopsy lead to a

finding of child abuse or neglect, the cause, manner, and narrative on the

death certificate should reflect that finding. Unfortunately, misdiagnosis

and failure to correctly identify contributing causes in such deaths is still

widespread. In addition, few coroners or medical examiners who do

recognize a case as neglect or abuse actually fill out the forms with the

level of detail required to indicate that abuse or neglect occurred

(Kochanek, verbal testimony, 1994). Fewer still actually report the case to

local authorities. In addition, while attending physicians are supposed to

defer their decisions on cause of death to a medical examiner when the

cause is not obvious, many do not (See Appendix E for a sample death

certificate).

Medical misdiagnosis is common, because in many States,

determination of the causes of a child's death is made by a coroner with

little or no medical training. Even highly trained medical examiners may

not recognize the often subtle medical signs of child abuse and neglect

(See Chapter Two). Moreover, there is still widespread reluctance among

coroners and medical examiners to implicate a child's parents or involve

themselves in criminal cases.

In addition, coroners and medical examiners are under constant

pressure to complete a death certificate quickly so that a child can be

buried or cremated, often long before a police investigation is complete.

As the Hoyt case illustrates, even if criminal investigators, CPS workers,

Child Death Review Teams, o. prosecutors later determine that a child was

killed by abuse or neglect, coroners and medical examiners mlly ;lot take

the time to submit the information necessary to amend the original death

certificate.

U. S. Advisory Board on Child Abuse And Neglect

7
Chapter One

"FROM THE TRENCHES":

In 1992, over 3,700 children under the age of 15 died in Texas.

Approximately two-thirds of those died within the first year of life, of

which 40 percent died within the first month. Death certificates only

identified about 10 of these as a result of abuse and neglect, yet CPS had

about 100 mortality cases in their files alone. Neither number is correct.

Richard Bays, State Registrar, Texas Department of Health, Dallas

Public hearing, 1994.

Unclear Definitions and Poor Case-Level Data

Beyond the tremendous problems created by official

underreporting, two key problems complicate the gathering of good data

from official sources: the lack of definitions for what constitutes an abuse

or neglect fatality and disagreement over data elements authorities should

gather about the circumstances surrounding a child's death.

A major problem in identifying child abuse and neglect fatalities

arises from the International Classification of Diseases system overseen by

the World Health Organization. The CDC cannot fully assess the cause in

child abuse and neglect deaths in part because the international code

known as ICD-9, used to classify cause of death on death certificates, is

"not up to par when it comes to certain causes, especially child-abuse or

child maltreatment deaths" according to Phillip McClain of the CDC

(verbal testimony, 1994).

The code's special category thr specifying child abuse deaths is

based upon an outmoded approach that narrowly focuses on the Battered

Child Syndrome. The category is restricted to fatalities in which other

abuse occurred befiffe the events that caused the child's death (Kochanek,

verbal testimony, 1994). Thus, if a 4-year-old dies of starvation due to

withholding of food, but no previous incidents of abuse are detected, the

death is generally listed as "natural" or "undetermined." Coroners and

U. S. Advisory Board on Child Abuse And Neglect

"In many instances it's

still called a natural death

with no mention of child

abuse or neglect if a child

died of pneumonia and is

covered with injuries

including genital trauma."

Dr. Michael Durfee,

founder of the California

and L.A. County Child

Death Review Team

systems, New York Focus

group, 1994

7 1

23
Chapter One

"Until we get some case-level

data, which I know we're just

starting to do, we're not going

to he able to identifi, any

relationships which are going

to suggest ways to prevent

fatalities."Karen McCurdy,

Principal Analyst, NCPCA,

New York Focus group, 1994

24

medical examiners can even choose "cardiopulmonary arrest," which

simply means the child's heart stopped beating and the lungs failed. This

is not a cause, but a definition of death.

Insufficient Data Collection on Individual Cases

As long as one agency collects data on a dead child's age, but

nothing about family income, and another collects data on past incidents

of family abuse, but nothing about whether the parents were substance

abusers, we will gain little insight into the complex matrix of social

problems of which these tragedies are usually a part. Only about 25 States

report to NCPCA the ages of children who die from abuse or neglecta

key issue in creating prevention programs. Other important details simply

are not given (McCurdy, verbal testimony, 1994).

With a detailed description, critical questions could be answered

and factors could be pinpointed that characterize certain types or clusters

of death. Once identified, these factors may suggest ways to launch better

public education campaigns and design more effective public policy.

Highly Inadequate Research Efforts

This Board heard from dozens of experts nationwide who

disagreed in many areas but shared one profound frustration: the failure of

the Federal Government, States and private foundations to provide the

level of research monies that are justified by the 2,000 deaths and 141,700

serious injuties each year caused by child maltreatment (NCCAN, 1991).

This is compounded by the failure of scientiftc organizations and

universities to initiate research on serious and fatal child abuse and

neglect.

Given the small amount of research funds available, it is all the

more unfortunate that many studies are conducted by groups with little

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

experience that may fail to use scientific methods, control groups,

sufficient samples or other minimum requirements for producing

meaningful information (NRC, 1993).

Indeed, the disparate information gathered thus far provides no

answers to the most pressing question: Why do parents kill their children

or become so neglectful that their children die? Investigators disagree on

whether abuse and neglect represents a continuum of behaviors ranging

from mild physical discipline to severe abuse and neglect, or a set of

unique behavioral problems with distinctive etiologies (Gel les, 1991).

Since no single risk factor has been identified, the focus is upon multiple

tisk factors that may overtake the protective behaviors parents normally

demonstrate.

One mystifying issue is the large overrepresentation of African

American families in known child abuse and neglect fatalities, which is

twice or three times the rate seen in other racial groups. The data show a

dramatic overrepresentation of African Americans in fatal abuse and

neglect deaths, but there has been almost no study to understand this issue.

Yet the numbers should deeply concern policymakers and the public: one

study showed the homicide rate of African American infants studied over

a 10-year period to be 25 per 100,000. This approaches the rate of violent

death for African Americans (39 per 100,000), which, in contrast, is a

widely discussed area of concern (Levine et al, 1994; Levine et a), 1995).

Many researchers believe that discussions of race obscure the true

contributing factorpoverty, which affects roughly one in two American

Indians and one in three African American and Hispanic families, but only

one in nine white or Asian families (American Almanac Statistical

Abstract of the United States, 1994). However, while poverty afflicts

nearly one in three Hispanics families, they do not appear to be

overrepresented in fatal child abuse and neglect (Robinson & Stevens,

25

U. S. Advisory Board on Child Abuse And Neglect

7 3
Chapter One

1992).

Others have suggested to this Board that the problem is not

poverty, but psychological stress caused by dealing with limited

opportunities and the effects of racism. These important questions remain

unanswered.

STRATEGIES FOR IMPROVEMENT

Seeking Common Definitions and Data Elements

Common definitions and data elements are critical to making

Common definitions meaningful comparisons of the cause and manner of child deaths, and to

and data elements are developing prevention strategies. Uniform data-reporting protocols are critical

necessary since any single jurisdiction will have only a small number of

cases for statistical analysis. Large numbers of cases are desiraole for

study. But data cannot be combined unless collected in a reasonably

uniform manner in all jurisdictions. Greater uniformity will require

extensive literature review, research, and consensus-building that involve

State and local agency representatives, researchers, and data collection and

analysis experts.

26

Use of Estimation Models by the Centers for Disease Control and

Prevemigll

The CDC has developed promising estimation models that should

be given high priority. McClain et al (1993) have attempted to analyze

existing data sets to estimate prevalence rates and patterns of fatal abuse

and neglect. In the long term, estimation should be replaced by accurate

counts of actual cases. This Board is particularly interested in analyses of

rates of death, since the figure for total child abuse and neglect deaths will

undoubtedly grow as the Nation's population grows, while increases or

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

decreases in the rate will give a true picture of the effectiveness of

intervention and prevention strategies.

Sending a Clear Public Message

A lack of communication and cohesion exists within the loosely

connected groups that generate and collect data on childhood deaths from

abuse and neglect. Further study of various data from CPS agencies, State

agencies that gather vital statistics, and the FBI's UCR could be

encouraged and overseen by the CDC. In addition, regular communication

should be instituted among these three entities in order to avoid sending

confusing and sometimes contradictory messages about the scope and

nature of fatal child abuse and neglect to the public , policymakers, and

practitioners.

For example, in 1994 the Department of Justice (DOJ) released a

report Murder in Families, which identified mothers as the most frequent

killers of children (Dawson & Langan, 1994). The DOJ data appear to

reflect who is prosecuted and convicted. However, this information was

misconstrued by television networks and major newspapers, and was cited

as proof of a looming "mother" problem. As we have made clear, it has

been shown by several new studies that go beyond prosecution and

conviction figures that fathers and other male caretakers account for

significantly more abuse and neglect deaths than mothers or other female

caretakers. Yet this information is not reaching those who should hear it.

This Board believes such critical communication problems can be

addressed through an annual release of data that provides the media and

public with a single, consolidated source of information.

"In Missouri, rather than

having motor vehicle

injuries as the leading cause

of trauma death (for infant

and small children), our

studies show that

maltreatment was the

leading cause of death. That

really created deep concern

among the state's

legislators: leading cause of

death." Ying Ying 7'.

Yuan, New York Focus

group, 1994

27

U. S. Advisory Board on Child Abuse And Neglect

f I)
Chapter One

"What you'll find is that

80 percent of these

fatalities occur in 10

percent of the census tracts

in any given community. If

you're going to research

the child fatalities in these

census tracts, you've also

got to map the other

violence and homicide in

that community.

Otherwise, you're not

going to get the picture."

Richard Gelles, Family

Violence Research

Program, The University of

Rhode Island, New York

Focus group, 1994

...it is time for

Congress, States,

private foundations,

and universities to

dramatically increase

research in this poorly

studied field.

28

A New Effort by the National Child Abuse and Neglect Data System

One hopeful development is the NCANDS, a project of the

NCCAN, to collect case-level information on child abuse and neglect

cases. The information will come from data gathered by CPS agencies

and Child Death Review Teams and complied by statewide child abuse

indices. So far, 20 States have agreed to participate annually (Ying-Ying

T. Yuan, verbal testimony, 1994).

The NCANDS technical assistance contractor team is actively

working to help all 50 States build their technical capacity to provide child

fatality data and is working with them to agree upon definitions of the

phenomena. Moreover, the NCANDS team is also helping States correct

data from previous years.

Greatly Expanded Research Efforts

We believe it is time for Congress, States, private foundations, and

universities to dramatically increase research in this poorly studied field.

The Board recommends several critical areas where research is needed in

Recommendation 2.

In 1993, the NRC called for States to pool their research efforts on

complex topics, such as the efficacy of abuse and neglect intervention

programs, in order to create better-funded, larger, and more rigorous

evaluation groups in an era of restricted budgets (NRC, 1993). In

addition, the NRC called for a doubling in research budgets by the end of

1996 within NCCAN, the National Institutes of Mental Health (NIMH),

the National Institute of Child Health and Human Development

(NICCHD), CDC, and DOJ. This would increase to $30 million the

estimated $15 million now earmarked for study primarily relevant to child

abuse and neglect (NRC, 1993). We wholeheartedly concur with the need

for this federal expenditure.

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

The Emergence of Child Death Review Teams

A growing number of States and communities offer a way to

integrate data collection and discover patterns and causes of child abuse

and neglect deaths through the efforts of Child Death Review Teams,

which are described in detail in Chapter Three. The teams involve

health, social service, and criminal justice professionals in a

multiagency, confidential forum. They review the various systems'

involvement with children and their families before and after a child's

death. Teams often identify abuse and neglect fatalities that were

missed by individual agencies. These teams appear to offer the best

hope for an accurate count of fatalities and detailed information on the

circumstances surrounding such deaths.

We are a long way, however, from relying upon Child Death

Review Teams to gather the information needed to create a comprehensive

national child death data system, or to promote meaningful laws and

programs that would arise from such a system. Although most States have

a statewide review team and many urban and rural centers have a local

review team, the majority of communities still do not. Thus, it may be

some years before the teams serve as a national source of information on

the true nature and scope of abuse and neglect deaths.

"We spend so much money

researching and analyzing the

cause and prevention of

airplane deaths, yet the

number of airplane victims is

a fraction of the number of

child homicides."Paul

DerOhannesian, Albany

Assistant Prosecutor, Oregon

public hearing, 1994

29

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

30

CHAPTER ONE RECOMMENDATIONS

Significantly reducing fatal child abuse and neglect, and the

attendant social and economic costs of severe abuse and neglect among

survivors, requires the highest level of attention, a far more sophisticated

understanding of the problem, and a much greater commitment of

resources. For this reason, ABCAN recommends:

Recommendation 1: Our Nation must establish a national

commitment at the highest levels to understand the scope and nature

of fatal child abuse and neglect.

We urge the U.S. Attorney General and the Secretary of the

Department of Health and Human Services (DHHS) to devote existing

resources and expertise to address the lack of knowledge regarding the true

nature and extent of child abuse and neglect fatalities in America.

To accomplish this, the CDC, NCCAN, DOJ, State and local

agencies, and Child Death Review teams must work across many

disciplines to identify these deaths more effectively when they occur. An

existing mechanism for interagency collaboration, the Interagency Task

Force on Child Abuse and Neglect, should be utilized to further these

efforts. Such efforts should include:

Development of a uniform definition of child abuse and neglect

fatalities.

Uniform completion of death certificates to accurately record child

abuse and neglect fatalities.

Establishment of uniform data elements for collection and analysis

(e.g., age, gender, previous abuse or neglect reports, substance

abuse, domestic violence, relationship of victim to suspect).

DHHS and DOJ should provide leadership in developing common

data sets to be collected by investigators and Child Death Review

Teams.

Linking of data generated by different agencies, including child

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

welfare agencies, criminal justice agencies and public health.

States should integrate information from multiple sources in annual

reports on the nature and extent of child abuse and neglect deaths.

Collaboration and analysis of national data spearheaded by Federal

agencies and national associations. DHHS and DOJ could create

or contract for a special component to collect child abuse and

neglect fatality data from States operating wit.11, well-established

Child Death Review Teams.

Recommendation 2: Federal and State agencies must significantly

increase research efforts on serious and fatal child abuse and neglect.

We concur with the NRC's call in 1993 for a doubling from $15

million to $30 million, in Federal research on child abuse and neglect by

DHHS (NCCAN, NIMH, NICCHD, CDC), and DOJ. We urge that a

significant portion of the increase go to issues involving severe and fatal

abuse and neglect. We also urge States to devote more research funds to

this crucial issue.

We recommend emphasis in the following areas:

Research into the role of socioeconomic correlates, such as poverty

and race, in serious and fatal child abuse and neglect.

Research into the role of behavioral correlates, such as substance abuse

and domestic violence, in serious and fatal abuse and neglect.

Research into the effectiveness of current services in preventing

fatality and serious injury and the effects of offering no services at all.

Such research should also examine which kinds of parents are

amenable to services and treatment.

Research into "trigger-reaction" behavior and its causes, including

why some parents or caretakers respond violently t3 stressful behavior

and others do not.

Research into the overrepresentation of African Americans as victims

and as perpetrators of child abuse and neglect fatalities.

Research into the discrepancies that may exist in services and

interventions offered to different economic classes, ethnic, and racial

31

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

32

groups, and whether this affects child safety.

Research into the current effectiveness of, and ways to improve, Child

Death Review Teams in identifying abuse and neglect deaths,

promoting system improvements, and creating meaningful prevention

strategies.

Research into the designing of better "risk assessment" tools th:ut help

professionals decide which families are at risk of serious abuse, and

what intervention is required.

Basic research into the medical aspects of serious and fatal abuse and

neglect, including the role of abuse and neglect in causing permanent

disabilities.

Comparative study of the effectiveness of existing interventions, such

as family preservation and family support programs, foster care, family

maintenance services, and termination of parental rights in reducing

serious and fatal abuse and neglect.

Comparative study of multiple factors in families of children

hospitalized for fatal and near-fatal injuries from accidental and

intentional causes. Such research will help to determine incidence, and

risk factors, and effectiveness of multiagency interventions assessing

fatal and near-fatal injuries will increase the base rate for comparison.

U. S. Advisory Board on Child Abuse And Neglect

SO
Chapter One

CHAPTER ONE REFERENCES

Abel, E. (1986). Childhood homicides in Erie County. Pediatrics,

77, 709-713.

Alexander, R., Crabbe, L., Sato, Y., Smith, W., & Bennet, T.

(1990). Serial abuse in children who are shaken. American Journal of

Diseases of Children, 144, 58-60.

Alexander, R. (1993, June 25). Written testimony. Public Hearing

on Child Maltreatment Related Fatalities. Chicago, Illinois: Sponsored by

U.S. Advisory Board on Child Abuse and Neglect.

Alfaro, J. (1988). What can we learn from child abuse fatalities? In

D. Besharov (Ed.), Protecting Children from Abuse and Neglect. Policy

and Practice. Springfield, Illinois: Charles C. Thomas.

The American Almanac Statistical Abstract of the United States

(1994). Austin, Texas: The Reference Press.

American Bar Association. (1994). The Impact of Domestic

Violence on Children [A Report to the President of the American Bar

Association]. Washington, DC: American Bar Association.

Baden, M. (1994, June 13-15). Verbal testimony. Focus group on

Child Maltreatment-Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Baladerian, N. J. (1991). Abuse Causes Disabilities. Disability and

the Family. Culver City, California: SPECTRUM Institute.

Baladerian, N. J. (1993, December 2). Written testimony. Hearing

on Child Maltreatment-Related Fatalities. Pittsburgh, Pennsylvania:

Sponsored by the U.S. Advisory Board on Child Abuse and Neglect.

Baladerian, N. J. (1994, July 21-22). Verbal testimony. Los

Angeles, California: Sponsored by the U.S. Advisory Board on Child

Abuse and Neglect.

Bonner, B. (1994, June 13-14). Verbal testimony. Workshops on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

U. S. Advisory Board on Child Abuse And Neglect

S I

33
Chapter One

34

Bonner, B., & Thigpen, S. (1993). Child Abuse and Neglect

Fatalities in Oklahoma: A Seven Year Study 1981-1993. University of

Oklahoma: Center on Child Abuse and Neglect.

Centers for Disease Control. (1971). Summary of Notifiable

Diseases. Atlanta: Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention. (1995, Personal

Communication). Atlanta.

Chicago Tribune. (1994, January). Killing Our Children. Chicago

Tribune Series.

Colorado Child Fatality Review Committee. (1993). Annual

Report. Denver: Colorado Department of Health.

Cooper, A., Floyd, T., Barlow, B., Niemirska, M., Ludwig, S.,

Seidl, T., O'Neill, J., Templeton, J., Ziegler, M., Ross, A., Ghandhi, R., &

Catherman, R. (1988). Major blunt trauma due to child abuse. Journal of

Trauma, '5?, 1483-1487.

Dawson, J., & Langan, P. (1994). Murder in Families. Bureau of

Justice Special Report. Washington, DC: Department of Justice.

DePanfilis, D., & Salus, M. (1992). A Coordinated Response to

Child Abuse and Neglect: A Basic Model. National Center on Child

Abuse and Neglect. Washington, DC: U.S. Department of Health and

Human Services.

Diamond, L. J., & Jaudes, P. K. (1983, April). Child abuse in

cerebral-palsied population. Developmental Medicine and Child

Neurology, pp. 169-174.

Ewigman, B. (1994, June 13-15). Verbal testimony. Workshops on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Ewigman, B., Kivlahan, C., & Land, G. (1993). The Missouri

Child Fatality Study: Underreporting of Maltreatment Fatalities Among

Children Younger Than Five Years of Age, 1983 Through 1986.

Pediatrics, 91, 330-337.

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

Federal Bureau of Investigation. (1992). Uniform Crime Reports

for the United States. Washington, DC: Department ofJustice.

Federal Bureau of Investigation. (1994). Uniform Crime Reports

for the United States. Washington, DC: Department ofJustice.

Gannett News Service. (1990, December). Getting Away With

Murder.

Gel les, R. (1991). Physical violence, child abuse and child

homicide: A continuum of violence or distinct behaviors?Human Nature,

2(1), 59-72.

Gel les, R. (1994, June 13-15). Verbal testimony. Focus Group on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Goldstein, B., & et al. (1993). Inflicted versus accidental head

injury in critically injured children. Critical Care Medicine, 21, 328-332.

Grunson, L. (1994, March 28). A 25-year trail to 5 murder charges,

sudden deaths of her 5 children were slayings, police say. The New York

Times, pp. B1, B2.

Guzman, S. (1995). [Director of Public Affairs] ( Jill Stewart).

National Head Injury Foundation.

Hegar, R. L., Zuravin, S. J., & Orme, J. G. (1994). Factors

predicting severity of physical child abuse injury: A review of the

literature. Journal of Interpersonal Violence, 9, 170-183.

Kantor, G. K., & Williams, L. M. (1993, June 25). Written

testimony. Public Hearings on Child Maltreatment Related Fatalities.

Chicago, Illinois: Sponsored by the U.S. Advisory Board on Child Abuse

and Neglect.

Kochanek, K. (1994, June 14). Verbal testimony. Focus group on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Langer, C. (1991). Who Killed Adam Mann? [Public Broadcasting

Service, Frontline].

35

U. S. Advisory Board on Child Abuse And Neglect
Chapter One

36

Levine, M., Compaan, C., & Freeman, J. (1995, February).

Maltreatment-related fatalities: Issues of policy and prevention. Law &

Policy, 16, pp. 449-471.

Levine, M., Compaan, C., & Freeman, J. (1994, August). The

Prevention of Child Fatalities Associated with Child Maltreatment. State

University of New York at Buffalo.

Levitt, C., Smith, W. L., & Alexander, R. (1994). Abusive Head

Trauma. In Bob Reece (Ed.), Child Abuse: Medical Diagnosis and

Management. Philadelphia, Pennsylvania: Lea and Febiger.

Mackellar, F. L., & Yanagishita, M. (1995, February). Homicide in

the United States: Who is at risk? (Vol. 21). Washington, DC: Population

Reference Bureau.

Margolin, L. (1990, JulyAugust). Fatal Child Neglect. Child

Welfare, pp. 309-319.

Martin, A. (1994, April 15). Dad Held in Tot's Beating Death.

Chicago Tribune, p. 1.

McClain, P. (1995, March 21). [Centers for Disease Control and

Prevention] ( Anne Marie Finn). Atlanta, Georgia.

McClain, P., Sacks, J., & Frohlke, R. (1993). Estimates of Fatal

Child Abuse and Neglect, United States, 1979 Through 1988. Pediatrics,

91, 338-343.

McCurdy, K. (1994, 13-15/June). Verbal testimony. Workshops on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

McCurdy, K., & Daro, D. (1994). Current Trends in Child Abuse

Reporting and Fatalities: The Results of the 1993 Annual Fifty State

Survey. National Center on Child Abuse Prevention Research. Chicago,

Illinois: National Committee for Prevention of Child Abuse.

National Center on Child Abuse and Neglect. (1991). National

Incidence and Prevalence of Child Abuse and Neglect: The 1988 Revised

Report (NIS-2) [Westati. Washington, DC: Department of Health and

Human Services.

U. S. Advisory Board on Child Abuse And Neglect

8 4
Chapter One

National Center on Child Abuse and Neglect. (1994). Child

Maltreatment 1992: Reports from the States to the National Center on

Child Abuse and Neglect. Washington, DC: U.S. Department of Health

and Human Services.

National Research Council. (1993). Understanding Child Abuse

and Neglect. Washington, DC: National Academy of Sciences.

Rainey, R. (1994, July 21-22). Verbal testimony. Focus group on

Child Maltreatment Related Fatalities. Los Angeles, California: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Robinson, D. H., & Stevens, G. M. (1992, April 16). Child Abuse

and Neglect Fatalities: Federal and State Issues and Responses.CRS

Report for Congress. Washington, DC: Congressional Research Service.

Showers, J. (1994, March). Shaken Baby Syndrome. Don't Shake

the Baby Campaign News, pp. 1-2.

Sivit, C., Taylor, G., & Eichelberger, M. (1989). Visceral injury on

battered children : A changing perspective. Radiology, 173, 659-661.

Staff. (1994, March 25). Decades later, mother held on children's

deaths. The New York Times, p. Bl.

Westover Consultants. (1990). Interagency Task Force on Child

Abuse and Neglect [Prepared for the Office of Human Development

Services, U.S. Department of Health and Human Services]. Washington,

DC.

Yuan, Y. Y. (1994, June 15). Verbal testimony. Workshops on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Zuravin, S. (1991). Research definitions of child abuse and

neglect: Current problems. In R. Starr & D. Wolfe (Eds.), The Effects of

Child Abuse and Neglect: Issues and Research. New York, New York:

Guilford Press.

U. S. Advisory Board on Child Abuse And Neglect

c-1 5

37
Chapter Two

"In the little world in which children have their existence,

Whosoever brings them up,

There is nothing so finely preserved and so finely felt as injustice."

Charles Dickens

Great Expectations

CHAPTER TWO

ADDRESSING SHARED RESPONSIBILITY:

CASE INVESTIGATION AND PROSECUTION

CASE INVESTIGATION AND PROSECUTION

When a child dies in America today at the hands of an abusive or

neglectful parent, there is too often a lack of accountability on the part of

government agencies, front-line professionals, and the perpetrator. Such

deaths often fall through the cracks between the many organizations,

including law enforcement, medical, judicial, educational, and social

service agencies that comprise the child protection system. No

mechanisms exist to assure that responsibility is taken within this

multiagency system for determining how and why a child dies, or whc

should be held accountable. As noted by the Congressional Research

Service, many law enforcement systems investigate child deaths only if a

coroner's autopsy finds the death suspicious; yet coroners do not

consistently assure that children are autopsied (Robinson & Stevens,

1992). When autopsies are ordered, they may be incomplete or

incompetent.

In short, nobody speaks loudly enough for the children when these

tragedies occur. The system created in the United States to ensure that

"Good systems will emerge from

well-trained people." Michael

Wald, Deputy General Counsel,

DHHS, Board member, ABCAN

meeting, Washington., 1994

39

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

.1

adult homicides are thoroughly identified, investigated, and prosecuted is

failing to serve infants and children who die of maltreatment.

In times past, children were often seen as property. Many police,

judges, and prosecutors viewed such deaths as a strictly social problem,

not a criminal issue. Today, systemic problems created by those attitudes

linger.

1 1 II II I U.I1, '1 t'11 . I 4, '

Many of the key agencies that make up the child protection

network do not understand their role in abuse and neglect investigation

procedures or in assuring a child's safety. The holes in the safety net can

easily be seen in the numbers of front-line professionals from education,

law enforcement, medicine, and other fields who do not notify child

protective service (CPS) agencies about children they suspect of being

abused or neglected, even though they are legally mandated to do so.

Zellman et al (1990) found that 22 percent of these mandated

A recent study found that reporters, who include pediatricians, school principals, and day care

69 percent of operators, do not report suspected abuse, citing as top reasons their professionals who

suspected abuse did not lack of hard evidence of abuse or neglectwhich, in fact, is not

report it. required for a reportand their belief that "I can do better than the

40

system." A recent study found that 69 percent of professionals in

medicine, law enforcement, and other fields who suspected abuse did not

report it to CPS or any other authority (Reiniger et al, 1995). They are

often breaking State law.

The ineffectiveness of the mandated reporter system was made

clear in 1988 by the National Committee to Prevent Child Abuse's

(NCPCA) National Telephone Survey. It found that teachers, who are

considered among the most critical members of the system, receive little

U.S. Advisory Board on Child Abuse and Neglect

6 7
Chapter Two

education in identifying, reporting, or intervening in suspected child abuse

and neglect. Less than half of the teachers had ever attended an inservice

workshop on child abuse or neglect. Of those, half believed their

instruction was insufficient (McCurdy & Daro, 1988). According to

testimony, mandated reporters suffer a "serious knowledge gap" about

how and when to report abuse (Reiniger, verbal testimony, 1994).

Such practices among individuals who are supposed to be

protecting children become extremely important in light of the number of

abused and neglected children who die before anyone alerts a CPS

agency. Martinez and Sommer (1988) found that while 40 percent of the

children who die from abuse and neglect are under age 1, such children

account for only 13.8 percent of abuse cases substantiated by CPS

agencies.

There even have been cases reported where LIR Tessionals have

sought to protect the perpetrators. Helen Shore, Regional Coordinator,

Child Fatality Review Project, Neosho, Missouri, told the Board of a

Missouri coroner who wanted to label a case of inflicted suffocation as

Sudden Infant Death Syndrome to protect a family's reputation (verbal

testimony, 1994).

A few States are making some attempt to address the lack of

training for mandated reporters. For instance, California requires 8 hours

of training on child abuse and neglect for licensure of family therapists

including psychologists and licensed clinical social workers, though not

for physicians. Iowa requires 2 hours of training every 5 yearsfor

mandated reporters. New York requires 2 hours of initial training for

mandated reporters. Any efforts to train mandatory reportersshould

provide them with skills to recognize the signs of potentially fatal child

abuse and to act quickly on their suspicions.

"Teachers saw my bruises.

They saw what I was going

through. I went from an honor

student to a kid that didn't

have no respect for authority,

all of a sudden. Do you

understand what I'm

saying?"A Woman of the

Family Violence Program,

Bedford Hills Correctional

Facility, 1994

41

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

The Role of Child Protective Services

Testimony before this board in 1993 and 1994 indicated a

widespread lack of faith in CPS investigative efforts and in CPS' role in

detecting or reducing fatalities from abuse or neglect. Many overburdened

CPS agencies, although expressly mandated to protect children, "do not

see themselves as having a serious role in investigating maltreatment

deaths, due to the criminal implications" (Beveridge, verbal testimony,

1993).

"1 believe in my heart ifCPS had

monitored and had me go to

counseling with my mother,

something might have been done.

But ifyou say you are going to

monitor and you don't ever come,

and when you decide to come you

call me first, that gives me a

chance: 'Put on the long sleeves,

honey.' Clean up, and all that."

A Woman of the Family Violence

Program, Bedford Hills

Correctional Facility, June 1994

42

Many professionals do not trust CPS to conduct thorough

investigations of nonfatal abuse or neglect cases before listing them as

"unsubstantiated." In cases where children die or are severely injured

after CPS investigated and dismissed reports of abuse or neglect, States

sometimes take criminal action against CPS workers.

In 1992, 1.9 million reports of abuse and neglect involving 2.9

million children were received by CPS agencies, a figure which

includes multiple incidents within some families (NCCAN, 1994).

While many States purge unsubstantiated abuse and neglect cases to

prevent families from being kept in CPS records, a few States have chosen

to keep unsubstantiated cases on file. Many experts argue that retaining

unfounded reports allows caseworkers to detect past patterns of abuse

when investigating new allegations that a child is in danger (Reininger,

verbal testimony, 1994). Today, Child Death Review Teams and police,

who routinely review records of deceased children, consider prior reports

of unsubstantiated abuse to be potentially important aids in gathering

evidence in those States where records are saved (Smith, verbal testimony,

1994).

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

The Role of Prosecution

Even after a fatality caused by abuse or neglect is recognized

and an investigation is launched to identify a perpetrator, the criminal

justice system often responds insufficiently. The Board heard the

testimony of prosecutors who conceded that charges of child homicides,

including heinous cases, are routinely reduced to lesser crimes.

Prosecutors reduce charges or do not charge perpetrators at all

because existing murder statutes do not fit many child abuse and neglect

fatalities and cases can be difficult to prove in court. For example, most

prosecutors have little or no experience with abuse and neglect cases;

police often fail to gather sufficient evidence; and autopsies are seldom

performed by medical examiners with pediatric expertise. Witnesses are

rare aside from the perpetrator because most deaths occur in the privacy

of the home, and some juries simply cannot believe that any parent or

caretaker would commit such acts upon a child.

In one example of an attempt to anticipate jury disbelief, a Peoria,

Illinois, prosecutor waited 7 months to issue a charge of manslaughter

against an aunt who killed her baby nephew with a stun gun. Brandon

Jordon, age 7 months, died from multiple assaults from a 70,000-volt stun

gun. Police say the aunt shot the baby on May 28, 1994, to stop his

crying. Authorities were uncertain if they could convince a jury that

anyone could commit such a terrible act, and prosecutors delayed charging

the aunt while "investigating the effects of stun guns on children" (Staff,

Peoria Journal-Star, June 30, November 24, November 29, 1994).

Charges of child

homicides are routinely

reduced to lesser

crimes.

A Struggle for States

Several States have tried to address the many troubling issues

presented by the flaws in investigating and prosecuting abuse and neglect

"The goal must be to

prosecute child

homicides as

aggressively as we now

prosecute adult murders.

To be successful, the

greatest barrier to

achieving equal justice

must be overcome--the

public's disbelief

Ryan H. Rainey, Senior

Attorney, National

Center for Prosecution of

Child Abuse, Los Angeles

Focus group, 1994.

43

U.S. Advisory Board on Child Abuse and Neglect

0
Chapter Two

"Researchers spend a lot of

time investigating how CPS

agencies failed when a death

occurs, but in most cases CPS

was not aware of that family

or that child's existence before

the death. But somebody,

somewhere, was aware."

Jose Alfaro, Director of

Research, Children's Aid

Society, New York Focus

group, 1994

44

deaths. Colorado has established guidelines for the role of CPS, law

enforcement, and health professionals when investigating suspicious child

deaths. Oregon provides clear guidelines for the specific roles of all

professionals involved in death investigations: CPS workers are expected

to provide case management information and family history to

investigators, and police are expected to report witness information and

provide scene photographs, physical evidence, and background and

suspect information. Health professionals are expected to provide

thorough analyses of deaths through autopsies.

Most experts believe that thousands of families in which a child

died in the past decade, whether known to CPS or not, were often wellknown to a physician, police officer, probation or parole officer, welfare

worker, therapist, or other professional. Indeed, many of these families

have multiple problems including drug abuse, domestic violence,

unemployment homelessness that bring them in frequent contact with

such agencies. However, few front-line professionals have the training or

knowledge to respond to the dangers to children from abuse and neglect.

With such basic, deep-rooted problems, it is not hard to see why

the system seems to have fallen into disarray when yet another tragic death

of a child is made public in the media. All concerned professionals and

agencies must help carry the weight that cannot be borne by CPS alone

and become active participants in identifying and reporting abuse and

neglect. That effort will hinge, to a large degree, upon a (..omplete

rethinking of how we train and guide .;ic people on whom these

responsibilities rest.

U.S. Advisory Board on Child Abuse and Neglect

(,) 1
Chapter Two

Provision of Available and Necessary Medical Care to Children

A particularly difficult issue that was brought to the attention of the

Board during the preparation of this report, is the issue of religious

exemption or religious immunity or deference in cases of medical neglect

of children. These phrases have been used to refer to the policies and laws

which seek to exempt or immunize parents of children who do not provide

available and necessary medical care to a child because of their religious

beliefs. This issue involves balancing constitutional guarantees of

freedom of religion, parental rights, and societal and governmental

responsibilities to protect children from serious harm or death.

The right of a person in the United States to practice his or her

religious beliefs is a key principle in our Nation's history and is clearly

articulated in the Constitution. Government must not seek to limit that

right. However, government has enacted important laws that are designed

to protect the health and well-being of children, who because of their very

nature are dependent upon their parents for care, nurturing, and protection.

Such laws provide for governmental intervention to ensure that a child

will have access to available medical care when the child has been harmed,

or is at substantial risk of harm. At present, this can be accomplished

through the application of child abuse reporting, investigation, and

treatment laws in each State.

This issue has been complicated by Federal statutory and

regulatory changes that have evolved over the past two decades The

Federal Government became involved with this issue in 1974, following

the enactment of the nation's first Federal child abuse statute, the Child

Abuse Prevention and Treatment Act (CAPTA) (P.L. 93-247, as

amended). Regulations implementing CAPTA directed that, in order to

receive Federal funds under this new grant program, States had to

41,

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

46

construct their civil child abuse statutes in such a way as to ensure that "a

parent or guardian legitimately practicing religious beliefs who thereby

does not provide specified medical treatment for a child, for that reason

alone shall not be considered a negligent parent or guardian." The

regulation went further to indicate that "such an exception shall not

preclude a court from ordering that medical services be provided to the

child, where his health requires it."

Against a backdrop of heightened awareness and concern about

the problem of child abuse and neglect and the desire to take advantage of

the financial incentive in this area, most States enacted child abuse and

neglect reporting laws that exempted or immunized parents from a finding

of negligence if their failure to provide medical treatment was based on

religious beliefs. Some States amended their criminal statutes as well,

prohibiting prosecution of parents who did not provide medical care for

their children, regardless of the outcome.

Throughout the next decade state child protective services expanded

and reports of abuse and neglect grew tk9mendously. In addition, reports

of instances in which children became seriously ill, disabled, or died due

to a lack of medical treatment came to the attention of CPS agencies, the

courts, and the Federal government.

In 1983, the Department of Health and Human Services (DHHS)

issued new regulations addressing medical neglect. To continue to receive

federal CAPTA funds, States then had to explicitly add medical neglect to

their child abuse statutes. In addition, the Department dropped the

requirement that States have religious exemption or immunity provisions

and clarified that while states may exempt parents from being adjudicated

as negligent, the State must have the authority to intervene to protect the

child and provide necessary medical care.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

In recent years, as the DHHS has continued to review States' child

abuse and neglect statues to determine whether they meet the

requirements of CAPTA, some States have lost Federal funding and

others were influenced to change their laws related to the medical care of

children. In 1995, Congress imposed a moratorium on DHHS action

with respect to these laws.

Although the Department's policy has been consistent since the

issuance of the 1983 regulationsall children are entitled to available

ana necessary medical care, regardless of the religious beliefs or

practices of their parents or guardiansthis aspect of the child abuse

Federal policy has been the subject of recurrent debate. It has reportedly

caused confusion among many child protection agenc: - regarding their

authority to intervene in reported child medical neglect cases if the

parent's action or inaction based upon their religious beliefs. In an effort

to clarify this issue, some States have added spiritual healers to their list

of mandatory child abuse reporters. The courts in various States have

interpreted the religious exemption or immunity statutes differently:

some have upheld criminal prosecutions of parents whose children suffer

serious disability or die as a result of religion-based failure to seek or

provide necessary medical care while others have ruled that the States

religious exemption or immunity prevents such prosecutions.

Medical professionals and child advocates have voiced increasing

concern that continuation of the current policy will endanger more

children because children who are at risk of serious harm as a result of a

lack of medical treatment often do not come to the attention of medical

or child protection professionals until the situation is critical or after the

child has died or suffered permanent injury. ln addition, there is concern

that the current policy undermines the legal responsibility that all parents

47

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

48

have to care for their children and sends a confusing message to parents,

spiritual healers, and professionals involved in the child protection

system.

It appears that the religious exemption, religious immunity, or

deference provisions regarding medical care of children in some State

statutes may have created unintended barriers to the provision of timely,

necessary medical care for children. After lengthy consideration, the

Board is concerned that such an exemption leads people to fail to report

cases of inadequate medical care to appropriate authorities. The results

have proven to be devastating in a number of widely reported cases.

The reauthorization of CAPTA and the Federal role in child abuse

and child welfare programs is under review in the Congress this year.

However the Congress may decide these questions, the compelling issue

of protecting children who may be denied needed medical care remains.

Therefore, the Board recommends that States take action to ensure the

protection of all children.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

CURRENT ISSUES: TRAINING WEAKNESSES

A RECENT CASE:

The 5-year-old was brought to Lincoln Hospital in the Bronx four

times over several months, each time with a different injury: a skull

fracture, extensive bruising, cigarette burns on her hands and chest, and

severe scalding from hot tapwater. On her final trip, she was DOA. An

autooy revealed that she died from a lacerated liver, the result of being

severely punched. When the Medical Examiner collected hospital records,

he noticed that a different doctor had seen the girl each time, and the

seemingly carbag family always gave a history of accidentsa clumsy

little girl who put her hands in ashtrays, stepped into scalding water, or fell

down a flight of stairs. Each time, the new doctor, untrained in the signs of

inflicted abuse, believed the story.Dr. Michael Baden, New York State

Police Medical Examiner's Office, New York Focus group, 1994.

The greatest impediment to creating competence among

professionals who respond to child deaths is the lack of specialized

training and crosstraining. From the time of death, while a child's body

lies motionless on a hospital bed or at home in a crib, to the time of

reckoning, when a parent or caretaker is brought before a judge, a lack of

expertise on the part of front-line professionals infuses the process with

confusion and missed clues.

The system is so strained that the question of who harmed a child

may never be asked or answered, and in too many cases perpetrators have

gone on undetected to harm or kill other children. Sometimes this is due

to a lack of crosstraining which is necessary for effective coordination

among agencies. It is not unusual for law enforcement to be aware of

domestic violence problems in a family, for CPS to know about an

allegation of molestation against the mother's boyfriend, and for public

health nurses to be tracking an infant in the home suffering from

"We have become

experts at finding

someone to blame, but

somewhere right now, a

child is dying at the

hands of his/her parent

or caretaker, and we

don't know how to find

them in time."Yvonne

Chase, ABCAN Board

member and Deputy

Commissioner,

Department of Health

and Human Services,

State of Alaska, ABCAN

meeting, 1994

49

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

50

malnutrition or failure to thrive. Yet more often than not, none of this

information is seen in its entirety by any one professional.

Some States are using the knowledge gained from Child Death

Review Teams to dramatically improve training and awareness. In

Missouri, for example, training developed by experts from Child Death

Review Teams is regularly conducted at association meetings of coroners,

prosecutors, and others. However, other regions appear to be moving in

the opposite direction. In New York City, for example, the child

protective training academy is being dismantled and transferred out of the

child welfare system. According to Dr. Megan McLaughlin, Executive

Director of the Federation of Protestant Welfare Agencies, the critical

training of case workers has been made an expendable part of the child

protection program (verbal testimony, 1994).

Physicians and Other Hospital Personnel Are Unaware of Abuse

Clues

A RECENT CASE:

In Rhode Island, a battered woman appeared at a hospital

emergency room with her bruised toddler. None of the doctors or nurses

who treated the mother examined the child, and after the woman was

patched up, no one thought to netify CPS. Nine months after the mother's

visit to the ER, the baby was killed by the same violent boyfriend who had

been beating the mother. A member of the Child Death Review Team

noted, "The cLild died essentially because of the failure of an emergency

room to identify risk, witnessed through the serious abuse of the mother."

Dr. Richard Gelles, Family Violence Research Program, University of

Rhode Island, New York Focus group, 1994.

Several medical examiners testifying before this Board gave

detailed accounts of hospital cases where the presence of child abuse or

neglect was not ascertained until autopsy. In many cases, the medical

U.S. Advisory Board on Child Abuse and Neglect
Chapt(n. Two

examiners believed the cause of the child's injuries should have been

determined, or at least questioned, by those who treated the child in an

ambulance, in an emergency room, or in intensive care. Child Death

Review Teams have found that because many emergency rooms are

staffed by rotating physicians with various specialties, an abused or

neglected child might be seen by a physician who is unaware of the health

records of children and is unprepared to recognize the symptoms of child

abuse or neglect (Minnesota State Department of Human Services, 1991).

Moreover, unknown numbers of children never make it to a

medical examiner for autopsy because of a lack of training and awareness

among emergency room and intensive care workers, emergency medical

technicians (EMT's), and other medical personnel. Often, the true cause

of death remains a mystery, and the parent or caretaker is treated as a

bereaved victim.

Despite the dimensions of this life-threatening medical crisis,

only 400 pediatricians nationally have membership in the American

Academy of Pediatrics (AAP) Section on Child Abuse. In States as large

and populous as Texas, that translates into less than 10 pediatric

specialists, all of whom are on faculty at medical schools (Garcia, 1994

testimony.) Because child abuse is not a defined specialty in pediatrics, it

is not required as a rotation during pediatric residency training.

II' k II 1 Abuse and Neglect

The vast majority of medical examiners and forensic pathologists

lack specific training in identifying the cause of a child fatality, and only a

handful of medical examiners in the country specialize in autopsies of

children. Moreover, although there is a new certification specialty for

U.S. Advisory Board on Child Abuse and Neglect

"Doctors, especially

younger doctors, want to

believe that parents only

beat older children. I have

to keep telling them, no,

they beat babies."Dr.

Margaret McHugh, Child

Protection Team, Bellevue

Hospital, New York Focus

group, 1994

9 8

51
Chapte r Two

"No parent or guardian ever

comes in and says 'I've been

beating up my child' They

always say, 'The kid fell down,

a dog jumped on the kid a

swing hit the kid' For medical

examiners, it is critical to

detect the injuries that show

the child couldn't have done it

to himself "Dr. Michael

Baden, Chief Medical

Examiner, New York State

Police, New York Focus group,

1994

52

pediatric pathology, there is no certification requirement for medical

examiners or forensic pathologists who autopsy children.

These problems represent a significant weakness in the system

because children succumb to unique and sometimes subtle injuries and

maladies from abuse and neglect that are easily missed by an examiner

trained to find causes of adult death. Moreover, parental deceit and denial

are common. Complicating the situation, 28 States rely upon coroners or

justices of the peace who are elected to office based only on the

qualifications that they are at least 18 years of age and a resident of that

county (CDC, 1993).

Most States have very limited funding and do not provide

autopsies and death scene investigations for all unexplained deaths,

particularly for children. As Gannett's 1990 series showed, "autopsies on

children are conducted almost by whim." The series found that four

Southern States examined, on average, only 31 percent of dead children,

compared with five Western States that autopsy, on average, 54 percent of

dead childrenthe highest national average (Gannett News Service,

1990). Gannett found that, nationwide, one in every 12 SIDS deaths is

diagnosed as SIDS without support of an autopsy--a flagrant violation of

necessary medical procedure (Lundstrom & Sharpe, 1991). In

Pennsylvania, many local coroners are reticent to perform autopsies on

any child, and very often do not have the funds or basic training to do so

(Carrasco, verbal testimony, 1993). In Texas, if the death of a child

younger than age 18 is unexpected, the law requires an autopsy, but a

justice of the peace, who may need only be a high school graduate, makes

the critical decision on whether the death was unexpected (Evans, verbal

testimony, 1994).

U.S. Advisory Board on Child Abuse and Neglect

5 9
Chapter Two

This outmoded approach to certifying death has led to

problems such as local coroners who refuse to consider abuse as a

cause of death because "the parents seemed like such nice people" or

"they had an unusually clumsy child," as experts testified before this

Board in 1993 and 1994. As a result of these intertwined problems of

undertraining and personal reluctance, hundreds, and perhaps thousands,

of children die each year from abuse and neglect only to have their deaths

misidentified by coroners and medical examiners as being due to natural,

accidental, or undetermined causes. Indeed, Child Death Review Teams

often find themselves probing issues that a qualified coroner or medical

examiner could have already fully addressed.

"the parents seemed like

such nice people"

Police Often Are Not Trained to Detect or Deal With Serious and

Fatal Child Abuse

Homicide detectives investigate a child's death only when it

appears that the death may have been at the hands of another. Howeve

their expertise is usually limited to what they know from investigating

adult homicides. Unlike most child fatalities, the unnatural death of an

adult is often obvious, and detectives quickly focus on who

committed the crimenot on determining whether a crime has even

occurred.

Retrospective reviews of child fatality cases have discovered

r,

If police focus on children

involved in domestic

violence, child abuse could

more effectively be

identified.

too many instances where police had contact with abusive parents or

caretakers, but for many reasons failed to assure the child's safety. If

investigating police focused on children in families involved in domestic

violence and drug abuse, child abuse could more effectively be identified

and reported (Minnesota State Department of Human Services, 1991). In

addition, the police sometimes fail to identify children who show signs of

53

U.S. Advisory Board on Child Abuse and Neglect

1 0 0
Chapter Two

"The clock starts when a

child's death is noted to be

suspicious. Law enforcement

should be involved and have

begun the case evaluation,

death scene evaluation, and

cleared criminal justice, and

CPS records, all within 2

hours."Capt. John Welter,

San Diego Police

Department, Los Angeles

Focus Group, 1994

54

neglect, such as being underweight, dehydrated, or in need of medical

care. Saving an infant or small child could be as simple as "looking under

their shirt or blanket" before leaving the home, as several experts testified.

There have been a number of improvements within some police

agencies recently. The Los Angeles County Sheriff, for example, now

requires that investigating officers view the bodies of all living children

who are reported to be victims of alleged physical abuse. The policy was

instituted in 1992 in response to a case in which a preschooler died after

deputies responded to an abuse complaint, but did not look at the child's

body as he "slept" under a blanket. Had the deputies looked, they would

have discovered extensive injuries to the boy's legs, torso, and arms from

being tied down. During Child Death Review Team meetings, Los

Angeles City police shared their protocol for inspecting children's bodies,

which was soon replicated by the Sheriff's Department. This protocol is

now part of the State's Peace Officer Standards and Training.

In addition, Dallas and some other cities now use officers

specifically trained in abuse and neglect issues to investigate child

fatalities and have created "family violence units" that respond both to

child abuse and domestic violence complaints. Because it is critical that

police coordinate with other agencies, Dallas CPS workers and child

fatality detectives are housed in the same building and respond to deaths in

teams. In Des Moines, Iowa, the impetus has come not from the police but

from the city's Pediatric Trauma Team, which assures thd there is an

immediate response to all reports of serious and fatal child abuse by

police, juvenile courts and CPS investigators 24 hours per day. However,

most improvements in investigation are recent, and no data are available to

determine their impact on child deaths from abuse or neglect.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

Child Protection Workers Are Often Inexperienced, Undertrained, or

Overextended

The NCPCA estimates that about 42 percent of the children who

died have had previous or current contact with a CPS agency. Other

studies found prior CPS contact with 30 to 45 percent of families in which

a fatality occurred. The "prior contact" figure ranges from 17 percent in

Colorado to 63 percent in San Diego (McCurdy & Daro, 1988).

The current system is susceptible to too many human errors and

flaws. These problems arise from the recent history of child welfare,

which has rapidly changed from role of "helper" or "counselor" to

"investigator" in order to respond to the burgeoning crises of family

violence and family breakdown. Governments have neither consciously

acknowledged the cultural changes required within CPS agencies nor

addressed the professional training required to make these changes. In

some States, child protection workers receive little training to determine

the cause of a child's injuries before they result in death or to detect clues

that might indicate that a child is in danger.

Even well-trained workers cannot function adequately with

unmanageable caseloads. While some regions and States do much better

than others, in many jurisdictions caseloads are so high that the best CPS

can do is take the complaint call, make a single visit to the home, and

decide whether the complaint is founded or unfounded. Often, there is no

subsequent monitoring of the family.

For example, CPS in New York has reached a saturation point,

according to James Cameron, Executive Director, New York State Chapter

of the NCPCA (verbal testimony, 1994). In New York, CPS agencies

receive over one hot-line call per minute from relatives, neighbors, friends

and professionals reporting suspected cases of abuse or neglect. Leah

"It is incongruent and

unreasonable to continue to

expect poorly trained, lowpaid staff to appropriately

assess the needs of children

and their families."Megan

E. McLaughlin, D.S.W.,

Federation of Protestant

Welfare Agencies, New York

Public hearing, 1994

55

U.S. Advisory Board on Child Abuse and Neglect

i 02
Chapter Two

56

Harrison (1994), of the Child Protection Center of Montefiore Medical

Center in New York, testified that the Center works with the local child

welfare agency to protect children. She has found that the agency's staff is

unaware of the implications of many medical diagnoses and sometimes

makes decisions based on their rules and regulations without taldng into

consideration the implications of their decisions. Moreover, according to

Harrison, many caseworkers lack the resources needed to create an

appropriate service plan for the family to ensure a child's safety.

New York is hardly alone. In many cities and States, a litany of

child abuse and neglect tragedies have resulted in lawsuits and highly

negative press coverage and have created the appearance of widespread

professional incompetence. Nevertheless, this Board believes it is a

mistake for the public to hold CPS agencies solely responsible for these

failures to save children. Placing such a large burden on a single,

beleaguered agency is akin to expecting school truancy officers to identify

and resolve the complex and persisting problem of urban street gangs.

U.S. Advisory Board on Child Abuse and Neglect

3
Chapter Two

Multiple Problems Deter the Prosecution of Perpetrators

ONE RECENT CASE:

An Oklahoma mother asked her boyfriend to babysit for her infant

girl. While she was gone, the boyfriend became enraged overthe baby's

crying and violently shook the child until the infant was dead. An autopsy

revealed severe brain damage caused by shaking. After the boyfriend's

arrest, a photograph of him ran in local newspapers showing him wearing

a bill cap popular in Oklahoma that read, "Number One Dad." At his trial,

the man admitted he had attacked the child, but the jury found him not

guilty. Later, the district attorney (D.A.) was criticized for charging the

boyfriend with first-degree murder, since the jury was not able to accept

the killing as premeditated.Barbara Bonner, Verbal testimony, New

York focus group, 1994.

Most prosecutors are not specially trained to prosecute child

homicides by abuse or neglect. Specialized training and vertical

prosecution, in which one attorney carries a case from referral to

disposition, are now common in cases of sex crimes against children, but

not in cases of child homicides, including fatalities from abuse or neglect.

In addition, judges at all levels have inadequate knowledge about

child maltreatment-related fatalities, and too often they are not provided

with critical information regarding family history before they impose

sentences. Consequently, judges often agree with prosecutors that child

homicide defendants should be allowed to plead to lesser crimes.

Prosecutors suggest lesser pleas for several reasons: the investigation has

failed to provide sufficient evidence to prove the charges beyond a

reasonable doubt; the prosecutor lacks the knowledge on how to prove the

charges; or there is an absence of a felony murder statute with which to

charge the accused for the child's death.

57

U.S. Advisory Board on Child Abuse and Neglect

i 0 4
Chapter Two

"Prosecutors all over the

country will tell you that the

easiest murder to get away

with is the killing of an infant

or small child by a parent or

caretaker.".1. Tom Morgan,

Atlanta D.A. and ABCAN

board member, October 1994.

58

Prosecutors face major hurdles. Jury members often will not

believe that parents and caretakers ..ould seriously hurt or kill children,

and the legal system often encounters spouses and relatives who side with

perpetrators and delay or cripple investigations. In one Missouri case, the

Jackson County prosecutor could not gather enough evidence on the death

of a 4-year-old girl because so many of the family's adults had abused the

child that no one could determine who inflicted the fatal blow. Surviving

siblings and young cousins were threatened into silence and would not

testify (Fincham, verbal testimony, 1994).

Despite these many obstacles to prosecution, there are some

improvements underway. More perpetrators are being arrested and

convicted with information gathered by Child Death Review Teams, the

use of more and better autopsies, and extra efforts by concerned

physicians. The National Center for Prosecution of Child Abuse deserves

recognition for providing nationwide training and consultation for

prosecutors in this area.

Yet much more must be done, and we will suggest stracegies for

change, including dramatically improved training of all front-line

professionals, immediate-response joint criminal investigations, and

adoption of statutes that allow prosecution of these crimes without the

need to prove premeditation.

U.S. Advisory Board on Child Abuse and Neglect

5
Chapter Two

STRATEGIES FOR IMPROVEMENT: EXPANDING THE

EXPERTISE

Broad New Training Efforts for All Front-Line Workers

CPS Training

With CPS increasingly consumed by investigations, CPS managers

and line staff are now realizing that a graduate degree in social work alone

does not prepare professionals to conduct such investigations and lither

evidence related to criminal prosecutions. Some States are considering a

dramatic shift that places police in charge of investigating serious cases

and high-risk families, thus allowing both CPS and law enforcement to

perform the tasks for which they are most skilled.

Some States, such as New Mexico and Connecticut, have enriched

their CPS training programs in response to litigation. Alaska has designed

and implemented mandatory, competency-based training for all child

welfare and child protection workers.

Specialized training for CPS workers should prepare them to

become knowledgeable members of Child Death Review Teams. This

Board suggests a training model for CPS workers aimed at identifying and

preventing serious and fatal abuse and neglect and helping workers assist

other agencies in gathering child death investigation information. Such

training should include:

How to identify family strengths as well as risk factors associated with

diverse groups and cultures. This would include how to identify

normal child development markers via growth charts as well as

markers for sufficient language development.

Cross-training to relate better to other disciplines, with the aim of

increasing cooperation among agencies, fostering greater awareness of

clues to abuse, and sharing information on fatality cases.

59

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

"What we need in those

intervention and

prevention stages is

understanding from people

like us. If somebody that's

sitting next to me has not

been through a bit of

abuse, how are they going

to recognize an abusive

situation?"A Woman

from the Family Violence

Program, Bedford Hills

Correctional Facility,

1994

60

Training of, and with, community-based workers.

Training and access to "user-friendly" automated client tracking and

case management information systems that can greatly improve access

to important information on a family or case.

Beyond training, one important, but problematic requirement must

be keeping competent, highly trained people from leaving CPS due to

burnout and stress. Low salaries exacerbate this problem. Regular

consultation and inservice programs to minimize burnout, preparation for

workers dealing with their own emotions after a case results in a fatality,

and salaries commensurate with their responsibilities would do much to

attract and retain good workers.

Medical Training

SHOWING THE WAY:

The University of Oklahoma Science Center is implementing

voluntary interdisciplinary training for 180 doctors and other health

professionals on child abuse and neglect fatalities. They will be taught

how to recognize clinical Signs of child abuse and neglect, informed of

their obligation to report abuse, and encouraged to work with police and

CPS.Dr. Robert Block, Oklahoma Child Death Review Team, Dallas

Public hearing, 1994.

Health care delivery settings, including public and private hospitals

and clinics, health maintenance organizations, (HMO's), preferred

provider organizations (PPO's) and special children's health programs

should provide incentives and significant funding for the development and

ongoing training of medical specialists in child abuse and neglect. This

commitment should match training in other leading causes of death for

children. Such an effort will require public health policymakers to

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

understand the link between child abuse and subsequent lifetime medical,

mental health, crimit .1, and educatioral costs of untreated and

unrecognized child abuse.

ONE HOSPITAL'S EFFORTS:

Over the past 5 years, the Strong Critical Care Center at the

University of Rochester Medical Center, in cooperation with a Child

Death Review Team, has produced a series of papers identifying red flags

for suspected child maltreatment-related deaths: inconsistent history

compared with the physical examinations, history of drug or alcohol

abuse, and past history of child abuse or previous involvement with the

Department of Social Services. The red flags are now used to train

medical staff to spot abuse cases. Dr. Brahm Goldstein, Associate

Professor of Pediatrics, University of Rochester School of Medicine, New

York Focus group, 1994.

Increased Use of Immediate Response Joint Criminal Investigations

Joint criminal death investigations have existed at least since the

time of Sherlock Holmes and Dr. Watson. For many years, physicians,

law enforcement officials and others have informally collaborated to

determine the cause and manner of human fatalities. Today, in response to

systemwide weaknesses, some cities and counties are creating and training

criminal investigation teams that immediately respond to questionable

child deaths.

Joint criminal investigation teams differ from Child Death Review

Teams in one critical aspect: their miss;on is law enforcement. They

conduct criminal investigations of wrongdoing, rather than retrospective or

prospective systemwide reviews of how the child's death happened or

could have been prevented.

This Board believes that each team should include, at a minimum,

a medical examiner, detective, a CPS caseworker, and a prosecutor.

U.S. Advisory Board on Child Abuse and Neglect

i 0 8

61
Chapter Two

"Our efforts have made

borderline cases stronger,

and strong cases

unbeatable. And we ensure

that those tragic child

deaths that are accidental

are accurately characterized

as quickly as possible."

Lucinda Suarez, Special

Victim's Bureau, Queens

County District Attorney,

New York Public hearing,

1994

62

Protocols should be developed with clear guidelines for the role of each

team member from the moment a child's death or impending death is

reported. Medical, CPS, criminal histories and other information must be

freely shared among all involved.

Because of the hidden nature of many child deaths, the most

effective joint criminal investigation teams conduct immediate-response

death investigations for all children who die under suspicious

circumstances. Prosecutors described to this Board the reluctance to share

information between agencies and confusion over roles, problems that are

often resolved or greatly decreased by the innovative aspects of team

investigations.

For example, the Los Angeles Police Department's child abuse

unit, composed of specially trained child abuse detectives, immediately

sends a team to the scene of any suspected child abuse or neglect death. A

team, including a prosecutor and coroner's investigator, interviews the

parents, visits the hospital, and contacts CPS to determine over the phone

whether the family has a history with the agency. The team has even sent

the pathologistday or nightto the death scene to review the child's

injuries and witness the evidence. When the team's highly detailed and

promptly collected evidence is presented in court, cases are usually

prosecuted successfully (Smith, verbal testimony, 1994).

In Queens, New York, an immediate response criminal

investigation team has taken the concept a step further, videotaping the

death scene to be used as evidence. Such evidence has proved persuasive

to juries. The videotape also prevents parents and caretakers from

fabricating information or concealing evidence.

Despite these positive results, members of such teams also testified

that the work hours are demanding, the pay is the same as colleagues who

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

do not handle child death investigations, and the burnout level is high. For

this reason, jurisdictions should provide incentives for child death

investigation team members.

Suspected Child Abuse and Neglect Teams and Other Hospital Efforts

A growing number of hospitals are creating Suspected Child Abuse

and Neglect (SCAN) teams responsible for evaluating, reporting, and

treating child abuse and neglect and for providing consultation for other

hospital staff and other agencies. The core teams include a physician,

nurse, and social worker.

SCAN teams build liaisons with law enforcement and fire

department EMT's, which provide important contact with "first

responders"those who are first at the scene of a child trauma. Teams

may also develop liaisons with home visiting professionals, including

public health nurses. This broadens home intervention efforts and

provides access to prior medical records from public hospitals and clinics.

Most hospitals do not have SCAN teams. Hospitals with such

teams provide varying levels of service depending on whether their team

offers primary care or acts as a referral center. We believe every child

"Children are re-molested, reabused and even die because an

untrained medical practitioner,

acting without benefit of a

specialized SCAN team, did not

recognize indicators of a serious

or life-threatening injury.

Conversely, many families are put

through traumatic experiences

when their children are

inaccurately diagnosed as victims

of abuse." Dr. Astrid Heger,

Director, Pediatric SCAN Team

Los Angeles Focus group, 1994

Every child and family

and family should have access to a "Center of Excellence" for tertiary should have access to a

referral in their region, staffed with trained experts to ensure accurate

"Center of Excellence"

diagnosis and appropriate treatment. In rural areas, use of telemedicine

techniques can enable any SCAN team to consult with a tertiary center

hundreds of miles away.

63

U.S. Advisory Board on Child Abuse and Neglect

0
Chapter Two

64

AN IDEA THAT WORKS:

Bellevue Hospital's Child Protection Team is made up of

representatives from pediatrics, court-appointed special advocates

(CASA), substance abuse, and the psychiatric department. It reviews every

trauma case admitted, including adult cases where a child is in the home,

as well as all cases of domestic violence. Any Bellevue staff member who

is unsure about a case may request team review. The team integrates its

work with the D.A. The team routinely identifies cases of child abuse and

neglect that are missed by hospital physicians and other health

professionals.Dr. Margaret McHugh, Director of Child Protection

Team, Bellevue Hospital, New York Public hearing, 1994.

Mandated Autopsies

This Board heard strong agreement from professionals in many

disciplines that the single most critical stage in determining the cause and

manner of death of an infant or child is the autopsy. Yet here, in an area

where the need for professional expertise is so obvious, the system fails

dramatically. Few jurisdictions routinely perform autopsies when children

die unexpectedly. Among the reasons given are:

clear guidelines or regulations on when an autopsy should be

performed;

funds;

competent medical examiner;

political system in which an elected official decides if an

autopsy is needed;

religious prohibitions both actual and claimed;

personal reluctance, especially among coroners who may know

the family.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

Some States and regions are showing the way in this extremely

critical area. As of 1992, Kansas appeared to be alone in requiring

autopsies of all children who die under suspicious circumstances or of

unknown causes (National Center for the Prosecution of Child Abuse,

1994). Georgia requires autopsies of all children age 7 and under, a law

which sufficiently captures the high-risk age groups. Curiously, child

autopsies have been mandated in the past 5 years in Maine, Nebraska,

Oklahoma, Illinois, Iowa, Ohio and Missouri in response to public

concern; but, depending on the State, these mandates exclude children who

die after age 3, age 2, or age 1 (National Center for the Prosecution of

Child Abuse, 1994). Thus most State autopsy mandates do not apply to

many children who die from abuse or neglect.

Some localities have chosen to be far more inclusive without

waiting for State mandates. For instance, Tarrant County, Texas,

(Fort Worth) has adopted a policy requiring that all children who

die under the age of 15 be completely autopsied, with microscopy

and comprehensive toxicology studies (Peerwani, verbal testimony,

1994). Oregon's medical examiner system reviews all unexplained

deaths within 24 hours, and most autopsies are performed by

board-certified forensic pathologists (Lewman, verbal testimony, 1994).

Missouri provides its Child Death Review Teams with a Certified ChildDeath Pathologist Network. Mary Case, Chief Medical Examiner, St.

Louis County, notes that prosecutors in Missouri are far more willing to

pursue cases because forensic pathologists are much better at presenting

evidence to a jury, and attorneys are far more educated about the nature of

maltreatment fatalities (verbal testimony, 1994).

"The attitude of rural deputy

prosecuting attorneys is that child

protection cases are just 'kiddy'

cases."Ed Vandusen, Program

Manager, Division of Family and

Children's Services, Idaho Dept. of

Health and Welfare, Oregon public

hearing, 1993

65

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

Murder is no less a

crime because a child,

rather than an adult, is

the victim.

66

Enhanced Prosecution and Evidence Gathering

Murder is no less a crime because a child, rather than an adult, is

the victim. Only 21 States have either legislatively delineated child abuse

as an underlying felony contributing to felony murder or enacted homicide

by child abuse statutes (Rainey, personal communication, 1995). In States

without such legislative intent, felony murder charges may not be

possible.

Felony murder statutes allow juries to return a verdict of guilty

when the prosecutor has proved beyond a reasonable doubt that the

defendant intended to commit a felony (i.e., child abuse) which resulted in

the homicide. If a defendant is shown to have intended to commit felony

child abuse, the defendant may be convicted of murder if the child dies.

Elements of the murder such as malice aforethought, premeditation, and

intent to killwhich are difficult to prove in child homicideare not

required.

Jurisdictions that have adopted felony child murder or equally

effective "homicide by child abuse" laws have experienced increased

convictions when prosecuting perpetrators. For example, Oregon differs

from the Nation as a whole in that it has a higher rate of criminal

prosecution of fatal child abuse cases (approximately 68 percent). "It is

possible that Oregon's prosecution rate is higher due to a murder by an

abuse statute that passed in 1989. This statute enables prosecutors to

charge an alleged offender for a crime that specifically addresses the

dynamics often present in child death without requiring proof of intent to

murder, a condition seldom provable in child abuse fatalities" (Oregon

Department of Human Services, 1993, p. 4). Children in every State

deserve a similar level of justice.

U.S. Advisory Board on Child Abuse and Neglect

; _1. 3
Chapter Two

CHAPTER TWO RECOMMENDATIONS

This Board has identified a critical need to better educate

professionals to identify and respond to fatal child abuse and negint and

to hold perpetrators responsible for their actions. Without a greater

understanding among police, physicians, CPS workers, coroners,

prosecutors, mandated reporters, and others about the circumstances, red

flags, subtleties, systemic problems, attitudes, and obstacles that

characterize fatal abuse and neglect cases, innocent children continue

to fall through the cracks in the sysizm. Moreover, if society fails to

communicate to parents that child abuse and neglect fatalities must receive

the same level of justice as adult homicides, a tacit and dangerous message

is sent that such deaths are more acceptable and carry less severe

'consequences. We therefore recommend:

Recommendation 3: The supply of professionals qualified to identify

and investigate child abuse and neglect fatalities should be increased.

The leadership of DHHS and the Department of Justice (DOJ)

should work with professional associations to develop a national strategy

to address the dramatic lack of medical, law enforcement, and legal and

social service professionals qualified to identify and investigate child

abuse and neglect fatalities. This effortshould focus on:

Recruitment and training of more practitioners by offering

scholarships or loan forgiveness.

A review by each discipline ofprojected training patterns to determine

if it can produce enough experts. Each discipline should promote ways

to increase expertise via development of continuing education,

improvements in school curricula requirements, and inservice training.

Increasing medical expertise, in particular. This goal should be

addressed by the American Medical Association (AMA), National

Association of Medical Examiners (NAME), AAP, American Public

Health Association (APHA), and others, working cooperatively with

67

U.S. Advisory Board on Child Abuse and Neglect

;14
Chapter Two

68

States should include development of: competent forensic medical

examiners in every State; training of medical examiners who specialize

in pediatric pathology; creation by National Institutes of Health (NIH)

of funded medical fellowships in forensic pediatrics as well as forensic

pathology, pediatric radiology, and public health/child abuse;

enactment by States of a requirement that any doctor in pediatrics,

emergency medicine, or family practice complete child abuse training

within a short time of licensure; and creation of a study section for

child abuse within the NIH.

Recommendation 4: There must be a major enhancement of joint

training by government agencies and professional organizations on

the identification and investigation of serious and fatal child abuse

and neglect.

The Secretary of Health and Human Services and the U.S.

Attorney General should utilize funds to improve multidisciplinary

training in all disciplines charged with identifying and investigating child

abuse and neglect fatalities, with an emphasis on crosstraining where

possible. This effort should be tailored to a broad audience including child

welfare workers, law enforcement officers, prosecutors, mental health

practitioners, physicians, paramedics, EMTs, and others who might work

in a front-line capacity.

Regular training should be provided by the National Center for

Prosecution of Child Abuse, AAP, NAME, AMA, Society for Pediatric

Radiology, American Hospital Association, American Professional

Society on the Abuse of Children, American Public Welfare Association,

APHA, the Association for Death Education & Counseling, Association of

SIDS Program Professionals, National Association of Children's Hospitals

& Related Institutions, National Association of Social Workers, National

Fetal Infant Mortality Review Program, the National Council of Juvenile

and Family Court Judges, the International Association of Chiefs of

Police, the International Homicide Investigator's Association, Peace

Officer Standards and Training Board, and NCPCA.

Finally, the National District Attorneys Association should

develop, with the AMA, joint training for all professionals involved in the

identification, investigation, and prosecution of fatalities.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

Recommendation 5: States, military branches, and Indian Nations

should implement joint criminal investigation teams in cases of fatal

child abuse and neglect.

All States should create criminal investigation teams either at the

local or regional level to investigate any "unexpected child death," as

previously defined in this report. The Department of Defense should

create teams for the military branches. Indian Nations, DOJ, and Indian

Health Service should ensure that such teams operate to review deaths in

Indian Country. Each team should, at minimum, include a medical

examiner or coroner, law enforcement officer (preferably a child abuse or

homicide detective), child protection worker and prosecutor, who work

under a protocol that clearly defines each role and allows for effective,

confidential sharing of medical, family and criminal histories.

Recommendation 6: States and the Joint Commission on

Accreditation of Health Care Organizations (JCAHO) should adopt

requirements to assure all hospitals with pediatric services have

SCAN teams.

Any hospital with a pediatric unit should be required by the state,

military branch, Federal agency, or Indian Nation that oversees its

certification to have a SCAN team, including a physician, social worker,

and nurse specially trained to evaluate, treat, report, and consult on child

abuse or neglect cases. The JCAHO should adopt this requirement. Such

teams should interact with investigators and other agencies on

abuse/neglect and suspicious injury cases involving children.

Recommendation 7: All States should enact legislation establishing

child autopsy protocols. Federal funding for autopsies of children

who die unexpectedly should be available under the Medicaid

program.

Autopsies should be required, at a minimum, when any child's

death is suspected by investigators as being a homicide, suicide, the child

was not under supervision of medical personnel at time of death, or the

cause of death is not readily determinable. In addition, no cause of a

child's death should ever be listed as SIDS without an autopsy, death

scene investigation, and clinical review. Such autopsies are also in the

interest of parents of SIDS infants, who suffer doubt when an infant dies

69

U.S. Advisory Board on Child Abuse and Neglect

1 lb
Chapter Two

70

suddenly and unexpectedly. To implement this effort, Federal funding for

autopsies should be an option under the Medicaid program.

Recommendation 8: States should take steps to ensure that all

children have awess to available, necessary medical care when they

are at risk of serious injury or death.

Laws protecting children must be applied equally and fairly. All

States should ensure that civil child abuse laws include the provision

that the failure of parents to provide medical care, when such care is

available and necessary to protect a child from death or serious harm,

is reportable under the State child abuse and neglect reporting law,

regardless of the religious beliefs or practice of the parents. State child

abuse reporting laws should not differentiate the handling of possible

medical neglect cases based upon the parent's religious beliefs.

State courts must retain clear authority to order necessary medical care

when parents and others, legally responsible for providing medical

care, fail to provide it.

Decisions regarding prosecution of parents who fail to provide

available, necessary medical care for their children should be made

within each State.

States should ensure that all health care providersincluding spiritual

healers who provide health care for payment through public or private

insurance reimbursementare listed as mandatory reporters of child

abuse and neglect, thereby involving such providers in training

activities that are conducted for mandatory reporters.

Recommendation 9: States should enact "felony murder or homicide

by child abuse" statutes for child abuse and neglect. States that

currently define child abuse as a misdemeanor should establish laws

to define child abuse and neglect as felonies.

Felony murder statutes should specifically include child abuse or

neglect felonies as one of the underlying felonies, as in 21 States currently.

In some States, an alternate but equally effective law may be "homicide by

child abuse or neglect."

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

CHAPTER TWO REFERENCES

Alfaro, J. (1988). What can we learn from child abuse fatalities? In

D. Besharov (Ed.), Protecting Children from Abuse and Neglect, Policy

and Practice. Springfield, Illinois: Charles C. Thomas.

Beveridge, J. (1993, March 11). Verbal testimony. Hearing on

Child Maltreatment-Related Fatalities. Denver, Colorado: Sponsoredby

the U.S. Advisory Board on Child Abuse and Neglect.

Blame hard to place in boy's death: System 'worked as it was

supposed to' with 5 year old found starved in Milpitas. (1994, July 6). San

Jose Mercury News, p. 1.

Bonner, B. (1994, June 13-14). Verbal Testimony. Workshops on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Boy who starved was returned to parents by reluctant judge. (199-i,

September 25). Los Angeles Times, p. A 12.

Cameron, J. (1994, June 16). Verbal testimony. Public Hearing on

Child Abuse and Neglect Fatalities. New York, New York: Sponsored by

the U.S. Advisory Board on Child Abuse and Neglect.

Carrasco, M. (1993, December 2). Verbal Testimony. Hearing on

Child Maltreatment Related Fatalities. Pittsburgh, Pennsylvania:

Sponsored by the U.S. Advisory Board on Child Abuse and Neglect and

People of Color Leadership Institute.

Case, M. (1994, August 1). Verbal testimony. Public hearing on

Child Maltreatment Related Fatalities. St. Louis, Missouri: Sponsored by

the U.S. Advisory Board on Child Abuse and Neglect.

Cassidy, M.. (1995). [San Jose Mercury New Reporter- Personal

Communication] (Jill Stewart).

Centers for Disease Control and Prevention. (1993). National

Center for Environmental Health, Surveillance and Programs. Atlanta:

Centers for Disease Control and Prevention.

71

U.S. Advisory Board on Child Abuse and Neglect

i 1 8
Chapter Two

72

Evans, C. (1994, August 30). Verbal testimony 1994 Crimes

Against Children presented by Dallas Police Department (Ed.). Public

Hearing for Child Maltreatment Related Fatalities. Dallas, Texas:

Sponsored by the U.S. Advisory Board on Child Abuse and Neglect.

Fincham, K. (1994, August 1). Verbal testimony. In National

Symposium on Child Fatalities: The Missouri Experience. Public Hearing

on Child Maltreatment Related Fatalities. St. Louis, Missouri: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Gannet News Service. (1990, December). Getting Away with

Murder.

Garcia, R. (1994, August 30). Verbal testimony. Public hearing on

Child Maltreatment-Related Fatalities. Dallas, Texas: Sponsored by the

U.S. Advisory Board on Child Abuse and Neglect and Dallas Police

Department.

Harrison, L. (1994, June 16). Verbal testimony. Public hearing on

Child Maltreatment-Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Lewman, L. (1993, September 30). Verbal testimony. Public

hearing on Child Maltreatment-Related Fatalities. Salem, Oregon:

Sponsored by the U.S. Advisory Board on Child Abuse and Neglect.

Lundstrom, M., & Sharpe, R. (1991, Summer). Easy to kill a child

and bury a secret. Public Welfare, pp. 19-29.

Martinez, L., & Sommer, P. (1988). Illinois Child Abuse and

Neglect Fatalities: Characteristics & Profiles. Chicago: Illinois

Department of Children and Family Services, Office of Quality Assurance,

Division of Child Welfare, and Protective Services.

McCurdy, K., & Daro, D. (1988). Current Trends on Child Abuse

Reporting and Fatalities, 1087. National Center on Child Abuse

Prevention Research. Chicago: National Committee for Prevention of

Child Abuse.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Two

McLaughlin, M. (1994, June 16). Verbal Testimony. Public

Hearing on Child Maltreatment Fatalities. New York, New York:

Sponsored by the U.S. Advisory Board on Child Abuse and Neglect.

Minnesota State Department of Human Services. (1991). Progress

Report of Minnesota Child Mortality Review Panel. St. Paul: Minnesota

State Department of Human Services.

National Center for the P.,.osecution of Child Abuse. (1994). Social

Procedure in Child Homkide Investigation, Mandatcpy Autopsied, and

Child Death Review Teams. APRI. Washington, DC: NCPCA,

National Center on Child Abuse and Neglect. (1994). Child

Maltreatment 1992: Reports from the States to the National Center on

Child Abuse and Neglect. Washington, DC: U.S. Department of Health

and Human Services.

Oregon Department of Human Resources. (1993). Task Force

Report oe, Child Fatalities and Critical Injuries due to Abuse and Neglect.

Children's Services Division. Salem, Oregon: Oregon Department of

Human Resources.

Peerwani, N. (1994, August 30). Verbal testimony. In 1994 Crimes

Against Children Presented by Dallas Police Department. Public Hearing

on Child Maltreatment Related Fatalities. Dallas, Texas: Sponsored by the

U.S. Advisory Board on Child Abuse and Neglect.

Rainey, R. (1995, March 19). [National Center for the Prosecution

of Child Abuse] ( Deanne Tilton Durfee). Washington, DC.

Reiniger, A. (1994, June 16). Verbal Testimony. Hearing on Child

Maltreatment Related Fatalities. New York, New York: Sponsored by the

U.S. Advisory Board on Child Abuse and Neglect.

Reiniger, N., Robinson, E., & McHugh, M. (1995, January).

Mandated training of professionals: A means for improving reporting of

suspected child abuse. Child Abuse and Neglect.

Robinson, D. H. & Stevens, G. M. (1992, April 16). Child Abuse

and Neglect Fatalities: Federal and State Issues and Responses. CRS

Report to Congress. Washington, DC: Congressional Research Service.

73

U.S. Advisory Board on Child Abuse and Neglect

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Chapter Two

74

Shore, H. (1994, August 1). Verbal Testimony. In National

Symposium on Child Fatalities, The Missouri Experience. Hearing on

Child Maltreatment Fatalities. St. Louis, Missouri: Sponsored by the U.S.

Advisory Board on Child Abuse and Neglect.

Smith, B. (1994, July 21-22). Verbal testimony. Workshop on

Child Maltreatment Related Fatalities. Los Angeles, California: Sponsored

by the U.S. Advisory Board on Child Abuse on Neglect.

Staff. (1994, June 30). Baby's stun gun death ruled homicide:

Pathologist says infant was severely underweight and had been neglected.

Peoria Journal-Star, p. 1.

Staff. (1994, November 24). Aunt faces charges in baby's death:

Lyons announces manslaughter counts. Peoria Journal-Star, p. 1.

Staff. (1994, November 29). Aunt charged with manslaughter in

baby's death. Peoria Journal-Star, p. 1.

Zellman, G., & Anther, S. (1990, Winter). Mandated reporters and

CPS: A study in frustration, misunderstanding, and miscommunication

threaten the system. Public Welfare, 48,. 30-37.

U.S. Advisory Board on Child Abuse and Neglect

2 1
Chapter Three

"Who killed Cock Robin?...

Not I certainly says the fly;

My dear, this polyhedral eye

Can only make things out nearby

I mind my own bee's wax;

that's my Alibi"

W.D. Snodgrass

Coroner's Inquest

CHAPTER THREE

THE NEED FOR A NATIONWIDE SYSTEM OF

CHILD DEATH REVIEW TEAMS

In the previous two chapters we have described the dimensions of

fatal abuse and neglect that will, in the 1990s alone, take the lives of

thousands of infants and small children who are alive today or yet to be

born. We have also detailed our society's patchwork system of inadequate

efforts to identify, investigate, and understand these tragedies and to

prosecute the perpetrators.

This Board has concluded that child abuse and neglect fatalities

and serious injuries cannot be significantly reduced or prevented without

more complete information about why these deaths occur and how such

tragedies might be avoided. Despite instance after instance of system

breakdown, inadequate response, and misplaced effort described in

testimony during 1993 and 1994, we also heard agreement from scholars,

professionals, and officials that a system of comprehensive Child Death

Review Teams can make a major difference.

It is important that we make clear that this growing national

movement to understand and reduce child abuse and neglect deaths is not,

as some may believe, a "low payoff' pursuit, particularly in a country such

as ours. The United States has long been corn- tted to improving the

quality of life of its citizens, expending years of strenuous and costly effort

75

U.S. Advisory Board on Child Abuse And Neglect

22
Chapter Three

"Teams have to perform not

just a medical autopsy but

literally a social autopsy on

that family to determine what

led to that child's death."

Dr. William L. Kincai4 Acting

Director of Health and

Hospitals, City of St. Louis, St.

Louis Public hearing, 1994

76

to save modest numbers of lives by changing risky or inappropriate human

behavior.

It took decades of high-profile public awareness campaigns,

regulatory pressure on car makers, gradually toughened drunk-driving

laws, and the lowering of highway speed limits to reduce U.S. motor

vehicle deaths from 23.1 per 100,000 in 1963 to 16.3 per 100,000 in 1993,

amounting to 1,564 fewer lives lost in 1993 over 1963 (Bureau of the

Census, 1993; National Safety Council, 1994). And it took years of public

awareness campaigns, increasingly stringent regulations, and stronger

union demands on safety conditions to reduce on-the-job fatalities from 12

per 100,000 workers in 1984 to 8 per 100,000 in 1993, representing 2,600

fewer lives lost per year (National Safety Council, 1994).

Our message is that we, as a society, have always pursued avenues

that we hope will reduce untimely deaths, even if it takes 30 years to make

major inroads, and even if a decade is too brief a time to declare success.

This Board believes that, if a long overdue national commitment is finally

made, we will over time see a significant reduction in child deaths,

disabilities, and severe injuries from abuse and neglect.

The formation of Child Death Review Teams in all jurisdictions is

important to achieving this goal. Just as with other efforts to reduce

fatalities and severe injuries, measurable results will not be immediately

apparent. In fact, it is our prediction that, in the first few years after Child

Death Review Teams are adopted in each area, the known number of

abuse and neglect deaths will dramatically increase as we become better at

investigating and accurately identifying such deaths.

U.S. Advisory Board on t. hiW Abuse And Neglect

23
Chapter Three

THE HISTORY OF CHILD DEATH REVIEW TEAMS

The first large-scale, systematic Child Death Review Team

comprised of criminal justice, health, and social service professionals was

created in Los Angeles County in 1978 by Dr. Michael Durfee, a

California child psychiatrist who was frustrated by the failure of law

enforcement, medical, or child protection systems to determine why

hundreds of Los Angeles-area infants and small children were dying under

often vague and violent circumstances. Under the auspices of the InterAgency Council on Child Abuse and Neglect (ICAN), a multidisciplinary

group from several agencies gathered to review deaths which seemed

potentially related to abuse or neglect. The team discovered many abuse

and neglect deaths that had been missed. It suggested improvements to

make agencies more accountable, helped increase prosecutions, and

promoted ideas to improve services and treatments for high-risk families

(Durfee et al, 1992).

Slowly, the ideas from Los Angeles County were adopted in a

handful of other areas. Then, in the late 1980's and early 1990's, as a

result of a grassroots movement fueled by efforts of earlier teams,

cooperation from public agencies, and the increasing numbers of other

muqidisciplinary child abuse teams that shared resources and provided

information and support, Child Death Review Teams began to proliferate,

all with the same basic goal: to understand and prevent child deaths.

According to the American Bar Association (ABA), eight States

passed statutes for Child Death Review Teams in 1992 alone (Robinson

& Stevens 1992). Today, the early efforts undertaken by Dr. Durfee are

being replicated in many communities, from quiet Missouri towns to

Colorado mountain resorts to large Eastern cities, as recognition spreads

that the teams can fill a great unmet need.

U.S. Advisory Board on Child Abuse And Neglect

The first systematic

Child Death Review

Team was created in

Los Angeles County in

1978.

Eight states passed

statutes for Child Death

Review Teams in 1992

alone.

77
Chapter Three

Currently 45 States

have local and/or

statewide Child

Death Review

Teams.

78

The Child Death Review Team phenomenon is still so new and

evolving that much of the public and national media are not aware of the

very existence of the teams. Nevertheless, dozens of experts testifying

before this Board in 1993 and 1994 agreed that well-designed, properly

organized Child Death Review Teams appear to offer the greatest hope for

defining the underlying causes and scope of fatalities from child abuse and

neglect, identifying child protection system weaknesses, and for

determining future avenues for prevention and treatment.

A RICH SOURCE FOR UNDERSTANDING

Already, Child Death Review Teams have become one of our

richest sources for understanding the factors surrounding the untimely

deaths of children. Currently 45 States have local and/or statewide Child

Death Review teams. It was partly through Child Death Review Team

findings, in the form of annual reports by teams in California, Oregon,

Colorado, Missouri, Ohio, Oklahoma, Vermont, South Carolina, North

Carolina, Arizona, and elsewhere that important information came to light

on the very young age of most victims, evidence of previous agency

involvement with many families, demographic data on income and

ethnicity, and profiles of individual perpetrators (ICAN, 1994; Oregon

Department of Human Resources, 1993; Colorado Child Fatality Review

Committee, 1993; Stangler & Kivlahan, 1993; Missouri Department of

Social Services, 1993; Schirner & Griggs, 1992; Vermont Child Review

Committee, 1991; South Carolina Department of Human Resources, 1993;

Brown & Cox, 1994; Arizona Department of Health Services, 1994).

On a regular basis, teams grapple with systemwide flaws and

outmoded policies that often prevent authorities from recognizing and

properly responding to the deaths of infants and small children due to

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

abuse and neglect. Thus, the teams are in an ideal position to recommend

reforms and innovations that, it is hoped, will one day save children's

lives.

Some States, such as Missouri, Colorado, and California, have

highly effective local and State teams that are already making a difference.

In Los Angeles County, for instance, as a direct result of the collaborative

efforts of team review and improved criminal investigations, the

percentage of child abuse and neglect homicides presented to the district

attorney (D.A.) grew from 50 percent of child abuse and neglect

homicides in 1989 to 87 percent in 1992. The percentage of cases in

which murder charges were filed by the D.A. increased from 78 percent in

1989 to 100 percent in 1992 (ICAN, 1993).

In response to review team findings of abuse and neglect fatalities

missed by the system in Colorado, the death certificate has been

substantially revised and a 1992 law gives coroners access to child

protective service (CPS) records when investigating questionable child

deaths.

In Georgia, the first State effort to review child deaths was

undertaken in 1989 in response to a newspaper exposé on suspicious child

fatalities by the Atlanta Journal-Constitution. The State review unveiled

so many hidden instances of fatal abuse and neglect that Georgia mandated

a system of local Child Death Review Teams and reformed the State's oldfashioned elected coroner system. Coroners had often misdiagnosedand

in some cases had even helped to cover upall but the most obvious child

abuse and neglect deaths. Today, a full medical examiner's inquiry is

required for any unexpected or unexplained death of a child under age 7.

In Iowa, Child Death Review Teams successfully promoted a new

rule for handling disputes among physicians over whether a child has been

abusedan issue of great importance in deciding whether a child can

"Now that the teams have

scrutinized all children's deaths

in Colorado, we see clearly the

numbers of children who have

died needlessly, brutally, or in

circumstances of gross neglect.

Out of this wasteland must come

some meaning."Dr. Donna

Rosenberg, Pediatrician,

Denver Public hearing, 1993

79

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

Well-organized

teams have produced

impressive results.

80

safely be returned home. If two doctors disagree, the decision is taken out

of the hands of the CPS case worker and made by a third, mutually

acceptable physician, or by a physician with greater expertise.

Well-organized local efforts have also produced impressive results.

One team with a well-developed review procedure is the Franklin County,

Ohio, Deceased Child Review System, which now works with hospitals

and health authorities to identify postpartum mothers who are at high risk

for abuse and neglect and immediately links them with services.

In Los Angeles, the countywide team discovered during case

review that many males involved in fatal child abuse were boyfriends or

former partners of the mother who did not live in the home, yet were

allowed to babysit. The Director of Children and Family Services

subsequently alerted all CPS workers to evaluate the caretaking abilities of

each family's babysitters as an integral part of assessing risk to children in

the home.

Teams have proven valuable in efforts to reform the flawed system

for collecting and analyzing data on child abuse and neglect deaths

described in Chapter One. Arizona, California, Colorado, Missouri,

Oklahoma, and others have developed comprehensive data forms for

recording each child fatality by demographics, medical history, previous

CPS contact, and other factors important to improving services and

creating prevention strategies.

While teams may initially focus their efforts on the most extreme

cases of abuse and neglect, and upon deaths whose causes seem suspicious

or vague, over time most teams expand their focus to include review of all

child deaths. Many teams have identif ied trends in child deaths due to

accidents and other causes, leading to the development of preventive

actions.

For example Child Death Review Teams have promoted many

laws and agency-level policy improvements aimed at reducing child death

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

caused by so-called "supervision neglect," such as swimming-pool

drownings and tragedies involving children playing with guns. California,

Florida, and Minnesota, for instance, now hold parents responsible if a

child injures or kills himself or someone else with a family gun left

accessible to the child.

Other teams have been equally successful. A team in Sacramento

coauthored regulations for backyard pool fencing following a rash of child

drownings, and a team in Placer County, California, undertook an

education campaign with doctors and parents after several toddlers

drowned in small tubs and 5-gallon buckets. A team in Franklin County,

Ohio launched a program assuring that all families with young children

were issued smoke alarms, and a team in Oregon developed a Relief

Nursery Program for parents at high risk for abuse. The Los Angeles

County team joined several State Attorneys General in petitioning the

Food and Drug Administration (FDA) to child-proof the packaging of

prenatal iron tablets and change the coloring to make them look less like

candy. This action followed the poisoning deaths of 12 infants and small

children in Los Angeles County who swallowed handfuls of the tablets

while unsupervised. In October 1994, the FDA published proposed

regulations to implement the changes.

As the teams continue to spread to new areas, it is hoped they will

gather enough information to guide society as it designs a new generation

of prevention efforts. They will have even greater influence, using what

they know to draw a more detailed picture of the families and situations

involved in severe and fatal child abuse. This Board believes that such

efforts can provide direction to child abuse and neglect prevention and

treatment services, and one day dramatically reduce the unacceptable rates

of child abuse and neglect fatalities in the Nation.

U.S. Advisory Board on Child Abuse And Neglect

28

81
Chapter Three

82

A RECENT CASE:

A sheriff's deputy in a California suburb thought there was

something familiar about her latest case, that of a seriously injured little

boy. Then she remembered that the same babysitter had been watching

baby girl Jennifer, a 7-month-old who had died 2 years earlier from a

massive subdural hematoma. After Jennifer's death, a fellow deputy had

asked the Child Death Review Team for help because she sensed that

neither parent had killed Jennifer. The Review Team found that Jennifer

died from a blow to her head equal to a direct hit with an iron frying pan.

They pinpointed the time of the attack to the period in which the babysitter

was watching Jennifer. Unfortunately, the babysitter disappeared. Two

years later, the quick-thinking deputy, investigating the serious abuse of

another young child, and armed with information from an effective Child

Death Review Team, remembered the same babysitter and arrested her for

Jennifer's murder.Deanne Tilton Durfee, Written testimony, Los

Angeles, 1994

ONE COOPERATIVE SUCCESS:

Team investigations and prosecutions are being successfully used

by the Bridge Child Advocacy Center in Texas to increase the prosecution

and conviction rate of perpetrators of child abuse and neglect. With this

new cooperation, the prosecution and conviction rate has increased from

35 to 90 percent for homicide/felony murder.James Farren, J.D.,

Assistant District Attorney, Potter County, Texas, Dallas Public hearing,

1994

A TEAM SENDS A MESSAGE:

The team in Multnomah County, Oregon, reviews all cases of child

abuse and neglect in the county. Based on what the team learned,

Multnomah County created "red flag" protocols to help CPS identify highrisk cases and increase review of families in which children may be in

danger. These red flag protocols are being integrated in child welfare

system policies statewide.Helen Smith, Deputy District Attorney,

.Multnomah County, Oregon, Oregon Public Hearing, 1994

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

flOW TEAMS OPERATE

Local Teams

Unlike criminal investigation teams described in Chapter Two, the

primary goal of Child Death Review Teams is not to find and bring a

perpetrator to justice. The Review Teams determine the circumstances

surrounding a child's death and recommend appropriate follow up. They

track the system's response to the child's death and recommend ways to

protect and serve surviving siblings; improve the procedures and

accountability of the child protection, lawenforcement, and public health

systems; and reduce future child deaths.

Local teams tend to be more investigatory than statewide teams,

which usually act as reviewers of aggregate information on child death. In

order to perform well, local teams must be diverse, expert, and granted

broad access to information.

Local teams often review the same cases that detectives are

investigating. They focus on obvious abuse and neglect fatalities and

suspicious deaths to ensure that police and medical authorities do not

overlook such deaths, as so often happens. Teams may work closely with

a local prosecutor, creating a multidisciplinary, multiagency effort that

serves a case-building function. The composition of local teams often

includes the coroner or medical examiner, prosecutor, law enforcement,

medical representative, CPS staff, and others on an as-needed basis.

However, local Child Death Review Teams range in size,

composition, types of deaths reviewed, purpose, and effectiveness. Some

urban areas, such as New York City, use a case-review process controlled

by a single CPS agency that reviews only its own cases. Such teams miss

significant numbers of deaths in their regions, since less than half of child

abuse and neglect deaths occur in families known to official CPS agencies.

"As the team reviews the

moments, days, and months

preceding the death of a

child at the hands of a

caretaker, an overwhelming

sense of loss, failure, and

anger is inevitable."

Deanne Tilton Durfee,

Chairperson, ABCAN,

Director of ICAN, Los

Angeles, July 1994

83

U.S. Advisory Board on Child Abuse And Neglect

3 0
Chapter Three

84

Single-agency reviews also lack the accountability of systemwide,

multiagency peer review.

The makeup and expertise of local teams vary considerably from

rural to urban areas. The definitions and the kinds of information

collected differ, creating barriers to compiling a complete nationwide

picture.

FROM THE TRENCHES:

Since the death review process was first attempted in Idaho in

1989, team members have encountered resistance from local law

enforcement and judicial personnel who do not want to work on child

abuse and neglect cases. Local agencies lack the resources and personnel

to counteract problems created by misunderstood confidentiality

regulations and county coroner systems that rely on coroners with little or

no medical training. Ed Vandusen, Division of Family and Children's

Services, Idaho Department of Health and Welfare, Oregon Public

Hearing, 1994.

Statewide Teams

The epidemiological approach of well-designed statewide Child

Death Review Teams is invaluable. They collect larger samples of cases

than local teams, allowing them to detect trends and view information with

a perspective that is not always obvious in local analysis. Today, 31 States

have statewide teams. In addition, the District of Columbia and the

Department of Defense have teams for all its military branches. However,

14 States still have only local teams, often serving just one major city, and

5 States have no team of any kind at the time of this publication.

Statewide teams usually meet periodically for retrospective

reviews that can include a backlog of months or years of cases. They may

review deaths from abuse and neglect as well as other suspiciou 4eaths.

Because of the large number of deaths reviewed and the difficult logistics

of assembling a State team, they generally are not designed to offer

U.S. Advisory Board on Child Abusp d Neglect
Chapter Three

investigative assistance or to help access services for surviving family

members.

State teams usually have a diverse composition, often including

individual experts, government officials, and agency representatives.

Officials from the state Departments of Public Health, Social Services, and

Attorney General's office may be part of a larger team that includes

members from education, pediatrics, forensic pathology, child psychiatry,

mental health, social services, and nursing. The members may provide

expertise on substance abuse, domestic violence, Sudden Infant Death

Syndrome (SIDS), perinatal mortality, suicide prevention, child advocacy,

religious issues and other fields. This interaction can promote significant

improvement across many agencies and disciplines.

State government involvement in designing and implementing

teams varies. Colorado and Oregon have statewide committees that

actively function as both case-level and retrospective review teams, while

California's and Missouri's State panels monitor and assist county review

teams.

ONE STATE'S STRUGGLE:

In Houston, a lack of funding or incentives creates burnout and

turnover on the local team. Often the team doesn't have the personnel or

time to collect and review all pending child death cases. Complicating

matters, largely unfounded fears about confidentiality between agencies

cause a great deal ofconfusion and missed opportunities in investigating

and prosecuting abuse cases.Denise Oncken, J.D. Assistant District

Attorney, Chief of Child Abuse Division, Harris County, Texas, Dallas

Public hearing, 1994.

However, resistance to and underutilization of statewide teams

present problems. Politics and individual reluctance have prevented or

delayed the formation of review teams. Populous States such as Michigan,

U.S. Advisory Board on Child Abuse And Neglect

85
Chapter Three

Florida, Ohio, and Virginia have lagged behind. Other populous States,

such as New York and Pennsylvania, are just now launching state teams.

Increasingly, areas with poorly designed teams, or no teams, will

find themselves left behind as other areas begin to understand basic

systemic problems and move to impiement reforms designed to protect

children. States with less intensive or no review team efforts have little

idea of the extent of child abuse in their areas.

For example, Missouri (population 5.1 million) found more than

40 child abuse and neglect deaths in both 1992 and 1993 using its

extensive child death review system, but Michigan, a state with almost

twice as many people (population 9.3 million), has never reported more

than 19 abuse or neglect deathsa highly unlikely figure. Similarly,

Fatal abuse and neglect Colorado (population 3.3 million) has used its effective State review ranks with annual deaths

of teenage gunfire team to reveal about 30 deaths per year from abuse and neglect, while

victims. Kansas (population 2.5 million), a State that lacks comprehensive

86

review, could find only 6 such deaths in 1993 or 1994 (McCurdy & Daro,

1994; U.S. Census, 1990).

While these raw numbers for fatal abuse and neglect may appear

small when broken down to a State level, they in fact rank with annual

deaths of teenage gunfire victims (Bureau of the Census, 1993) and motor

vehicle deaths of children age 15 and under (Children's Safety Network,

1994).

One State's Experience:

When Oregon's State team discovered a high rate of fatalities

involving Shaken Baby Syndrome, a public awareness campaign was

launched on the dangers of shaking babies. The team sought

improvements in protocols of State welfare agencies, which now obtain

more background on families involved in all child abuse and neglect cases.

They give cases involving infants and preschool children a higher priority

and assign difficult cases only to experienced CPS staff.Connie

Gallagher, Program Development Manager, Children's Services Division,

and Co-Chair of Oregon's Child Fatality Review Team, Oregon Public

hearing, 1994.

U.S. Advisory Board on Child Abuse And Neglect

3 3
Chapter Three

Many experienced local teams and comprehensive State teams

have identified far more cases of child maltreatment-related deaths than

previously determined by the old system; they have also discovered

patterns that led up to these deaths. Effective teams have begun to press

for new policies and increased awareness aimed at protecting children.

Missouri, Colorado, and California offer three dramatic examples of how

competent, multidisciplinary, multiagency review can significantly change

what we know about child abuse and neglect deaths. They are described

below.

The Missouri Model

In 1992, Missouri enacted a visionary law creating a child death

review system that requires all 115 counties to have teams that include a

prosecutor, Division of Family Services official, medical examiner or

coroner, and others. A statewide team was given policy-level

responsibilities, while county-level teams conduct case-by-case review

within 48 hours of the death of any child younger than age 15. All local

teams include individuals already mandated to investigate a particular

case, such as police officers, juvenile officers, or Department of Family

Services workers. The law was the result of efforts by a handful of

frustrated and highly motivated individuals in leadership positions who

saw a need and addressed it.

Under Missouri law, extensive data collection is mandated.

Review teams must complete a standardized data form, for every death of

a child age 15 years or younger. All deaths are initially reviewed by the

coroner or medical examiner, and if certain characteristics are present,

such as a lack of witnesses or explanation for the death, the case must be

87

U.S. Advisory Board on Child Abuse And Neglect

.34
Chapter Three

The Missouri team

confirmed a startling

84 percent more child

deaths from abuse

and neglect in 1992

than in 1989.

88

reviewed by the entire team. In order to counteract the reliance upon

coroners, who, unlike medical examiners, may have no medical training,

the chairman of the review team must agree that the coroner is correct in

deciding that a case is not reviewable.

Since the Missouri team began its effort, 35 percent of all child

deaths under age 15 have been found to require review. Investigators

confirmed a startling 84 percent more child deaths from abuse and neglect

in 1992 than the traditional system found in 1989 (Stangler & Kivlahan,

1993).

Work by the teams has directly affected the outcome of numerous

investigations by child protection and law enforcement agencies because

social workers and police on the review team routinely get information

they would not otherwise learn, either from each other or from the

pathologist, who often provides new witnesses and followup information.

Officials believe they are counting and determining the accurate cause of

death for virtually all young children in Missouri, a unique and major

achievement.

The Colorado Model

The Colorado Child Fatality Review Committee investigates risk

factors; evaluates services and system response to children and families

considered to be at high risk for any type of fatality; develops findings that

can be addressed by public policy; and improves information via autopsy

reviews, death investigations, and death certificates (Thigpen & Bonner,

1994).

Unlike Missouri's legislative mandate, the Col orado Committee

was created by an agreement between the State Department of Health

Services and Social Services, and includes representatives from those

Departments, as well as Education, Transportation, and Criminal Justice,

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

along with community experts who together review cases and issue an

annual report.

As a result of the Committee's work, Colorado has passed

legislation to improve exchange of records among professionals

working on child death cases; developed death scene investigation

guidelines for police, coroners and CPS; revised the State's death

certificate; and increased the number of autopsies that are conducted in

cases deemed to be SIDS.

Colorado revised the

State's death certificate

and increased the

number of autopsies

that are conducted in

cases deemed to be

SIDS.

The California Model

The California State team began functioning before a law passed in

1992 made it official. The major activities of the State team are:

coordinating and supporting activities of 45 local teams by sharing local

reports, prevention programs and training; providing case and team

consultation and training; supporting regional multi-county meetings;

and assisting with multicounty and multistate programs and cases. Fortyfive of the State's 58 counties have teams covering about 28.5 million

people, which represents 95 percent of the State, or more than 11 percent

of the Nation's population (Durfee, testimony, 1994).

The California State team established the Nation's first integrated

State child death data system, using existing data contained in State

indexes. The system matches case-level data on child homicid:: by

county and by victim's age, using vital statisticsfrom the Department of

Health Statistics, child homicides reported in the California Department

of Justice homicide file, and fatal child abuse and neglect cases from the

State's Child Abuse Index.

This crossreferencing helps ensure that cases are not misc.,- by the

system. Correction and matching ofcase-level data have impro.

information in each of these databases, improved interagency

U.S. Advisory Board on Child Abuse And Neglect

The California State

team established the

nation's first

integrated State child

death data system,

using existing data.

0 6

89
Chapter Three

There is a critical

need to link State

teams.

90

collaboration, and led to reforms in management of child abuse and

neglect cases.

STRATEGIES FOR IMPROVEMENT

Toward National Leadership

Child Death Review Team members from many regions repeatedly

testified before this Board that they need a common, national-level

mechanism for sharing information, identifying trends, and giving voice to

key issues concerning fatal child abuse and neglect that otherwise may not

progress much beyond a team's own boundaries. There is a critical need

to add to this in order to share protocols, legislative models and resources,

as well as to address cases that cross State lines as families move or

perpetrators flee.

A national structure is needed to incorporate the knowledge of the

teams, establish a mechanism for disseminating that knowledge, and

facilitate development of a national perspective to prevent child abuse and

neglect fatalities. This can be accomplished through the designation of

individuals within the Department of Health and Human Services (DHHS)

and the Department of Justice (DOJ) who could assume ongoing

responsibility to support this process and the semiannual convening of

experts from throughout the country to review and analyze relevant data,

share information, track national trends, and develop recommendations.

An annual report would be compiled and disseminated by the DHHS and

DOJ staff.

We are not advocating a new bureaucracy, but a task-oriented

structure and process. This would ensure that information and guidance

are provided to States and localities seeking to initiate or improve their

efforts to identify, review, and prevent child abuse and neglect fatalities.

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

We note that a national child fatality review team concept has

strongly been endorsed by the Child Fatality Review Advisory Work

Group of the Federal Interagency Task Force on Child Abuse and Neglect.

Although our Board is not recommending the establishment of a formal

team with defined membership, we believe the structure and process

described above will accomplish the desired goals developed by the Task

Force as a result of hearings held by the Health Resources and Services

Administration's Maternal and Child Health Bureau (MCHB).

In addition, DHHS should designate an appropriate Federal entity

to provide clearinghouse services to ensure that services and training

materials are shared with all States.

Beyond the need for a national focus and an ongoing clearinghouse

function, State and local Child Death Review Teams must be integrated

into Federal and State health care planning. The health care establishment

does not perceive child abuse and neglect fatalities as "their problem."

DHHS can change both the perception, and the practice, if the Secretary

directs that policymakers under her supervision work to integrate Child

Death Review Teams into planning processes and policy development.

The assistance of the Centers for Disease Control and Prevention (CDC)

and National Institutes of Health (NIH) may be helpful.

We are already seeing heightened interest in Child Death Review

Teams and maltreatment-related death by Federal agencies and national

associations. In July of 1993 the Centers for Disease Control and

Prevention, together with the Maternal and Child Health Bureau,

sponsored a work group to help develop a model death-scene protocol.

The ABA Center on Children and the Law and ICAN are working

under an the National Center on Child Abuse and Neglect (NCCAN) grant

to provide models for training Child Death Review Teams nationally,

update the rapidly changing map of review team locations, update the

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U.S. Advisory Board on Child Abuse And Neglect

:I 8
Chapter Three

92

national directory, and create a newsletter. With the involvement of the

Federal Government, all of these activities could be centrally coordinated,

and the information they produce disseminated to their States and

localities. Such an effort should lead to improvement in the expertise and

effectiveness of Child Death Review Teams.

Confronting Confidentialiti Obstacles

A RECENT CASE:

Douglas died in California at the age of 14 months of posttraumatic seizure disorder, but his autopsy showed the all-too-common

evidence of past assaults: old subdural injuries and fluid collection. The

local sheriff had taken Douglas away at 7 months of age with the head

injuries that eventually led to his seizures, but a physician who had raised

suspicions of abuse withdrew his suspicion and Douglas was released to

his parents. Social Services followed the family with 5 months of

voluntary services, and Douglas was sent for a medical workup to a

children's hospital and a regional medical center. Both hospitals

theorized, without having access to his medical or family history, that

Douglas must have been injured by a traumatic birth. After Douglas died,

a coroner finally reviewed Douglas' medical records and discovered that

he had not experienced a traumatic birth. The medical examiner ruled his

death a homicide.Los Angeles Workshop, July, 1994.

Concerns over confidentiality were cited again and again by

experts testifying before this Board as a real obstacle to saving children's

lives. Child Death Review Teams encounter this problem daily.

However, the ABA's published documents and testimony to this Board

should allay fears among CPS workers, doctors, police, teachers,

prosecutors, and others over criminal penalties or loss of Federal funding.

The ABA has found that as long as Child Death Review Teams carefully

manage their records, fear of criminal penalties or loss of funding within

agencies who share their information is unfounded (Kaplan, personal

communication, 1994).

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

Federal regulations require that, in order to qualify for Federal

funds under the Child Abuse and Prevention Act (CAPTA) and Titles IVB and IV-E, States must enact laws providing that all records concerning

reports of child abuse and neglect are confidential. Unauthorized

disclosure is a criminal offense. However, these Federal regulations have

specifically exempted multidisciplinary review teams from restrictions on

sharing information within team settings (Regulation 45 C.F.R. 1340.11).

Nevertheless, misconceptions about the law are widespread.

Many researchers and front-line workers believe these widely

misinterpreted confidentiality regulations hinder the protection of children.

Coroners and medical examiners, public health officials, and law

enforcement agencies often encounter stubborn resistance from CPS

officials who believe they must withhold their case information (Anderson

et al, 1991).

Teams with established procedures for handling confidential

information are proving they know how to handle sensitive information in

a responsible way. However, this issue presents such a major obstacle that

legislative clarification is needed at the state and federal levels. We urge

the ABA, National District Attorney's Association, National Association

of Medical Examiners, American Academy of Pediatrics, CDC, American

Public Health Association, and law enforcement and child protection

associations to push for implementation of model confidentiality

legislation.

"Too often, caretakers who

abuse are given every

opportunity to bury their

deeds in the name of

confidentiality, while we bury

their children." Randell

Alexander, ABCAN Board

member, Los Angeles

Workshop, 1994

93

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1 4 0
Chapter Three

94

ONE STATE'S ANSWER:

Arizona law (Title 36, Chapter 35, Article 1) provides that

members of a team, persons attending a team meeting, and persons

presenting information to a team may not be questioned in any civil or

criminal proceedings regarding information presented in or opinions

formed as a result of a meeting. The law also notes: "Nothing in this

subsection shall be construed to prevent a person from testifying to

information obtained independently of the team or which is public

information."

Defter Team Design and Support

Differences in composition and function of Child Death Review

Teams have not been systematically studied, in part because most teams

are so new. However, there is a great need to determine which models

work best and to show States ways to support those models. Suggestions

from Missouri's experience include establishing an extensive Crime/Event

Scene Checklist that ensures all pertinent aspects of an investigation are

performed thoroughly and consistently; creating protocols to improve

interviewing of victims, witnesses, and suspects; and improving

photography and sketches of the death scene (Stangler & Kivlahan, 1993).

One well-established design is Los Angeles County's, the first

team in the country. Every morning, the county coroner's office compiles

a list of all child death cases that came to its attention in the previous 24

hours, and specific case information is sent to the ICAN, where it is routed

to team members from the D.A's office, Department of Children and

Family Services, Los Angeles Police Department, county Sheriff's

Department, and county Department of Health Services. Members check

their agencies' computers and files for any previous contacts with that

child or family. The results of crosschecking are then returned to ICAN

for analysis. The team decides which of the fatalities should be reviewed

U.S. Advisory Board on Child Abuse And Neglect

41
Chapter Three

due to unique circumstances or questions and asks agency staff involved

with a case to attend discussions and share their knowledge.

Deaths caused by abuse or neglect; all child suicides; and any

accidental, natural, or undetermined child deaths that meet team protocols

for review are compiled by the coroner in a year-end summary. In 1993,

271 reviewable deaths were reported by the coroner's office to the ICAN

Child Death Review Team. Figure 1 summarizes how those 271 deaths

were categorized and where discoveries led to changes in cause of death:

Ho

Cases

Iupon

Case

I liPon

1 Cluld Abuse Accidental Homdes Deaths

Flow Chart of Case Distribution for Analysis

271 Initially Referred by Coroner

Record Checks by

Department of Children's Services Law Enforcement District Attorney

Department of Health Services

Department of Justice

0

icicles

Jmcluded

trfleW

2

; added

review

Source: ICAN, 1994

42

fetal Deaths

95

U.S. Advisory Board on Child Abuse And Neglect

42
Chapter Three

96

Findings of all teams should be disseminated and used to improve

efforts to prevent child abuse and neglect and resulting fatalities. Such

reports also alert the community, State and Nation to the scope of

fatalities. Each team should educate the public and recommend legislation

to protect children. Team findings and efforts should also be integrated

with all child and family service systems, including family support and

preservation programs designed for families at highest risk.

While no official national standards exist for team design, this

Board supports the following guidelines. Teams should:

assure broad makeup with a range of viewpoints independent from any

specific agency or entity;

seek cultural diversity, including in their membership persons who

competently reflect the various cultural concerns manifest in the issues

of child death;

include professionals from such fields as pediatrics, mental health,

publi k.. health, nursing, medical examiners or coroners, domestic

violence, substance abuse, CPS, law enforcement, education, vital

statistics, developmental disabilities, and prosecution;

be specifically authorized by legislation or government recognition;

be given broad confidentiality waivers;

monitor outcome data to assess team effectiveness in improving

criminal justice response and other system improvements;

make dissemination of findings a fundamental part of their mission;

ensure that surviving family members receive appropriate grief

counseling;

work with fetal infant mortality review teams and others looking at

causes of child fatalities;

assure competency in, or have access to, resources for addressing

issues of disability (e.g., hearing impaired);

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

receive cases from public health or coroner's records;

establish liaisons and collaborate with the military and Indian nations.

AN IDEA THAT WORKS:

Oregon approved a State law to provide noncompetitive grants to

counties to support local Child Death Review Teams. Funds are raised

through charges paid by persons convicted of felonies and misdemeanors.

Most of the money comes from traffic tickets. The Deschutes County

team, for example, receives $60,000 to $80,000 a year for staff and other

needs. This could be implemented in other States.Chris Gardner,

Deputy District Attorney, Oregon Task Force on Sex Offenses Against

Children, Oregon Public hearing, 1994.

Helping Surviving Victims

The findings of review teams make clear that the terrible human

effects of child maltreatment fatalities go well beyond the dead child and

the perpetrator. Surviving siblings may witness the abuse or suffer

additional abuse, which can have a devastating impact upon them for

decades. Siblings and other relatives need intervention and treatment, yet

often receive few or no services. Crisis intervention and bereavement

counseling are urgently needed (Durfee, 1994).

Michelle Kelley, a clinical psychologist in Denver, is among the

few experts working with sibling survivors of fatal abuse and neglect.

Her work has revealed a range of problems including post-traumatic

stress disorder, sleep disorder, depression, anxiety, withdrawal and

acting out. She has found that surviving children can be helped through

involvement in the grieving process and by an ongoing support system

(Kelley, verbal testimony, 1993).

In Los Angeles, ICAN's Child Death Review Team has convened

a group of professionals, including therapists and line staff, to build a

support system for surviving family members and others who have known

Surviving children can

be helped through

involvement in the

grieving process and by

an ongoing support

system.

97

U.S. Advisory Board on Child Abuse And Neglect

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Chapter Three

98

someone who died as a result of child abuse or domestic violence. Their

goal is to ensure that survivor needs are met through education, (e.g., how

to plan a funeral), grief counseling, and personal and professional support.

Many families find comfort within their religious community. The

clergy, therefore, represent a major resource to provide solace and grief

counseling to surviving siblings and other family members.

Yanira

Lenicia B. Weernes School -- 5th Grade

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

CHAPTER THREE RECOMMENDATIONS

Our understanding of fatal child abuse and neglect is hampered by

societal indifference combined with avoidance of the issue. In the 33

years since Dr. C. Henry Kempe first described the battered child

syndrome, more children have died from child abuse and neglect than

from urban gang wars, AIDS, or measles, yet the contrast in public

attention and commitment of resources is vast. Diverting even a small

fraction of our national attention and resources to an integrated and

comprehensive approach to the defense of children's lives is a

monumental task. Chapter Three's recommendations are designed to

begin this challenging process through the use of Child Death Review

Teams.

Recommendation 10: The Secretary of DHHS, the U. S. Attorney

General, and the Secretary of Defense should work together to assure

there is an ongoing national focus on fatal child abuse and neglect and

to oversee an ongoing structure to support the national system of

local, State, and Federal child abuse and neglect fatality review

efforts.

This should include:

Designation of federal agency contacts DHHS, DOJ, and the

Department of Defense, who will have ongoing responsibility to

support the process.

The convening semiannually of a group of advisors to review the

current status of child death review teams, team reports, data

collection, intra-and interstate sharing of resources, as well as intraand interstate management of cases that cross geographic boundaries.

This will involve the reviewing and analyzing aggregate data, tracking

of national trends, and developing recommendations on related policy

and procedural issues.

To ensure needed expertise and diversity of views, equal or

substantial representation should come from Federal agencies, State and

99

U.S. Advisory Board on Child Abuse And Neglect

4 6
Chapter Three

100

local teams, national professional groups and programs, and individual

experts. The DHHS and DOJ should provide support of this defined

effort.

An annual report should be developed. This report would compile

the information from the States, give a nationwide perspective on the

nature and extent of child abuse and neglect deaths, and suggest preventive

strategies. The report would be designed to assist professionals and

educate the public and Congress.

Recommendation 11: A national-level effort should ensure that

services and training materials on fatal child abuse and neglect are

made available to all States by an appropriate Federal-level

clearinghouse as designated by the DHHS and the DOJ.

Federal resources must be allocated to provide a far more

meaningful level of expertise, technical assistance, and resources to

professionals and agencies who need it. This effort is intended to support

and augment the development of State and local Child Death Review

Teams.

Because of the broad interdisciplinary nature of these issues, the

Secretary of DHHS and the U.S. Attorney General should oversee this

effort.

Recommendation 12: All States should have State-level Child Death

Review Teams. Such teams should also be established within the

military branches, Indian Nations and territories

Every state should have a multidisciplinary, multiagency statewide

Child Death Review Team whose membership includes criminal

justice, health, social service, and other relevant agencies and

individuals. Multidisciplinary, multiagency teams should also be

established within the military branches, Indian Nations and territories.

Teams should examine causes of all child death under age 18, with

particular attention to unexplained and unexpected child deaths and

others that may be caused by child abuse and neglect. Teams should

publish an annual report that strives for uniformity of data collection

with other States, summarizes case findings, and recommends system

improvements.

U.S. Advisory Board on Child Abuse And Neglect

A

4
Chapter Three

Federal support should ensure ongoing functioning of teams by

offering incentives to create and maintain teams, and model team

protocols and reports.

State teams must be diverse, meeting the criteriapreviously described.

Recommendation 13: Child Death Review Teams should be

established at the local or regional level within States.

Local multiagency, multidisciplinary teams are the core of the

system, particularly for heavily populated States. They facilitate

investigations and case management, suggesting system improvements

and followup. In certain cases, regional teams should be established.

These cases include rural counties that can share a single team and

resources, border areas with other States or nations, and highly populated

regions where counties want to share information and strategies. To

facilitate communication between different locales as well as different

agencies such as military and nonmilitary, liaisons should be identified.

Recommendation 14: Model legislation should be enacted to address

confidentiality.

NCCAN should continue its work in this area. Legislation should

provide clear legal immunity from legal sanctions for team members who

share information in the course of the team's work, protect such

information from judicial discovery, and specify protocols regarding

public access to the teams' work.

Confidentiality barriers must also be removed between military

and civilian authorities; within the military, between local, State, and

Federal agencies; and Indian Nations.

States should enact legislation to clarify their ability to share

information among law enforcement, CPS, mental health, and health

agencies.

In addition, States should develop and maintain child abuse

registries that provide updated and retrievable information on related

fatalities. Investigation teams including law enforcement, CPS, and Child

Death Review Teams, as well as other States, should have ready access to

these registries.

U.S. Advisory Board on Child Abuse And Neglect

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101
Chapter Three

102

Recommendation 15: States and communities should assure that the

religious community is included in efforts to prevent child abuse and

neglect fatalities as well as in the provision of grief counseling to

surviving family members following the death of a child. The

religious community should take a proactive role in becoming

involved in these efforts.

As emphasized in the Board's 1993 report Neighbors Helping

Neighbors, religious communities represent centers of service, places of

acceptance, and a source of moral leadership in the comprehensive

community-based child protection system. The religious community has a

unique capacity to reach out to and provide support and counseling to

families, including those with small children who are isolated from public

service systems. As has been demonstrated in many States, the clergy

could play a critical role in efforts to prevent serious and fatal child abuse

and neglect. Members of the clergy also are a vital resource in the

provision of personal support, spiritual guidance, and counseling to

surviving siblings and other family members. The Board believes States

and communities should actively seek the involvement of the religious

community and encourage religious organizations to work together to

increase their awareness, participation, and collaboration.

U.S. Advisory Board on Child Abuse And Neglect
Chapter Three

CHAPTER THREE REFERENCES

Anderson, T. L., Wells, S., & Salus, M. (1991). Data Collection

for Child Fatalities: Existing Efforts and Proposed Uniform Guidelines.

Washington, DC: American Bar Association.

Arizona Department of Health Services. (1994). Arizona Child

Fatality Review Team, 1st Annual Report. Phoenix: Arizona Department

of Health Services.

Brown, G., & Cox, P. (December, 1994). North Carolina Fatality

Prevention Team, Child Fatalities, I year profile [Special Report]. Chapel

Hill, North Carolina: Office of Chief Medical Examiner.

Bureau of Census. (1990). United States Census. Washington, DC:

Bureau of Census.

Bureau of Census. (1993). Statistical Abstract of the United States

(113th Edition). Washington, DC: Department of Commerce.

Children's Safety Network. (1994). Building Safe Communities:

State and Local Strategies for Preventing Injury and Violence. Arlington,

Virginia: National Center for Education in Maternal and Child Health.

Colorado Child Fatality Review Committee. (1993). Annual

Report. Denver: Colorado Department of Health.

Durfee, M. (1994, Winter). The Rest of the Story: Psycho-social s.

American Professional Society on the Abuse of Children (APSAC)

Advisor.

Durfee, M., Gellert, G., & Tilton Durfee, D. (1992). Origins and

clinical relevance of child death review teams. Journal of the American

Medical Association, 237, 3172-3173.

Durfee, M. (1994, July 21-22). Verbal testimony. Focus group on

Child Maltreatment Related Fatalities. Los Angeles: Sponsored by the

U.S. Advisory Board on Child Abuse and Neglect.

Kaplan, S. (1994, December). [American Bar Association, Center

on Children and the Law] ( Deanne Tilton Durfee). Washington, DC.

103

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Kelley, M. (1993, March 11). Verbal testimony. Public Hearing on

Child Maltreatment Related Fatalities. Denver, Colorado: Sponsored by

the U.S. Advisory Board on Child Abuse and Neglect.

Los Angeles County Interagency Council on Child Abuse and

Neglect. (1994). ICAN Multi-Agency Child Death Review Team Report for

1993. El Monte, California: ICAN.

McCurdy, K., & Daro, D. (1994). Current Trends in Child Abuse

Reporting and Fatalities: The Results of the 1993 Annual Fifty State

Survey. National Center on Child Abuse Prevention Research. Chicago:

National Committee for Prevention of Child Abuse.

Minnesota State Department of Human Services. (1991). Progress

Report of Minnesota Child Mortality Review Panel. St. Paul: Minnesota

State Department of Human Services.

Missouri Department of Social Services. (1993). Missouri Child

Fatality Review Project Annual Report, 1992. Jefferson City, Missouri:

Missouri Department of Social Services.

National Safety Council. (1994). Accident Facts. Itasca, Illinois:

National Safety Council.

Oregon Department of Human Resources. (1993). Task Force

Repol on Child Fatalities and Critical Injuries due to Abuse and Neglect.

Children's Services Division. Salem, Oregon: Oregon Department of

Human Resources.

Robinson, D. H., & Stevens, G. M. (1992, April 16). Child Abuse

and Neglect Fatalities: Federal and State Issues and Responses. CRS

Report for Congress. Washington, DC: Congressional Research Service.

Stangler, G., & Kivlahan, C. (1993). Missouri Child Fatality

Review Project, Interim Progress Report (Vol. April). St. Louis: Missouri

Department of Social Services and Missouri Department of Health.

Schirner, P., & Griggs, H. (1992). Franklin County, Ohio,

Deceased Child Review System, 1991 Annual Report. Grove City, Ohio:

Franklin County Children Services.

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South Carolina Department of Human Resources, C. S. (1993).

1989 through 1991: Fatal Child Abuse and Neglect in South Carolina.

Columbia, South Carolina: South Carolina Department of Social Services.

Thigpen, S., & Bonner, B. (1994, Winter). Child Death Review

Teams in Action, Special Issue on Child Fatalities. American Professional

Society on the Abuse of Children (APSAC) Advisor.

105

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Chapter Four

"Your Children are not your children,

They are the sons and daughters of life's longing for itself,

...For their souls dwell in the house of tomorrow."

Khalil Gibran

The Prophet

CHAPTER FOUR

TOWARD A BETTER FUTURE:

SERVICES AND INTERVENTIONS FOR

CHILDREN AND FAMILIES

AND FATALITY PREVENTION

PART ONE: SERVICES AND INTERVENTIONS

Child protective services (CPS), law enforcement and the juvenile

courts have a statutory mandate to assume a major role to protect children

from threats to their safety from parents and caretakers. However, as we

as emphasized in Chapter Two, if the system is going to save children,

the responsibility must increasingly be seen as a collaboration among

social service, public health, education systems, law enforcement, and

the courts. The elements of the final critical component are the

neighbors, family, friends and local agencies that comprise a

community. We must confront the fact that this larger system is not

playing the role that it could.

Federal efforts to protect children and prevent abuse and neglect

have centered around four pieces of legislation. In 1974, two major laws

were created: Title XX of the Social Security Act, which made funds

available to States for a variety of social services, and the Child Abuse

"If I had my , uthers, I'd

chisel into the foundation stone or

the archway of every childwelfare agency this simple

statement: Our first job is keeping

kids alive. And when we fail it's

something for which the public

doesn't forgive us."Jose Alfaro,

Director of Research, Children's

Aid Society, New York Focus

group, June 1994.

107

U.S. Advisory Board on Child Abuse and Neglect

, 5 3
Chapter Four

"Until all those geniuses

out there cure poverty and

the problems in the world,

somebody's got to protect

children, and you can't do

that with good intentions.

That's a perspective from the

autopsy room. Dr.

Michael Baden, Director of

Forensic Services, New York

State Police, New York

Focus group, 1994

108

Prevention and Treatment Act (CAPTA). CAPTA provided modest

discretionary and state grants and created the National Center on Child

Abuse and Neglect (NCCAN) to encourage prevention programs and offer

technical assistance to States.

In 1980, the Adoption Assistance and Child Welfare Act (P.L. 96-

272) was passed in hopes of preventing unnecessary placements and

lengthy stays in foster care. The act required "reasonable efforts" to keep

children with their parents, timely and safe reunification of families, and

expeditious adoption for children unable to return home. But the State

plans required by the legislation were so bureaucratic as to be unworkable;

Judge Richard FitzGerald of Louisville, Kentucky, called them "a work of

fantasy belonging in the fiction section of a bookstore" (Edwards, 1994, p.

28). Judges added to the problems, in that they often performed only

cursory reviews of case plans submitted by CPS for specific families.

States finally began operating Family Preservation Programs in the

mid1980's, largely funded by reallocating money from foster care. This

led to criticism that total funding to help troubled families and their

children did not increase.

The 5-year, $1 billion Family Preservation and Family Support Act

(P.L. 105-66) has given States and counties a tremendous opportunity to

shift from a crisis-response system to a system with the potential to reduce

the core family problems that lead to abuse and neglect fatalities. In its

most recent survey of 46 States, the National Committee for the

Prevention of Child Abuse (NCPCA) found that most States intend to use

about half of the money for family support services, and half for family

preservation (McCurdy & Daro, 1994).

Family support programs differ substantially from family

preservation programs in that they are designed to help overstressed and

troubled families cope with and improve their circumstances before an

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

incident of abuse or neglect occurs. The NCPCA notes: "This suggests

that States are about to make the first tangible investment in child abuse

prevention in recent memory" (McCurdy & Daro, 1994, p. 18).

It is the strong belief of this Board that this most recent legislation

should be used to help remold the child welfare system into an integrated,

prevention-oriented, community-based support system for families. In this

chapter, we will present a plan for achieving these and other crucial goals.

Jamie

Washington School 6th Grade

, ""iNs- "VI

44o"

s'1;';';,.:

109

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

Child protection

workers struggle on a

daily basis to make

responsible decisions,

but often lack the time,

tools, and money to

provide the help they

so obviously need.

"Prior contact with CPS

does not imply that the

family received needed

help. We have reason to

believe the vast bulk of

CPS reports end with the

investigation, whether

abuse is found or not."

Murray Levine, ABCAN

board member, New York

Focus group, 1994

110

CURRENT ISSUES

Inadequate Services and DecisionMaking

Testimony before this Board in 1993 and 1994 showed that child

protection workers struggle on a daily basis to make responsible decisions

about providing services to troubled families, but often lack the time, tools

and money to provide families and children with the help they so

obviously need.

Perhaps the most alarming trend is the frequency with which no

services for children and families are offered at all. According to the

NCPCA survey, 22 States in 1993 indicated that almost one in three

families in which abuse or neglect was substantiated received no

counseling, intervention, or other help. That translates to some 300,000

cases of substantiated abuse or neglect that received no basic social

services to counteract the effects of abuse or neglect, or to prevent future

problems (McCurdy & Daro, 1994). Moreover, current programs rely

heavily on counseling or parenting classes, when overburdened parents

often need a few hours respite from the child or help in coping with

spousal abuse (Ewigman, verbal testimony, 1994; Nazario, verbal

testimony, 1994).

In many regions and agencies, a debate is underway regarding

which decision-making guidelines should be applied to the thousands of

high-risk cases that come before CPS agencies each year. A study by

Cornell University found that the desire of caseworkers to reward or

punish certain parents, the internal values of the particular system, and

efforts by caseworkers to anticipate how a judge might rule all influence

whether a family receives services, court intervention, or nothing at all

(Alfaro, verbal testimony, 1994).

U.S. Advisory Board on Child Abuse and Neglect

5
Chapter Four

Efforts are underway to provide workers with better decision

making tools. For example, researchers at the University of Chicago are

attempting to describe, for possible wider use, a decision-making model

used by experienced, highly trained CPS social workers (Chapin 1-lall

Center for Children, 1989). Protocols for assessing family risks to a

child's safety have been developed in the past decade. Unfortunately, the

purpose of risk assessment has become seriously diluted and confused.

Risk assessment tools were meant to draw CPS staff attention to

circumstances that research indicates are correlated with abuse and

neglect. The intent of risk assessment was to identify predictive factors so

that appropriate prevention strategies and interventions could be developed

and implemented.

However, many elected officials, policymakers, and the public

have come to believe that assessment tools can be used to accurately

predict which parents are going to kill their children. This is not

supported by design or research and is far beyond the intended purpose of

risk assessment instruments. It is difficult to devise risk factors to predict

abuse or neglect with accuracy. It is all the more difficult to predict child

deaths.

Confusion Over and Misapplication of Family Preservation Services

Over a decade ago, in the State of Washington, Behavioral

Sciences Institute, Inc., developed the Homebuilders service delivery

model. This model was designed to help families through crises by

providing intensive, home-based services for 6 weeks. Because many

families had ongoing problems, the program linked families to longer-term

social services after the crisis ended. The program helped families through

a variety of difficulties, including reports of child abuse and neglect that

might otherwise have resulted in a foster care placement.

II I

U.S. Advisory Board on Child Abuse and Neglect
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"It is difficult to balance

family preservation policy

with the understanding that

some children require

immediate intervention and

removal."Jane Beveridge,

Child Protection Program

Administration, Colorado

Focus group, 1993

112

Because of the potential of this program model to help children and

families and to avoid foster care, its strategy became central to the

discussion of the 1980 Adoption Assistance and Child Welfare Act and to

its emphasis on making "reasonable efforts" to avoid foster care. Many

jurisdictions have since adopted or adapted the Homebuilders model.

However, as highlighted in recent media reports and in testimony

before this Board, the expansion of family preservation efforts has given

rise to a number of controversies that have a direct bearing on child

fatalities.

First, the term "family preservation" has different meanings in

various jurisdictions. In some areas, family preservation refers to a

philosophy of child protection, complete with its own set of guiding

principles. In others, it has a more pragmatic meaning: a specific set of

intensive services available 24 hours a day to families in crisis. In still

others, "family preservation" is used as a general rubric to indicate

avoidance of foster care. As a result, tremendous confusion has arisen.

Researchers, policymakers, and the public are equating incompatible

definitions and programs, leading to further misunderstanding.

Second, some supporters of family preservation programs

inappropriately promote them as a "magic bullet" able to meet all needs of

any family. As a result of such thinking, jurisdictions too often use

programs indiscriminately for any family reported for child abuse or

neglect.

Finally, family preservation programs have been promoted

primarily as a way to save money on foster care. Unfortunately, saving

public funds is too often made the only goal or the primary goal, while far

more important goals--such as helping families negotiate a crisis or using

foster care to protect childrenhave taken a back seat.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

In view of today's debates over "reasonable efforts," this Board

assumes that Congress intended jurisdictions to make efforts to avoid

placing children unnecessarily in foster care only if the safety of the

child could be reasonably assured. It is clear that future State and

Federal legislation focused on families and children must explicitly

state all desired goals, including child safety, to avoid putting children

at risk for injury or death.

These are pressing problems that must be addressed if family

preservation is to succeed and if children's lives are to be saved. We will

recommend a number of ways to clarify and improve family preservation

programs and to change the sometimes haphanrd manner in which

families are selected for this important service.

Congress did not specify

that the "reasonable

effort" take precedence

over assuring a child's

safety.

Inappropriate Placements

Whenever a child's safety is in serious jeopardy, that child must be

removed from the custody of the parentstemporarily if it appears that

safe reunification with the parents is feasible in the foreseeable future, and

permanently, if there is no reasonable likelihood of safe reunification.

Today, the number of child abuse and neglect-related fatalities in

foster homes and in children's institutions appears to be relatively low

(McCurdy & Daro, 1994). However, it must be recognized that removing

a child from the parental home does not guarantee a child's freedom from

abuse, neglect, or even death. Because foster homes, group homes, and

residential treatment centers act on behalf of the larger society to care for

children taken from their parents, governance bodies for such institutions,

as well as government itself, must take every step to assure that children

are safe in these facilities.

In recent years, the number of children living with relatives as an

alternative to foster care has increased dramatically. This Board generally

"To answer your question

about when do you step

in to me it is not

unconstitutional to step in

f 1 send a child to school

and the child has my

handprint on their face.

You took away that child's

rights. Now we take away

your rights." A Woman

of the Family Violence

Program, Bedford Hills

Correctional Facility,

1994.

...removing a

child from a

parent does

not guarantee

a child's

freedom from

abuse...

113

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

"My oldest son was placed

with my sister, but my brotherin-law was abusive. My son

would come (visit me in

prison) and he'd cry and say,

'Mommy, nobody believes me.'

So 1 called the social worker.

She goes there, everything is

fine. What about the bruises?

Oh, he hurt himself while

playing outside. He fell. He

got into a fight. But it's not

true."A Woman of the

Family Violence Program,

Bedford Hills Correctional

Facility, 1994

114

supports the trend toward having extended families provide this traditional

support. For many children, living with relatives is positive as it continues

family contact while protecting the child and it allows the child to stay in a

familiar area and school.

The kinship care issue is complex, and we cannot attempt an

indepth discussion in this report. However, we wish to emphasize that the

importance of staying with family does not supersede the importance of

providing children safe, nurturing, and healthy environments. When

kinship care is used, appropriate services must be provided. For example,

financial support for relatives is as critical for meeting the child's needs as

is the financial help given to foster parents. Similarly, the social services

and therapeutic support provided to children in foster care are often

equally needed by relatives providing care to children who have been

abused or neglected. However, if relatives or kin are not capable of

providing care, support, and adequate supervision of a child, despite the

system's best efforts, then a safe foster care setting, with well-trained

caretakers, is more appropriate.

A highly publicized example of improper extended family

placement involved a ChiFago youth, "Yummy" Sandifer. Yummy was

first seen by the authorities when he was a 22-month-old with bruises and

scratches. A year later Yummy and his six brothers and sisters were

removed from their mother's care. The children's mother was a crack

addict who had been arrested 41 times t. the time of the children's

removal, an older brother was blind because of neglect; a sister had

second degree burns because of a "fall on a radiator"; and Yummy had

welts on his legs from an electrical cord and burns and bruises on his

shoulders and buttocks.

The children were placed with the maternal grandmother even

though her psychiatric report described her as having a "severe borderline

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

personality disorder." Either because of court placement or abandonment,

the grandmother was responsible for the care, at one time or another, of 30

grandchildren in a 3-bedroom house.

At age 11 Yummy was wanted for the murder of a 15-year-old girl.

The victim was shot when Yummy fired a 9-mm semiautomatic weapon

into a crowd of kids playing football. A few days later Yummy was

murdered. At the time of his death, Yummy had 23 felony arrests (Gibbs,

1994; Los Angeles Times, 1994, p. 1). We cannot know whether

Yummy's life would have turned out differently if he had been placed in a

less problematic environment. Nevertheless, it is reasonable to deduce

that in this case, keeping Yummy within his biological family was not the

appropriate course.

Jeremy Special Education

Division

Fair Avenue School

115

U.S. Advisory Board on Child Abuse and Neglect

,61.

1
Chapter Four

Family

preservation is not

a magic bullet.

116

STRATEGIES FOR IMPROVEMENT

Intensive Family Preservation Seryices

This Board believes that when family preservation programs are

designed well, perceived dichotomies between child safety and

preservation will be seen as artificial. Family preservation, as a

philosophy and as a program model, should seek to keep families together

only when the safety of all family members can be reasonably assured.

Some critics, including some domestic violence program leaders, perceive

some family preservation programs as attempts to keep families together

even while ...Ju lt violence continues in the household. However, no

legitimate program will promote family preservation "at all costs," and no

agency should have such a practice.

On the contrary, it is critical that CPS and domestic violence

programs explicitly state that they will first conduct a review of risk to all

family members and will decide to pursue preservation efforts only if it

presents a reasonably safe strategy for the chnd and others. Family

preservation is not a magic bullet, and it need not be tried for each family.

It should rather be included among an array of options when considering

alternatives to foster care that are in the "best interest" of the child.

There is insufficient research indicating whether existing family

preservation programs achieve the goal of protecting children while saving

families. It is also unknown which families receive the most benefit, or

which problems in a family are best addressed. Moreover, there are no

meaningful data that compare child deaths or serious injury within family

preservation programs to data on child deaths or serious injury among

similar families who have other interventions, such as foster care.

U.S. Advisory Board on Child Abuse and Neglect

G 2
Chapter Four

Despite the lack of conclusive outcome data, this Board recognizes

family preservation as both an appropriate philosophical goal and as a

legitimate model of service delivery. The limited amount of research

should not prohibit its use any more than the lack of research prohibits

using other interventions.

While each community must define the array of services it will

provide, we believes that family preservation services should be available

in every jurisdiction. We suggest below several critical elements to a

strong family preservation program model, which we describe more fully

in Recommendation 20.

Child safety is always a priority in any service decision.

Ongoing assessment of the family service plan and of potential risk is

critical. This would include a culturally competent assessment of both

family strengths and problems, which is critical to implementing a

viable service plan that respects family heritage or tradition. Workers

must assure that abuse is not allowed under the guise that it is

culturally appropriate.

Services should be:

Comprehensive.

Provided primarily in the family's home or apartment, including faceto-face contact with all of the children and family members.

Intensive, particularly during the period of crisis.

Provided by staff with small caseloads who are available 24-hours per

day, 7 days a week, from multiple agencies in the community with

specialized staff available as needed.

Designed with time-limited goals, with ongoing evaluation as to goal

achievement.

Closely related to other long-term services to meet a family's needs

after the crisis is over.

"The preservation offamilies

is an important goal, but not

more important than the

safety of children. All of us

should be seeking to keep

families togetheras long as

we can provide for the safety

of all family members."

Michael Weber, ABCAN

Board member, Director of

the Program for the

Community Protection of

Children, Washington DC

Board meeting, 1994

117

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

Family preservation

services must

include the

flexibiliO to assure

families receive help

over a longer time

period.

118

Guided by values emphasizing active family participation as well as

protection of the child.

We emphasize that family preservation, correctly designed, is a

crisis intervention model that can help a family through difficult situations

that might otherwise lead to the placement, abuse, or neglect of a child.

However, a 6-week program does not constitute a complete program of

family therapy. Six weeks cannot reverse a long pattern of unacceptable

childrearing or a lifetime's acquiring of inappropriate social skills.

To make long-term changes, family preservation services must

include the flexibility to ensure that families receive help over a longer

time period and are supplemented by a complement of needed services,

such as mental health, substance abuse, domestic violence counseling,

respite care, shelters for battered women, health care, and homemaker

assistance. This is one of the necessary interactions between family

preservation services and the broader array of family and children's

programs.

ONE PROMISING EFFORT:

In Los Angeles County, child safety is the top priority of the Family

Preservation program. All CPS workers and community network service

providers must formally agree to this priority. Under a pilot program,

decisions on whether a child is taken into custody or remains home and is

enrolled in a preservation program are made by the Child Abuse Response

Unit, comprised of a sheriff's deputy specializing in child abuse and a

social worker. The team responds to abuse reports and jointly assesses the

family. One important tool is a "red flag" list of five parental factors and

three child factors that put a child at high risk for serious injur, or death.

If either team member feels the child is in danger, the family is not chosen

for the program. If the family is selected, a network of community

agencies develops a customized plan of services and ongoing evaluation.

The program was developed in the wake of public criticism that children

were not protected while participating in family preservation programs.

Bruce Rubenstein, Deputy Director, Los Angeles County Department of

Children's and Family Services, New York Focus group, 1994.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

Expedited Decisions on Permanence

For some children, attempts to seek a safe reunification with their

parents will fail. For others, particularly in egregious cases of abuse, it

will be immediately clear that the child cannot be returned home safely. In

both cases, an alternative family must quickly be sought. However, there

are no national standards or policies used to guide decisions on when to

seek termination of parental rights (TPR). Michigan, Washington, Iowa,

and Oregon are among the few States with written guidance on thresholds

for situations requiring removal.

When caseworkers reasonably believe enough changes will be

made in and by the family to permit a safe reunification, services designed

to promote those changes must be started as soon as the child enters foster

care. Otherwise, their efficacy will not be tested, and the child may linger

in foster care.

Communities increasingly realize that some children must be

removed from their parents' custody through legal TPR and quickly

placed in stable, nurturing, permanent homes. But all too often, this does

not happen. Confusion over what constitutes "reasonable efforts," as

described earlier, has actually resulted in longer foster care stays for

children in some areas as agencies make multiple attempts over many

years to reunite problematic families. New York City released a study in

December of 1994 uat found that foster children in New York now

languish in foster care for an average of nearly 4 years, instead of the 2-

year average in 1988 (New York Times, 1994).

A troubling example is that of the siblings of Adam Mann, two

young boys who struggled through many foster care placements after both

parents wf:re convicted in the killing of the boys' little brother. Officials

agree that TPR should have been completed, but it was not, and the

children might be returned to their mother when she is released from

"We often neglect to

consider the high risk

to children who are

born unplanned and

unwanted. One of the

most effective ways to

prevent serious and

lethal child abuse and

neglect is family

planning."Dr. Harry

Wilson, Providence

Memorial Hospital, El

Paso, Texas. Denver

Public hearing, 1993

119

U.S. Advisory Board on Child Abuse and Neglect

63
Chapter Four

120

prison. The controversy has set off a debate, with many arguing that the

boys were victimized twicefirst by their own parents, then by the system

(Langer, 1991).

TPR takes years in many States and counties, even in obvious

cases of severe abuse or neglect. However, as we discussed in the 1993

U.S. Advisory Board on Child Abuse and Neglect (ABCAN) Report

Neighbors Helping Neighbors, some areas are addressing this problem

(ABCAN, 1993).

It is critical that once expedited termination has occurred,

preference for placement must be given to extended family members and

kin, ifthose adults are able to safely care for and nurture the child. If the

child is old enough, his or her wishes should be considered. There must be

far more intensive efforts to recruit quality permanent homes and to

develop family-like residences. For adoptive and long-term foster care

recruitment to work, and for good adoptive and foster care families to be

retained, policies must support the care and services needed for the child.

ONE GROUP'S VISION:

Court Appointed Special Advocates (CASA's) are often used to

keep children from languishing in foster care. CASA's are trained

volunteers appointed by judges to represent the best interest of children in

the courts. CASA programs operate in all 50 States, the District of

Columbia and the Virgin Islands. This program is designed to help mostly

older children. By late 1994, there were 36,000 trained CASA's

advocating for 110,000 children. CASA children spend about 15 months

in foster care, compared to the average 27 months. In Texas last year,

CASA saved over $40 million in foster care costs, and helped prevent

many children from drifting through the system without receiving a final

decision on permanence.Jane Quentan, Executive Director, Texas

CASA, Dallas Public hearing, 1994.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

PART TWO: FATALITY PREVENTION

We, as a society, want swift action and clear-cut policies. We

abhor what appears to be the failure of the system and the passing of the

buck. However, after 2 years of testimony from experts in a wide range of

fields, this Board is convinced that the public debate over who "made a

mistake" that led to a child's death usually focuses on the wrong issues.

The best chance we have for reducing these deaths is by focusing on the

right issues.

Who Is At Fault?

Mistakes are sometimes made in clear-cut cases of danger to a

child, and these tragic human errors deserve media or public attention.

But when the Chicago Tribune asks, in its 1994 series on child

homicides, "Who is at fault?" for failing to rescue children from

households that are clearly in turmoil, the unfortunate answer must be:

usually, no one person or agency is at fault. The difficult truth is that,

except in obvious cases of imminent danger, no individual has the

Chances are high that

most of the families in

which a child will die

will escape notice until

the death occurs.

understanding or scientific tools needed to foresee serious abuse or neglect

that causes the death of a child.

One challenge faced by those who deal with high-risk families who

might seriously harm or kill their children is the difficulty of predicting

which family will actually become a statistic. Becausethild abuse and

neglect deaths are a "low base-rate" phenomenon, with about 2,000 deaths

as compared to about 1.9 million reports of abuse and neglect, chances are

high that a professional cannot predict which particular family will

become so abusive or neglectful that their child dies (McClain et al, 1993;

U.S. Advisory Board on Child Abuse and Neglect

121
Chapter Four

NCCAN, 1994). Chances are also high that most of the families in which

a child will die will escape notice until the death occurs.

However, it is possible to identify and address the families at

highest risk for potentially fatal abuse and neglect because the population

of seriously abused and neglected children who each year are severely

injured (141,700) or left with permanent damage (18,000) is not a "low

base-rate" phenomenon (NCCAN, 1991; Baladerian, 1991). We need to

pay more attention to intervening with families who are at high risk for

potential injury.

The effort is analogous to the war against polio, in which hundreds

of thousands of children at risk were inoculated because it was impossible

to determine which among them would actually contract polio. This was

not perceived as a wasted effort but as a rational prevention strategy.

Today, tens of thousands of infants and small children are living in

situations that could pose a risk to their safety. For example, in 1992, 14.5

million families with children were living in poverty (NCCAN, 1994;

Bureau of the Census, 1994). In 1993, between 500,000 and 650,000

parents and children were living in the streets either temporarily or

permanently (personal communication, Debbie Chang, National Alliance

to End Homelessness); 3.3 to 10 million households with children

contained a violent male with a history of domestic abuse (Schecter &

Edleson, 1994), and 11 million parents were abusing drugs and alcohol

(personal communication, Narconon, U.S. Drug Education Division).

Poverty, history of violence, and substance abuse are all warning signs of

child fatality or injury from abuse or neglect. In families where these

risks overlap, which they often do, die threat is believed by experts to be

greatly increased.

Because we lack the capacity to identify which children might die

at the hands of their parents or caretakers, this Board is urging Congress,

"We keep saying the cause is

povertyand 1 think

sometimes we libel poor

peoplethe truth is, most poor

people don't abuse and

neglect their kids."Jose

Alfaro, Director of Research,

Children's Aid Society, New

York Focus group, 1994

122 U.S. Advisory Board on Child Abuse and Neglect

us
Chapter Four

the states and policymakers to develop prevention strategies that provide

nonstigmatizing, readily available, culturally acceptable resources to assist

all parents in their task of caring for their children. At the same time, we

must redouble our efforts to reach families at high risk for severe or fatal

abuse and neglect. By creating a comprehensive safety network for all

children, including those clearly at risk, we can hope to improve the lives

of many families, and thus protect those who need help the most.

Addressing the Perpetrators

As we have emphasized, researchers have not identified a

consistent set or cluster of personality traits that can accurately predict

which parents will become extremely abusive or neglectful enough to

cause severe injury or death. However, the experiences of dozens of Child

Death Review Teams and thousands of front-line workers continue to bear

out the fact that many such parents stand out because of behavioral,

emotional, and cognitive difficulties; histories of other violence;

involvement in substance abuse; and highly negative views ofthemselves

and their children.

Abusive parents, when compared to nonabusers, show greater

physiological reactivity, irritation, and annoyance in response to both their

children's positive and negative statments and behaviors (Casanova et ai

1992). They often perceive their own children as more aggressive,

disobedient, stupid and annoying than other children, even though nonfamily observers see none of these problems in the children (Mash et al

1983; Reid et al 1987). Studies have identified parental characteristics

associated with child abuse and neglect: low self-esteem, poor impulse

control, depression, anxiety, and antisocial behavior including aggression

and substance abuse (Pianta et al, 1989).

"We don't create safe

places for people. We

create punitive places.

We create judicial

places. But we don't

create safe environments

for a mother to come and

say, look 1 don't like

how I treat my children."

Sharon Smolick

Director, Family

Violence Program,

Bedford Hills

Correctional Facility,

1994

123

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

"Policymakers need to see

the beaten woman when

they see the beaten child,

and recognize that

battered women have few

real choices and simply

cannot leave."Alana

Bowman, Office of City

Attorney, Domestic

Violence Unit, Los Angeles

Focus group, 1994

Child protection

professionals rarely

identift, report, or

intervene to stop or

prevent domestic

violence.

124

Given these many deep-seated problems among seriously abusive

or neglectful parents, it is not surprising that little definitive research exists

that "demonstrates reductions in re-abuse among parents who receive

parent training" (NRC, 1993). Because the challenge is so great, and few

efforts have made a significant difference in altering abusive and

neglectful parental behavior, this Board will offer recommendations

designed to improve primary child abuse and neglect prevention efforts

and more consciously focus on the high-risk parent population in which

most abuse and neglect deaths and serious injuries occur.

Understanding Domestic Violence

The role of domestic violence in fatal child abuse is rarely

discussed in studies. Nevertheless, some experts argue that domestic

violence is the single major precursor to child abuse and neglect fatalities

in the United States (Stark, verbal testimony, 1994).

Child protection professionals rarely identify, report, or intervene

to stop or prevent domestic violence. According to Stark, almost half of

the mothers of abused children are being battered. Children not only

become covictims, but, Stark argues, they mimic abusive behavior (Stark,

verbal testimony, 1994). Many women may be discouraged from

reporting spousal abuse or related risks to their children for fear they could

lose custody of the children.

Because fathers and other males are difficult to reach through

traditional avenues such as health care and social programs, and because

policymakers have for so long focused on mothers, many prevention

programs are directed to single mothers who, in fact, do not play the

dominant role in child abuse and neglect fatalities, and may themselves be

victimized by the males in their lives. For example, Missouri officials

were recently stymied by this problem as they designed a new clinical

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trial. The trial involves intensive intervention for infants and toddlers

whose mothers receive public assistance from the Women, Infants and

Children Program (WIC) and who use physical discipline, score high on

an anger scale, and are believed to be at high risk for abuse. Ultimately,

Missouri officials decided that it was hard enough to persuade mothers to

attend training or to allow home visiting, and almost impossible to

persuade men, so men were not included.

The Challenge of Helping Hard-Hit Communities

Some neighborhoods suffer a highly disproportionate share of

child abuse and neglect fatalities; however, the cause remains unknown

(NRC, 1993). It is often assumed that certain neighborhoods promote

violence and household isolation, which can be factors in abuse by

parents. Researchers point out that it is equally possible that troubled

neighborhoods can develop when violent, disruptive families group

together as more stable families leave a declining area. However, fatalities

have been shown in a few studies to be as common in very isolated rural

areas as in very poor urban districts, despite a long-time assumption that

this is an inner-city problem (Jason et al, 1982; Stang ler & Kivlahan,

1993).

Household isolation that keeps neighbors, friends and relatives

away is believed to play an extremely important role in serious and fatal

abuse and neglect of infants and small children. The parent or caretaker

receives no parenting support and continues to act inappropriately in

complete privacy since the child is too young for school, where he or

she has a chance of being noticed by a teacher or other adult.

The National Research Council (NRC) noted in 1993 that much

more must be learned about using networks of friends and relatives as

"It's important to have

help in the neighborhood

where the kids can go. But

we need to educate the

neighborhood, because 1

wouldn't go to my

neighbor's house either

when I was being abused

as a child. They were

beating the shit out of their

kids. I wouldn't go

there."A Woman of the

Family Violence Program,

Bedford Hills Correctional

Facility, 1994

Some neighborhoods

suffer a highly

disproportionate share

of child abuse and

neglect fatalities.

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126

prevention systems. Household isolation may be a result of neighbors and

relatives rejecting parents with deviant behavior; thus, these families may

have no social network that will willingly help. On the other hand,

abusive parents may select friends or maintain ties with relatives who

condone their maladaptive parenting styles, increasing the likelihood of

continued abuse or neglect of the children (NRC, 1993).

The Problem of Overselling Prevention Efforts That May Not Work

Because we do not yet fully understand how to prevent many child

abuse and neglect fatalities, it is important that policymakers not oversell

promising new programs that may fail to live up to hopes or backfire due

to human error or unanticipated problems. This could generate further

negative public reaction and perhaps even put children's lives in danger by

creating a false sense of security.

An example in Illinois demonstrates how human error can

compromise even promising new programs. Recently, the State

experienced the starvation death of a child who had just been visited by

three child protection workers in a program that gave the family intensive

in-home attention and services. Each of the workers merely believed the

child to be underdeveloped. Yet at death, the child was 5 years old and

weighed only 25 pounds (McCurdy, verbal testimony, 1994).

Many prevention efforts are based upon the idea that enough

education will stop inappropriate parental behaviors. But there are

numerous examples of parental education missing the mark, indicating

that many parents either need to learn far more effective copitig skills or

need more vigilant monitoring. For example, a man was recently

convicted in Iowa for inflicting severe brain damage on a baby he had

violently shaken. The mother was also convicted for failing to stop his

many attacks. The man later admitted seeing Des Moines-area public

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72
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service TV spots warning about Shaken Baby Syndrome and stated "I

knew that I would never do anything like that to a baby" (Randy

Alexander, verbal testimony, 1994 Board meeting).

A variety of improved prevention efforts can be developed in

response to better information. For example, to prevent an infant from

falling from an apartment window, building codes may be modified to

require window guards with safety latches. While such so-called

"engineering" solutions may seem easy to implement, it is quite another

matter to prevent a father from severely beating a toddler for failing toilet

training, or to convince a drug-addicted mother to stop leaving her baby at

home alone for hours on end. Success at preventing such behavior will

remain elusive until we know more about the causes.

A RECENT CASE:

The investigation of the death of a young child revealed that the

family was actively involved in a home visiting program, but the home

visitor had not wanted to involve CPS in the family's many problems

because CPS was viewed as a negative entity. CPS, in turn, did not want

to involve police because it saw law enforcement as a negative entity. In

the end, the child quite possibly died in part because agencies did not

know, trust, or like each other and were convinced that they each offered

the best answer.--Dr. Michael Durfee, Los Angeles Hearing, 1992.

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Research suggests

that the same basic

kinds of high-risk

family situations are

producing both fatally

and seriously injured

children.

128

STRATEGIES FOR IMPROVEMENT: CASTING A WIDER NET

This Board believes a universal approach that reaches all families

is the best fatality prevention strategy at this time. This effort must begin

with services such as universal home visiting by trained professionals or

para-professionals, hospital-linked outreach to parents ofinfants and

toddlers, community-based programs designed forspecific neighborhoods,

effective public education campaigns and innovative ways to reach males.

Research suggests that the same basic kinds of high-risk family

situations are producing both fatally and seriously injured children (Hegar

et al, 1994; Goldstein et al, 1993). If true, prevention efforts directed at

the larger group of families with the potential to seriously injure their

children will encompass the smaller group offamilies at risk for fatalities.

With the right approach, we also may be able to prevent so-called "serial"

fatal abuse and neglect by parents who have already lost one child bui

remain undetected by the system because the death was diagnosed as

accidental or natural (Alexander et al, 1990; Olds & Kitzman, 1993).

Broadly Expanded Voluntary Home Vis4ing

Universal home visiting for new parmts who voluntarily accept

such services, a previous recommendation of this Board, is a promising

model for helping children and families in need. Hawaii, Iowa, and New

York have already approved legislation that encourages comprel: nsive

home visiting efforts. We strongly reiterate the pressing need for

voluntary home visiting.

There is one dramatic, unifying factor upon which home visiting

and early interventions can be built: studies show that 75 percent or more

of deaths from abuse and neglect strike children under 5 years of age

(McClain et al, 1993, Levine et al, 1994; Levine et al, 1995). This

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preponderance of death among the very young underscores the fact that

current interventions oftca do not reach the smallest children, who are in

the deepest trouble and yet are largely invisible to CPS agencies.

However, home visiting is not a panacea, and its value in reducing

abuse and neglect fatalities has not been conclusively proven. Home

visitors may be public health nurses, paraprofessionals, or trained

indigenous workers. While indigenous workers may provide rapport

with a family, early research has shown problems when these volunteers

sympathize with the client or project their personal situations onto a

client (Daro, 1993). Another problem is the labor and cost-intensive

nature of home visiting programs, which is critical to the design. For

example, Hawaii's Healthy Start program costs $7 million dollars a

year and serves 52 percent of families with newborns (Breakey &

Pratt, 1993). these costs, however, are far below the expense of out of

home care that could result from a lack of these preventive services.

Nevertheless, efforts such as Hawaii's Healthy Start,

NCPCA's Healthy Families America, and the Minneapolis Visiting

Nurse Program seem promising because they are based on a preventive,

public health or paraprofessional model, not on an arbitrary intervention

model. To date, however, no controlled study has been done of Hawaii

Healthy Start to compare its families' abuse, neglect or death rates with

other interventions for comparable families (McCurdy, verbal testimony

1994). The NCPCA believes such studies are necessary, and we

wholeheartedly agree. We also recognize that home visiting must be

integrated within a comprehensive service system of parent education,

respite care, housing, and prenatal care.

"My best guess would be that

having an extra set of eyes in

the home would allow people to

identi.6, problems earlier and

help families get more support,

and that's why we support the

model. But it hasn't been

proven that that's the case. Not

yet."Karen McCurdy,

Principal Analyst, NCPCA, New

York Focus group, 1994

Home visiting must be

integrated within a

comprehensive service

system of parent education

respite care, housing, and

prenatal care.

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,

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"When a child is born, we

immediately do a test which is

called an Apgar, used to

predict the mental and

physical development of the

newborn. We should also do

an Apgar on the parents."

Frederick A. Ward, Randolph,

Mo., County Coroner, St.

Louis hearing, 1994

A well-designed

public education

campaign can go a

long way.

130

Reaching New Parents

In describing government programs that work, Vice President Gore

has used the analogy of "on-time delivezy" in manufacturing, which

means that all materials necessary to create a product are available at the

precise moment needed. In the case of families, this Board believes

pregnancy and the birth of a child are special opportunities for growth,

when "on-time delivery" of services must be made available, before

families develop habits or difficulties that could threaten the safety of their

new child. If given help early, we believe most families in need, and their

children, will benefit.

In addition, this Board believes some parents do not comprehend

how an infant or small child can be killed during a single assault or an act

of extreme carelessness. A well-designed public education campaign can

go a long way toward dissuading parents from using violence or leaving

infants and small children alone in what can quickly become perilous

situations.

One Community's Effort:

The Parenting Education Program (PEP) ;.s a low-cost primary

prevention program that identifies high-risk parents while at the hospital.

PEP offers both adult and teen parent training, help for substance-abusing

parents, and training of professionals and volunteers in parenting risks to

children. In 1994, PEP served 500 adult mothers, 87 teen parents, and 19

substance abusing parents.Laurel Whitaker, SUNY Health Sciences

Center.)

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Creating a Caring Community

The Board presents this report on fatalities in response to public

concern, a congressional mandate, and the Board's longtime belief that

addressing child fatalities carries a moral and ethical imperative that

provides an important window into the difficult lives of millions of abused

and neglected children.

However, we emphasize that each community must not raise

concerns only when a child dies. Rather, the tragic death of a child should

serve as a reminder that this Nation needs to create a comprehensive CPS

system that helps families before serious abuse or death occurs. Child

deaths are a sign of the failure of total support systems, including the

community of neighbors, friends, and family who must be alert to children

living in households at high risk of abuse or neglect.

A RECENT CASE:

The little girl had been bitten on the cheek, and a medical

examiner's investigation later showed, that she had received severe

internal injuries that killed her. Detectives determined that she had been

used for karate-kicking practice by the boyfriend of the mother, in front of

the rest of the children. She was beaten intermittently for more than a

week. Many neighbors in the well-to-do Nassau County, New York,

neighborhood saw her badly marked face. But neighbors did not think it

was their business, and the family was not reported. Only when the child

was killed did the beatings come to attention of authorities. Caring

communities must take action to save children from abuse if this tragedy is

to 1>e prevented.Dr. Michael Baden, Director of Forensic Services, New

York State Police, New York Focus group, 1994.

Each community must

not raise concerns

only when a child dies.

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Chapter Four

"Ifyou see your next-door

neighbor, and all of a

sudden she's got the dark

glasses on and she's walking

around with her head down.

you know she's covering up

black eyes. When they can't

talk themselves, we must talk

for them. That may be the

saving factor." A Woman

from the Family Violence

Program. Bedford Hills

Correctional Facility, 1994.

132

A community system should be built upon the philosophy that

families need help, support, and encouragement in raising children.

Natural supports such as extended families, relatives, friends and

neighbors have traditionally played this role, but such support is often

lacking in the very families most in need of it. Low-income families often

move from place to place, neighbors sometimes believe it is not their

concern, and in some devastated urban areas, residents are so accustomed

to violence that even the abuse of an innocent child can get lost in the

turmoil.

Yet even in these highly stressed, poor, urban communities where

child abuse and fatality rates are high, local agencies and individuals can

help families move in a more positive direction. The same argument can

be made for rural communities. We believe most parents are eager to be

their 1,urturer, first teacher, and coach as they grow toward

adulthood. With community support, most parents can be.

As we made clear in Chapter Two, the fact that a number of

families with children who die from abuse or neglect were known to at

least one public agency is not necessarily a condemnation, but an

opportunity to learn and improve. We hope this report will inspire the

level of community commitment necessary to create a comprehensive

neighborhood-based system, which previous ABCAN reports have

envisioned.

In our 1993 report Neighbors Helping Neighbors, we described the

theoretical basis for a community-based system. We would like to be able

to say that this model now exists in many cities, but no areas nave yet

adopted a complete system. This Board hopes this model will be broadly

adopted soon.

Briefly, the values of such a system must address the three key

goals of: child safety, child well-being, family preservation. The

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community system must include a network of primary services and family

social services which, along with income supports, assist parents in

providing for their child's safety and well-being. However, unless

both parents in a two-parent family are included this is often

difficult, and the chances of effecting change are greatly reduced.

A "community-based" philosophy assumes that a diverse and

inclusive set of community members will be stakeholders in creating a

network of services that are responsive to needs of local families.

Community members in such a system would agree to share the

responsibility for protecting children, and some would personally

volunteer their time to provide support to families at high risk of abuse and

neglect.

A community system must be responsive to the demographics of

the families it servesracial and ethnic heritage, language, family

structure, income, and housing. Services must be.. tailored for single-parent

families; multigenerational families; low-income families; multilingual

families; blended families of step-parents, half-siblings, and A community system must

relatives; and mixed racial families. It also means that services are be responsive to racial and

ethnic heritage, language,

located nearby, are open during appropriate hours, and are family structure, income

culturally compatible with the area. Within such a community and housing.

system, "safety" must not be limited to the prevention of child

fatalities. It must include the child's nutrition, safe housing, and

preventive medical care, as well as community safety from crime and

violence.

When community-based supports are available on an accessible

and flexible basis, and a viable child protection system is operating, we

believe most families will use and benefit from such a system, and serious

and fatal injuries from child abuse and neglect will be reduced.

A system must address:

child safety,

child well-being,

family preservation.

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U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

"In the Oklahoma shaken baby

data, we found that the largest

number were killed by men

acting alone. But as you know,

most of our prevention effort

on Shaken Baby Syndrome is

with mothers." Dr. Barbara

Bonner, Center on Child Abuse

and Neglect, University of

Oklahoma, New York Focus

group, 1994

134

Increasing the Emphasis on Family Support Services

Clearly the most effective way to stop fatalities is to prevent highrisk behavior in the first place. Support services are based on a philosophy

of lending families a helping hand well before they need CPS. As Family

Support programs become more widespread, we urge policymakers to find

ways to actively draw in those families whose multiple needs could one

day put them at risk for abuse or neglect.

Reaching Fathers and Other Males

There is no easy way to reach fathers, male companions, or

stepfathers. Even hospital-based, new parent intervention programs face

tremendous difficulties identifying and involving fathers, who all too

often are not even named on birth certificates.

Public education campaigns are one obvious way to inform new

parents, including males. But males must somehow be pinpointed for

education and intervention. We are recommending several innovative

approaches (see Recommendation 23).

One such place to reach males is in prison. Programs may help

incarcerated men address their violent behavior and learn ways to control

their anger toward others. We urge policymakers to put their best thinking

to work on this all-important effort.

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j. 8 0
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ONE PROMISING INNOVATION:

A grant from the Administration for Children and Families (ACF)

in the Department of Health and Human Services (DHHS) is allowing the

California Youth Authority prison system to launch a positive parenting

training program for young incarcerated fathers. Young Men as Fathers is

being implemented in four institutions to attempt to demonstrate that child

abuse and neglect can be reduced among children of men at high risk for

perpetrating abuse and neglect.Young Men as Fathers: Positive Parting

for Incarcerated Fathers. Grant No. 90-CA-1502.

Getting the Private and Nonprofit Svciors Involved in Prevention

This Board urges far more corporate and foundation involvement

in fighting fatal abuse and neglect, such as distributing educational

information with diapers, bottles, or other products for infants and

toddlers; creating public service announcements about the warnings signs

of abuse and neglect and ways to report it; and fundity' ,,ublic prevention

campaigns.

National campaigns, such as those sponsored by the NCPCA and

the American Media Council on Child Abuse and Neglect, can awaken the

nation to child abuse and neglect. Media efforts, such as KABC-TV Los

Angeles' year-long campaign on fatal child abuse prevention, have

engaged entire communities in prevention efforts. Public messages, such

as the wisdom of counting to 10 when angry, or what to do in a grocery

store when one suspects a child is being abused by a parent, should be

tested experimentally to determine the best means of influencing the

intended population.

One recent corporate example has been set by the NCPCA and

Ertel Co., manufacturer of Jibba Jabber, a fantasy doll with a long neck

that squeaks when shaken. When told about Shaken Baby Syndrome, the

company voluntarily worked with the NCPCA to place an insert in Jibba

Jabber packaging explaining that while Jibba Jabber is for fun, a lethal

U.S. Advisory Board on Child Abuse and Neglect

Campaigns, such as

those sponsored by

NCPCA, KABC-TV Los

Angeles and the

American Media

Council on Child

Abuse, have engaged

entire communities in

prevention efforts.

135
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136

form of child abuse involves the shaking of babies. The pamphlet lists

seven ways to react positively to a child rather than resorting to violence.

ONE FOUNDATION SPREADS THE WORD:

Many groups have launched public service campaigns to teach

basic messages and overcome widespread ignorance among high-risk

parents about threats to children. The Children's Trust Fund is educating

the public about Shaken Baby Syndrome, and is erecting a monument in

Texas dedicated to children who have died of abuse and neglect, with the

hope of increasing societal awareness.Mary Alice Brown, Manager of

Research and Evaluation, Children's Trust Fund, Dallas Hearing, 1994.

Reducing Preventable Deaths from Household Hazards

Thousands of children are killed and disabled each year by

preventable accidents and intentional attacks involving common

environmental hanrds. Recent research by Phillip Hyden has shown that

1,300 children up to age 18 die from building fires, scald burns, and other

burns each year, while 4,000 are disabledsometimes horribly so (verbal

testimony, 1994). Scald injuries, which cause the most hospitalizations,

are overwhelmingly blamed on excessively hot tap water. Emergency

room workers and coroners see too many severe immersion scald burns on

infants and very small children, accidentally or purposefully inflicted by

parents and caretakers with easy access to needlessly hot tap water. A

simple product is on the market that prevents the water fi orn heating to a

dangerous temperature. This device, if routinely installed, could reduce

the number of abuse and neglect cases and accidental deaths from

scalding.

Another device that could save lives is the quick-release safety

latch. Some cities require that homes with barred windows have latches,

removable from the inside, so that children and others are not trapped in

burning buildings, a tragedy that is reported every week somewhere in the

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Chapter Four

United States. It is now up to communities to mandate such safeguards.

Other cities have initiated drowning prevention campaigns that have

resulted in an increase in public awareness and in the passage of

ordinances requiring barrier fencing and other structural safeguards to

reduce the number of toddler drownings. Thus, simple, inexpensive

devices can do much to save children's lives.

aSS**The

NIwi Children

Los Angeles County Fire Department

1995 Drowning Prevention Campaign

137

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138

CHAPTER FOUR RECOMMENDATIONS

In Chapter One, our Recommendations addressed the widespread

lack of knowledge and insufficient information that badly hampers our

ability to prevent fatal child abuse and neglect. In Chapter Two, our

Recommendations furthered our philosophy of better educating

professionals to identify abuse and neglect and of holding perpetrators

responsible for child deaths. In Chapter Three, our Recommendations

emphasized the critical importance of Child Death Review Teams in

assessing fatalities, pinpointing system flaws, and promoting prevention.

In this fourth and final Chapter, we are urging the creation of

reasonable, positive services for families in need of help and suggesting a

design for primary prevention that stresses child and family well-being in

a healthier, more active, community-based setting. We are pinpointing the

populations at greatest risk for bconming victims of serious and fatal abuse

and neglectvery young children -0..s well as those at greatest risk for

becoming perpetrators--male caretakers and parents of toddlers and

infants. We are emphasizing the urgent need for private and foundation

involvement in public awareness campaigns. And we are urging that when

a family completely fails a child, that child be given a second chance with

a new life and a new family in an expeditious manner. We, therefore,

recommend:

Recommendation 16: All child and family programs must adopt child

safety as a major priority.

Family, child welfare, health, mental health, and education

programs must adopt children's safety as a major priority and explicitly

assess the child's safety while providing services. But their goals must

also include the child's overall well-being and development and the

preservation of the family, as long as the safety and well-being of family

members can be provided for.

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Recommendation 17: All relevant State and Federal legislation must

explicitly identify child safety as a goal.

To avoid any confusion as to whether other goals override child

safety, Congress and State legislatures, when considering future Federal or

State legislation regarding programs for families and children or

reauthorizing legislation, must explicitly identify child safety as a major

goal. This goal must be statutorily presented as consistent with other

public policy goals such as family preservation and permanence for

children.

Recommendation 18: The decision to remove children from their

homes or initiate family preservation services should be made by a

team.

Child protection and law enforcement agencies, when deciding

whether to initiate family preservation services or to remove a child from

the parental home, should use multidisciplinary team assessment and

decision making whenever possible. Such agencies should never allow

such a decision to be made by one person alone. Except in emergency

cases, these decisions should never be made by only one person.

Recommendation 19: Family preservation services should be

available in every jurisdiction.

Whenever removal of a child is being considered by CPS, law

enforcement, or a juvenile court, intensive family preservation services, as

previously described in this chapter, should be viable enough so that they

should be available to evely jurisdiction as an option.

Recommendation 20: States should follow guidelines when

considering family preservation services.

Until the completion of badly needed research on the families most

likely to be helped by family preservation services, States should use the

following guidelines in determining whether family preservation services

are the appropriate option for a specific family:

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55
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140

The decision to use family preservation services within the parental

home should be made in the context of ongoing assessment of risk to

the child's safety and of the family's commitment and willingness to

participate in the program.

The safety and well-being of the children must be the priority in the

selection of family preservation (or any other) service program for

families and children.

Family preservation services should be utilized only when the

professionals most familiar with the family situation, particularly those

in the CPS agency, are professionally comfortable with the use of

those services. No agency should have policies that resultin what is

essentially mandatory use of family preservation services.

Family preservation service providers should both anticipate a positive

result from the provision of services and be comfortable with the

safety of the child in the home before agreeing to initiate services.

Public agency contracts with service providers must include

protections against agencies having to accept inappropriate referrals in

order to maintain their fiscal solvency.

After the death of a child due to parental abuse or neglect or after

egregious abuse or neglect, surviving children must not be left in the

home with or under the care of the perpetrator of the abuse.

The decision to utilize family preservation services should focus on the

extent of the abusive or neglectful behavior, the parent's willingness to

be an active participant in services, the risk to the child's safety

presented by conditions in the home, and the frequency and duration of

contact with the family by community service agencies.

Family preservation services cannot be effective ifthe parent(s) is so

affected by disabling substance abuse, mental retardation, or untreated

mental illness that she/he cannot participate in the service delivery

program.

If domestic violence is a pattern in the home, there must be sufficient

protection provided to family members and to family preservation staff

to assure that services are safe and effective.

(The Board notes that the American Professional Society on the Abuse of

Children (APSAC) has established a committee to develop standards for

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.56
Chapter Four

the appropriate use of family preservation services, and the Board looks

forward to the contribution their efforts will make).

Recommendation 21: An array of primary prevention services and

supports, including home visiting, must be made available to all

families.

Primary prevention means helping families before an incident of

abuse or neglect occurs. Available Federal funds from the Family

Preservation and Family Support Act, CAPTA, and Title IV-B should be

provided with flexibility to the States for implementation, integration, and

evaluation of comprehensive primary prevention services. Services should

be provided using an interdisciplinary, multiagency approach in

conjunction with existing primary prevention efforts.

Because it is impossible to predict which families will kill their

children, the most effective prevention is to support parents in being

effective and nurturing, to provide treatment services when family

problems do arise, and to respond quickly and appropriately when abuse or

neglect is identified. To accomplish this, each community should make

available to families a comprehensive array of supportive programs,

resources, and social services.

This Board particularly emphasizes the ne_xl for:

Voluntary home visiting provided to all expectant and new parents.

Substance abuse treatment programs, particularly for pregnant women

and parents at risk of abusing or neglecting their children.

Drop-in child care and respite care programs, particularly for parents

with fragile or nonexistent natural support systems and parents of

children with disabilities.

Parent education programs focusing on the healthy development of

children.

In addition, we recommend:

Parenting preparation programs in elementary and secondary schools

that emphasize ways of dealing with stress, coping with conflict and

aggression, and positive methods of discipline.

Family recreation facilities, resource centers, and drop-in centers.

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142

Recommendation 22: Family support services funding should be used

for prevention programs aimed at families of infar.ts and toddlers.

Because most children die from abuse or neglect before age 4,

available Family Support funds and other prevention funds should be used

to significantly increase the emphasis on mothers, fathers, and other

caretakers of infants, toddlers, and preschoolers.

Such families, particularly those whose situations and needs put

them at high risk of abuse or neglect, should receive services through

prenatal and postnatal programs, as well as WIC and day care programs.

Parents of older children may be reached through Headstart.

Recommendation 23: States and local agencies should design

prevention programs for men. Programs should also intczrate

services and training on child abuse and domestic violence.

The longtime targeting of prevention programs toward women has

created a dramatic gap in critical interventions and other services available

for men. Reports indicate males, acting alone or together with women, are

responsible for many child deaths due to abuse and some of deaths by

neglect. Specific strategies must reach men and alert women to the

potential role of men in abuse, and should be funded with Federal Family

Preservation and Support monies, as well as public and private sources at

the State and local level.

Because of the correlation and frequent coexistence of domestic

violence and child abuse, programs should address all forms of family

violence, especially when small children are in the home.

Strategies could include, but should not be limited to:

Parent "mentoring" that involves fathers at baby's birth.

Hospital-based education of new fathers on coping with "triggers" of

violence.

Preventive education programs for prison-based males, a population

marked by low-income, substance abuse and other correlates closely

associated with child abuse and neglect.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

Domestic violence programs that recognize that adults who abuse a

spouse or partner are also at high risk of abusing a child.

School programs designed specifically to educate children about male

roles in parenting.

Recommendation 24: Expedited termination of parental rights should

be developed in every State.

When voluntary relinquishment is not an option, CPS, States, and

the juvenile courts should develop ways to expedite court TPR and

placement with a permanent substitute family when a child cannot safely

remain with or return to parental custody. Federal laws do not require

long, unreasonable efforts to preserve unsalvageable families, but most

States currently lack specific guidelines regarding when to seek TPR and

methods of expediting this legal process. Therefore:

States, assisted by the ABA and the National Council on Family and

Juvenile Court Judges (NCFJCJ), should adopt guidelines for CPS

agencies and prosecuting attorneys representing CPS agencies to use in

determining when to file TPR and seek permanent placement of

children with adoptive families.

States, with assistance from ABA and NCFJCJ, should develop

legislation providing juvenile courts with procedures to streamline the

TPR process to reduce court procedural delays that now may add years

of foster care for children awaiting a permanent family. Court

improvement grants available from the Family Preservation and

Family Support Services Program should be used to help implement

strategies for reducing such delays.

Recommendation 25: A broad public prevention campaign should be

developed to address serious and fatal child abuse and neglect.

Well-constructed campaigns can help educate parents about the

triggers associated with serious injury and deaths of infants and children

and suggest alternatives to cope with such problems. Such campaigns can

substantially increase public awareness with regard to reporting abuse and

how to prevent harm to children.

The media should play a major role in this effort because of their

unique ability to reach into homes of millions of people, including those

who need help and those who might help others. Campaigns should be

143

U.S. Advisory Board on Child Abuse and Neglect

;89
Chapter Four

144

sensitively created and culturally and linguistically appropriate, producing

material parents are likely to see or read rather than information presented

in a way that alienates. However, "shock value" campaigns such as

California's antismoking effort should also be included.

These efforts should be spearheaded by the Department of Health

and Human Services (DHHS) and other Federal, State, and local agencies

and sponsored by communities, the private sector, foundations, and the

media.

Campaigns should include:

Warnings to parents about "triggers" associated with parental violence

toward children, such as inconsolable crying and difficulties of toilet

training.

Informing parents how they can prevent deaths and serious injuries,

such as bathtub drownings, drownings in 5-gallon buckets, and

poisonings.

Voluntary involvement by major mar Lacturers, such as diaper and

baby bottle companies, to print inforni..iion on their products that

educate parents about the natural developments and setbacks they

should expect in toilet training and feeding.

Recommendation 26: Regulatory measures should be adopted to

reduce environmental dangers.

Regulations and codes should be enacted to end preventable child

fatalities and serious injuries from household hazards and environmental

dangers. State legislatures and local governments should enact laws,

building codes, or regulations to:

Require heat regulators on hot water faucets in new residential

construction to prevent severe or fatal scalding injuries of young

children.

Require door locks and fencing directly adjacent to yard swimming

pools to prevent drownings of children due to accidents or lack of

supervision.

U.S. Advisory Board on Child Abuse and Neglect

I. 9 0
Chapter Four

Require window guards with safety latches in multilevel and high-rise

buildings where children are likely to reside.

Promote public awareness of the dangers of toddlers drowning in

accessible buckets of water due to their "top heavy" center of gravity

and the need for smoke alarms and other fire safety measures.

145

U.S. Advisory Board on Child Abuse and Neglect

9 1
Chapter Four

146

CONCLUSION: THE CHALLENGE

With this report, we call upon Congress, the Administration,

States, communities, child advocates, and the media to take actions to

address the crisis of children dying from abuse and neglect. Our Nation

has a responsibility to make the health, well-being, and very survival of

children a national priority. This report contains 26 Recommendations

aimed at pre.3erving children's lives. We urge that these

Recommendatiuns be considered carefully, be fully discussed, and then

embraced by America s decisionmakers. By taking decisive action now,

we can begin to shape a future that ensures the health and safety of our

Nation's children.

U.S. Advisory Board on Child Abuse and Neglect

fl .1 0 4,
Chapter Four

CHAPTER FOUR REFERENCES

Alexander, R., Crabbe, L., Sato, Y., Smith, W., & Bennet, T.

(1990). Serious abuse in children who are shaken. American Journal of

Diseases of Children, 144, 58-60.

Alexander, R. (1994, December). Verbal testimony. Executive

Committee Meeting, The U.S. Advisory Board on Child Abuse and

Neglect. Washington, DC.

Alfaro, J. (1994, June 13-17). Verbal testimony. Workshop a on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse.

Baladerian, N. J. (1991). Abuse Causes Disabilities. Disability and

the Family. Culver City, California: SPECTRUM Institute.

Breakey, G., & Pratt, B. (1993). Healthy Start Home Visiting:

Hawaii's approach. The APSAC Advisor, 6, 7-8.

Bureau of Census. (1993). Statistical Abstract of the United States

(Vol. 113th Edition). Washington, DC: Department of Commerce.

Casanova, G. M., Domanic, J., McCanne, T., & Milner, J. (1992).

Physiological response to non-child-related stressors in mothers at risk for

child abuse. Child Abuse and Neglect, 16(1), 31-44.

Chang, D. (1995). [National Alliance to End Homelessness] (Jill

Stewart).

Chapin Hall Center for Children. (1989). Child Abuse and Neglect

Decision Making in Cook County. Chicago: University of Chicago.

Chicago Tribune. (1994, January). Killing Our Children. Chicago

Tribune Series.

Daro, D. (1993). Child Maltreatment Research: Implications for

Program Design. In D. Cicchetti & S. L. Toth (Eds.), Child Abuse, Child

Development and Social Policy: Advances in Applied Developmental

Psychology. Norwood, New Jersey: Ablex Publishing.

147

U.S. Advisory Board on Child Abuse and Neglect

i 93
Chapter Four

148

Edwards, L. (1994). Improving Implementation of the Federal

Adoption Assistance and Child Welfare Act of 1980. Juvenile and Family

Court Journal, National Council of Juvenile and Family Court Judges,

45(3).

Ewigman, B. (1994, June 13-15). Verbal testimony. Workshops on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

Gibbs, N. (1994, September 9). Murder in Miniature. Newsweek

Magazine, pp. 54-59.

Goldstein, B., et al. (1993). Inflicted versus accidental head injury

in critically injured children. Critical Care Medicine, 21, 328-332.

Hegar, R. L., Zuravin, S. J., & Orme, J. G. (1994). Factors

predicting severity of physical child abuse injury: A review of the

literature. Journal of Interpersonal Violence, 9, 170-183.

Hyden, P. (1994, June 16). Verbal testimony. Public Hearing on

Child Maltreatment Fatalities. New York, New York: Sponsored by the

U.S. Advisory Board on Child Abuse and Neglect.

Jason, J., Andereck, N. D., Marks, J., & Tyler Jr., C. W. (1982,

December). Child abuse in Georgia: A method to evaluate risk factors and

reporting bias. American Journal of Public Health, pp. 1353-1358.

Langer, C. (1991). Who Killed Adam Mann? [Public Broadcasting

Service, Frontline].

Levine, M., Compaan, C., & Freeman, J. (1994, August). The

Prevention of Child Fatalities Associated with Child Maltreatment.

University of New York at Buffalo.

Levine, M., Compaan, C. & Freeman, J. (1995, February).

Maltreatment-related fatalities: Issues of policy and prevention. Law &

Policy, 16. pp. 449-471.

Mash, E. J., Johnson, C., & Kovitz, K. (1983). A comparison of

mother-child interaction of physically abused and non-abused children

during play and task situations. Journal of Clinical Psychology, 12, 337-

346.

U.S. Advisory Board on Child Abuse and Neglect
Chapter Four

McClain, P., Sacks, J., & Frohlke, R. (1993). Estimates of Fatal

Child Abuse and Neglect, United States, 1979 Through 1988. Pediatrics,

91, 338-343.

McCurdy, K. (1994, June 13-15). Verbal testimony. Workshops on

Child Maltreatment Related Fatalities. New York, New York: Sponsored

by the U.S. Advisory Board on Child Abuse and Neglect.

McCurdy, K., & Daro, D. (1994). Current Trends in Child Abuse

Reporting and Fatalities: The Results of the 1993 Annual Fifty State

Survey. National Center on Child Abuse Prevention Research. Chicago:

National Committee for Prevention of Child Abuse.

Narconon. (1995). [U.S. Drug Education Division] ( Jill Stewart).

National Center on Child Abuse and Neglect. (1991). National

Incidence and Prevalence of Child Abuse and Neglect: The 1988 Revised

Report (NIS-2) [Westati. Washington, DC: Department of Health and

Human Services.

National Center on Child Abuse and Neglect. (1994). Child

Maltreatment 1992: Reports from the States to the National Center on

Child Abuse and Neglect. Washington, DC: U.S. Department of Health

and Human Services.

National Research Council. (1993). Understanding Child Abuse

and Neglect. Washington, DC: National Academy of Sciences.

Nazario, J. (1993, June 14). Verbal testimony. Workshops on Child

Maltreatment Fatalities. New York, New York: Sponsored by the U.S.

Advisory Board on Child Abuse and Neglect.

Olds, D., & Kitanan, H. (1993). Review of research on home

visiting for pregnant women and parents of young children. The ASPAC

Advisor, 6(3), 19-24.

Pianta, R. C., Egeland, B., & Erickson, M. F. (1989). The

antecedents of maltreatment: Results of the mother-child interaction. In C.

Cicchetti & V. Carlson (Eds.), Child Maltreatment: Theory and Research

on the Causes and Consequences of Child Abuse andNeglect (pp. 203-

253). New York: Cambridge University Press.

U.S. Advisory Board on Child Abuse and Neglect

, 95

149
Chapter Four

150

Reid, R. T., & Kavanagh, K. B. (1987). Abusive parents'

perceptions of child problem behaviors: An example of parental bias.

Journal of Abnormal Child Psychology, 15, 457-466.

Schecter, S., & Edleson, J. L. (1994, June 8-10). In the Best

Interest of Women and Children: A Call for Collaboration Between Child

Welfare and Domestic Violence Constituencies. Wingspread. Racine,

Wisconsin.

Staff. Life of Violence Catches Up to Suspected Murderer. (1994,

September 2). Los Angeles Times.

Staff. (1994, December 22). Children Held Longer in Limbo of

Foster Care: A New York study blames a fixation by bureaucracy on

natural parents. New York Times, p. B12.

Stangler, G., & Kivlahan, C. (1993). Missouri Child Fatality

Review Project, Interim Progress Report (Vol. April). St. Louis: Missouri

Department of Social Services and Missouri Department of Health.

Stark, E. (1994, June 16). Verbal testimony. Public Hearing on

Child Maltreatment Fatalities. New York, New York: Sponsored by the

U.S. Advisory Board on Child Abuse and Neglect.

U.S. Advisory Board on Child Abuse and Neglect. (1993).

Neighbors Helping Neighbors: A New National Strategy for the

Protection of Children (Vol. Fourth Report). Washington, DC:

Department of Health and Human Services, Administration for Children

and Families.

Vermont Child Review Committee. (March, 1993). A Review of

Deaths of Vermont Children, Birth to 18 Years in 1991. Vermont Child

Review Committee.

U.S. Advisory Board on Child Abuse and Neglect

196
Epilogue

EPILOGUE

In June 1994, Board members met with the members of the Family

Violence Program, at the Bedford Hills Correctional Facility to discuss

the impact of the child protection system and social services upon their

experience as abused children and as perpetrators of abuse. Board

members and the Bedford Hills staff discussed the problems of current

prevention services with the program members.

Most of the women were victims of tremendous violence and

extreme family chaos throughout their lives. Ultimately, these victims

became violent victimizers, involved in destructive relationships, lashing

out at their children and others, and eventually committing the crimes of

which they are convicted Their desire to understand the role of violence

in their lives has led them to join the Family Violence Program.

The eloquent written and oral testimony of the women in the

Family Violence Program reaffirmed the need for comprehensive services

for children and parents in the child protection system. All the women had

great insight into the failure of "the system" throughout their lives and the

need to improve the protection of children.

Here are two stories, in the words of the women, of their journeys:

Speaker A:

"My terror and rage led to the death of my 6-week-old son. I make

no excuses for my acts. What I share with you is an effort to understand

myself and others, and perhaps in some way to find even a small degree of

forgiveness in myself.

What I want this Board to know is two things: first, that my son's

death was tragic; and, second, that it was not until a series of

investigations of the events that any meaningful intervention worked for

the rest of my five children.

My husband first had sex with me when I was 4 years old, and later

he had sex with me and my children. My life and my children's lives have

always been hard. On the day my son died, I had gone to a place where I

was high on pills and alcohol at least 80 percen: of the time. I was

disgusted with everything and furious. The more I drank, the angrier I got.

In my craziness that day, I was trying to run away from my

husband with my children. The baby's zipper got stuck. I was panicking

U.S. Advisory Board on Child Abuse and Neglect 151

197
Epilogue

152

because I thought he was coming home, and when my son cried, I struck

him. I was so out of control I didn't even realize he was dead. He was

quiet. I dressed him and put all the kids in the car and started driving

around.

I attempted to kill us all by driving over an embankment into

Sheepshead Bay. All I succeeded in doing was banging up the car, and my

husband found us. I was never arrested for the death of my son or charged,

but my husband and I were later charged with and found guilty of sexual

abuse. The irony is that they thought my son died as a result of whiplash.

I share these things with you because I deeply know that things

have to change. At times I am bitter because there were no interventions

for me as a child. I was tortured physically and sexually for as long as I

can remember. I never knew what normal was or could be. I am a woman

and a mother who hurts deeply inside, but I am not a monster. I am a

hurting soul. I have a wounded soul, and perhaps the deepest pain is that I

became just like all of those people in my life that tortured me."

Speaker B:

"It was winter, and for 4-1/2 years of my marriage the abuse

escalated. About the time my son was born, 1-1/2 years into the marriage,

the abuse became physical. There were words, fists, threats, silence, and

isolation.

I lived in constant fear and was always anticipating and trying to

avoid the next beating. By the time my daughter was born, it was a

nightmare. When she would cry, he constantly threatened that I had better

shut her up, and that she had better go to sleep. The baby cried and

continued to cry. His hollering, my fear, the craziness of our lives. How

could a baby sleep?

I was desperate. I didn't think I wanted to end her life. I only

wanted her to be quiet. I'm not sure how sane I was at that point. I have

questioned that every year of my imprisonment. I've wondered what his

abuse, the postpartum issues also played in my insanity. His threats got

severe. They got worse. And the beatings increased. My wrist was broken.

He damaged my right eye. He cracked one of my ribs. The bruises, the

fear, the terror.

All I know was that somehow I focused on the baby. If only I

could get her to quiet down. Every whimper from the baby would send me

U.S. Advisory Board on Child Abuse and Neglect

198
Epilogue

into a panic, trying to calm her to avoid his anger. But I was angry, terribly

angry, and knew her crying was angering him. I was terrified and angry.

I gave her some formula, and I put something in it. I thought it

would just help to quiet her down. But what I really did was poison her.

When I discovered her quiet in the crib and having difficulty breathing, I

took her to the hospital. She was very quiet, and I was very scared. I have

relived over and over again the memories of putting that poison in her

bottle, and the fact that I killed my innocent child.

When I was sentenced, my husband said to me, you shut her up,

and now no one will hear you because you are going to prison."

The Family Violence Program at the Bedford Hills Correctional

Facility is an outgrowth of a hearing held at the prison in 1985 on the

relationship between incarcerated women and domestic violence. The

program began in 1987 through funding and support provided by the New

York State Department of Correctional Services and the Women's Division

of the Governor's Office. The goal of the program is to provide women

with a safe and supportive environment in which they can begin to identibi

and address experiences of violence and victimization in their lives.

The program currently has 150 participants, with a waiting list of

60. Women come to the program voluntarily and must participate in an

8-week orientation to become a member. The program's membership

represents a variety of socioeconomic classes and ethnic groups. The

Family Violence Program has included women who are African American,

Hispanic, Latino, White, Jamaican, Colombian, Albanian, Chinese, Greek,

and American Indian. Many of the women have obtained high school

diplomas, as well as bachelors' and masters' degrees while incarcerated.

The program offers traditional and nontraditional forms of

individual and group therapy for the participants. Besides therapy, the

participants are also active in community outreach. Members have

worked with domestic violence centers and the Governor's Office to

educate the public about family violence. Program members have

produced and edited a film called We Are Not Who You Think We Are.

The film depicts the connection between victimization and drug use and

recently received the Bronze Apple Award from the National Education

Association.

The Family Violence Program is the only program of its kind in the

country.

U.S. Advisory Board on Child Abuse and Neglect 153
Epilogue

154 U.S. Advisory Board on Child Abuse and Neglect

KmSpecial Education Division

New School for Child Development

MIIMION 2 0 0
Appendix A

U.S. ADVISORY BOARD MEMBERS

In accordance with the provisions of the 1988 Amendment to the Child Abuse

Prevention and Treatment Act (CAPTA), the U.S. Advisory Board on Child Abuse

and Neglect (ABCAN) comprises 15 members, each of which "is recognized for

expertise in an aspect of the area of child abuse." Of the 15 members, 2 are Federal

employees who are also members of the inter-Agency Task Force on Child Abuse

and Neglect; and 13 members represent the general public.

Following is a list of the current Board members. Each entry includes the

beginning and ending dates of a member's term of appointment and specific expertise

mandated by statute that a member brings to the Board.

Deanne Tilton Durfee, Chairperson

Executive Director

Los Angeles County Inter-Agency Council

on Child Abuse and Neglect (ICAN)

4024 North Durfee Avenue

El Monte, CA 91732

Yvonne M. Chase, Vice-Chairperson

Deputy Commissioner

Department of Health and Social Services

State of Alaska

P.O. Box 110601

Juneau, AK 99811

Randell C. Alexander

Associate Professor

Division of Developmental Disabilities

Department of Pediatrics

209 Hospital School

University of Iowa

Iowa City, IA 52242-1011

Enid A. Borden

President

The Borden Group

101 North Alfred Street, Suite 200

Alexandria, VA 22314

(818) 575-4362 - Office

(818) 444-4851 - Fax

Representing: At-large

Term Ending: May 29, 1995

(907) 465-3030 - Office

(907) 465-3068 - Fax

Representing: Social Services

Term Ending: May 29, 1995

(319) 353-6136

(319) 356-8284

Representing:

Term Ending:

- Office

- Fax

Medicine

May 29, 1997

(703) 548-3692 - Office

(703) 548-8024 - Fax

Representing: Teachers

Term Ending: May 29, 1995

155

U.S. Advisory Board on Child Abuse and Neglect

201
Appendix A

156

Jane Nady Burnley

Executive Director

VALOR

Groups

P.O. Box 862

McLean, VA 22101-0862

Nancy Hoit

Family Policy Consultant

1175 Main Street

Hingham, MA 02043

Frances E. Jemmott

Executive Director

California Self Help Center

UCLA Psychology Department

3227 Franz Hall

Los Angeles, CA 90024-1563

Murray Levine

Professor

Psychology Department

State University of New York (SUNY) at Buffalo

Room 228 Park Hall

Buffalo, NY 14260

Elba Montalvo

Executive Director

Cnmmittee for Hispanic Children

and Families, Inc.

140 West 22nd Street, Suite 302

New York, NY 10011

J. Tom Morgan

District Attorney, Deka lb County

Deka lb County Courthouse

556 North McDonough Street

Decatur, GA 30030

(703) 538-6898

(703) 761-2459

Representing:

Term Ending:

(617) 749-5563

(617) 749-5638

Representing:

Term Ending:

- Office

- Fax

Voluntary

May 29, 1996

- Office

- Fax

Parents' Groups

May 29, 1996

(310) 825-3406 - Office

(310) 825-1799 - Message

(310) 825-0790 - Fax

Representing: Parent

Self Help Groups

Term Ending: May 29, 1997

(716) 645-3660,

(716) 645-3801

Representing:

Term Ending:

(212) 206-1090

(212) 206-8093

Representing:

Term Ending:

(404) 371-2561

(404) 371-2981

Representing:

Term Ending:

U.S. Advisory Board on Child Abuse and Neglect

x228 - Office

- Fax

Psychology

May 29, 1995

- Office

- Fax

Adolescents

May 29, 1997

- Office

- Fax

Law

May 29, 1997

202
Appendix A

Lawrence F. Potts

Director, Administrative Group

Boy Scouts of America, National Office

1325 West Walnut Hill Lane

P.O. Box 152079

Irving, TX 75015-2079

(Please direct mail to: 1627 Amherst, Plano, TX 75075)

(214) 580-2225 - Office

(214) 580-7896 - Fax

Representing: At Large

Term Ending: May 29, 1996

Prince Preyer, Jr. (205) 532-1505 - Office

Commissioner, District Six (205) 532-1515 - Fax

Madison County Commission Representing: State and

3210 Hi Lo Circle, Suite B Local Govermnent

Huntsville, AL 35811 Term Ending: May 29, 1996

(Please direct mail to: P.O. Box 181, Huntsville, AL 35804)

Michael S. Wald

Deputy General Counsel

Office of the General Counsel

Department of Health and Human Services

Room 700F Humphrey Building

200 Independence Avenue, S.W.

Washington, DC 20201

Michael W. Weber

Director

Program for the Community

Protection of Children

325 Cedar Street, Suite 303

St. Paul, MN 55101

John J. Wilson

Acting Administrator, Office of Juvenile

Justice and Delinquency Prevention

Office of Justice Programs

Department of Justice

633 Indiana Avenue, N.W.

Washington, DC 20531

(202) 690-6318 - Office

(202) 690-7998 - Fax

Representing: Inter-Agency

Task Force on Child Abuse

and Neglect

Term Ending: Indefinite

(612) 221-4042 - Office

(612) 223-8245 - Fax

Representing: Organizations

Providing Services to

Disabled Persons

Term Ending: May 29, 1997

(202) 307-5911 - Office

(202) 514-6382 - Fax

Representing: Inter-Agency

Task Force on Child Abuse

and Neglect

Term Ending: Indefinite

U.S. Advisory Board on Child Abuse and Neglect 157
Appendix A

158

U.S. Advisory Board Staff

Preston Bruce, Executive Director

U.S. Advisory Board on Child Abuse and Neglect

200 Independence Avenue, S.W.

Washington, DC 20201

202-690-7059 - Office

202-260-6309 - Fax

Lynne I. Heneson, Acting Deputy Director

202-690-8332

Marilyn J. Gosdeck, Program Analyst

Eileen H. Lohr, Program Analyst

202-690-6053

Tawana Keys, Clerical Assistant

202-690-7036

Joan M. Williams, Project Specialist

202-690-8178

U.S. Advisory Board on Child Abuse and Neglect

204
Appendix B

PARTICIPANTS OF THE 1992, 1993, AND 1994

FOCUS GROUPS AND HEARINGS

The following is a list of the names and affiliations of individuals who addressed the

Board during its meetings and the development of this report.

LOS ANGELES, CA

FIELD VISIT TO ICAN MULT1AGENCY CHILD DEATH REVIEW TEAM

APRIL 2, 1992

Henry Barbonza

Supervising Children's Social Worker

Los Angeles County Department of

Children's Services

Los Angeles, CA

Wivory Brand le

Supervising Deputy Probation Officer

Los Angeles County Probation Department

Los Angeles, CA

Lt. Tom Connally

Juvenile Division, Operations Section

Los Angeles Police Department

Los Angeles, CA

Azin Ehsan

Law Clerk

Los Angeles County District Attorney's

Office

Los Angeles, CA

Eva Heuser

Deputy Medical Examiner

Los Angeles County Department of

Coroner

Los Angeles, CA

Pat Barron

Investigator

Los Angeles Police Department

Abused Child Unit

Los Angeles, CA

Ed du Conge

Program and Contracts Coordinator

Los Angeles County

Department of Coroner

Los Angeles, CA

Michael Durfee

Medical Coordinator, Child Abuse

Prevention Program Los Angeles County

Department of Health Services

Los Angeles, CA

Astrid Heger

Director

Los Angeles County/University of

Southern California Medical Center

Pediatric Suspected Child Abuse and

Neglect Team

Los Angeles, CA

Myrna Kyte

Deputy Children's Service Administrator

Los Angeles County Department of

Children's Services

Los Angeles, CA

U.S. Advisory Board on Child Abuse and Neglect

205

159
Appendix B

160

Ann Lloyd

Nursing Coordinator

University of Southern California Medical

Center Pediatric Suspected Child Abuse

and Neglect Team

Los Angeles, CA

Mitch Mason

Program Analyst

Los Angeles County Inter-Agency Council

on Child Abuse and Neglect

Los Angeles, CA

Jeanene Morimoto

Administrative Assistant

University of Southern California Medical

Center

Medical Information Services

Los Angeles, CA

Oralia Velasquez

Senior Clinical Social Worker

Los Angeles County

University of Southern California Medical

Center Pediatric Suspected Child Abuse

and Neglect Team

Los Angeles, CA

Billie Weiss

Director

Injury Prevention and Control Project

Los Angeles County Department of Health

Services

Los Angeles, CA

Lois Walters

Program Specialist

Child Abuse Prevention Program

Los Angeles County Department of Health

Services

Los Angeles, CA

Ella Martin

Deputy County Counsel

Los Angeles County Counsel

Los Angeles, CA

Lt. Al Moen

Los Angeles Police Department

Abused Child Unit

Los Angeles, CA

Deputy Bobby Smith

Juvenile Division, Operations Section

Los Angeles Police Department

Los Angeles, CA

Sally Davidson Ward

Children's Hospital of Los Angeles

Los Angeles, CA

Penny Weiss

Assistant Director

Los Angeles County Inter-Agency Council

on Child Abuse and Neglect

Los Angeles, CA

U.S. Advisory Board on Child Abuse and Neglect

206
Appendix B

LOS ANGELES, CA

HEARING ON CHILD MALTREATMENT-RELATED FATALITIES

APRIL 3, 1992

Brian Blackbourne

Chief Medical Examiner

San Diego, CA

Michael Durfee

Medical Coordinator

Los Angeles County Department of Health

Services

Child Abuse Prevention Program

Los Angeles, CA

Astrid Heger

Director

Los Angeles County/University of

Southern California SCAN Team

Los Angeles, CA

Carole Langer

Producer and Director

Frontline

New York, NY

Mitch Mason

Program Analyst

Los Angeles County Inter-Agency Council

on Child Abuse and Neglect

Los Angeles, CA

Ryan Rainey

Deputy District Attorney

Los Angeles County District Attorney's

Office

Los Angeles, CA

Peter Digre

Director

Los Angeles County Department of

Children's Services

Los Angeles, CA

Judge Harry Elias

Municipal Court

San Diego County

San Diego, CA

Eva Heuser

Deputy Medical Examiner

Los Angeles County Department of

Coroner's Office

Los Angeles, CA

Il lona Lewis

Director

Los Angeles County Department of Corner

Los Angeles, CA

Frank Oliver

Investigator

Los Angeles County District Attorney's

Office

Los Angeles, CA

Lynn Reeder

Los Angeles Sheriff s Department

Homicide Bureau

Los Angeles, CA

U.S. Advisory Board on Child Abuse and Neglect 161

207
Appendix B

162

Lt. Joe Surgent

Child Abuse Detail

Los Angeles Sheriff's Department

Los Angeles, CA

Stan Wilkins

Manager, Violent Crime Information

Systems

State of California Office of the Attorney

General

Rita Swan

President and Founder

Children's Healthcare is a Legal Duty

(CHILD) Inc.

Sioux City, IA

U.S. Advisory Board on Child Abuse and Neglect

208
Appendix B

DENVER, CO

FATALITIES FOCUS GROUP

MARCH 11, 1993

Jane Beveridge

Director

Child Protection Services

Colorado Department of Human Services

Denver, CO

Michelle Kelley

The Children's Hospital

Child Advocacy and Protection Team

Denver, CO

Donna Rosenberg

Pediatrician

Denver, CO

Harry Wilson

The Children's Hospital

Pathology Department

Denver, CO

Michael Durfee

Child Abuse and Prevention Program

Department of Health Services

Los Angeles, CA

James L. Kramer

Pueblo Coroner's Office

Pueblo, CO

Jill-Ellyn Straus

Deputy District Attorney

Adams County District Attorney's Office

Brighton, CO

U.S. Advisory Board on Child Abuse and Neglect 163

209
Appendix B

164

WASHINGTON, DC

MINI HEARING ON RELIGIOUS EXEMPTION

MAY 26, 1993

Philip G. Davis

Federal Representative

The First Church of Christ Scientist

Washington, DC

Madelyn Nesse

Department of Health and Human Services

Office of the General Counsel

Washington, DC

Ellen Mugmon

Child Protection Group Representative

Washington, DC

Written testimony provided by:

American Academy of Pediatrics

1331 Pennsylvania Avenue, N.W.

Washington, DC

U.S. Advisory Board on Child Abuse and Neglect
Appendix B

CHICAGO, IL

HEARING ON CHILD MALTREATMENT-RELATED FATALITIES

JUNE 25, 1993

Jan Bays

Executive Director

Child Abuse Unit

Emmanuel Hospital

Portland, OR

Thomas Curran

Defender Association of Philadelphia

Child Advocacy Unit

Philadelphia, PA

Paul DerOhannesian

Albany County Office of the

Public Guardian

Chicago, IL

Presiding Judge Harry Elias

North County Municipal Court

North San Diego Municipal Court

Vista, CA

Glenda Kaufman-Kantor

Family Research Laboratory

University of New Hampshire

Durham, NH

Colleen Kivlahan

Medical Director

Department of Social Services

Jefferson City, MO

Sharon O'Conner

Office of the Medical Examiner

Cook County

Chicago, IL

Barbara Bonner

Director

Center on Child Abuse and Neglect

University of Oklahoma

Health Service Center

Department of Pediatrics

Oklahoma City, OK

Deborah Daro

National Center on Child Abuse

Prevention and Research

Chicago, IL

Bernardine Dohrn

Director

Children and Family Justice Center

Northwestern University Legal Clinic

Chicago, IL

Bill Hammond

2101 Wilson Boulevard

Arlington, VA

Robert Kirschner

Deputy Chief Medical Examiner

Cook County Office of the

Medical Examiner

Chicago, IL

Patrick Murphy

Public Guardian

Cook County Office of the Public Guardian

Chicago, IL

Robert Reece

Case Western Reserve University

Rainbow Babies and Children's Hospital

Cleveland, OH

U.S. Advisory Board on Child Abuse and Neglect 165

211
Appendix B

166

Patricia Toth

National Center for the

Prosecution of Child Abuse

Alexandria, VA

Linda Williams

University of New Hampshire

Family Research Laboratory

Durham, NH

U.S. Advisory Board on Child Abuse and Neglect

:2 I
Appendix B

SALEM, OR

HEARING ON CH1LD-MALTREATMENT FATALITIES

SEPTEMBER 30, 1993

Sadikifu Akina-James

Manager

King County

Community Services Division

Member of the National Black Child

Development Institute

Janet Bays

Executive Director

Child Abuse Unit

Emmanuel Hospital

Portland, OR

Detective Jim Bellah

Member of Multhomah County

Multidisciplinary Team

Chris Gardner

Deputy District Attorney

Deschutes County

Member of the Oregon Task Force on

Sex Offenses Against Children

Cynthia Grayson

Grayson and Associates

Seattle, WA

Judith Armatta

Legal Counsel

Oregon Coalition Against

Domestic and Sexual Violence

Kristi Martin Bayya

Director of Social Services

Silets Tribe

Connie Gallagher

Program Development Manager for

Children's Services Division

Co-Chair of the Interdisciplinary

State Child Fatality Review Team

Salem, OR

Grant Higginson

Manager

Child Health Section

Oregon Health Division

Member of the Oregon State

Interdisciplinary Review Team

Portland, OR

Larry V. Lewman

Oregon State Medical Examiner

Portland, OR

U.S. Advisory Board on Child Abuse and Neglect 167

213
Appendix B

168

Kay Lorraine

Assistant Director

Children's Advocacy

Marion County

District Attorney's Office

Helen Smith

Deputy of District Attorney

Multnomah County, OR

Dee Wilson

Division of Children and

Family Services

Spokane, WA

Rita Schmidt

Director

Child and Adolescent Health Division

Parent Child Health Services

Washington State Department of Health

Health Member of Advisory Board

Children's Safety Network

Member of the Department of Health

Interagency Workgroup on

Injury and Injury Prevention

Ed Vandusen

Program Manager

Division of Family and Children's Services

Idaho Department of Health and Welfare

U.S. Advisory Board on Child Abuse and Neglect

214
Appendix B

PITTSBURGH, PA

HEARING ON CHILD MALTREATMENT-RELATED FATALITIES

DECEMBER 2, 1993

Nora Baladerian

Director

Disability, Abuse, and

Personal Rights Project

SPECTRUM Institute

Culver City, CA

Robert Block

Chief Child Abuse Examiner

University of Oklahoma

Health Science Center

Tulsa, OK

James Cameron

Executive Director

Federation of Child Abuse and Neglect

National Committee to

Prevent Child Abuse

Albany, NY

Michael Durfee

Child Abuse and Prevention Program

Department of Health Services

Los Augeles, CA

Donna Pincavage

Director

Office on Child Abuse Prevention

State of New Jersey

Jacy Showers

Special Projects Coordinator

Pueblo City-County

Health Department

Pueblo City, CO

Jane Beveridge

Director

Child Protection Services

Colorado Department of Human Services

Denver, CO

Barbara Bonner

Director

Center on Child Abuse and Neglect

University of Oklahoma

Health Service Center

Department of Pediatrics

Oklahoma City, OK

Mary Carrasco

Director

Family Intervention

Children's Hospital in Pittsburgh

Pittsburgh, PA

Joyce Jennings

Program Director

Colorado's Children Trust Fund

William Ratay

Child Protective Investigative Supervisor

State of Florida

Children and Family Division

Protective Services

James Singer

Psychotherapist

Dubois, PA

U.S. Advisory Board on Child Abuse and Neglect 169

215
Appendix B

170

Kathryn Turman

Senior Associate

Public Administration Service

McLean, VA

Patricia West

Representing the Pennsylvania Chapter

American Academy of Pediatrics

Philadelphia, PA

U.S. Advisory Board on Child Abuse and Neglect

216
Appendix B

NEW YORK, NY

FOCUS GROUP ON PREVENTION, DATA COLLECTION, AND CHILD

SAFETY AND FAMILY PRESERVATION

AND

HEARING ON CHILD MALTREATMENT-RELATED FATALITIES

JUNE 13 - 17, 1994

Jose Alfaro

Director of Research

Children's Aid Society

New York, NY

Michael Baden

Director of Forensic Services

New York State Police

Albany, NY

Tanisha Cagl in

U.S. Department of

Health & Human Services

Office of Minority Health

Rockville, MD

Geoffrey Canada

President

Rheedlen Centers for Children and

Families

New York, NY

Michael Durfee

Child Abuse and Prevention Program

Department of Health Services

Los Angeles, CA

Richard Gelles

Professor of Sociology and Psychology

Director

Family Violence Research Program

The University of Rhode Island

Kingston, RI

Jonathan Arden

Medical Examiner

Office of the Chief Medical Examirmr

New York, NY

Barbara Bonner

Director

Center on Child Abuse and Neglect

University of Oklahoma

Health Service Center

Department of Pediatrics

Oklahoma City, OK

3..mes Cameron

Executive Director

Federation of Child Abuse and Neglect

Albany, NY

Olivia Carter-Bokras

U.S. Department of

Health & Human Services

Office of Minority Health

Rockville, MD

Bernard Ewigman

University of Missouri

Health Science Center

Columbia, MO

Brahm Goldstein

Assistant Professor of Pediatrics

University of Roclester

School of Medicine and Dentistry

Rochester, NY

U.S. Advisory Board on Child Abuse and Neglect 171
Appendix B

Marlene Halpern

Legal Services of New York City

New York, NY

Phillip W. Hyden

Director

Child Protection Team

New York, NY

Donna Lawrence

Executive Director

Family Dynamics, Inc.

New York, NY

Phil McClain

U.S. Department of

Health & Human Services

Centers for Disease Control & Prevention

Atlanta, GA

Margaret McHugh

Director

Child Protection Team

Bellevue NYU - Bellevue

Pediatric Clinic

Bellevue Hospital

New York, NY

Jose Nazario

Senior Social Worker

MFY Legal Services, Inc.

New York, NY

172

Miriam Rabban

Staff Director

Intensive Family

IFPS National Network

New York, NY

Leah Harrison

Assistant Director

Child Protection Center

Bronx, NY

Kenneth Kochanek

Statistician

National Center for Health Statistics

Hyattsville, MD

Louis Martinez

Program Specialist II

Tennessee Department of Human Services

Mt. Juliet, TN

Karen McCurdy

Principal Analyst

National Committee to Prevent Child Abuse

Chicago, IL

Megan McLaughlin

Executive Director/CEO

Federation of Protestant Welfare Agencies

New York, NY

Congressman Major R. Owens

1 lth District

Brooklyn, NY

Anne Reiniger

Executive Director

The New York Society for the

Prevention of Cruelty to Children

New York, NY

U.S. Advisory Board on Child Abuse and Neglect

21
Appendix B

Dale Robinson

Congressional Research Service

Washington, D.C.

Valorie Smith

Bronx, NY

Evan Stark

Director

Domestic Violence Training

Public Administration & Social Work

New Haven, CT

Ying Ying T. Yuan

Vice President

Walter R. McDonald & Associates, Inc.

Gaithersburg, MD

Bruce Rubenstein

Deputy Director

Los Angeles County

Department of Children's Services

Los Angeles, CA

Lucinda Suarez

Deputy Bureau Chief - Special Victims

Queens District Attorney's Office

Kew Gardens, NY

Laurel Whitaker

Coordinator

Parenting Education Program

SIJNY Downstate Medical Center

Brooklyn, NY

U.S. Advisory Board on Child Abuse and Neglect 173

4 219
Appendix B

174

LOS ANGELES, CA

FOCUS GROUP ON DATA COLLECTION AND IDENTIFICATION AND

INVESTIGATION OF CHILD FATALITIES

JULY 21 - 22, 1994

Nora Baladerian

Director

Disability, Abuse, and

Personal Rights Project

SPECTRUM Institute

Los Angeles, CA

Brian Blackbourne

Chief Medical Examiner

San Diego County

San Diego, CA

Howard Davidson

Director

Center on Children and the Law

American Bar Association

Washington, DC

Presiding Judge Harry Elias

North County Municipal Court

North San Diego Municipal Court

Vista, CA

Astrid Heger

Director

Los Angeles County

University of Southern California

Medical Center

Pediatric Suspected Child Abuse and

Neglect Team

Los Angeles, CA

Ryan Rainey

Senior Attorney

National Center for the Prosecution of

Child Abuse

Alexandria, VA

Jane Beveridge

Director

Child Protection Services

Colorado Department of Human Services

Denver, CO

Alana Bowman

Office of the City Attorney

Domestic Violence Unit

Los Angeles, CA

Michael Durfee

Child Abuse Prevention Program

Department of Health Services

Los Angeles, CA

Sandra Guine

Los Angeles Department of Health Services

Child Abuse Prevention Program

Los Angeles, CA

Lt. Comdr. N.G. Cindy Jones

Assistant Chief of Staff, Director

U.S. Navy

Family Advocacy Treatment Center

San Diego, CA

Alison Renteln

Associate Professor of Political Science

University of Southern California

Los Angeles, CA

U.S. Advisory Board on Child Abuse and Neglect

2 2 0
Appendix B

Diana Roberts

Program Manager

Oregon Department of Human Resources

Children's Services Division

Salem, OR

Claudia Spencer

Program Manager

Child Abuse Prevention

San Bernardino County

Department of Public Health

San Bernardino, CA

Capt. John Welter

San Diego Police Department

San Diego, CA

Donya Witherspoon

Consultant

Dallas, TX

Deputy Bobby Smith

Juvenile Division, Operations Section

Los Angeles Police Department

Los Angeles, CA

Hershel K. Swinger

Clinical Director

Children's Institute International

Los Angeles, CA

Donna Wills

Deputy District Attorney

Los Angeles, CA

U.S. Advisory Board on Child Abuse and Neglect 175

221
Appendix B

176

ST. LOUIS, MO

HEARING ON CHILD MALTREATMENT-RELATED FATALITIES

AUGUST 1, 1994

Mary E.S. Case

Chief Medical Examiner

St. Louis County Medical Examiner

St. Louis, MO

Katharine Fincham

Child Homicide Prosecutor

Assistant Prosecuting Attorney

Jackson County Prosecuting Office

Kansas City, MO

William L. Kincaid

Acting Director of Health & Hospitals

City of St. Louis

Department of Health & Hospital

St. Louis, MO

Carmen K. Schulze

Division Director

Missouri Division of Family Services

Jefferson City, MO

Fred A. Ward

Randolph County Coroner

President

Missouri Coroner's and

Medical Examiner's Association

Cairo, MO

Bernard Ewigman

University of Missouri

Department of Medicine

Columbia, MO

Mary Adele Greer

Prosecuting Attorney

Morgan County

Versailles, MO

Debra McDermott

St. Louis Urban Case Coordinator

Child Fatality Review Services

St. Louis, MO

Helen Shore

Regional Coordinator

Child Fatality Review Project

Missouri Division of Family Services

Neosho, MO

Gloria Moore

U.S. Department of Health and Human Services

Atlanta, GA

This hearing took place during the National Symposium on Child Fatalities,

The Missouri Experience, sponsored by the Missouri Department of Social Services.

U.S. Advisory Board on Child Abuse and Neglect

222
Appendix B

DALLAS, TX

HEARING ON CHILD MALTREATMENT-RELATED FATALITIES

AUGUST 30, 1994

Richard B. Bays

State Registrar

Texas Department of Health

Austin, TX

Robert Block

Chairman

Oklahoma Child Death Review Committee

c/o Jan Parks

Community Services Council

Tulsa, OK

Pat Devin

Deputy Director

Protective Services for

Families and Children

Texas Department of

Protective and Regulatory Services

Austin, TX

James Farren

Assistant District Attorney

47th District Attorney's Office

Amarillo, TX

Rafael R. Garcia

Associate Professor

Texas Tech University

Health Science Center

Lubbock, TX

Victor Ilegbodu

City of Houston

Health v nd Human Services Department

Houston, TX

Denise Oncken

Assistant District Attorney

Harris County District Attorney's Office

Houston, TX

Robert Bux

Deputy Chief Medical Examiner

Bexar County Forensic Science Center

San Antonio, TX

Mary Alice Brown

Manager of Research and Evaluation

Children's Trust Fund of Texas

Austin, TX

Judge Cindy Evans

Justice of the Peace

McLennan County Courthouse

Waco, TX

Janie Fields

Executive Director

Children's Trust Fund of Texas

Austin, TX

Rhonda Hurley

Assistant District Attorney

Child Protection Team

Austin, TX

Sandra Martin

Executive Director

Travis County Childre i's Advocacy Center

Austin, TX

Nizam Peerwani

Chief Medical Examiner

Office of Tarrant County Medical Examiner

Ft. Worth, TX

U.S. Advisory Board on Child Abuse and Neglect 177

223
Appendix B

178

Ana Maria Pozo Jane Quentan

Director Executive Director

Children's Justice Act Project Texas CASA, Inc.

Child Fatality Review Team Project Austin, TX

Austin, TX

Martha Smithy

Assistant Professor

Department of Sociology and

Criminal Justice

University of Texas at El Paso

El Paso, TX

Lt. Bill Walsh

Dallas Police Department

Dallas, TX

This hearing took place in conjunction with the 1994 Crimes Against Children

Seminar sponsored by the Dallas Police Department and the Dallas Children's

Advocacy Center.

U.S. Advisory Board on Child Abuse and Neglect

224
Appendix C

REVIEW OF CHILD FATALITIES RESEARCH AND LITERATURE

compiled by

Cheryl D. Compaan and Jennifer B. Freeman

under the direction of Dr. Murray Levine

The literature review for this study involved a systematic computer search of the

following databases: PsychLIT, Medline, and the University of New York (SUNI9 at

Buffalo's Bison index. The search used key terms such as child maltreatment,

fatality, homicide, severe, abuse, neglect, and any derivatives or variations of those

terms. In addition to the computer search, bibliographies of relevant articles were

reviewed for citations of important earlier research. Searches included current

research and articles dating up to 20 years prior to the release of this report.

Finally, the authors also reviewed several State and Federal reports on child

fatalities as well as documents of testimony given at various US. Advisory Board on

Child Abuse and Neglect conferences on child fatalities.

Childhood Homicide

Abel, E.L. (1986). Childhood homicide in Erie County, New York.

Pediatrics, //(5), 709-713.

Childhood homicide during 1972 to 1984 constituted 7.6 percent of

the total homicides in Erie County, N.Y., a relatively higher percentage

than for the United States as a whole. Notably, the age-specific rate for

African American children less than 4 years of age was 17.9 per 100,000,

a rate higher than that for Northern Ireland. In addition to child's age and

race, this study examined various demographic and situational

characteristics associated with childhood homicide as an initial step in

developing prevention strategies.

Blaser, M.J, Jason, J.M., Weniger, B.G., Elsea, W.R., Finton, R.J., Hanson,

R.A., & Feldman, R.A. (1984). Epidemiologic analysis of a cluster of

homicides of children in Atlanta. Journal of the American Medical

Association, 2.51(24), 3255-3258.

Lie authors sought to define the epidemiologic characteristics of a

cluster of unsolved child homicides and disappearances in Atlanta and to

U.S. Advisory Board on Child Abuse and Neglect

179
Appendix C

180

determine whether there were identifiable factors associated with

increased risk of homicide.

Christoffel, K.K. (1984). Homicide in childhood: A public health problem in

need of attention. American Journal of Public Health, 74,68-70.

Based on children's changing developmental vulnerabilities, it is

possible to characterize three subtypes of child homicideinfanticide,

fatal child abuse and neglect after infancy, and homicide in the

community. Specific approaches to primary prevention include measures

to strengthen families and their community support systems and to educate

adults and children concerning appropriate behaviors of children at

different ages.

Christoffel, K.K. (1990). Violent death and injury in U.S. children and

adolescents. American Journal of Diseases of Children,144,697-706.

This article reviews what is known about violent injury to US

children and adolescents aged 0 to 19 years and presents data for 1985.

The violent injuries addressed include child abuse and neglect

(maltreatment by responsible adults); assault (by personsstrangers,

peers, or others- not responsible for the victim); and homicide (death due

to child abuse and neglect or assault).

Christoffel, K.K., Anzinger, N.K., & Amari, M. (1983). Homicide in

childhood- distinguishable patterns of risk related to developmental

levels of victims. The American Journal of Forensic Medicine and

Pathology, 4(2), 129-137.

A review was done of the 29 medical examiner-autopsied children

under 10 years of age who died under suspicious circumstances in Cook

County, IL, in the first half of 1981. Variables including age of victim,

family composition, socioeconomic status, ethnicity, and type of death

were examined. The data suggest that there are three clinically

distinguishable types of homicide in childhoodinfanticide, fatal child

abuse and neglect after infancy, and murder in the communityrelated to

developmental characteristics of the victims.

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

Christoffel, K.K., Anzinger, N.K., & Merrill, D.A. (1989). Age-related

patterns of violent death, Cook County, Hlinois, 1977-1982.

American Journal of Diseases of Children, 143,1403-1409.

To clarify age-related patterns of violent death in childhood, a

study was undertaken of medical examiner records concerning 437 deaths

of Cook County, IL residents, younger than 15, who died from 1977

through 1982, and whose deaths were ruled as homicides or of an

undetermined manner. African American children were overrepresented.

Parents were usually perpetrators for victims younger than age 5 and

others for victims older than age 5. Different circumstances of death

characterized victims who were younger and older, and incidence was

associated with urban residence and poverty as well as youngest and oldest

age groups.

Copeland, A.R. (1985). Homicide in childhood: The Metro-Dade County

experience from 1956 to 1982. The American Journal of Forensic

Medicine and Pathology, 01), 21-24.

This study is concerned with all homicides in Metro-Dade County

in victims 12 years of age or less during the 27-year period from 1956 to

1982. Cases were readily subdivided into two groupsthose exhibiting

child abuse and those that did not. These two groups were further

characterized by age, race, sex, cause of death of victim, and perpetrator

fatal act. It was apparent that not all childhood homicides involved child

abuse.

Crittenden, P.M. & Craig, S.E. (1990). Developmental trends in the nature

of child homicide. Journal of Interpersonal Violence, 5(2), 202-216.

Citing a need to identify a coherent pattern or set of patterns

among cases of childhood homicide, this study differentiated among

neonatal, early, and middle childhood deaths. The authors looked

carefully at types and circumstances of deaths in reference to child age.

They conclude that it is difficult, or even impossible, to identify

preventively specific cases of incipient homicide.

Goetting, A. (1990). Child victims of homicide: A portrait of their killers

and the circumstances of their deaths. Violence and Victims, 5(4),

287-296.

The population of 93 arrestees for homicides committed against

children between 1982 and 1986 in Detroit, MI, is analyzed in the context

of their killings. Analyses include demographic and social relationships

U.S. Advisory Board on Child Abuse and Neglect

181
Appendix C

182

between offenders and victims, circumstances of offense, and arrest

disposition.

Hollander, N. (1986). Physical abuse as a predictor of child homicide. Texas

Medicine, 82, 21-23.

Sequential records of 48 child deaths that occurred from 1979

through 1984 were reviewed to ascertain whether it is possible to predict

and prevent child deaths caused by abuse. Information of the cases was

available from the Dallas County Child Welfare Department. 25 of the

deaths were the result of homicide or undetermined cause, and in 23 of the

total deaths reported (92 percent) of these, physical abuse or other physical

violence in the home preceded the episode of fatal abuse. Detailed

examination of the cases indicates that fatalities could be prevented by

considering physical abuse a reason for removing a child from the abusive

parent either permanently or until appropriate intervention has occurred.

Jason, J. (1983). Child homicide spectrum. American Journal of Diseases of

Children, 137,578-581.

National homicide data for persons younger than 18 from 1976

through 1979 were used to characterize child homicide. Two broad

categories were identified: the first predominates until the victim age of 3

years, is intrafamilial, and is associated with bodily force and poorly

defined precipitating events. It can be described as fatal child abuse. The

second type predominates after the victim age of 12 years, is extrafamilial,

involves guns or knives, occurs during arguments or criminal acts by the

offender, and may represent children unsupervised in an adult

environment.

Jason, J. (1984). Centers for Disease Control and the epidemiology of

violence. Child Abuse and Neglect , 8,279-283.

The Center for Health Promotion and Education, the Centers for

Disease Control (CDC) has begun to apply epidemiologic techniques to

study the problems of child abuse, child homicide, homicide, and suicide.

This paper discusses an epidemiological investigation of the

underrecording of child homicide in the United States.

Jason, J., Gilliand, J.C., & Tyler, C.W. (1983). Homicide as a cause of

pediatric mortality in the United States. Pediatrics, 22(2), 191-197.

National law enforcement data from 1976 through 1979 were

analyzed to characterize and differentiate neonaticide, infanticide, filicide,

and overall child homicide. Analyses include incidence, types of deaths,

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

demographic characteristics of victims and offenders, and victim-specific

rates by geographic region. The authors examine the possible role of

pediatricians in identifying risk factors for child homicide.

Muscat, J.E. (1988). Characteristics of childhood homicide in Ohio, 1974

1984. American Journal of Public Health, 7.8(7), 822-824.

Childhood homicide deaths in Ohio from 1974 to 1984 were

examined using Ohio Vital Statistics records and U.S. Census Data.

Homicide rates varied from 25/100,000 for African American infant males

to 0.8/100,000 for white females ages 5-9. Child battering was the

leading cause of death for children under 5 years of age. Firearms

accounted for a large percentage of deaths for children 10-14 years of age.

Childhood homicide was associated with low socioeconomic indicators in

the four largest Ohio cities.

Paulson, J.A. & Rushforth, N.B. (1986). Violent death in children in a

metropolitan county: Changing patterns of homicide 1958-1982.

Pediatrics, 28(6), 1013-1020.

Data from the Cuyahoga County, OH, coroner's office pertaining

to homicides in children younger than age 15 between 1958 and 1982 were

analyzed. Findings indicate fatal child abuse in younger children and

deaths attributed to community violence in older children. Homicide rates

increased in the first 20 years and then stabilized. Nonwhite males had the

highest death rate except in one period. Assailants were usually

adolescents and young men, however, 43 percent of children under age 5

were killed by women. Firearms were the leading cause of homicide.

Fatal Child Maltreatment

Anderson, IL, Ambrosino, R., Valentine, D., & Lauderdale, M. (1983).

Child deaths attributed to abuse and neglect: An empirical study.

Children and Youth Services Review, 5,75-89.

This study of 267 child deaths associated with abuse or neglect in

Texas during 1975 through 1977 suggests a number of indicators for

identifying potential child fatalities. Families where abuse or neglect is

implicated in a child fatality are characterized by small family size, young

parents, and underutilization of community support services.

183

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

184

Alfaro, J.D. (1988). What can we learn from child abuse fatalities? A

synthesis of nine studies. In Besharov, D. Protecting Children From

Abuse and Neglect. Springfield, IL: Charles C Thomas, Publisher.

This synthesis report examines the methods and results of recent

child maltreatmentfatality studies. It focuses on nine studies that have

examined maltreatment fatalities from the child protective service

perspective. The methods of these studies vary, making the comparability

of their data uncertain, but they have a common purposeto improve one

or more aspects of the child protection system.

Bergman, A.B., Larsen, R.M., & Mueller, B.A. (1986). Changing spectrum

of serious child abuse. Pediatrics, 77, 113-116.

To determine whether the spectrum of serious child abuse has

changed over the past decade, hospital and medical examiner records in

the Seattle area were reviewed for the years 1971 to 1973 and 1981 to

1983. Although the incidence of hospitalized cases was similar in the two

time periods, the proportion of severe injuries that occurred increased

significantly.

Christoffel, K.K., Zieserl, E.J., & Chiaramonte, J. (1985). Should child

abuse and neglect be considered wben a child dies unexpectedly?

American Journal of Diseases of Children, 139, 876-880.

Deaths during 2 years at a pediatric teaching hospital were studied

to develop guidelines for clinicians who must decide when to explore the

possibility of child abuse or neglect when a child dies unexpectedly. The

two factors "dead on arrival" and "1 year of age or less" identify a highrisk group requiring at least hospital-based investigation into the

possibility of abuse or neglect. Reporting for suspected child abuse and

neglect is warranted when (1) unsuspected trauma is found post mortem,

(2) there is direct physical or social evidence of child abuse or neglect, or

(3) the child is in the high-risk group and hospital-based investigation fails

to eliminate the possibility that maltreatment contributed to the child's

death.

Durfee, M. (1989). Fatal child abuse -intervention and prevention.

Protecting Children, 9-12.

An overview of the problem of fatal child abuse explains the

role of a multiagency, multidisciplinary case review team in bringing order

to intervention and prevention of such deaths.

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

Jason, J. & Andereck, N.D. (1953). Fatal child abuse in Georgia: The

epidemiology of severe physical child abuse. Child Abuse &

Neglecta, 1-9.

Fifty-one fatal child abuse cases occurring in Georgia between July

1975 and December 1979 were compared with nonfatal cases and to the

Georgia population. Overall rates of fatal child abuse were higher for

male perpetrators compared with female and black perpetrators compared

with white. The highest child abuse fatality rates were found in poor,

rural, white families and in poor, urban, black families. Risk factors for

fatal abuse included early childhood, parental teenage childbearing, and

low socioeconomic status.

Krugman, R.D. (1985). Fatal child abuse: Analysis of 24 cases.

Pediatrician, 12,68-72.

Analysis of 24 cases of fatal child abuse reveals that

multidisciplinary review can assist in the determination of whether fatal

injury was accidental or non-accidental. All cases had both a 'discrepant

history' and some 'delay' in seeking care. The predisposing child factor

was inconsolable crying in infants under 12 months, and was associated

with a bowel or bladder accident or diaper change in 9 of 12 cases where

children were over 1 year of age. Head injury accounted for 17 of the 24

deaths.

Margolin, L. (1990). Fatal child neglect. Child Welfare, (29,309-319.

This study examined the circumstances associated with

fatal child neglect in one state to differentiate fatal child neglect from fatal

physical abuse and from other types of neglect that are not life-threatening.

The typical neglect fatality was a male child, younger than three, living

with his mother and two or three siblings.

McClain, P.W., Sacks, J.J., Ewigman, B.G., Smith, S.M., Mercy, 3.A., &

Sniezek, J.E. (1994). Geographic patterns of fatal abuse or neglect in

children younger than 5 years old, United States, 1979 to 1988.

Archives of Pediatrics & Adolescent Medicine, 148, 82-86.

This study used a death certificate-based model to estimate the

occurrence of fatal child abuse and nelgect and to examine geographic

patterns of fatal child abuse and neglect among children younger than 5 in

the United States between 1979 and 1988. The authors estimate that from

868 to 1815 deaths from child abuse and neglect annually occur among

this population and that death rates were higher in the South and West,

intermediate in the North and Central States, and lowest in the Northeast.

185 U.S. Advisory Board on Child Abuse and Neglect

31
Appendix C

186

McClain, P.W., Sacks, J.J., Froehlke, R.G., & Ewigman, B.G.

(1993). Estimates of fatal child abuse and neglect, United States, 1979

through 1988. Pediatrics, 21, 338

343.

This study explored the use of death certificate data to estimate the

number of fatalities due to child abuse or neglect in the United States

among children 0 through 17 for 1979 through 1988. After formulating 3

models, for the 10-year period, the estimated mean annual child abuse and

neglect fatalities ranged from 861 to 1,814 for ages 0 through 4 and from

949 to 2022 for ages 0 through 17. It is concluded that the magnitude of

fatal child abuse and neglect can be estimated from death certificates, but

that the death coding system should be modified to make identification of

child abuse and neglect fatalities easier.

McCurdy, K. & Daro, D. (1994). Child maltreatment: A national survey of

reports and fatalities. Journal of Interpersonal Violence, 2,75-94.

This article examines the scope of the child maltreatment

problem in the United States. Representatives of child protective service

agencies in each state and the District of Columbia were interviewed to

obtain current estimates of child maltreatment reports and fatalities. The

results of the survey indicate that rates of reported and substantiated cases

of child maltreatment as well as confirmed child deaths due to abuse or

neglect have steadily increased over the past 8 years. Evidence shows that

very young children face the greatest risk of dying from maltreatment.

Sabotta, E.E. & Davis, R.L. (1992). Fatality after report to a child abuse

registry in Washington State, 1973-1986. Child Abuse & Neglect,

627-635.

For 11,085 children born in Washington State between 1973 and

1986 and reported to the State child abuse registry, authors analyzed the

fatality rate subsequent to reported abuse and compared it to a population

of nonabused children matched on sex, county of birth, and year of birth.

Children reported to the child abuse registry had an almost threefold

greater risk of death than the comparison population.

Zumwalt, R.E. & Hirsch, C.S. (1980). Subtle fatal child abuse. Human

Patbology,11,167-174.

The authors present six instances of fatal child abuse that illustrate

the types of unusual physical and chemical assault and the covert

negligence that kill children. Unfamiliarity with the law, lack of suspicion

U.S. Advisory Board on Child Abuse and Neglect

:232
Appendix C

in approaching cases, and failure to utilize necessary techniques to

establish the mechanism of death can obscure recognition of the homicidal

nature of such fatalities.

Investigating Child Fatalities

Durfee, M.J., Gellert, G.A., & Tilton-Durfee, D. (1992). Origins and

clinical relevance of child death review teams. Journal of the

American Medical Association, 267,3172-3175.

This article provides an introduction to the unique

factors and magnitude of suspicious child deaths and to the

concept and process of interagency child death review.

Helpern, M. (1976). Fatalities from child abuse and neglect:

Responsibility of the medical examiner and coroner. Pediatric

Annals, 41-57.

The author discusses the responsibilities of a coroner and of a

medical examiner and emphasizes the difficulties involved in determining

the true cause of death. Case examples are provided.

Lundstrom, M. & Sharpe, R. (1991). Getting away with murder.

Public Welfare, summer, 18-29.

Adapted from a four part series published by Gannett News

Services, this article includes and examples of misclassification of

maltreatment fatalities and discussion of factors involved in the

investigation process.

Schloesser, P., Pierpont, J. & Poertner, J. (1992). Active

surveillance of child abuse fatalities. Child Abuse & Neglect,

3-10.

Birth and death certificates were correlated with information in the

State Child Abuse and Neglect Registry on 104 abuse-related fatalities.

Significant findings include: very young age of parents at the first

pregnancy; high rate of single parenthood; significantly lower educational

achievement of victims' mothers; late, inadequate prenatal care;

complications during pregnancy; and low birth weight among victims.

Stangler, G.J., Kivlahan, C., & Knipp, M.J. (1991). How can we tell

when a child dies from abuse? Public Welfarc, fall, 5-11.

Authors offer a synopsis of how Missouri is proceeding

to determine whether fatal child abuse is accidental or intentional. This

U.S. Advisory Board on Child Abuse and Neglect

) ,$) 3

187
Appendix C

188

report also includes findings and circumstances leading to the

establishment of Missouri's death review teams.

Severe Physical Abuse

Johnson, C.F., & Showers, J. (1985). Injury variables in child abuse. Child

Abuse & Neglect, 2,207-215.

The child abuse reporting records of 616 children seen by the child

abuse team in a metropolitan Ohio children's hospital were analyzed.

Variables examined include: victim gender, victim race, victim sex,

perpetrator relationship, type of injury, injury site, and type ofinstrument

used.

Friedman, S.B., & Morse, C.W. (1974). Child abuse: A five-year follow-up

of early case finding in the emergency department. Pediatrics, 54,

404-410.

A total of 156 children under 6 years of age seen for injuries in an

emergency department had been previously studied and their injuries were

judged by the investigators to represent unreported "suspected abuse,"

"gross neglect," or an "accident." Five years later, all cases of "suspected

abuse" and "neglect," and a random sample of "accidents" were included

in a study involving interview of parents and a survey of medical facilities

for subsequent contact with these children. At the time of follow up, it

was found that children judged to have experienced "accidents" had a

lower incidence of subsequent injuries, their siblings had fewer injuries,

their relationship to their mother was judged to be better, and there were

fewer emotional and social problems in their families.

Hegar, R.L., Zuravin, S.J. & Orme, J.G. (1994). Factors predicting severity

of physical child abuse injury: A review of the literature. Journal of

Interpersonal Violence, 2,170-183.

This article reviews the research literature about predictors of

severe and fatal physical child abuse, an important question for the design

of risk assessment instruments for use at child welfare intake. Of various

factors relating to the victim, the perpetrator, and the report of child abuse,

the only one found in this review of the literature to relate consistently to

severity of injury is the age of the child.

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

Reece, R.M. (1990). Unusual manifestations of child abuse. Pediatric

Ciinics of North America, n, 905-921.

Although the scales have fallen from our eyes when confronted

with familiar forms of child maltreatment, instances still exist in which,

unless we include child abuse in our differential diagnostic list, the true

diagnosis could elude detection. The cases reviewed here represent only a

selected few from the literature and from experience but should serve to

make the point that things are not always what they seem to be.

Rosenthal, J.A. (1988). Patterns of reported child abuse and neglect. Child

Abuse & Neglect, 12,263-271.

Confirmed reports of abuse and neglect logged in a large state

registry file from 1977 to 1984 are analyzed. Boys tend to sustain more

frequent and more serious injuries. Victims of male perpetrators tend to

sustain more serious injuries. A modest same-sex perpetrator/victim

pattern is revealed for physical abuse; males are more likely to physically

abuse boys while females are more likely to physically abuse girls.

Among younger victims boys outnumber girls in all reporting categories

except sexual abuse. Among adolescent victims, female victims greatly

outnumber male victims in all reporting categories.

Seaberg, J.R. (1977). Predictors of injury severity in physical child abuse.

Journal of Social Service Research, 1,63-77.

This study is a preliminary examination of factors that might

reasonably account for variation in the severity of physical child abuse. If

distinctive patterns of such factors can be demonstrated to account for this

variation, an empirical basis for typology of physical abuse situations may

emerge. Such a typology could provide a basis for developing and testing

differential treatment and dispositional modalities.

Showers, J. & Garrison, K. (1988). Burn abuse: A four-year study. The_

Journal of Trauma, 28, 1581-1583.

Data are presented for 139 children assessed for abuse by

burning, and findings are contrasted with previous reports in the

literature. The results support assertions that burn abuse is most

prevalent among children under 3 years of age and is usually

perpetrated by a caretaker who is young, single and poorly educated. The

data do not support findings from other studies that boys outnumber girls

as victims. Previous reports that immersion burns constitute the major

burn type are also contradicted by the present study, and results are

examined in terms of sampling techniques.

U.S. Advisory Board on Child Abuse and Neglect 189
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190

International Data on Childhood Homicide and Fatal Abuse

Baldwin, J.A. & Oliver, J.E. (1975). Epidemiology and family

characteristics of severely-abused children. British Journal of

Preventive and Social Medicine, 22, 205-221.

Severe child abuse in Northeast Wiltshire, England, was studied

retrospectively during the period 1965 to 1971, and prospectively for 18

months from January 1972, after a period of consultive activity with those

actively involved to increase awareness of the phenomenon. An abuse rate

of 1 per 1,000 children under 4 years of age was obtained together with a

death rate of 0.1 per 1,000. The implications of the ascertaitunent and

death rates are discussed in relation to data from other studies, and the

need emphasized for detailed studies of the apparent clustering of disorder

in the families, using linked record systems.

Christoffel, K.K. & Liu, K. (1983). Homicide death rates in childhood in 23

developed countries: U.S. rates atypically high. Child Abuse and

Neglect, 2, 339-345.

World Health Organization vital statistics data were used to

compare U.S. homicide death rates with those in 23 other developed

countries. Using rank ordering and comparison with mean and median

rates for the other countries, U.S. homicide rates for the general population

were found to be exceptionally high. Similarly, U.S. homicide rates for

infants and for 1-4 year olds were atypically high. The U.S. infant

homicide rate was also characterized by a male predominance.

Christoffel, K.K., Liu, K., & Stamler, J. (1981). Epidemiology of fatal

child abuse: International mortality data. Journal of Chronic

Diseases, 34, 57-64.

World Health Organization data for 1974 on age-specific death

rates due to definite and possible inflicted injuries (DII and PII) in 52

countries were studied. DII death rates for children under age 1 and for all

ages were independent internationally. DII death rates for children aged 1

to4 and for all ages were independent in developing countries, but in

developed countries came close to correlating. DII death rates were

somewhat higher for young children in developed countries and accounted

for a greater proportion of deaths in children under 5. Analyses of Pll

deaths gave less consistent results.

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

Creighton, S.J. (1985). An epidemiological study of abused children and

their families in the United Kingdom between 1977 and 1982. Child

Abuse and Neglect, 2,441-448.

Between 1977 and 1982 there were 6,532 children placed on the

child abuse registers maintained by the National Society for the Prevention

of Cruelty to Children (NSPCC) in England. This paper examines the data

on these children. While the rate of physical injury increased over the

time period, the percentage of fatal and serious injuries decreased.

Gartner, R. (1990). The victims of homicide: A temporal and cross-national

comparison. American Sociological Review, 55, 92-106.

This paper develops and tests a model of cross-national and

temporal variation in homicide rates using sex- and age-specific

victimization data from 18 developed nations for the years 1950 to1980.

The results indicate that the structural and cultural factors that explain

homicide rates in the United States are also associated with sex- and agespecific homicide rates in other countries.

Hargrave, D.R. & Warner, D.P. (1992). A study of child homicide over two

decades. Medicine, Science and the Law, 3_2(3), 247-250.

The child homicides which were notified to the Leeds University

Department of Forensic Medicine between 1970 and 1989 were studied.

There were 131 cases, and information regarding age of victim, mode of

death, and postmortem evidence of previous abuse was noted. Incidence,

age of victim, and type of death are examined. Blunt injury accounted for

almost half the deaths, and 34 percent of cases showed evidence of

previous physical or sexual abuse. Many infant deaths were attributed to

"Shaken Baby Syndrome."

Kotch, J.B., Chalmers, D.J., Fanslow, J.L., Marshall, S., & Langley, J.D.

(1993). Morbidity and death due to child abuse in New Zealand.

Child Abuse and Neglect, 17, 233-247.

The purpose of this study was to explore underdiagnosis and racial

bias among child abuse morbidity and mortality data from New Zealand.

Computerized files of all intentional injury fatalities among children 16

years of age and under for 1978 to 1987, and all hospital discharges for

intentionally injured children 16 and under for 1988 were analyzed for

evidence of physical and sexual abuse. Among the 92 fatalities, only 21 of

68 deaths due to physical and/or sexual abuse were so coded. In both the

mortality and the morbidity data, there was an association between the

diagnosis of child abuse and race.

U.S. Advisory Board on Child Abuse and Neglect 191
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192

Oliver, J.E. (1983). Dead children from problem families in NE Wiltshire.

British Medical Journal, 286,115-117.

Analysis of 147 families in Northeast Wiltshire, England, known

to have suffered child neglect or abuse over two generations showed that

in 560 children had been born in a 21-year period. Of these, 513 were

known to have been neglected or assaulted or both; 41 had died. Detailed

collated confidential information indicated that parental behavior towards

the dead children, in particular those aged from 5 weeks to 1 year, had

often caused or contributed to their deaths, including some claimed to be

clear-cut cases of accident or illness.

Somander, L.K.H. & Rammer, L.M. (1991). Infra- and extrafamilial child

homicide in Sweden 1971-1980. Child Abuse and Neglect, 15,45-55.

Over the 10-year period studied, a total of 96 children under 15

years of age were killed in Sweden. This number constituted an average

annual rate of 0.6 per 100,000 children. The violence, most frequently

involving strangulation, shooting, and stabbing, was largely directed at

young children. The pattern of child homicide was mainly characterized

by intrafamilial violence, especially in connection with the suicide of a

parent-perpetrator. Extrafamilial homicides were rare and only committed

by male perpetrators. Cases of child abuse by a parent and cases of sexual

abuse were infrequent.

Wilkey, 1., Pearn, J., Petrie, G., & Nixon, J. (1982). Neonaticide,

infanticide and child homicide. Medicine, Science, and the Layv,,22(1),

31-34.

A total population study of neonaticide, infanticide, and child

homicide in Queensland, Australia is reported. Using case records,

coroner records, and inquest files of every case of nonaccidental injury and

child neglect, the authors have identified seven distinct syndromes of

unlawful child killing. Analyses include age of victim, type and

circumstances of death, and geographic location by year of death.

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

Type of Death

Bass, M., Kravath, RE., & Glass, L. (1986). Death-scene investigation

in sudden infant death. The New England Journal of Medicine,

315,100-105.

Death-scene investigations were conducted in 26 consecutive cases

in which a presumptive diagnosis of sudden infant death syndrome (SIDS)

was made among infants who were brought to the emergency room at the

Kings County Hospital Center in Brooklyn, NY, between October 1983

and January 1985. In six cases there was strong circumstantial evidence of

accidental death. In 18 other cases, various possible causes of death other

than SIDS were discovered. This study suggests that many sudden deaths

of infants have a definable cause that can be revealed by careful

investigation of the death scene and that the extremely high rate of SIDS

reported in the population of low socioeconomic status served by this

hospital center should be questioned.

Berger, D. (1979). Child abuse simulating "near-miss" sudden infant death

syndrome. The Journal of Pediatrics, 9,5(4), 554-556.

Two examples of child abuse by suffocation presenting as nearmiss sudden irifant death syndrome (SIDS) demonstrate the diftulty in

differentiating these diagnoses. In both cases the initial histories,

presentations, physical examinations, and laboratory findings were

compatible with either diagnosis. Social factors, cited as risk factors for

child abuse but also common to SIDS, add to the difficulty of differential

diagnosis. Careful examination of near-miss SIDS cases is seen as

imperative.

Ludwig, S. & Warman, M. (1984). Shaken baby syndrome: A review of 20

cases. Annals of Emergency Medicine,13(2), 104-107.

Twenty cases of shaken baby syndrome are reviewed to determine

important signs, symptoms, physical findings, laboratory parameters, and

prognosis.

Reece, R.M. (1993). Fatal child abuse and sudden infant death syndrome:

A critical diagnostic decision. Pedhltrics, 91(2), 423-429.

Distinguishing between an unexpected infant death due to sudden

infant death syndrome (SIDS) and one due to fatal child abuse challenges

pediatricians, family physicians, pathologists, and child protection

agencies. All agree that the state of our knowledge in this area is

incomplete and that ambiguity exists in some cases. Investigating infant

U.S. Advisory Board on Child Abuse and Neglect 193
Appendix C

194

deaths requires application of current knowledge, the resources necessary

to conduct essential procedures, and the sensitivity and wisdom to perform

the task without causing distress to innocent family members. These

issues are discussed.

Perpetrator Characteristics

Archer, J. (1991). Human sociobiology: Basic concepts and limitations.

Journal of Social Issues, 47(3), 11-26.

Principles underlying the sociobiological, or functional

evolutionary, approach to behavior are outlined. Application of

sociobiological principles to topics in Psychology, such as altruism,

homicide, child abuse, and socialization, are outlined. Problems with the

functional approach are identified, notably limitations to the assumption of

the adaptiveness of behavior, and confusion of functional and causal

explanations.

Bourget, D. & Bradford, J.M.W. (1990). Homicidal parents. Canadian

Journal of Psychiatry, 35(3), 233-238.

In a retrospective study of 13 cases of parents who have killed their

children, the relevant demographic and clinical data are reviewed. The

diagnostic classification using the DSM-III-R is discussed in detail. A

higher incidence of maternal perpetrators was found, and exposure to a

variety of psychosocial stresses appears to have been a major factor.

Similarly the suicidal history and behavior of the subjects is significant.

Daly, M. & Wilson, M. (1985). Child abuse and other risks of not living with

both parents. Ethology and Sociobiology, fi, 197210.

This study was undertaken to quantify various risks to children as a

function of the identity of the person(s) in loco parentis. The household

circumstances of children in a midsized Canadian city were surveyed by

telephone, and combined with information on child abuse victims,

runaways, and juvenile offenders, to arrive at victimization rates according

to age and household type. Both abuse and police apprehension w, -e least

likely for children living with two natural parents. Whereas abuse risk

was significantly higher for children living with a stepparent than for those

with a single parent, the reverse was true of the risk for apprehension for

criminal offenses.

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

d'Orban, P.T. (1979). Women who kill their children. British Journal of

Psychiatry,134,560-571.

During a 6-year period (1970-75), 89 women charged with the

killing or attempted murder of their children were examined in a female

remand prison. Six types of maternal filicide were distinguished: battering

mothers (36), mentally ill mothers (24), neonaticides (11), retaliating

mothers (9), women who killed unwanted children (8) and mercy killing

(1). Types of filicide were compared on a number of social and

psychiatric characteristics and on their offence patterns and court

disposals.

Husain, A. & Anasseril, D. (1984). A comparative study of filicidal and

abusive mothers. Canadian Journal of Psychiatry, 29.(7), 596-598.

In this paper the authors report on a study of 8 filicidal and 52

abusive mothers referred to them by courts for pre-trial psychiatric

evaluation. They found that there were significant differences between the

two groups with regard to previous mental illness. They conclude that

filicidal mothers are different from abusive mothers and that the risk of

fatality as a complication of child abuse increases significantly when

psychiatric illness is present in the mother.

Kaplan, M.F. (1988). A peer support group for women in prison for the

death of a child. Journal of Offender Counseling, Services, and

Rehabilitation, 13(1), 5-13.

A peer support group program for women in prison for the death

of a child has helped the participants reduce their isolation, mourn their

loss, identify their responsibility in the death and change destructive

patterns of feelings and behavior. Follow up of women who have been

paroled indicates their positive adjustment to the community.

Kaplun, D. & Reich, R. (1976). The murdered child and his killers.

American Journal of Psychiatry, 133(7), 809-813.

The authors studied 112 cases of child homicide in New York City

during 1968-1969 to identify contributing social and psychiatric factors

and to determine the fate of the surviving siblings and the degree of

involvement of the city's social agencies with the families. There was a

pattern of long-term familial child maltreatment extending to the siblings

and continuing after the murders. The victims were usually illegitimate

preschoolers; the assailants, usually the mothers or their paramours, had

backgrounds of assaultiveness and social deviance and killed in impulsive

rage. Case illustrations and prevention guidelines are presented.

195

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

196

Korbin, J.E. (1986). Childhood histories of women imprisoned for fatal

child maltreatment. Child Abuse and Neglect, IQ, 331-338.

A history of childhood maltreatment is the most consistently

reported characteristic of abusive parents. Retrospective research with

nine women imprisoned for fatal child abuse revealed childhood histories

of maltreatment. Detailed life histories indicated that early abuse had an

impact on later abusive parenting. Childhood abuse was only one in a set

of factors contributing to abusive parenting.

Korbin, J.E. (1987). Incarcerated mothers' perceptions and interpretations

of their fatally maltreated children. Child Abuse and Neglect, 11, 397-407.

Fatally maltreated children are an elusive component in the

complex interaction that has led to their premature deaths. Retrospective

research with women imprisoned for fatal child maltreatment indicated

recurring themes of maternal interpretations of their children as rejecting

and developmentally abnormal, either advanced or delayed. Separations

and difficulties during reunions were critical. The fatality was not a

one-time event, but the exit point of a recurrent cycle of abusive

interaction.

Korbin, J.E. (1989). Fatal maltreatment by mothers: A proposed

framework. Child Abuse and Neglect, a 481-489.

This paper proposes a framework for understanding fatal

maltreatment by mothers based on an in-depth study of incarcerated

women. Despite its extreme outcome, fatal maltreatment is not

homogeneous. While the specifics of each case varied, the circumstances

leading to the fatality followed a similar progression. The framework is

characterized by a recurrent pattern of abuse culminating in the fatality.

All of the women had abused the deceased child prior to the fatality, and

had provided warning signals to professionals and to members of their

personal networks. Intervention approaches are also discussed.

Silverman, R.A. & Kennedy, L.W. (1988). Women who kill their children.

Violence and victims, 3(2), 113-127.

This paper examines in what way homicides in which women have

killed tl:eir children are distinctive from spousal homicides, specifically in

terms of the characteristics of the offenders and victims, the circumstances

of the murders, and the motivations attached to the offenders.

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

Weisheit, R.A. (1986). When mothers kill their children. The Social

Sciences Journal, 23(4), 439-448.

Of 460 female homicide offenders admitted to a state prison for

women during 1940-1983, 39 were institutionalized for killing their

children. Among these offenders, several interesting changes over time

were noted. Woinen in the earlier time periods were more likely to be

married and white. The authors note also that women who kill their

children are becoming more similar over time to other types of female

homicide offenders.

Community and Social Factors

Daniel, J.H., Hampton, R.L., & Newberger, E.H. (1983). Child abuse and

accidents in black families: A controlled comparative study.

American Journal of Orthopsychiatry, 53,645-653.

This paper presents a comparison of risk indicators for accidents

and abuse among the African Ameican families that participated in a

larger study of pediatric social illnesses. Socioeconomic factors that play

a significant role in imposing undue stress upon many families are

identified, and implications for prevention and for practice are offered.

Gelles, R.J. (1989). Child abuse and violence in single-parent families:

Parent absence and economic deprivation. American Journal of

Orthopsychiatry, 59,492-501.

A national survey of 6,000 households found single parents

to be more likely to use abusive forms of violence toward their children

than are parents in dual-caretaker households. Abusive violence appears

to be a function of poverty in mother-only homes but unrelated to income

among single fathers.

Gelles, R.J. (1992). Poverty and violence toward children. American

Behavioral Scientist, 35, 258-274.

This article examines the relationship between poverty and

violence toward children. To avoid the labeling bias inherent in clinical

and official records of child maltreatment, the author draws on data

collected from two national family violence surveys.

197

U.S. Advisory Board on Child Abuse and Neglril
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198

Garbarino, J. (1977a). The price of privacy in the social dynamics of child

abuse. Child Welfare, 51,565-575.

Under certain conditions, family isolation serves as the catalytic

agent for child abuse. Privacy that excludes intrusive kinship and

neighborhood networks can be a danger to children.

Garbarino, J. (1977b). The human ecology of child maltreatment: A

conceptual model for research. Journal of Marriage and the Family,

721-735.

This paper seeks to place the phenomenon of child maltreatment in

the perspective of family development. It focuses on necessary and

sufficient conditions and the research implications of an ecological

perspective. Concepts discussed include maltreatment as a consequence of

stressful role transition, the role of cultural support, and a model of child

maltreatment as a problem of family asynchrony.

Garbarino, J. & Kostelny, K. (1992). Child maltreatment as a community

problem. Child Abuse & Neglect, Ifi, 455-464.

The study involves 77 community areas within the Chicago, IL,

metropolitan area. Child maltreatment rates are related to indicators of

socioeconomic and demographic well-being for these neighborhoods and

for the subunits within them. The results reveal a strong influence of

socioeconomic and demographic factors on child maltreatment rates.

High-risk areas are characterized by social disorganization and lack of

social coherence in contrast to the low-risk areas which evidence a

stronger social fabric. These effects extend to differences in child abuse

fatalities.

Gaudin, J.M. & Polansky, N.A. (1986). Social distancing of the neglectful

family: Sex, race, and social class influences. Children and Youth

Services Review, 8,1-12.

A social distance questionnaire was constructed and administered

to 232 urban residents. Scalogram analysis yielded two scales of social

distancing behavior applicable at the neighborhood level. Males and

working class respondents averaged greater distancing than females and

members of the middle class among both African Americans and whites.

implications are offered for social network interventions to prevent

neglect.

U.S. Advisory Board on Child Abuse and Neglect

-)

,_ 4 4
Appendix C

Gaudin, J.M., Polansky, N.A., Kilpatrick, A.C., & Shilton, P.

(1993). Loneliness, depression, stress, and social supports in

neglectful families. American Journal of Orthopsychiatry, CI, 597

605.

Comparisons of neglectful with nonneglectful low-socioemnomic

status parents revealed that the neglectful parents reported more life

stresses, greater depression and loneliness, and weaker informal social

supports. In the neglectful families, loneliness was positively associated

with life stresses and negatively associated with network supports, but not

with caseworker-assessed social isolation.

Hampton, R.L. (1987). Race, class, and child maltreatment. Journal of

Comparative Family Studies,111,113-126.

The goal of this study is to determine whether and where ethnic

differences may exist within a sample of maltreated children with respect

to the nature, type, and severity of maltreatment or factors associated with

maltreatment. Using data from the NIS study, comparisons are made

among African American and Hispanic maltreatment cases.

Hampton, R.L., & Newberger, E.H. (1985). Child abuse incidence and

reporting by hospitals: Significance of severity, class, and race.

American Journal of Public Health, 15,56-60.

Estimates from the National Study of the Incidence and Severity of

Child Abuse and Neglect suggest that hospitals recognized over 77,000

cases of child abuse between May 3 1979, and April 30, 1980. Compared

to the other agencies in the sample, hospitals identified children who were

younger, African American, lived in urban areas, and had more serious

injuries. Hospitals failed to report to child protection agencies almost half

of the cases that met the study's definition of abuse. Disproportionate

nimbers of unreported cases were victims of emotional abuse and came

from families of higher income. Their mothers were more often White

and more often alleged to be responsible for the injuries.

Miller, J.L., & Whittaker, J.K. (1988). Social services and social

support: Blended programs for families at risk of child maltreatment.

Child Welfare, 41,161-174.

Social support, increasingly put forth as fundamental

in helping multiproblem families to avoid placement, is a complex

construct not easy to define and far more difficult to carry out

conceptually and practically. This article describes four family support

programs that illustrate certain common denominators for implementation.

U.S. Advisory Board on Child Abuse and Neglect

199
Appendix C

200

Nixon, J., Pearn, J., Wilkey, I., & Petrie, G. (1981). Social class and violent

child death: An analysis of fatal nonaccidental injury, murder, and

fatal child neglect. Child Abuse and Neglect, 5, 111-116.

A total population study to analyze socioeconomic status (SES)

concomitants of violent and nonaccidental deaths involving children in

Queensland, Australia is reported. All children dying of nonaccidental

injuries, neglect, and murder were included. Of the 43 children in the

study, 58 percent were girls. All of the children who died as a result of

nonaccidental injury were from lower SES groups.

Polansky, N.A., Ammons, P.W., & Gaudin, J.M. (1985). Loneliness and

isolation in child neglect. Social Casework, 38-47.

This investigation of 156 African American and white low-income

families from rural Georgia contrasted neglectful with control families.

The isolation and loneliness of neglectful mothers was confirmed,

although their neighborhoods were no less supportive than those of nonneglectful mothers.

Seagull, E.A. (1987). Social support and child maltreatment: A

review of the evidence. Child Abuse & Neglect, 11,41-52.

This review critically examines what is known regarding the

relationship between child maltreatment and parental isolation from

informal helping networks. The author argues that the existing research is

fraught with both conceptual and methodological problems and that little

conclusive evidence exists.

Telleen, S. (1990). Parental beliefs and help seeking in mothers' use of a

community-based family support program. Journal of Community

Psychology, 11,264-276.

The purpose of the study was to examine help seeking from family

support programs within an attributional framework. Mothers

participating in a community-based family support program were

compared to mothers not using a family support program in a Midwestern

town with a manufacturing economic base, high unemployment, and an

increasing rate of confirmed child abuse. Though the mothers seeking

help were not depressed, they believed that they lacked competence and

expressed more need for social support in parenting than did the

comparison mothers not using the program.

Vondra, J.I. (1990). The community context of child abuse and

neglect. Marriage & Family Review,15,19-38.

U.S. Advisory Board on Child Abuse and Neglect

9 A 0
Appendix C 1

Focusing on community-level analysis and using an

ecological perspective, this article reviews both the empirical

literature and the incidence data on riLk factors that characterize

families involved in and circumstances surrounding child

maltreatment. The discussion of risk factors focuses on parents

and stepparents who demonstrate inadequacies of caregiving that

meet common definitions of abuse and neglect.

Zuravin, S.J. (1989). The ecology of child abuse and neglect:

Review of the Literature and presentation of data. Violence and

Victims, 4, 101-120.

ThiS report assesses current knowledge about the ecological

determinants of child maltreatment and presents data from an aggregate

study of covariation between seven community characteristics and

maltreatment rates. Nothing is known about the ecology of sexual abuse,

and studies of physical abuse and neglect have done little more than

demonstrate covariation between reported incidence and neighborhood

population and housing characteristics.

Prevention

Donnelly, A.H.C. (1991). What we have learned about prevention: What we

should do about it. Child Abuse and Neglect,15, Supp.1,99-106.

This paper looks generally at the focus on prevention of child

abuse efforts throughout the world. It reviews what has transpired in the

last decade with regard to advocacy and public policy and outlines the

challenges that lie ahead in years to come.

Honig, A.S. & Pfannenstiel, A.E. (1991). Difficulties in reaching low-income

new fathers: Issues and cases. Early Child Development and Care, 21,

115-125.

Of a group of 67 low-income first-time fathers-to-be, half were

randomly assigned during the second trimester of pregnancy to participate

in an intervention program designed to acquaint fathers with information,

insights, and clinically appropriate techniques in responsive care for

infants. Difficulties in recruitment of fathers were caused by lack of

commitment of father to partner or infant, by suspicion of a project about

babies, by father drug and alcohol abuse, illiteracy, and personality

problems. Transportation to the clinic and oral presentation helped ensure

participation. Early identification of fathers, skill and persistence of the

201

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

202

intervener, and continuity of caring are identified as prognosticators of

success in reaching low-income fathers-to-be.

Kelley, S.J. (1992). Parenting stress and child maltreatment in drug-exposed

children. Child Abuse and Neglect, 1, 317-328.

This study was conducted to examine the relationship between

prenatal exposure to drugs and parenting stress and child maltreatment.

The sample was comprised of 48 subjects including 24 drug-exposed

children and a comparison group of 24 non-drug-exposed children

matched on age, race, gender, and socioeconomic status. As predicted,

mothers who used drugs during pregnancy reported higher levels of stress

than foster mothers and comparison mothers on total parenting stress,

child related stress, and parent related stress. Biological mothers and

foster mothers of drug-exposed infants scored higher than comparisons on

child-related stress, most notably in the areas of hyperactivity,

distractibility, and adaptability. A strong association was found between

maternal use of drugs and child maltreatment serious enoug!I to necessitate

removal of children by child protective services. Implications for

intervention are discussed.

Maney, A.C. & Kedem, B. (1982). A binary time-series analysis of domestic

child homicide--on monitoring critical, rare criteria of system

performance. Evaluation Review, fi(3), 393-402.

This article seeks to evaluate the significance of variations in the

number of domestic child homicides and to do this in a way that facilitates

the search for causes in a community's child protection system. Domestic

child homicide is but one of many possible outcome measures, one seldom

used and almost never related to other events in the system designed to

protect children from such catastrophe. The study proposes a novel

solution to the statistical problems associated with the evaluation of rare

events.

Schmitt, B.D. (1987). Seven deadly sins of childhood: Advising parents

about difficult developmental phases. Child Abuse and Neglect, it

421-432.

Seven of the more difficult developmental phases for any parent to

deal with are colic, awakening at night, separation anxiety, normal

exploratory behavior, normal negativism, normal poor appetite, and toilet

training resistance. For the child living in a high-risk family, these

innocent acts can trigger dangerous or even deadly abuse. The two

behaviors most commonly associated with fatal abuse are colic and toilet

U.S. Advisory Board on Child Abuse and Neglect
Appendix C

1.1ining. When a child is recognized to be entering a provocative phase,

professionals should be prepared to advise the parents on practical

alternatives to a physical response.

Tertinger, D.A., Greene, B.F., & Lutzker, J.R (1984). Home safety: Development and

validation of one component of an ecobehavioral treatment program for abused

and neglected children. Journal of Applied Behavior Analysis,11,159-174.

In this study, the authors describe the development of a Home Accident

Prevention Inventory (HAPI), which was validated and used to assess hazards in

homes of several families under state protective service for child abuse and

neglect.The HAPI included five categories of hamrds: fire and electrical,

mechanical-suffocation, ingested object suffocation, firearms, and solid/liquid

poisons.

State Reports

Colorado

Colorado Department of Health, Colorado Department of Social Services. (June,1993).

Colorado Child Fatality Review Committee: 1993 Annual Report. Denver, CO:

Colorado Department of Health.

Florida

Child Abuse Deaths in Florida 1986-1991. (1991). 1991 FPSS Annual Report.

Indiana

Indiana State Department of Public Welfare. (1991). Fiscal Year Annual Report.

Illinois

Martinez, L. & Sommer, P. (1988). Illinois Child Abuse and Neglect Fatalities.,

Characteristics and Profiles. Illinois Department of Children and Family Services,

Office of Quality Assurance, Division of Child Welfare and Protective Services.

Michigan

Michigan Child Mortality Review Panel. (1991). Violent Deaths to Children. A Growing

Risk to Growing Up in Michigan, A Report to the Directors of the Michigan

Department of Public Health and the Michigan Department of Social Services.

U.S. Advisory Board on Child Abuse and Neglect

;) 4

203
Appendix C

204

Mississippi

Sellers, L.A. (1993). Child Homicide: Child Abuse Fatalities in Mississippi.

Hattiesburg, MS: University of Southern Mississippi.

Missouri

Missouri Department of Social Services. (November, 1993). Missouri Child Fatali(v Review

Project Annual Report 1992. Jefferson City, MO: Missouri Department of Social

Services.

Oklahoma

Bonner, B.L. & Thigpen, S.M. (1993). Child Abuse and Neglect Fatalities inOklahoma. A

Seven Year Study 1987-1993. Oklahoma City, OK: Center on Child Abuse and

Neglect, University of Oklahoma Health Sciences Center.

Oregon

Oregon Department of Human Resources, Children's Services Division. (1993).115k Force

t i e riti 11n. & . Salem, OR:

Oregon Department of Human Resources.

South Carolina

South Carolina Department of Social Services. (1993). 1989 through 1991: Fatal Child

Abuse and Neglect in South Carolina. Columbia, SC: South Carolina Department of

Social Services.

National Reports

McCurdy, K. & Daro, D. (1994). Current trends in child abuse reporting and

fatalities: The results of the 1993 annual fifty state survey. Working Paper

No. 808. Chicago, Il: National Committee to Prevent Child Abuse.

Robinson, D.H. & Stevens, G.M. (1992). Child Abuse and Neglect Fatalities: Federal

and State Issues and Responses. Washington, DC: Congressional Research

Service, The Library of Congress.

U.S. Department of Health and Human Services, National Center on Child

Abuse and Neglect. Child Maltreatment 1992: Reports From the States to the

National Center on Child Abuse and Neglect. Washington, DC: U.S.

Government Printing Office, 1994.

U.S. Advisory Board on Child Abuse and Neglect

5 0
Appendix I)

Map of Child Death Review Teams

AK

ND

SD

MS

RI

DC (Team)

MULTIAGENCY CHILD DEATH REVIEW TEAMS*

(Ontario Canada has a team')

*TEAMS INCLUDE:

- Criminal Justice, Social Services, Health

- Multiagency, Systematic, Peer Review

- Case Selection From Coroner or Health

CHILD DEATH REVIEW TEAMS

III State Team*

[i] Local Team* Only

0 Formal Planning

Survey - Michael Durfee M.D. - March 20, 1995 II.SON NIL III'S

: U.S. Advisory Board on Child Abuse and Neglect

251

BEST COPY AVAILABLE
1

Appendix D

State Contacts for Multiagency

Child Death Review Activities

Alabama

Steve Aldridge

District Attorney

Madison County Courthouse

100 Northside Square

Huntsville, AL 36101

(205) 532-3460

James Lauridson

State Medical Examiner

Department of Forensic Sciences

P.O. Box 240591

Montgomery, AL 38124

(205) 242-3093

(205) 260-8734

Mary Carswell

Department of Human Resources

Division of Family & Youth Services

50 Ripley Street

Montgomery, AL 36130

(205) 242-9500

(205) 242-1086

Alaska

Nina Kinney

Department of Health & Social Services

Division of Family and Youth Services

P.O. Box 110630

Juneau, AK 998110630

(907) 465-2104

(907) 465-3397

Anita Powell

Section of Maternal Child and Family

Health

Alaska Public Health

1231 Gambell Street

Anchorage, AK 99501

(907) 279-4711

(907) 274-1384

U.S. Advisory Board on Child Abuse and Neglect 207
Appendix D

208

American Samoa I

Fuala'au Hanipale

American Somoa Government

Department of Human Resources

Social Services Division

Pago Pago, AS 96799

(684) 633-1222

Arizona I

Bev Ogden

Chair

State Child Fatality Review Team

Governor's Office of Children

1700 West Washington, #404

Phoenix, AZ 85007

(602) 542-3191

(602) 542-4644

Robert Schackner

Manager

Child Fatality Review

Community and Family Health

Department of Health Services

1740 West Adams Street

Phoenix, AZ 85007

(602) 542-1875

(602) 542-2789

Arkansas

Caran Curry

Director

Office of Prosecutor Coordinator

323 Center Street, Suite 750

Little Rock, AR 72201

Tony Davis

SIDS

Arkansas DeiSartment of Health

4815 Markham, #17

Little Rock, AR 72205

(501) 682-5045 (501) 661-2727

(501) 682-5004 (501) 661-2055

Jerry Jones

Di rector

Program for Children at Risk

Arkansas Children's Hospital

800 Marshall Street

Little Rock, AR 72202-3591

Phyllis Moore

Executive Director

Commisssion on Child Abuse,

Rape, and Domestic Violence

4301 West Markham, Slot 606

Little Rock, AR 72205

(501) 320-1013 (501) 661-7975

(501) 320-3939 (501) 661-7967

U.S. Advisory Board on Child Abuse and Neglect

t f 253
Appendix D

Debbie Roark

Department of Human Services

Division of Children & Family Services

P.O. Box 1437-830

Little Rock, AR 72203-1437

(501) 682-2274

(501) 682-2335

California

Michael Durfee

Los Angeles County

Department of Health Services

241 North Figueroa, Room 306

Los Angeles, CA 90012

(213) 240-8146

(213) 893-0919

Mitch Mason

Los Angeles County

Inter-Agency Council on

Child Abuse and Neglect (ICAN)

4024 North Durfee Avenue

El Monte, CA 91732

(818) 575-4363

(818) 443-3053

Beth Gould

Program Manager

Crime Prevention Center

Attorney General's Office

1515 "K" Street

Sacremento, CA 95814

(916) 322-2900

(916) 324-5205

Stan Wilkins

Violent Crime Information Center

California Department of Justice

P.O. Box 903417

Sacramento, CA 94203

(916) 227-3280

(916) 227-3270

Colorado

Jane Beveridge

Colorado Department of Social Services

Division of Child Welfare

1575 Sherman Street

Denver, CO 80203-1714

(303) 866-5951

(303) 866-4214

Joe Carney

Director

Vital Statistics

Colorado Department of Health

4300 Cherry Creek Drive South

Denver, CO 80222-1530

(303) 692-2249

(303) 782-0095

209

U.S. Advisory Board on Child Abuse and Neglect

254
1

Appendix I)

210

Deborah Haack

Injury Prevention

Colorado Department of Health

4300 Cher ly Creek Drive South

Denver, CO 80222-1530

(303) 692-2587

(303) 782-0095

Connecticut I

James Cart

Director

Department of Children & Family Services

505 Hudson Street

Hartford, CT 06106

Stacey Gerber

Department of Children & Family

Services

505 Hudson Street

Hartford, CT 06106

(203) 550-6465 (203) 550-6465

(203) 566-8022 (203) 566-8022

Betty Spivack

Department of Pediatrics

Hartford Hospital

80 Seymour Street

Hartford, CT 06102

Vincent Sullivan

Department of Children & Family

Services

505 Hudson Street

Hartford, CT 06106

(203) 545-2316 (203) 550-6461

(203) 545 -4188 (203) 566-8022

Delaware

Lori Sit ler

Director

Victim Witness Assistance Program

Department of Justice

Carvel State Office Building

820 North French

Wilmington, DE 19801

(302) 577-2055

(302) 577-2479

Linda Shannon

Program Manager

Division of Family Services

1825 Faulkland Road

Wilmington, DE 19805

(302) 633-2650

(302) 633-2652

U.S. Advisory Board on Child Abuse and Neglect

255
Appendix D

District of Columbia

Calonette M. McDonald

Commission on Social Services

Department of Human Services

609 H Street, N.E., 5th Floor

Washington, DC 20002

(202) 727-5930

(202) 727-1687

Clarice Walker

Commissioner

Commission on Social Services

Department of Human Services

609 H Street, N.E., 5th Floor

Washington, DC 20002

(202) 727-5930

(202) 727-5971

[Florida

Pat Hicks

Florida Protective Services System

2729 Fort Knox Boulevard

Tallahassee, FL 32308

(904) 487-2006

(904) 921-2038

Georgia

Denise Brooks

Institute for Infant & Child Survival

Office of Medical Examiner

150 North Marietta Parkway

Marietta, GA 30060

(404) 590-0966

(404) 528-2207

Joseph L. Burton

Chief Medical Examiner

Metro Atlanta

150 North Marietta Parkway

Marietta, GA 30060

(404) 528-2200

(404) 528-2207

211

U.S. Advisory Board on Child Abuse and Neglect

or -o6
Appendix D

212

James Hendricks

Project Director

Criminal Justice Coordinating Council

503 Oak Place, Suite 540

Atlanta, GA 30349

J. Tom Morgan

Deka lb County District Attorney

Deka lb County Courthouse

556 North McDonough Street

Decatur, GA 30030

(404) 371-4728 (404) 371-2561

(404) 559-4960 (404) 371-2981

Guam 1 Mary Taijeron

Department of Public Health &

Social Services

P.O. Box 2816

Agana, GU 96910

(671) 477-8966

Hawaii

1 Gwendolyn Costello

USCINCPAC

Surgeons Office

(1073) Box Medical

Camp H.M. Smith

Honolulu, HI 96861-5025

(808) 477-6956

(808) 477-20:1;

Loretta Matsunaga

District Attorney's Office

1164 Bishop Street

Honolulu, HI 96813

(808) 523-4512

(808) 733-9032

Patricia Farstrup

MCH Branch

Department of Health

741-A Sunset Avenue

Honolulu, HI 96816

(808) 733-9022

(808) 733-9032

U.S. Advisory Board on Child Abuse and Neglect

:2 57
1

1

i

Appendix II

I Idaho

Mardell Nelson

Department of Health & Welfare

450 West State Street

Boise, ID 83720-5450

(208) 334-5700

(208) 334-6699

Ken Robbins

Deputy Prosecuting Attorney

Elmore County

P.O. Box 607

Mountain, ID 83647

(208) 587-2144

Illinois

Neil Hochstadt

Chairperson

State Task Force

LaRabida Hospital

East 65th and Lake Michigan

Chicago, IL 60649

(312) 363-6700

Sharon O'Conner

Cook County Office

of the Medical Examiner

2121 West Harrison Street

Chicago, IL 60612

(312) 997-4509

(312) 997-4400

Indiana

Paula Ferguson

Indiana Department of Public Welfare

402 West Washington, # W 364

Indianapolis, IN 46204

(317) 232-4429

(317) 232-4436

Jim Stewart

Marion County

Department of Public Welfare

145 South Meridian

Indianapolis, IN 46225

(317) 232-1773

U.S. Advisory Board on Child Abuse and Neglect

213
Appendix D

214

Iowa

Randy Alexander

University of Iowa

Hospital and Schools

Iowa City, IA 50319

Sue Tesdohl

St. Luke's Child Protection Center

St. Luke's Hospital

Cedar Rapids, IA

Wayne McCracken

Iowa Department of Human Services

Bureau of Individual &

Family Protection Services

Hoover State Office Building, 5th Floor

Des Moines, IA 50319

(515) 281-8978

(515) 281-4597

Kansas

Betty M. Glover

Executive Director

State Child Death Review Board

Office of Attorney General, 2nd

Kansas Judicial Center

Topeka, KS 66612-1597

Nancy Lindberg

Assistant to the Attorney General

Office of the Attorney General, 2nd

Floor

Kansas Judicial Center

Topeka, KS 66612-1597

(913) 296-2215 (913) 296-2215

(913) 296-0652 (913) 296-6296

Kathrine J. Melhorn

Department of Pediatrics

University of Kansas

School of Medicine - Wichita

3243 East Murdock, Level A

Wichita, KS 67214

(316) 688-3110

(316) 883-3227

U.S. Advisory Board on Child Abuse and Neglect

(.2 5 9

1
Appendix 13

Kentucky

Crystal Collins

Department of Social Services

275 East Main Street, 6W

Frankfort, KY 40621

(502) 564-2136

(502) 564-3096

Joel Griffith

Department of Social Services

275 East Main Street, 6W

Frankfort, KY 40621

(502) 564-2136

(502) 564-3096

Louisiana

Larry Hebert

Medical Director

Department of Health & Hospitals

P.O. Box 629

Baton Rouge, LA 70821-0629

(304) 342-4770

Cindy Phillips

Department of Social Services

Office of Community Services

P.O. Box 3318

Baton Rouge, LA 70821-0629

(504) 342-9928

(504) 342-9087

Maine

i.arry Ricci

The Child Abuse Program

Spurwink Clinic

17 Bishop Street

Portland, ME 04103

(207) 879-6160

(207) 879-6161

Maryland

Anne Dixon

State Medical Examiner

111 Penn Street

Baltimore, MD 21201

(410) 333-3250

Dan Timmel

MEDCHI

1211 Cathedral Street

Baltimore, MD 21201

(410) 539-0872

(410) 547-0915

U.S. Advisory Board on Child Abuse and Neglect

215

260
Appendix D

216

Caroline Fowler

Center for Injury Research

John Hopkins University

624 North Broadway

Baltimore, MD 21205

(410) 955-0442

(410) 614-2797

IMassachusetts

1 Diane Butkus

Massachucetts Department of

Public Health

Bureau of Family & Community Health

150 Tremont Street, 3rd Floor

Boston, MA 02111

Cindy Rodgers

Massachucetts Department of Public

Health Bureau of Family &

Community Health

150 Tremont Street, 3rd Floor

Boston, MA 02111

(617) 727-1246 (617) 727-1246

(617) 727-0880 (617) 727-0880

Michigan I

Joseph Kwiatkowski

Prosecuting Attorney

Cheboygan County

870 South Main Street

Cheboygan, MI 49721

(616) 627-8800

(616) 627-8405

Jan Ruff

Michigan Department of Public Health

P.O. Box 30195

Lansing, MI 48909

(517) 335-9372

(517) 335-8560

Marilyn Poland

Mutzel Hospital

4707 Street Antoinne

Detroit, MI 48201

(313) 577-1147

Kenneth Wilcox

Chief, Division of Epidemiology

Office of Policy, Planning, and

Evaluation

P.O. Box 30035

Lansing, MI 48909

(517) 335-8900

(517) 335-8560

U.S. Advisory Board on Child Abuse and Neglect

2 61
Appendix D

Minnesota

Erin Sullivan Sutton

Department of Human Services

Children's Services Division

444 Lafayette Road

St. Paul, MN 55155-3830

(612) 296-2487

(612) 296-6244

Stephen Vonderharr

Department of Human Services

Children's Services Division

444 Lafayette Road

St.Paul, MN 55155-3830

(612) 296-5324

(612) 296-6244

Mississippi

Larry La Fleur

Associate Professor

Department of Criminal Justice

University of Southern Mississippi

P.O. Box 9302

Hattiesburg, MS 39406

(601) 266-4509

Dot Roberts

Mississippi Department of Human

Services

P.O. Box 352

Jackson, MS 39205

(601) 359-4482

(601) 354-6660

Missouri

Gus Kolilis

Director

State Technical Assistance Team

P.O. Box 88

Jefferson City, MO 65103-0088

(314) 751-0850

(314) 751-1479

Donna Prenger

Administrator

State Technical Assistance Team

P.O. Box 88

Jefferson City, MO 65103-0088

(314) 751-0850

(314) 751-1479

Montana

Nora Gerrity

Great Falls Clinic

P.O. Box 5012

Great Falls, MT 59403

(406) 471-9320

(406) 454-0455

Christina Litchfield

City-County Health Department

Child Mortality Team

501 West Alder

Missoula, MT 59802

(406) 523-4750

U.S. Advisory Board on Child Abuse and Neglect

217

262
Appendix D

218

Charles McCarthy

Department of Family Services

P.O. Box 8005

Helena, MT 59604

(406) 444-5900

(406) 444-5956

Nebraska

Mary Jo Pankoke

Department of Social Services

P.O. Box 95026

Lincoln, NE 6859-5026

(402) 471-9320

(402) 471-9455

David Schor

Director

Maternal and Child Health

Nebraska Department of Health

Services

Lincoln, NE 68509

(402) 471-2907

(402) 471-0383

Nevada

1 Connie Martin

Department of Human Resources

Division of Child & Family Services

711 East Fifth Street

Carson City, NV 89710

(702) 687-4979

(702) 687-4722

Kathleen Shane

Department of Social Services

P.O. Box 11130

Reno, NV 89520

(702) 328-2300

(702) 328-3788

Judy New

Supervisor I

Clark County Department of Family &

Youth Services

3401 East Bonanza Road

Las Vegas, NV 89101

(702) 455-5361

(702) 455-5592

Carol Stillian

Department of Family & Youth

Services

3401 East Bonanza Road

Las Vegas, NV 89101

(702) 455-5430

(702) 455-5479

U.S. Advisory Board on Child Abuse and Neglect

263
1

1

Appendix D

INew Hampshire

Sylvia Gale

New Hampshire Division for

Children & Youth

6 Hazen Drive

Concord, NH 03301

(603) 271-4691

(603) 271-4729

1

INew Jersey

Robert Goode

New Jersey State Medical Examiner

325 Norfolk Street

Newark, NJ 07103

(201) 648-7259

Donna Pincavage

Governor's Task

Force on Child Abuse & Neglect

CN 700

Trenton, NJ 08625-0717

(609) 292-0888

(609) 292-6838

New Mexico

Patricia Mc Feeley

Assistant Chief Medical Investigator

University of New Mexico

School of Medicine

Albuquerque, NM 87131-5091

(505) 277-0710

(505) 277-0727

New York

Jonathan Arden

Office of Chief Medical Examiner

King County Hospital

Pathology Building, Room 141

451 Clarkson Ave.

Brooldyn, NY 11203

(718) 462-7177

June Bradley

Senior Investigator

New York State Police Child Abuse

Unit

Building 22, State Campus

Albany, NY 12226

(518) 485-8503

U.S. Advisory Board on Child Abuse and Neglect 219

264
010/./IJ

Appendix D

220

Tom Hess

Division of Family & Children's Services

40 North Pearl Street

Albany, NY 12243

(518) 473-8001

(518) 474-1842

INorth Carolina

Gail Brown

North Carolina Child Fatality

Prevention Team

Office of Chief Medical Examiner

CB# 7580 UNC Campus

Chapel Hill, NC 27599-6263

Mary Bobbitt Cooke

North Carolina Child Fatality Task

Force

Division of Maternal Child Health

P.O. Box 27687

Raleigh, NC 27611-7687

(919) 966-2253 (919) 715-3294

(919) 962-6263 (919) 715-3049

Marcia Herman-Giddens

115 Edmister Lane

Chapel Hill, NC 27516

(919) 968-6364

(919) 471-3820

Olivia Silber

Local Team Program Coordinator

North Carolina Child Fatality

Prevention Team

P.O. Box 27687

Raleigh, NC 27611-7687

(919) 715-3296

(919) 715-3049

Ilene Nelson

Guardian Ad Litem Service

North Carolina Administrative

Office of Courts

P.O. Box 2448

Raleigh, NC 27602

(919) 733-7107

U.S. Advisory Board on Child Abuse and Neglect
1

I

Appendix I)

North Dakota

Gladys Cairns

North Dakota Department of

Human Services/CFS

600 East Boulevard

Bismark, ND 58505-0200

(701) 224-4806

(701) 224-2359

Jim Vukelic

North Dakota Attorney General's Office

Bureau of Criminal Investigation

P.O. Box 1054

Bismark, ND 58502-1054

(701) 221-5500

(701) 221-5510

Jon Rice

Health Officer

North Dakota State Department of

Health

600 East Boulevard Avenue

Bismark, ND 58505-0200

(701) 224-2372

(701) 224-4724

Northern Mariana Islands

Chief of Criminal Division

Office of Attorney General

Administration Building, 2nd Floor

Capitol Hill, MP 96950

(670) 322-4311

(670) 322-4320

Margaret Olopai-Taitano

Division of Youth Services

Department of Community &

Cultural Affairs

P.O. Box 1000

Saipan, MP 96950

(670) 234-8950

(670) 322-2220

Ebert-Santos

Chief of Medical Staff

Department of Public Health &

Environmental Services

P.O. Box 409

Saipan, MP 96950

(670) 234-8950

(670, 234-8930

U.S. Advisory Board on Child Abuse and Neglect 221

266
Appendix D

222

Ohio

Jean Schafer

Chief, Children's Services

Ohio Department of Human Services

65 East State Street, 5th Floor

Columbus, OH 43215

(614) 322-4311

(614) 466-0164

Pam Schirner

Franldin County Children's Services

1951 Gantz Road

Grove City, OH 43123

(614) 275-2509

(614) 275-2755

Oklahoma

Kathryn Simms

Department of Human Services

P.O. Box 25352

Oklahoma City, OK 73125

(405) 521-2283

(405) 521-6684

Shelia Thigpen

Administrator

Center on Child Abuse and Neglect

Oklahoma Child Death Review

P.O. Box 26901, CHO 4N410

Oklahoma City, OK 73190

(405) 271-8858

(405) 271-2931

Oregon

Connie Gallegher

Children's Services Division

Department of Human Resources

500 Summer Street, N.E., 2nd Floor

Salem, OR 97310

(503) 945-5687

(503) 581-6198

Palau

Administrator

Behavioral Health Division

P.O. Box 6027

Koror, PW 96940

(680) 488-1907

(680) 488-1211

A. H. Polloi

Director of Public Health

Ministry of Health

Republic of Palau

P.O. Box 6027

Koror, PW 96940

(680) 488-2552

(680) 488-1211

U.S. Advisory Board on Child Abuse and Neglect

267
Appendix 13

Pennsylvania

Chukwudi Onwuachi-Saunders

City of Philadelphia Public Health Department

1600 Arch Street, 7th Floor

Philadelphia, PA 19103

(215) 686-5047

(215) 568-5050

Pat West

2134 Spring Street

Philadelphia, PA 19103

(215) 568-7811

c/o Tom Vernon (215) 575-4939

Suzanne Yunghans

Administrator Pennsylvania Chapter

American Academy of Pediatrics

Dayton Building, Suite 220

610 Old Lancaster Road

Bryn Mawr, PA 19010-3809

(215) 520-9123

(215) 520-9177

Puerto Rico

Maria Carrillo

Department of Social Services

Families with Children Program

P.O. Box 11398, Miramar

Santurce, PR 00910

(809) 723-2127

(809) 723-1223

rlihode Island

Laureen D'Ambra

Office of the Child Advocate

260 West Exchange Street, Suite 2

Providence, RI 02903

(470) 277-6650

(401) 277-6652

Kenneth Fandetti

Department for Children and Their

Families

610 Mt. Pleasant Avenue, Building 1 Providence, RI 02908

(401) 457-4950

(401) 521-4570

U.S. Advisory Board on Child Abuse and Neglect 223

268
Appendix D

224

William Hollinshead

Medical Director

Rhode Island Department of Health

Division of Family Health

3 Capitol Hill

Providence, RI 02908

(401) 277-2312

(401) 277-1442

South Carolina 1 Catherine C. Christophillis

Attorney-at-Law

1615-A Wade Hampton Building

Greenville, SC 29609

(803) 292-2500

Lt. Patsy Habbin

Child Fatality Investigation

Department

South Carolina Law Enforcement

Division

P.O. Box 21398

Columbia, SC 29221

(803) 737-7033

(803) 896-7041

South Dakota

Terry Engleman

Department of Health

MCH Program

Anderson Building

445 East Capitol

Pierre, SD 57501-3185

(605) 773-4476

9605) 775-5509

Merlin Weyer

South Dakota Department of

Social Services/CPS

Kneip Building

700 Governor Drive

Pierre, SD 57501

(605) 773-3227

(605) 773-4855

1

Tennessee

Sherry Abernathy

Tennessee Department of Human Services

400 Deaderick Street

Nashville, TN 37248

(615) 741-5927

(615) 741-4165

Louis Martinez

Tennessee Department of Human

Services

400 Deaderick Street

Nashville, TN 37248

(615) 741-5927

(615) 741-4165

U.S. Advisory Board on Child Abuse and Neglect

269
Appendix D

ITexas

1 Anne Ramsey

Project Coordinator

Child Fatality Review Team Project

Children's Justice Act

Department of Protection &

Regulatory Services

P.O. Box 149030, MC E611

Austin, TX 78714

(512) 706-5029

(512) 450-3022

Donya Witherspoon

900 Jackson Street

Dallas, TX 75202

(214) 977-9345

(214) 977-9379

Lt. Bill Walsh

Dallas Police Department

106 Harwood, Room 225

Dallas, TX 75201

(214) 670-5936

(214) 670-5099

Utah

Patricia Keller

Director

Department of Health

Division of Family Health

Child Injury Prevention Program

P.O. Box 16650

Salt Lake City, UT 54116-0650

(801) 538-8161

(801) 538- 6510

Mary Thompson

Child Injury Protection Program

Department of Health

Division of Family Health Services

P.O. Box 16650

Salt Lake City, UT 54116-0650

(801) 538-6348

(801) 538-6510

Pat Rothermich

CFS Specialist

DFS/DSS

P.O. Box 45500

Salt Lake City, UT 84145

(801) 538-4043

(801) 538-4016

U.S. Advisory Board on Child Abuse and Neglect

1

225

270
I

Appendix D

226

Vermont

George W. Brown

Vermont Child Fatality

Review Committee

Child Protection Network

One Burlington Square

Burlington, VT 05401

(803) 863-9626

(804) 371-6179

Leane Garland Page

Department of Social &

Rehabilitation Services

103 South Main Street

Waterbury, VT 056712401

( 80) 224-12100

(802) 244-2980

Virgin Islands

Dilsa Rohan

P.O. Box 539

St. Thomas, VI 00801

(809) 774-0930

1 Virginia

Division of Children Youth & Families

Department of Human Resources

Barbel Plaza South, Charlotte Amalie

St. Thomas, VI 00802

Rita Katzman

Department. of Social Services

730 East Broad Street, 2nd Floor

Richmond, VA 23229

(804) 692-1259

(804) 692-2215

Diane Maloney

Office of Prevention & Children's

Resources

Department of Mental Health,

Retardation, and Substance Abuse

P.O. Box 1797

Richmond, VA 23214

(804) 786-5399

(804) 371-6179

Washington

Lorrie Grevstad

Nursing Consultant

Community & Family Health

Department of Health

P.O. Box 47880

Olympia, WA 95804-7880

(206) 753-6060

(206) 586-7868

Maxine Hayes

Assistant Secretary for Parent Child

Health

P.O. Box 47880

Olympia, WA 95804-7880

(206) 753-7021

(206) 586-7868

U.S. Advisory Board on Child Abuse and Neglect
I

Appendix D

Eileen Keith

P.O. Box 47880

Olympia, WA 95804-7880

(206) 753-5853

(206) 586-7868

West Virginia

Janice Binder

State of West Virginia

Juvenile Justice Committee

214 Dickenson Street

Charleston, WV 25301

(304) 558-3649

(304) 558-0831

Maureen Runyon

Women and Children's Hospital

800 Pennsylvania

Charleston, WV 25302

(304) 348-2391

Kathie King

Office of Social Services

Department of Health & Human

Resources

Room 850, Building 6, State

Charleston, WV 25305

(304) 558-7980

(304) 558-2059

Wisconsin

Janet Breidel

Bureau for Children, Youth and Families

Department of Health & Social Services

1 West Wilson Street, Room 465

Madison, WI 53707

(608) 267-2245

Jeffery Jentzen

Milwaukee County Medical Examiner

933 West Highland Avenue

Milwaukee, WI 53233

(414) 223-1200

Juliet Brodie

Wisconsin State Department of Justice

P.O. Box 7857

Madison, WI 53707-7857

(608) 266-8943

(608) 267-2223

U.S. Advisory Board on Child Abuse and Neglect

227

272
1

Appendix D

228

[Wyoming

Jim Hammer

Director

Department of Social Services

Hathaway Building, # 319

Cheyenne, WY 82002

(307) 777-6789

(307) 777-7747

Rick Robb

Department of Social Services

Hathaway Building #322

Cheyenne, WY 82002

(307) 777-7150

(307) 777-7747

Jim Mitchell

Department of Social Services

Hathaway Building, #318

Cheyenne, WY 82002

(307) 777-6095

(307) 777-7747

U.S. Advisory Board on Child Abuse and Neglect
Appendix D

National Association Contacts for Multiagency

Child Death Review Activities

American Academy of Forensic Sciences

Mary E.S. Case

Saint Louis University

1402 South Grand

St. Louis, MO 63104

(314 578298

John D. McDowell

University of Colorado

School of Dentistry

4200 East 9th Avenue

Denver, CO 80262

(303) 270-6365

American Academy of Pediatrics

Scott Allen

American Academy of Pediatrics

Child Abuse Section

t41 North West Point Boulevard

P.O. Box 927

Elk Grove, IL 60009-0927

(708) 981-7880

(708) 228-5097

Carole Jenny

American Academy of Pediatrics

Child Abuse Section

Children's Hospital

1056 East 19th Street, Box B-138

Denver, CO 80218

(303) 861-6919

(303) 837-2791

Brahm Goldstein

Section on Critical Care, AAP

Oregon Services University

Department of Pediatrics

3181 Southwest Sam Jackson Park Road

Portland, OR 97201

(503) 494-8194

U.S. Advisory Board on Child Abuse and Neglect 229
Appendix D

230

American Association for Child and Adolescent Psychiatry

August Cervini

American Association for Child

and Adolescent Psychiatry

3615 Wisconsin Avenue, N.W.

Washington, DC 20016

(202) 966-7300

(202) 966-2891

American Bar Association

Sarah Kaplan

American Bar Association

Center on Children and the Law

1800 "M" Street, N.W.

Washington, DC 20036

(202) 331-2676

(202) 331-2220

Susan Wells

American Bar Association

Center on Children and the Law

1800 "M" Street, N.W.

Washington, DC 20036

(919) 942-4189

American Burn Association

G. Patrick Kea ley

Chair, Prevention Committee

Burn Treatment Center

University of Iowa Hospital and Clinic

200 Hawkins Drive, 1504 JCP

Iowa City, IA 52242-1086

(319) 356-7892

(319) 356-1304 or 8378

American Hospital Association 1 Bonnie Conners Jellen

Section for Maternal and Child Health

American Hospital Association

840 North Lake Shore Drive, 5 E

Chicago, IL 60611

(312) 280-4198

U.S. Advisory Board on Child Abuse and Neglect
Appendix D

American Humane Association

Robyn Alsop

Coordinator of Information Services

American Humane Association

63 Inverness Drive East

Englewood, CO 80112-5117

(303) 792-9900

(303) 792-5333

American Medical Association

1 Rodger Brown

Director

Department of Mental Health

American Medical association

515 North State Street

Chicago, IL 60610

(312) 464-5067

(312) 464-1943

American Probation and Parole Association

Ann Crowe

American Probation and Parole Association

P.O. Box 11910

Lexington, KY 40578-1910

(606) 231-1939

(606) 231-1943

Mickey Neel

American Probation and Parole

Association

P.O. Box 11910

Lexington, KY 40578-1910

(606) 231-1939

(606) 231-1943

American Professional Society for Abused Children

Barbara Bonner

University of Oklahoma Health Sciences

Department of Pediatrics

P.O. Box 26901

Oklahoma City, OK 73190

(405) 271-8858

(405) 271-8858

Theresa Reid

Executive Director

American Professional Society

for Abused Children (APSAC)

332 South Michigan Avenue, Suite 1600

Chicago, IL 60604

(312) 554-1066

(312) 939-8962

U.S. Advisory Board on Child Abuse and Neglect

231
Appendix D

232

American Public Health Association

Mila Aroskar

American Public Health Association

Public Health Nursing Section

c/o University of Minnesota

School of Public Health

420 Delaware Street, S.E.

Minneapolis, MN 55455-0734

(612) 625-0615

(612) 624-3972

Ken Jarrost

American Public Health Association

Social Work Section

do University of Pittsburgh

223 Parran Hall

Pittsburgh, PA 15261

(412) 624-3102

(412) 624-5510

Pat West

American Public Health Associaiton

Injury Control Section

2134 Spring Street

Philadelphia, PA 19103

(215) 568-7811

c/o Tom Vernon (215) 575-4939

American Public Welfare Association

Betsy Thielman

National Association of

Public Child Welfare Administrators

American Public Welfare Association

810 First Street, N.E., Suite 500

Washington, DC 20002-4267

(202) 682-0100

(202) 289-6555

Michael Durfee

American Public Health Association

Maternal Child Health Section

Family Violence Committee

210 Starlight Crest

La Canada, CA 91011

(818) 952-2053

(818) 952-2976

Ann Keith

American Public Health Association

Maternal Child Health

do University of Southern Maine

School of Nursing

96 Salmouth Street

Portland, ME 04103

(207 780-4138

(207) 780-4997

U.S. Advisory Board on Child Abuse and Neglect

:27'7
Appendix 13

Association for Death Education and Counseling

Ben Wolfe

President

Association for Death Education &

Counseling (ADEC)

638 Prospect Avenue

Hartford, CN 06105

(203) 586-7503

(203) 586-7550

IAssociation of Maternal Child Health Programs

Barbara Aliza

Association of Maternal Child

Health Programs

1350 Connecticut Avenue, N.W.

Washington, DC 20036

(202) 775-0436

(202) 775-0061

Tom Vitagione

Chief, Children and Youth Section

Department of Environment,

Health, and Natural Resources

P.O. Box 27687

Raleigh, NC 27611-7687

(919) 733-7437

(919) 733-0488

IAssociation of SIDS Program Professionals

Deborah Frazier

Executive Director

SIDS Program

Arkansas Department of Health

4815 Markham, Slot 41

Little Rock, AR 72205

(501) 322-8775

Mary McClain

President

Association of SIDS Program Professionals

Massachusetts Center for SIDS

818 Harrison Avenue

Boston, MA 02218

(617) 534-7437

(617) 534-5555

Sheila Marquez

Executive Director

Colorado SIDS Program

6825 East Tennessee, #300

Denver, CO 80224

(303) 320-7771

(303) 322-8775

U.S. Advisory Board on Child Abuse and Neglect 233

278
I

1

Appendix D

234

Association of State and Territorial Health Officers

Mary McCall

Project Director

Maternal Child Health

Association of State &

Territorial Health Officers

415 2nd Street, N.E., Suite 200

Washington, DC 20002

(202) 546-5400

(202) 544-9349

C. Henry Kempe Center

Donald Bross

C. Henry Kempe Center for the Prevention

and Treatment of Child Abuse and Neglect

1205 Oneida Street

Denver, CO 80220

(303) 321-3963

Children's Defense Fund

Mary Lee Allen

Director

Child Welfare and Mental Health Division

Children's Defense Fund

25 "E" Street, N.W.

Washington, DC 20001

(202) 628-8787

(202) 662-3550

Council of State Governments

Ann Crowe

Council of State Governments

P.O. Box 11910

Lexington, KY 40578-1910

Mickey Neel

Council of State Governments

P.O. Box 11910

Lexington, KY 40578-1910

(606) 231-1939 (606) 231-1939

(606) 231-1943 (606) 231-1943

U.S. Advisory Board on Child Abuse and Neglect

279
1

Appendix D

IHumane Society of the United States

Randy Lockwood

Humane Society of the United States

2100 "L" Street, N.W.

Washington, DC 20037

(202) 258-3030

(202) 258-3034

IInternational Homicide Investigators Association

Terry Green

President

International Homicide

Investigators Association

P.O. Box 670

Quantico, VA 22134-0670

(800) 742-1007

(703) 670-0407

IMissing and Exploited Children Comprehensive Action Plan

Kathryn Turman

Public Administrative Services

Missing & Exploited Children

Comprehensive Action Plan

555 4th Street, N.W., Room 36-33F

Washington, DC 20001

(202) 514-7130

(202) 514-9162

Llyational Association of Children's Hospitals and Related Institutions

Dorothy Albritten

National Association of Children's

Hospitals and Related Institutions (NACHRI)

401 Wythe Street

Alexandria, VA 22314

(703) 684-1355

(703) 684-1589

U.S. Advisory Board on Child Abuse and Neglect 235

280
Appendix D

236

National Association of Attorneys General

Lisa Wells Harris

Civil Rights and Criminal Law Counsel

National Association of Attorneys General

444 North Capitol Street, N.W., #339

Washington, DC 20001

(202) 434-8023

(202) 434-8008

I National Association of Counties

Sandra Markwood

National Association of Counties

440 First Street, N.W., 8th Floor

Washington, DC 20001

(202) 942-4235

(202) 737-8480

1

National Association of Medical Examiners

Joye M. Carter

Chief Medical Examiner

District of Columbia

1910 Massachusetts Avenue

Washington, DC 20003

(202) 724-8863

(202) 724-8920

Robert H. Kirschner

Deputy Chief Medical Examiner

Office of the Medical Examiner

County of Cook

2121 West Harrison Street

Chicago, IL 60612

(312) 997-4508

National Association of Social Workers

Isadora Hare

National Association of Social Workers

750 First Street, N.E.

Washington, DC 20002-4241

(202) 336-8227

(202) 336-8327

U.S. Advisory Board on Child Abuse and Neglect
Appendix D

I National Center for Missing and Exploited Children

Rueben Rodriquez, Jr.

Senior Analyst

Case Enhancement and Informational

Analysis Unit - NCMEC

2101 Wilson Boulevard

Arlington, VA 22201-3052

(703) 235-3900

(703) 235-4067

INational Center for the Prosecution of Child Abuse

Janet Dinsmore

National Center for the

Prosecution of Child Abuse

99 Canal Center Plaza, Suite 510

Alexandria, VA 22314

Trish Kelly

National Center for the

Prosecution of Child Abuse

99 Canal Center plaza, Suite 510

Alexandria, VA 22314

(703) 739-0321 (703) 739-0321

(703) 836-3195 (703) 836-3195

Ryan Rainey

National Center for the

Prosecution of Child Abuse

99 Canal Center Plaza, Suite 510

Alexandria, VA 22314

(703) 739-0321

(703) 836-3195

National Committee for the Prevention of Child Abuse

Karen McCurdy

National Committee for the

Prevention of Child Abuse

332 South Michigan Avenue

Chicago, IL 60604

(312) 663-3520

(312) 939-8962

U.S. Advisory Board on Child Abuse and Neglect

237

282
Appendix D

238

National Court Appointed Special Advocate (CASA) Association

Michael S. Piranirio

CEO

National Court Appointed

Special Advocate Association (CASA)

2722 Eastlake Avenue East, Suite 220

Seattle, WA 98102

(206) 328-8588

(206) 323-8137

National Fetal Infant Mortality Review Program

Lois Wolff

National Fetal Infant

Mortality Review Program

409 12th Street, S.W.

Washington, DC 20024-2188

(202) 863-1630

(202) 484-5107

INational Governors' Association

Nolan Jones

Director

Justice and Public Safety

National Governors' Association

444 Capitol Street, N.W., #267

Washington, DC 20001

(202) 624-5360

(202) 624-5313

INational Organization of Victim Assistance

Cheyl Tyiska

National Organization of Victim Assistance

1757 Park Road, N.W.

Washington, DC 20010

(202) 232-6682

U.S. Advisory Board on Child Abuse and Neglect

263
Appendix D

National Coalition Against Domestic Violence

Rita Smith

National Coalition Against

Domestic Violence

P.O. Box 18749

Denver, CO 80218

(303) 839-1852

(303) 839-9215

Society for Pediatric Pathology

Harry Wilson

Department of Pathology

Providence Memorial Hospital

439 Eudora

El Paso, TX 79902

(915) 545-7323

(915) 545-7073

ISociety of Critical Care Medicine

Brahm Goldstein

Oregon Health Services University

Department of Pediatrics

3181 Southwest Sam Jackson Park Rd.

Portland, OR 97201

(503) 494-8194

Society of Critical Care Medicine

8101 East Kaiser Boulevard

Anaheim, CA 92808-2214

(714) 282-6000

1 Zero to Three

Joan Miller

Project Coordinator

Zero to Three

National Center for Clinical Infant Programs

2000 14th Street, North, #380

Arlington, VA 22201-2500

(703) 528-4300

(703) 528-6848

U.S. Advisory Board on Child Abuse and Neglect

239

284
Appendix D

240

Federal Agency Contacts for Multiagency

Child Death Review Activities

Centers for Disease Control and Prevention

Shorunda Buchanan

Centers for Disease Control and Prevention

MS F-35

4770 Buford Avenue, N.E.

Atlanta, GA 30341

(404) 488-7060

(404) 488-7044

Phil McClain

Centers for Disease Control and Prevention

National Center for Injury Prevention & Control

MS K-63

1600 Clifton Road

Atlanta, GA 30333

(404) 488-4652

(404) 488-4422 or 4338

Randy Hanzlick

Centers for Disease Control and

Prevention

MS F-35

4770 Buford Avenue, N.E.

Atlanta, GA 30341

(404) 488-7060

(404) 488-7044

Congressional Research Service

Dale Robinson

Congressional Research Service

Education & Public Welfare Division

Library of Congress

101 Independence Avenue, S.W.

Washington, DC 20540-7440

(202) 707-2322

(202) 707-7338

U.S. Advisory Board on Child Abuse and Neglect
Appendix D

Department of Defense

Jana Lee Sponberg

Department of Defense

Office for Family Policy

4015 Wilson Boulevard, Suite 911

Arlington, VA 22203-5190

(703) 696-4555

(703) 696-6344

Paul Vasallo

Armed Forces Institute of Pathology

Office of the Medical Examiner

Washington, DC 20306-6000

(202) 576-3232

(202) 576-0373

[6-War:went of Interior _J

Marcella Giles

Attorney Advisor

Department of Interior

Office of Indian Affairs

1849 "C" Street, N.W., MS6456

Washington, DC 20240

(202) 208-6967

(202) 219-1791

IDepartment of Justice

Bernard Auchter

Program Manager

National Institute of Justice

Domestic Violence Program

633 Indiana Avenue, N.W., #867

Washington, DC 20531

Mary Incontro

Deputy Chief

Violent Crime Section

U.S. Department of Justice

P.O. Box 7179

Washington, DC 20044-7179

(202) 307-0154 (202) 514-0849

(202) 307-6394 (202) 514-8714

Winston C. Norman

Major Case Specialist, ViCAP

Behavioral Science Unit

Federal Bureau of Investigations

Quantico, VA 22135

(703) 640-1207

(703) 640-1354

U.S. Advisory Board on Child Abuse and Neglect

241

286
Appendix D

242

Indian Health Service

Richard Kotomori

Chief, Special Initiatives Section

Indian Health Service

5600 Fishers Lane, Room 5A-41

Rockville, MD 20857

(301) 443-4646

(301) 443-7623

Tom Welty

Office of Epidemiology

Public Health Service

Indian Hospital

3200 Canyon Lake Drive

Rapid City, SD 57702

(605) 348-1900

National Center for Health Statistics

Lois Fingerhut

Special Assistant

Injury Epidemiology

National Center for Health Statistics

6525 Belcrest Road, Room 750

Hyattsville, MD 20782

(301) 436-7026

(301) 436-8459

National Institutes of Health - NICHD

Marian Willinger

Center for Research for Mother's & Children

National Institute of Child Health &

Human Development

National Institutes of Health

6100 Executive Boulevard, Room 4B03

Rockville, MD 20852

(30!) 496-5575

(301) 402-20S5

U.S. Advisory Board on Child Abuse and Neglect
Appendix D

I National Center on Child Abuse and Neglect (NCCAN)

Emily Cooke

National Center on Child Abuse & Neglect

P.O. Box 1182

Washington, DC 20013

(202) 205-8709

(202) 205-9721

David Lloyd

Director

National Center on Child Abuse & Neglect

P.O. Box 1182

Washington, DC 20013

(202) 205-8646

Sally Flanzer

National Center on Child Abuse and

Neglect

P.O. Box 1182

Washington, DC 20013

(202) 205-8708

(202) 205-9721

NCCAN Clearinghouse

Sandy McLeod

NCCAN Clearinghouse on

Child Abuse and Neglect Information

and Family Violence

P.O. Box 1182

Washington, DC 20013

(800) 394-3366

Lenna Reid

NCCAN Clearinghouse on

Child Abuse and Neglect

Information

and Family Violence

P.O. Box 1182

Washington, DC 20013

(800) 394-3366

Office of Disease Prevention and Health Promotion

Jim Harrell

Deputy Director

U.S. Department of Health & Human Services

Office of Disease Prevention & Health Promotion

330 "C" Street, S.W., Room 2132

Washington, DC 20201

(202) 205-8611

(202) 205-9478

U.S. Advisory Board on Child Abuse and Neglect 243
Appendix D

244

Office of the Surgeon General I

Winnie Mitchell

Policy Analyst

Office of the Surgeon General

Room 736E, Humphrey Building

200 Independence Avenue, S.W.

Washington, DC 20201

(202) 690-6467

(202) 690-6498

Public Health Service I

Juanita C. Evans

U.S. Public Health Service

Health Resources and Services Administration

Maternal & Child Health Bureau

5600 Fishers Lane, Room 18A89

Rockville, MD 20857

(301) 443-4026

(301) 443-1296

U.S. Advisory Board on Child Abuse and Neglect (ABCAN) 1 Preston Bruce

Executive Director

U.S. Advisory Board on

Child Abuse and Neglect

Humphrey Building, Room 303-D

200 Independence Avenue, S.W.

Washington, DC 20201

(202) 690-7059

(202) 260-6309

Deanne Tilton Durfee

Chair, Fatalities Workgroup

Inter-Agency Council on

Child Abuse and Neglect (ICAN)

4024 North Durfee Avenue

El Monte, CA 91732

(818) 575-4362

(818) 443-3053

U.S. Advisory Board on Child Abuse and Neglect

289
Appendix D

International Contacts for Multiagency

Child Death Review Activities

Australia

Paul Tait

Westmead Hospital

NSW 2145

Westmead, Australia

Canada

James Young

Chief Coroner

2600 Grenville

Toronto, Ontario, Canada M712G9

(416) 314-4000

(416) 314-4036

I England

Kathleen Taylor

Community Services Division

Department of Health

Wellingtun House

133-155 Waterloo Road

London, SE1 8UG

(071) 972-2000

(071) 972-4519

245

U.S. Advisory Board on Child Abuse and Neglect
Appendix E

TYPEIPRINT PI LOCAL FtLE WAWA PERMANENT SLACK PIK DECEDENT'S NAME IFirsIJAI44Ie.Lest1

FOR

INSTRUCTIONS

SEE OMER SICE

ASIO HANDOOOK DECEDENT

U.S. STANDARD CERTIFICATE OF DEATH STATE FILE 10)011E0 S. SEX 3. DATE OF DEATH IMonth.D.y.Yeuri

SEE DEFINITION ON OTHER WE

ITEMS 24211 MUST SE COMPUTED SY ninon WHO

ARONOUNCES DEA

IKE INSTRUCTIONS

704 OTHER SIDE

CAUSE OF DEATH

SEE DEFINMON ON OTHER WE

4. SOCIAL SECURITY NUMBER Sa. AGE-Last Suthday Moral 5b. UNDER 1 YEAR Sc. UNDER 1 DAY Months ;Days Hours !Minutes S. DATE OF BIRTH (Month,

Day.Therl

7. BIRTHPLACE !Coy end Stele or

Foreign Country! S. WAS DECEDENT EVER IN U.S

ARMED FORCES? Ms or nal Ss. PLACE OF DEATH farce only one, see instructions on other ode) HOSPITAL: botl 0 ER/Outpationt 0 DOA

I OTHER: ,-, U Nursing Home 0 Residonce 0 Other (Specify!

/M. FACILITY NAME Of .701 11,180N1 .1, gor surf end number! I ft. CITY. TOWN. OR LOCATION OF DEATH ft COUNTY OF DEATH

10. MARITAL STATUS -Monied. Novo, Month], Widowed.

t:).PCd (Speclfyi 11. SURVIVING SPOUSE

ill *WC pevt amnion name! 12a. DECEDENT'S USUAL OCCUPATION

101th Lind Of wont lone doing most of rotting 04. Do not use retired! 120. KIND OF BUSINESSANDUSTRY

134. RESIDENCE-STATE 136 COUNTY 13c. CITY, TOWN OR LOCATION 134 STREET AND NUMBER

134. INSIDE CITY UMITS?

(Yes or nOl 131. 2IP CODE 14 WASDECEDENT OF HISPANIC ORIGIN?

(Specdy No of Yes-lt yes, specify Cuben.

Mennen. Puerto Rican. etc.) 0 No 0 Yth

Spemfy.

15. RACE-Amoncan Indian Slack. White. inc

(Specify] 14. DECEDENT'S EDUCATION

(Specify only Neer grade comPrted!

ErmentenelSrondery 10.1211Co6.ige 11-4 or 6.1 17. FATHER'S NAME (Firstriddielest.

)

IS. MOTHER'S NAME fFirst.PAiddr,fitadon Sumernel

thia. INFORMANT'S NAME /Typo/Aunt/ 111b. MAILING ADDRESS (Sewl end raiser or AM. ROV. N1114*, City or Teem Stem, Zep Code) 104. METHOD OF DISPOSITION 0 Waal 0 Crmation 0 pontoon hoot Stout

0 Donstion 0 Other (Specify!

206. PLACE OF DISPOSITION Mune of cemetery, arrtry, or other theme/ 204. LOCATION-City cc Town. State

210. SIGNATURE OF FUNERAL SERVICE UCENSEE OR

PERSON ACTING AS SUCH

PP .

210. UCENSE NUMBER

fol Licenser 22. NAME AND ADDRESS OF FACIUTY )Cows:Sete items 23eic onlY when certifying physician le not evallsble itt time of death

to certify cauth of death.

23e. To the both of my know**, deo* occurred et the lbw. date. end disco naiad. &envoi* end Titie If

230. UCENSE NUMBER 236. OATE SIGNED

fromIttley.Verl

I:`.4. TIME Of DEATH

I lg

25. DATE PRONOUNCED DEAD (rantA.Cry.Ver) 211. WAS CASE REFERRED TO MEDICAL EXAMINER/CORONER? Wes or no)

CERTIFIER

REGISTRAR PHS T 003 REV 1/113

27. PART I. Ent./ the OissEEs inniiies. or complications that couthd Th. death. Oo not entor the nude of dying. EoCh I. CloStC 01 tssOitstoty

arrest, shock, or mart failure. List only one causo on wet kith.

IMMEDIATE CAUSE (Final cl1$061111 of condition

toEuttioo in death)

Sequentially list condition..

if any, leading to immediate

cause. Ent., UNDERLYING

CAUSE Minorite or mgr.,. that intuited theme

tOEulteno in /11161 LAST

DUE TO (OR AS A CONSEQUENCE OFI:

Appcooltrtft.

I'Mantel Between Onoth and Oeath

DUE TO (OR AS A CONSEQUENCE OFI: DUE TO 101 AS A CONSEQUENCE OF). PART N. Other toond,CEnt Condalonl COntobuting to thath but not rssuItiog in tho untltlYto9 COO.. elven In Port I. 2114. WAS AN AUTOPSY

PERFORMED? Wes or no/ 266. WERE AUTOPSY FINDINGSAVAILABLE PRIOR TO

COMPLETION OF CAUSE Of DEATH? (754 on no) 26. MANNER OF DEATH 304. OATE OF INJURY 306. TIME OF 30c. INJURY AT WORK? 304. DESCRIBE HOW INJURY OCCURRED 0 !Mural 0 Pending fronth.Dey. nth/ iNJURY (VOl r nal

0 Accident 0 Suicide 0 Could not b.

0 HoinjcId. Detelnuned 304. PLACE OF INJURY-At home, fans, it1091, ?bonny, offIce 301, LOCATION (Sueet end Number or Purel Route Number, City or Town. StAtel building. etc. (Idea/ 315. CERTIFIER

(Chock onfy onel o CERTIFYING PHYSICIAN fehyskien certifying of deeth when mother phyeklen Aol pronouncod troth end comOrrd Item 231

To th boot of my knowledgo, deelh scorned due Hi 160 newels! end warmth se stated.

0 PRONOUNCINQ AND CERTIFYINg PHYSICIAN frisficion both promeuncing area end certifying to cease of troth)

To the beet el nty knowledge, death IICCORINI 1. VA Woe. dohs. and place. end duo se the amok) and menthe se etsiod. - - - --

0 MEDICAL EXAMINER/CORONER On the belie examination end/a InyeatIgellen, In my opinion, thath eccurrth It the Woe. slate. and piaci, and due to the tthath(e) and thennw 1. etatod. 316 SIGNATURE AND TITLE OF CERTIFIER 31e LICENSE NUMSER 314. DATE SIGNED tronth.Doy.Verul

32 NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (ITEM 271 ITypWPrint) 33. REGISTRAR'S SIGNATURE 34. DATE FILED thfonth,Dey.trol

U.S. Advisory Board on Child Abuse and Neglect

291 BEST COPY AVAILABLE

247
Appendix E

248

INSTRUCTIONS FOR SELECTED ITEMS

Item 0- Nos of Deeth

II the death.. 01000o0011 on 4 hos081.1. ChTch. Iho bat ...doming Ow decedent's status 11 the inlitetut.on knostient, emergency monvoutpatont. or dead on *rm. (DOAN. 11 Meth Weit 01000016.0 OftflorhoO. ChCk the Poi nOcating vonethei pronouncement occurred at a nurswg ham. resdence. or othe. locetion. It other is checked. specify where death "me legely pronounced. such Is offCf. the Waco whom the accident 0000094. a et work. Mans 13.4. - 01111111C4 of Decedent Resdenc of the deCedent is . place where he a e01 . ctually mode., The es ow 040 ossaray the Um* OS -home Stoic- Or -4941 residence " Never enter a tomporery rewdenc such es one

omd acnn, I w1.1 boswese Po. of vilclifoot.. PfIco of 14.01000 during tow al nutetery duty of durep Untmic COVV COM*61,100 SS temporary and should ba consolered the 00004 of teademe

lt &Cadent had been bog oIl facility where ...0.04.110000110 111411 rot T. long period of MM. such as group home, manual institution. moons home. pennenowy. II hospital for the cloomc0

ly 6. moon the location of that 1Hady in (terns 13. through 131

the decedent was en infant who nevei leaded at home, the pact 0 I.11dlflC4O that of the mewl.lor legal puerdien. Do mum an smite homnal's location m Om place of residence for any hem; 23 ana 31 - 160140 Cariffleation

TM PRONOUNCING PHYSICIAN 4 the person who determines that the decedent 4 legally dead but vrho was not In charge of the patient's cam for the Moss or condition which resulted w death. Item* 2310 through 23c we to im completm c2± +Mon the physiclon responsible for completing Me war.. carbfication of Wee of death °tern 271 4 not S0114,01 at limo of death to certify

0)01604 Wth. The pronounune physician 0.190084:0. lot completing only i4*,fo 23 11.1,1911 20. The CERTIFYING PHYSICIAN tho poison who determines the cause of desth 1Itern 271. This boo should be Checked In WM Caseli vrhert the POS. Whof60..43fOl.O Ihe 11.4.O4 Whf.fion 000. of death 4 not the Mrs. who aonounced death Men, 231. The candying physicion le reasOnsetle for completing Mona 27 through 32. TM PRONOUNCING AND CERTIFYING PHYSICIAN boa should be checked when the ewe moon tespontible for completing Wm 24 guaagh 32. %et H. when the Imne physician hee both

onouncol death and certified the come el death If this boa w checked. items 23e tlyough 230 Mould be left OW.

The MEDICAL EXAMINER/CORONER too 40.0u44 Do Chocked when investigation 4 lloodGcl by the WI Mona., Eaaminstion Act end the muse of Math le conipleted by 10e4i60 examiner or coronet. TM Medical (soma-. f tea. on. is iespon.04 fai completing mime 24 through 32. hem 27. - Cows. 0 Death TM came of death wane the 1344411114. abf.erhekty, INoly, of mooning that caused the <MM. not the WM Of thine, ouch 84 cardiac or imparetory arrest. Mock. or Posen Iplute.

in Pan 1, the immediate caum of Math 4 mooned on S. lol. Antecedent conditions. 4 any. which gave nee to the Wee 04 Mooned en Woe ad. HI. and NO. The OndWint C.o.. oho.ld to 15000144 1 testi. oold11 Part I. No onely nocostsr, ort tn. lb). 1111, ond 141 d the annediete caw.* of dimMon Me 41 &screw completely the train of events.ONLY ONE CAUSE SHOULD

IF ENTERED ON A UNE. Mahone Ws may to bdfloff rf necees.y. Provide the beet eetimete 0 Me intemel between 4. meet 0 tiech condition end death. Do not Neve the 01151011 IOWA: of ...w00% 10 WWI*. 11. enter otMt important diseeMs or condition, that me? We contributed to Math but &I fel moalt rt Woo orolkOdyinil 01018 al Math 007. at PINT 1. Soo ozorooloo bow.,

411411M400004

004

/ rt. 1.6.1 S. W.. mat awe m w ere. we rm. 0 060 no8 Wit Aimmitm

11111110111 6A014 00041. own. ea Lb. Only .

1

So...or 101 ono.. 1.6no to

saw Me Mmil01014

0A144 Now or Ow O.. oil T.. woolmo MO.. LAST

Rupture of myocardium

ma 100a MI A CONSIOuINClal. Acute myocardial infarction

ous 10 CO AS A C044400I400 Oil Chronic ischemic heart disease

OW TO WAS A COOMOUINCa

Mins.

6 days

5 years

P00116 Ofko 4110*4601414.0161141050041.1111040016410111100040011 0011 Diabetes, Chronic obstructive pulmonary disease, smoking

SU WAS AN AUTOPSY

14N.COKOP

IT. or Rol Yes

VA. went *MYST 01404430

011016A041 MOO TO

COWUTION 00061.110 OF OtAnsf 141 Yes

JO 440001 OF 04/1. N.. woe.. *"*"... 0 &Ave. 0000040040 0 17

Its 5111IM001*011 Oft 01,11111

Me. PAU Or ...Any 364 MN OP MPArt Pee. WAN, AI WORK/ OW INV 3Ikt. CelCMI NOw MAW' OCCIANIO

PM *LAC. OF IONST ....Too. ff.. T.O. T.., WO. NM LOCATTON 01144o0 Tod ikoolo o hoO Nom W.., C. o Toon, Ilrovol bohf.p. *K. Ilfroorrf

/ IT . 00014. In,. we ti semeHamm we.. Moo 0. v. Imo Oo .flo or SO.. MO. OW. ff....

0,4.1.40004.40404 Coage lloI o* Too sof.. ToTh

SOINDIATI W.411 Oro O.. 0.1.1. 1 *ON

41E111

1000441 MI <Y..% * CA, 1110. *0 wee.. 4.04(4411 601010YS44 CAUM COY. VW. awl wow 66 wet that

Cerebral laceration

OPE 70 t011 AS COMICIUMCF Oil Open skull fracture

OUP 70 KM At A CONMOUIACII Ill Automobile accident DUI TO KA AS A CONMOUMOI Oil

Som. Cow 4. I 0.0

I10 mins.

10 mins.

10 mins,

00004 0150. orp.fll cow... to. SA off Toor *ow In heir 4.. WAS AN AUTCST

0141041401 Ova Tr NY No M. VINE Alf10.11 MOWS WARMS! PIPS TO

COWS7101I OP CAUS4 Of NANO PM A. No

ki. liANI el 1:4114 0 Moro 0 w Se Owf000.

Pee. OAT! Of goat*. MenelDer. rm. ntiN Ca wag. 11/15/85 1 p. w

NH. 1141051 AT 1,03Al fVfo Tr./ No

40404411 NOW AMOY 00018110 2-car collision-driver 4. HACI Oa 08141- Ai row tank ww. Wm. ettoe 00. LOCATION dew aw *mime Rood AP" *m.o. C. Toon. NMI VorOW Street Route 4, Raleigh, North Carolina

U.S. Advisory Board on Child Abuse and Neglect

292 BEST COPY AVAILABLE
Department of Health and Human Services

U.S. Advisory Board on Child Abuse and Neglect

200 Independcnce Avenue, S.W.

Washington, D.C. 20201

(202) 690-8137

233