Child Maltreatment: Strengthening National Data on Child Fatalities Could Aid in Prevention
Published: 2011-07-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Children's deaths from maltreatment are especially distressing because they involve a failure on the part of adults who were responsible for protecting them. Questions have been raised as to whether the federal National Child Abuse and Neglect Data System (NCANDS), which is based on voluntary state reports to the Department of Health and Human Services (HHS), fully captures the number or circumstances of child fatalities from maltreatment. GAO was asked to examine (1) the extent to which HHS collects and reports comprehensive information on child fatalities from maltreatment, (2) the challenges states face in collecting and reporting this information to HHS, and (3) the assistance HHS provides to states in collecting and reporting data on child maltreatment fatalities. GAO analyzed 2009 NCANDS data--the latest data available--conducted a nationwide Web-based survey of state child welfare administrators, visited three states, interviewed HHS and other officials, and reviewed research and relevant federal laws and regulations.
section_title: What GAO Found
paragraphs: More children have likely died from maltreatment than are counted in NCANDS, and HHS does not take full advantage of available information on the circumstances surrounding child maltreatment deaths. NCANDS estimated that 1,770 children in the United States died from maltreatment in fiscal year 2009. According to GAO's survey, nearly half of states included data only from child welfare agencies in reporting child maltreatment fatalities to NCANDS, yet not all children who die from maltreatment have had contact with these agencies, possibly leading to incomplete counts. HHS also collects but does not report some information on the circumstances surrounding child maltreatment fatalities that could be useful for prevention, such as perpetrators' previous maltreatment of children. The National Center for Child Death Review (NCCDR), a nongovernmental organization funded by HHS, collects more detailed data on circumstances from 39 states, but these data on child maltreatment deaths have not yet been synthesized or published. States face numerous challenges in collecting child maltreatment fatality data and reporting to NCANDS. At the local level, lack of evidence and inconsistent interpretations of maltreatment challenge investigators--such as law enforcement, medical examiners, and child welfare officials--in determining whether a child's death was caused by maltreatment. Without medical evidence, it can be difficult to determine that a child's death was caused by abuse or neglect, such as in cases of shaken baby syndrome, when external injuries may not be readily visible. At the state level, limited coordination among jurisdictions and state agencies, in part due to confidentiality or privacy constraints, poses challenges for reporting data to NCANDS. HHS provides assistance to help states report child maltreatment fatalities, although states would like additional help. For example, HHS hosts an annual NCANDS technical assistance conference, provides individual state assistance, and, through NCCDR, has developed resources to help states collect information on child deaths. However, there has been limited collaboration between HHS and NCCDR on child maltreatment fatality information or prevention strategies to date. State officials indicated a need for additional information on how to coordinate across state agencies to collect more complete information on child maltreatment fatalities. States are also increasingly interested in collecting and using information on near fatalities from maltreatment.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Secretary of HHS take steps to further strengthen data quality, expand available information on child fatalities, improve information sharing, and estimate the costs and benefits of collecting national data on near fatalities. In its comments, HHS agreed with GAO's findings and recommendations and provided technical comments, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: Every year, children in the United States die after being physically  abused, severely neglected, or otherwise maltreated, frequently at the  hands of their parents or others who are entrusted with their care. Infants  and toddlers are the most vulnerable to such abuse and neglect.  According to estimates by the National Child Abuse and Neglect Data  System (NCANDS), 1,770 children in the United States died from physical  abuse or other forms of maltreatment in fiscal year 2009. Some experts  believe that more children have died from maltreatment than are captured  in these estimates. Additionally, experts expressed concern that national  data on these deaths may be problematic for understanding the issue  because of inconsistencies and limitations in the data collected and  reported to NCANDS by states. In addition, many more children are  severely harmed and may nearly die from maltreatment, but NCANDS  does not collect data specifically on near fatalities. Collecting complete  and consistent information is important for understanding the magnitude  of the problem and for targeting efforts to help prevent future child deaths  and near deaths from maltreatment.
The Department of Health and Human Services (HHS) is the principal  federal agency that provides oversight of state child welfare systems,  which are intended, in part, to protect children who have been maltreated  and help prevent maltreatment. To better understand the scope of child  maltreatment, including child fatalities, and inform efforts to address and  prevent it, the 1988 amendments to the Child Abuse Prevention and  Treatment Act (CAPTA) required HHS to establish a national data  collection and analysis program for child maltreatment data. HHS  responded to this mandate by establishing and maintaining NCANDS,  which is a voluntary data-reporting system. Since at least 2000, states  have increasingly provided data on children who were maltreated to HHS  for NCANDS. From these data, HHS publishes a yearly Child  Maltreatment report. The most recent report, for fiscal year 2009,  presents national data about child abuse and neglect known to child  welfare agencies in the United States. As of fiscal year 2009, all states  reported at least some data on child maltreatment to NCANDS.
To obtain more information about the quality of national data on child  fatalities and near fatalities from maltreatment, the Chairman, House  Ways and Means Committee, asked us to examine (1) the extent to which  HHS collects and reports comprehensive information on child fatalities  from maltreatment, (2) the challenges states face in collecting and  reporting information on child fatalities from maltreatment to HHS, and (3)  the assistance HHS provides to states in collecting and reporting data on  child fatalities from maltreatment.
We used multiple methodologies to address these three objectives. For  the first objective, we reviewed published research on the number of child  fatalities and systematically assessed the adequacy of each study’s  research methodology. We analyzed fiscal year 2009 NCANDS data  provided to HHS by states and additional data on child maltreatment  fatalities collected from states by a nongovernmental organization funded  by HHS, the National Center for Child Death Review. We confirmed the  reliability of these data for our purposes. We also interviewed HHS  officials responsible for NCANDS child maltreatment data, child welfare  practitioners, and other experts. We conducted a nationwide Web-based  survey of state child welfare administrators in 50 states, the District of  Columbia, and Puerto Rico between October and December 2010. We  received survey responses from all states, although not all states  responded to every question. To address the second objective, we  conducted site visits to California, Michigan, and Pennsylvania to obtain a  more in-depth understanding of states’ child fatality data issues in  addition to drawing upon the state survey. To address the third objective,  we interviewed HHS NCANDS officials and other experts, analyzed  survey results on states’ perspectives on additional NCANDS assistance  needed from HHS, and reviewed HHS technical assistance and other  documents relevant to child maltreatment fatalities and near fatalities. We  also reviewed CAPTA and implementing regulations and federal guidance  on collecting and reporting maltreatment data, as well as other related  laws, including pertinent state laws. (See app. I for additional information  on our scope and methodology.)
We conducted this performance audit from April 2010 through July 2011  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: About 53,000 children died from a range of causes in the United States in  2007—the latest year for which national data were available—according  to the Centers for Disease Control and Prevention (CDC). Major causes  of death among children include conditions originating in the perinatal  period, accidents (such as motor vehicle traffic accidents and drowning),  congenital anomalies, homicide, and cancer. Of all children who died in  fiscal year 2009, NCANDS estimates that 1,770 children died from  various types of maltreatment. (See fig. 1.) Moreover, 81 percent of  children who died from maltreatment were 3 years old or younger, and  more than half were infants 1 year or younger.
According to NCANDS, the estimated number of child maltreatment  fatalities has increased nationally over the past 5 years, from 1,450 in  fiscal year 2005 to 1,770 in fiscal year 2009. HHS reported that states  believe this increase may be due, in part, to new state legislation, new  procedures, and improved state reporting practices.
Protecting children from maltreatment is primarily the responsibility of  child welfare programs administered at the state and local levels. In all  states, child protective services (CPS) are part of the child welfare  system. CPS generally screens and responds to suspected child  maltreatment reported to it by mandatory reporters—including police  officers, doctors, teachers, and other professionals—as well as by  neighbors and family members. In fiscal year 2009, professionals initiated  58 percent of all reports of suspected maltreatment to CPS. CPS  investigators determine whether such reports are considered  maltreatment under state laws or policies. CPS also typically determines  whether interventions—such as placement with a foster family—are in the  best interest of the child. When CPS determines that a child’s death is  from maltreatment, CPS documents the case. The state’s child welfare  department reports it to NCANDS. (See fig. 2.)
At the federal level, most of the $8.4 billion in federal assistance  dedicated to child welfare purposes ($7.2 billion) in fiscal year 2010  supports state child welfare programs, including foster care, adoption  assistance, and child protection. HHS oversees funding provided to states  that support child welfare programs, and provides technical assistance  and training to states on a variety of child welfare issues. HHS has a  technical assistance contract specific to NCANDS and also provides  technical assistance on NCANDS and other data issues through its  National Resource Centers (NRC).
CAPTA is the key federal legislation focused on preventing and  responding to child maltreatment. Reauthorized in 2010, CAPTA provides  supports for, among other things, data collection activities and technical  assistance on child maltreatment. It also authorizes federal funding to  states for grants to support prevention, investigation, and treatment of  child maltreatment. In fiscal year 2010, funding for CAPTA programs  totaled about $97 million, of which $26.5 million was for basic state grants  to improve CPS. These grants are distributed to states by formula, and  may be used to improve CPS investigations, caseworker training, and  prevention programs. All states in fiscal year 2010 received CAPTA basic  state grants. To receive this grant, states are required to have an  approved state plan that outlines the activities that the state intends to  implement. It must include, for example, provisions or procedures for  receiving and responding to allegations of child abuse or neglect and for  ensuring children’s safety. For grant purposes, child abuse and neglect is  defined as “at a minimum, any recent act or failure to act on the part of a  parent or caretaker, which results in death, serious physical or emotional  harm, sexual abuse or exploitation, or an act or failure to act which  presents an imminent risk of serious harm.”
Each state receiving a basic grant is also required to establish and  support citizen review panels to evaluate the effectiveness of CPS  policies, procedures, and practices, and, according to the National Center  for Child Death Review, 14 states in 2003 reported that their child death  review teams serve a dual function as CAPTA citizen review panels for  child fatalities. The citizen review panels must be composed of volunteers  who are “broadly representative” of the community, including members  with expertise in the prevention and treatment of child abuse and neglect,  and may include members of foster care review boards or child death  review teams. Child death review teams exist in all but one state to  review child abuse and neglect fatalities and suspicious child deaths.  Results of these reviews may be used to improve services, advocate for  change, and conduct public awareness activities, ultimately for the  purpose of preventing future child maltreatment deaths.
subsections: section_title: Near Fatalities of Children from Maltreatment
paragraphs: CAPTA defines the term “near fatality” as “an act that, as certified by a  physician, places the child in serious or critical condition.” Although the  term is defined, neither CAPTA nor the applicable regulations further  discuss data collection on near fatalities. NCANDS does not have a  specific data field that identifies the case as a near fatality from  maltreatment.
section_title: Child Maltreatment Data Collected by NCANDS
paragraphs: NCANDS collects and analyzes data on children involved in situations in  which CPS either investigated an allegation of maltreatment or initiated  an alternative response. State CPS agencies generally are responsible  for submitting NCANDS data to HHS. Since 1996, states that receive  basic state grants under CAPTA have been required to report annually— ”to the maximum extent practicable”—at least 12 data items to NCANDS  on child maltreatment.
Data from NCANDS are an important source of information for several  publications, reports, and activities of the federal government, as well as  for child welfare officials, researchers, and others. NCANDS data are  compiled annually in the Child Maltreatment report, which, as of  December 2010, has been issued annually since 1992. HHS issues the  annual Child Welfare Outcomes: Report to Congress partly based on  state submissions of NCANDS data. This report presents information to  Congress on states’ performance on national child welfare outcomes,  including NCANDS data on reducing the recurrence of child maltreatment  and reducing child maltreatment in foster care. NCANDS data have also  been incorporated into the Child and Family Services Reviews (CFSR).   Finally, NCANDS data are used to help assess the performance of  several HHS programs in accordance with the Program Assessment  Rating Tool.
section_title: National Data Likely Underestimate the Number of Children Who Died from Maltreatment and Provide Incomplete Information on Circumstances
subsections: section_title: More Children Have Likely Died from Maltreatment than Are Counted in National Data
paragraphs: More children have likely died from maltreatment than are reflected in the  national estimate of 1,770 child fatalities for fiscal year 2009. According to  our survey, child welfare officials in 28 states thought that the official  number of child maltreatment fatalities in their state was probably or  possibly an undercount. Child welfare experts and HHS officials we spoke  with also thought that national estimates did not reflect the full extent of  children’s deaths from maltreatment and that undercounting was an issue  with child fatalities. Acknowledging the limitations of NCANDS data on  child maltreatment fatalities, HHS’s Child Maltreatment 2009 report states  that NCANDS fatality data are only a proportion of all child fatalities  caused by maltreatment. These data are based on reports provided to  NCANDS by CPS agencies within state child welfare departments.
A major reason for the likely undercounting of child maltreatment fatalities  is that nearly half of states report to NCANDS data only on children  already known to CPS agencies—yet not all children who die from  maltreatment were previously brought to the attention of CPS. Some  children may not have been previously maltreated, or their earlier  maltreatment may not have been noticed or reported to CPS agencies.  Child deaths from maltreatment are recorded in many state and local data  sources, such as death certificates from state vital statistics offices and  medical examiner or coroner’s offices, CPS records, and state and local  child death review team records (see fig. 3), and in Federal Bureau of  Investigation (FBI) Uniform Crime Reports at the federal level.
Because of this, HHS also attempts to capture the fatalities of maltreated  children who were not previously known to state CPS agencies.  Specifically, HHS instructs states on how to report data from non-CPS  agencies and encourages states to obtain information on child  maltreatment fatalities from other state agencies. However, in  responding to our survey, 24 states reported that their 2009 NCANDS  data did not include child fatality information from any non-CPS sources.  More specifically, for example, 43 states responded that their NCANDS  data did not include child fatality data from the vital statistics department.  (See fig. 4.) Since NCANDS is a voluntary data-reporting system, state  CPS agencies cannot be required to obtain information from other state  agencies, according to HHS officials.
Synthesizing information about child fatalities from multiple sources can  produce a more comprehensive picture of the extent of child deaths than  sole reliance on CPS data. In our review of research assessing whether  the number of child fatalities from maltreatment was accurate, we found  that key sources of information undercounted child deaths, sometimes by  significant amounts. For example, a peer-reviewed study of fatal child  maltreatment in three states found that state child welfare records  undercount child fatalities from maltreatment by from 55 percent to 76  percent. The data sources analyzed in this study were death certificates,  state child welfare agency records, state child death review team data,  and law enforcement reports to the FBI Uniform Crime Report system.  The study found that each data source reviewed undercounted the total  number of child maltreatment fatalities. However, more than 90 percent of  the child fatality cases could be identified by linking any two of the data  sources, demonstrating the value of using multiple existing data sources  to determine the extent of child fatalities from maltreatment. The study  also found that the multidisciplinary child death review team process may  be the most promising approach to identifying deaths from maltreatment if  there is a standardized data collection and reporting system in place.
Using a different methodology, HHS’s most recent National Incidence  Study of Child Abuse and Neglect (NIS-4)—issued in January 2010— estimated 2,400 child deaths from maltreatment in the study year  spanning portions of 2005 and 2006. The NIS is a congressionally  mandated, periodic effort of HHS to estimate the incidence of child abuse  and neglect in the United States. Unlike NCANDS, which relies primarily  on CPS data reported by states, the NIS-4 relies on multiple sources of  child death information. The NIS-4 used a nationally representative  sample of 122 counties to create national estimates of the incidence,  severity, and demographic distribution of child maltreatment, including  fatalities from maltreatment. The NIS-4 uses two standardized research  definitions of maltreatment in developing its findings. In each county,  NIS-4 collected CPS data as well as reports of child maltreatment cases  that came to the attention of community professionals in the county  sheriff’s office; the county departments of juvenile probation, health, and  public housing; municipal police departments; hospitals; public schools;  day care centers; shelters; and voluntary social services and mental  health agencies.
Furthermore, several factors complicate the ability to obtain  comprehensive information on child fatalities from maltreatment. As a  result, it can be difficult to compare child fatality data across states or  over time.
Inconsistent definitions of maltreatment: Although CAPTA  legislation establishes a minimum standard for the definition of child  abuse and neglect, states generally develop their own variations of  these definitions. Consequently, child maltreatment data at the  national level can reflect an underlying inconsistency across individual  states. For example, some states add medical neglect to the CAPTA  definition and define the concept differently. (See table 1.)
Some experts we interviewed said that definitions need to be  standardized nationally to improve the quality of NCANDS data.  When states submit data to NCANDS, HHS requires them to align  state definitions of child maltreatment with elements of the NCANDS  definitions, using a data-mapping process. HHS officials told us this  mapping process helps create more consistent data within NCANDS.  However, the mapping process may not fully address underlying state  differences in determining whether a child’s death was regarded as a  maltreatment death. HHS officials told us they considered definitional  variations less important as a factor affecting NCANDS data quality  than the difficulty in obtaining agreement among various local and  state investigators—such as law enforcement and medical  personnel—that maltreatment was the cause of a child’s death.    Differing legal standards for substantiating maltreatment:  Because states have different legal standards for substantiating  maltreatment, it is difficult to compare data across states. The  substantiation process generally requires child welfare caseworkers to  decide whether an allegation of maltreatment, or the risk of  maltreatment, meets the criteria established by state law or policy. In  a Congressional Research Service (CRS) analysis, state standards  for substantiating child maltreatment were categorized into three  groups, ranging from least to most rigorous. CRS found that states  with stricter standards for substantiating maltreatment have the lowest  rates of child maltreatment. (See table 2.)   Missing data: Some states do not report any information on child  fatalities in certain years (e.g., Alaska, Massachusetts, and North  Carolina for fiscal year 2009). Additionally, some states do not report  particular data elements. For example, in fiscal year 2009, 13 states  did not report information on children who died who, within the past 5  years, had been in foster care and had been reunited with their  families; 7 states did not report the relationship of the perpetrator to  the child who died; and 6 states did not report the race or ethnicity of  the child who died. In responding to our survey, states provided a  range of explanations for missing data in their NCANDS submissions.  For example, according to state child welfare officials, key reasons for  their not reporting some data were that other state entities, not child  welfare, collected the information; state data systems did not collect  those data; and delays occurred in data collection that affected  reporting.   Lack of death date: NCANDS does not ask states to identify the date  of a child’s death, and establishing maltreatment as the cause of a  child’s death can take many months, particularly when a criminal  proceeding is involved. As a result, child deaths reported to NCANDS  may have, in fact, occurred earlier than the year in which they are  reported.
section_title: HHS Collects but Does Not Report Some Useful Information on the Circumstances Surrounding Child Fatalities
paragraphs: NCANDS collects more data on the circumstances surrounding child  fatalities than are reflected in HHS’s annual Child Maltreatment report— information that could be useful for prevention. NCANDS collects  information from state CPS agencies about the demographics of children  who died, such as their age and race; the report of maltreatment and the  CPS agencies’ response and investigation; the perpetrator; services  provided to the family; and risk factors associated with the child and with  the caretaker. It also collects information on broad categories of  maltreatment—such as neglect, physical abuse, sexual abuse,  psychological maltreatment, and medical neglect—although it does not  collect more detailed information on how a child dies, such as from a  bathtub incident or swimming pool drowning resulting from a parent’s  neglect. However, HHS does not report some information it collects on  the circumstances surrounding child fatalities. For example, when we  analyzed unpublished fiscal year 2009 state data reported to NCANDS on  children’s deaths from maltreatment, we found the following:    Types of abuse: Rates of physical abuse were slightly higher among  older children who died from maltreatment (ages 8 to 18), while  neglect rates were slightly higher among younger children who died  from maltreatment (ages 7 and younger).   Child welfare history: At least 14 percent of children who died from  maltreatment had a previous substantiated or indicated incident of  child maltreatment.   Sixteen percent of perpetrators of fatal child maltreatment were  previously involved in an incident of child maltreatment that was  either substantiated or indicated by CPS.   Among parents who were perpetrators, about 60 percent were  female. Of unmarried partners who were perpetrators, 90 percent  were male.   Child’s risk factors: Two percent of maltreated children who died  had a disability such as a developmental disability, an intellectual  disability, or a visual or hearing impairment.
According to experts, detailed information on the circumstances  surrounding child fatalities can provide a more comprehensive  understanding of the issue of fatal child maltreatment, such as revealing  patterns that could aid prevention efforts.
In addition to what is known nationally through NCANDS data, extensive  information on the circumstances surrounding children’s deaths from  maltreatment is collected by the Child Death Review Case Reporting  System (CDR Reporting System), operated by the nongovernmental  National Center for Child Death Review (NCCDR). NCCDR serves as a  resource center for state and local multidisciplinary teams that review  cases of child deaths for the purpose of improving case identification,  investigations, services, follow-up, and prevention. Nearly all states  have child death review teams comprising CPS workers, prosecutors, law  enforcement, coroners or medical examiners, public heath care providers,  and others. While data received from NCCDR are more detailed in each  case, the data are less comprehensive than those reported to NCANDS,  according to HHS. Local review teams do not review all cases of possible  death due to maltreatment but rather vary in their roles and scope from  locality to locality. NCCDR is funded largely by the Maternal and Child  Health Bureau of the Health Resources and Services Administration  (HRSA).
Begun in 2005, NCCDR’s Web-based CDR Reporting System is  potentially a rich source of multistate data on child fatalities from all  causes, including child maltreatment. As of June 1, 2011, 39 states had  data use agreements with NCCDR, according to NCCDR officials.  NCCDR’s goal is to eventually have all state child death review teams  provide information on child fatalities to the data system, according to  these officials. NCCDR takes a public health approach to child death  review, with a focus on improving investigations and identifying modifiable  risk factors and strategies for preventing similar future deaths. According  to NCCDR, most states using the system analyze their data and publish  annual reports. Although NCCDR conducts in-house analyses for federal  partner organizations, such as the National Highway Traffic Safety  Administration, according to NCCDR officials, or of sudden cardiac  deaths for a hospital, CDR data on child maltreatment deaths have not  yet been synthesized or published, according to the NCCDR director.  (The sidebar describes the CDR data-reporting form.)
section_title: Local Investigative Challenges and Limited Coordination Hinder States’ Efforts to Collect Child Maltreatment Fatality Data and Report to NCANDS
subsections: section_title: Investigative Difficulties Can Hamper Local Data Collection Efforts
paragraphs: Challenges faced by local investigators, such as law enforcement  officials, medical examiners, and CPS staff, in determining whether a  child’s death was caused by maltreatment make it difficult for states to  collect complete data on child maltreatment fatalities. These investigative  challenges include lack of definitive medical evidence, limited resources  for testing, differing expertise and training, and inconsistent  interpretations and application of maltreatment definitions.    Lack of definitive medical evidence: Without definitive medical  evidence, it can be difficult to determine that a child’s death was  caused by abuse or neglect. According to our survey, 43 states  indicated that medical issues were a challenge in determining child  maltreatment. (See fig. 5.) For example, investigators we spoke with  in California said that determining the cause of death in cases such as  sudden unexplained infant death is challenging because the child may  have been intentionally suffocated but external injuries are not readily  visible. Similarly, a medical examiner we interviewed in Michigan said  that it is a challenge to appropriately determine the cause of death for  babies who may have been shaken to death or suffocated.   According to experts we spoke with, a lack of evidence also makes it  difficult to determine whether a death was caused by neglect. Medical  neglect is a type of maltreatment caused by failure of the caregiver to  provide for the appropriate health care of the child despite having the  resources—financial or otherwise—to do so. Medical neglect often  results from inattentiveness to a chronic illness or missing follow-up  medical appointments, according to a physician from the American  Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect.  For example, one expert told us that a medically fragile premature  infant who is discharged from the hospital but not brought back in for  a follow-up examination and later dies could be considered to have  died from medical neglect. Experts from the American Bar  Association’s (ABA) Center on Children and the Law said neglect  deaths are often categorized incorrectly, which may contribute to the  problem of undercounting deaths from neglect. County officials we  spoke with in Michigan added it is very difficult to determine medical  neglect as the cause of death because the death can appear to have  been from “natural” causes.   Limited resources for testing: Another challenge in determining  whether maltreatment was the cause of death is resource constraints  that can limit the ability to conduct autopsies and medical tests.  According to experts we spoke with from AAP, an autopsy provides  much information on the factors contributing to a child’s death—such  as infection, trauma, or congenital heart disease—that cannot be  determined based on visual inspection. These experts indicated that  financial constraints of local and state governments are the primary  reason autopsies are not conducted more regularly. In Pennsylvania,  a county coroner told us that even though autopsies can help clarify  the cause and circumstances of a death, coroners have to make  difficult choices in deciding when to order autopsies since they are  expensive and there is limited funding to cover them. According to a  2009 report by the National Academy of Sciences, insufficient funding  for testing influences cause-of-death determinations. A law  enforcement official we spoke with in Michigan noted that only 6 of his  20 requests for DNA testing were granted because of recent state  cutbacks affecting crime laboratories. In our survey, 36 states  identified limited resources as a challenge to identifying and  investigating maltreatment deaths. (See fig. 5.)   Differing expertise and training: Differing levels of investigator  expertise—particularly among those charged with determining the  cause and manner of death—also present challenges to states in  collecting child maltreatment fatality data. The National Academy of  Sciences notes that the skill and training of coroners and medical  examiners vary greatly. For example, in some counties, medical  examiners—who are physicians and typically receive death  investigation training—are charged with determining the cause and  manner of death, including identifying maltreatment, while other  counties rely on a coroner—who may or may not be a physician or  have had any medical training—to make these determinations. A  medical examiner and a coroner we spoke with in California noted  that because of differing expertise and training, forensic pathologists  and medical examiners might categorize sudden infant deaths  differently. In 1996, CDC developed a protocol for sudden infant  deaths in an effort to standardize reporting these deaths (see  sidebar). While training can enhance skills for conducting  maltreatment investigations, 35 states identified limited investigator  training as a challenge in our survey. (See fig. 5.) County officials in  the three states we visited also told us that a lack of funding  contributes to limited training opportunities. However, training  opportunities were available in the states we visited. For example,  state officials in California told us that all CPS staff are trained to  recognize and report child abuse. County officials also said coroners  in the state receive annual training that includes case presentations  by investigators and forensic pathologists, which often include child  deaths.
Inconsistent interpretations and application of maltreatment  definitions. Differing interpretations and application of maltreatment  definitions by investigators can lead to inconsistent determinations of  cause of death. Law enforcement officials we spoke with in California  noted that law enforcement officials and coroners sometimes disagree  on the manner or cause of death, for example, when the death is  suspected to be from natural causes but there is some indication of  abuse or neglect. In our survey, 29 states indicated that the level of  agreement among responsible entities—such as law enforcement  officials, medical examiners or coroners, and CPS—about how to  interpret and apply state definitions of child abuse or neglect was a  challenge for collecting information on child maltreatment fatalities.  (See fig. 5.) These entities may use their own definitions and have  different goals. For example, county officials in Michigan told us that  law enforcement investigates for the purpose of determining probable  cause for prosecution, while CPS investigates to determine if there is  a preponderance of evidence for maltreatment. AAP experts stated  that certain injuries—such as abusive head trauma—are often  incorrectly categorized on child death certificates as natural or  accidental when the real cause of death is abuse-related. It is also  difficult to distinguish at autopsy between sudden infant death  syndrome (SIDS) and accidental or deliberate suffocation with a soft  object, according to the AAP.
In our survey, 33 states indicated that variations across counties and  other jurisdictions in identifying cause of death pose a challenge for  collecting fatality information. For example, child death review team  officials in Pennsylvania noted significant variability across counties in  identifying child maltreatment deaths from head trauma. Similarly,  state officials in California noted that some counties interpret co- sleeping deaths as maltreatment, while other counties do not, which  creates inconsistencies in the numbers of child maltreatment deaths  at the state level. Officials we interviewed in Michigan told us that  when an external agency cross-checked its 2005 CPS data with  medical records for 186 cases, the analysis indicated that 37 child  deaths labeled as natural, accidental, or undetermined should have  been documented as maltreatment. This variability across counties  can result in greater data inconsistencies in states where the child  welfare agency is county-administered with state supervision, as  opposed to a state-administered system, according to national child  welfare advocates. While 11 states indicated in our survey that their  child welfare program was county- or locally administered, some of  these states have large child populations, including California, New  York, Ohio, and Pennsylvania.
section_title: Limited Coordination and Data Access Issues Pose Reporting Challenges
paragraphs: State child welfare officials indicated experiencing challenges  coordinating among geographic jurisdictions within the state and across  state lines. In our survey, 37 states indicated that the level of coordination  among different jurisdictions poses a challenge for obtaining information  on child maltreatment fatalities. (See fig. 6.) For example, a local CPS  official in Pennsylvania told us that it can be difficult for CPS to track  children when families cross county lines. State officials we interviewed in  Michigan also indicated that counties face challenges obtaining medical  records and death certificates from jurisdictions in another state when  children are taken across state borders to the nearest trauma center in  the interest of providing immediate care.
States also indicated that limited coordination with other state agencies— particularly obtaining records from the health department—can challenge  their ability to report information on child maltreatment fatalities to  NCANDS. According to our survey, 32 states faced challenges  coordinating among state agencies. Twenty-four states indicated that  agencies involved in collecting information on child maltreatment fatalities  do not generally or easily share information, and 23 states cited  confidentiality or privacy issues related to child maltreatment as a  challenge. (See fig. 6.) For example, child welfare officials in California  told us their department had restricted data sharing with the department  of public health after a security breach, and had only recently renewed its  data-sharing agreement. Michigan officials specifically identified  confidentiality and privacy restrictions as a challenge to obtaining child  maltreatment fatality data because stakeholder agencies, such as the  health department, are sometimes unsure what, if any, information they  can share with child welfare. Furthermore, state officials in Pennsylvania  told us that state and county child welfare officials are concerned about  their limited access to records from drug and alcohol programs—which  can include cases involving parents of a child who died—held by another  state agency. California has coordinated across multiple agencies in an  effort to produce a more accurate estimate of child maltreatment fatalities  (see sidebar).
States indicated that several issues related to their data systems— especially those affecting electronic capabilities—have affected the  completeness of child maltreatment fatality data they report to NCANDS.  For example, although Pennsylvania collects certain CAPTA data  elements, the state is unable to aggregate and report to NCANDS some  of the information received from counties because this information is not  recorded electronically, according to state officials. The inability to link  different agencies’ data systems with each other was also cited as a  reporting challenge by 28 states. (See fig. 7.) States also experienced  challenges reporting to NCANDS when they were either converting from  one data system to another or updating their current system. According to  our survey, 9 states were challenged by piloting or implementing a new  child welfare information system, and the Child Maltreatment 2009 report  shows that multiple states had incomplete or incomparable data because  of system conversions. For example, Michigan was unable to submit data  on child fatalities to NCANDS for fiscal year 2008, according to a state  official, because of data errors associated with conversion to a new data  system. In addition, 27 states responding to our survey reported that data  entry errors posed a challenge for reporting child maltreatment fatality  data to NCANDS. (See fig. 7.)
To help mitigate these and other challenges, states are implementing  quality controls on the child maltreatment fatality data they submit to  NCANDS. According to our survey, 34 of the 50 states responding to this  question indicated that their child welfare department had a quality control  process—aside from HHS’s Enhanced Validation and Analysis  Application (EVAA), which assesses the quality of state data—to improve  the accuracy of child maltreatment fatality data.
section_title: HHS Provides Assistance to States in Reporting on Child Maltreatment Fatalities, but States Would Like Additional Help
subsections: section_title: HHS Provides Technical Assistance to States in Reporting Data on Child Maltreatment
paragraphs: HHS provides assistance to states in several ways to help them report  information on child maltreatment to NCANDS. NCANDS is supported by  a technical team, composed of Children’s Bureau and contractor staff,  that provides technical assistance and tools to states for reporting child  maltreatment fatality data. There is also an NCANDS State Advisory  Group that worked closely with the technical team to design and  implement NCANDS and now continues to meet annually to review and  update NCANDS collection and reporting processes. According to HHS,  this 20-member group helps ensure that enhancements to NCANDS  accurately reflect states’ experiences collecting data. The NCANDS  technical team also hosts the NCANDS Annual State Technical  Assistance Meeting, a key means of assistance to states in which HHS  officials provide NCANDS training and updates and states share  questions and information. In 2010, child welfare representatives from 38  states participated in this 3-day meeting, which included workshops on  data validation, error reporting, and methods for improving the quality of  data provided to NCANDS. In our survey, 36 state officials reported that  these annual NCANDS meetings were moderately helpful to very helpful.  The NCANDS technical team has also developed Web-based resources  with information and guidance to states on NCANDS data reporting,  available through the NCANDS Web portal. The NCANDS portal is the  key interface between states and the NCANDS technical team, and  includes guidelines about reconciling and submitting data. The portal also  contains an NCANDS Listserv where state officials can share information  and obtain peer-to-peer assistance, according to HHS officials.
States can also obtain individualized NCANDS technical assistance upon  request. Each state has an assigned NCANDS technical team liaison who  can provide targeted information and support to help states report data to  NCANDS. During the 2010 data-reporting process, all states were in  communication with their NCANDS technical team liaisons, according to  an NCANDS report. In our survey, state officials reported high levels of  satisfaction with the technical teams’ assistance, with 29 of the 50 states  responding to this question identifying the help they received as  moderately helpful to very helpful. State officials can also request on-site  technical assistance regarding data collection and reporting from the  National Resource Center for Child Welfare Data and Technology.
HHS also provides assistance to states’ child death review teams through  NCCDR. NCCDR serves as a resource for state or local child death  review teams. NCCDR helps states share information by publishing their  child death review teams’ contact information, data, and annual reports  on its Web site. In addition, NCCDR has developed a Web site designed  to help child death review teams expand their prevention efforts. It offers  best practices for preventing the leading causes of injury and death  among children, including child abuse. The site contains links to  resources, partners, and a number of injury prevention strategies  including public education; legislation and policy changes; and  modifications to products, physical environments, and social  environments that have been rated according to their evidence-based  effectiveness.
Although NCCDR regularly collaborates with federal organizations to  analyze child fatality data and develop strategies to prevent child deaths,  there has been little routine information sharing between NCCDR and  NCANDS on child maltreatment fatalities. Federal organizations such as  CDC, the Department of Defense, and the National Highway Traffic  Safety Administration have collaborated with NCCDR to analyze  information and expertise about child death reviews and develop  prevention strategies, according to NCCDR officials. For example, in  2003, CDC developed an initiative to improve data collected on sudden  unexplained infant deaths (SUID) and develop prevention strategies by  monitoring trends and identifying risk factors. CDC partnered with  NCCDR to develop the SUID Case Registry Pilot Study, which utilized an  updated version of NCCDR’s Web-based data collection system. Officials  from NCCDR and the Children’s Bureau, under HHS’s Administration for  Children and Families (ACF), meet periodically in workgroups, and  officials from the Children’s Bureau told us that they refer states with  questions about child death reviews to NCCDR for assistance. In 2010,  officials from NCCDR and the ACF Commissioner met to explore ways to  enhance federal responses to child abuse deaths, and the ACF  Commissioner told us that they are moving forward to fund a child fatality  review conference and begin an initiative to examine evidence-based  practices for preventing child abuse deaths. However, NCCDR and  NCANDS officials acknowledged that, to date, they have not routinely  coordinated on child maltreatment fatality data or prevention strategies.
section_title: States Would Like Additional Assistance in Collecting and Using Data on Child Fatalities and Near Fatalities from Maltreatment
paragraphs: Although HHS provides a variety of assistance to states on how to report  data to NCANDS, state officials indicated a need for additional assistance  collecting child fatality as well as near-fatality data to use for prevention  efforts.
In our survey, almost half of states (23) reported needing additional  assistance in collecting information and reporting data on child  maltreatment fatalities or near fatalities. For example, several states  mentioned that assistance with multidisciplinary coordination could help  them overcome difficulties such as obtaining death certificates from  medical examiners’ or coroner’s offices. HHS recognizes that collecting  maltreatment fatality data from multiple sources results in more complete  data, so the agency encourages states to coordinate with other  organizations, such as medical examiners and departments of health.  HHS officials stated that this is often a topic of discussion at the NCANDS  annual meeting. However, HHS officials also noted that the agency  cannot require states to use additional data sources, and states are not  required to disclose whether they consulted with additional sources to  collect data.
Although the federal government does not currently collect data on  children who nearly die from maltreatment, states reported wanting  assistance to collect and use this information. CAPTA defines a near  fatality as “an act that, as certified by a physician, places the child in  serious or critical condition.” HHS officials believe that such cases are  most likely reported generally under maltreatment, but are not specifically  identified as near fatalities because NCANDS does not have a data field  identifying the case as a near fatality. HHS officials said it would be  difficult to operationalize a national definition. To add a near-fatality data  element to NCANDS, HHS would need to coordinate with the State  Advisory Group and obtain approval from the Office of Management and  Budget (OMB). However, the entire NCANDS data form will need to be  reapproved in 2012, and HHS officials stated that at that time all  NCANDS data elements will be reexamined. In commenting on a draft of  this report, HHS stated that it had initiated consultations with the states on  how to best address data collection on near fatalities of children and that  HHS is considering adding a field to identify these specific cases.
States are increasingly interested in collecting and using information on  near fatalities, according to HHS officials, and some states have already  begun this effort. Collecting data on maltreatment near fatalities was a  topic of discussion at the 2010 NCANDS Annual State Technical  Assistance Meeting. Additionally, the NCANDS Listserv was recently  used by two state officials to survey other states about how they review  and define near-fatality cases of maltreatment. Currently, states’ definition  of a near fatality varies (see fig. 8), and to establish a near-fatality data  element in NCANDS, states may need to reexamine their existing  definitions. According to our survey results, 32 states have a state law,  statute, or policy that defines a near fatality, and 19 states already collect  data on the number of child near fatalities from maltreatment. In addition,  some states obtain information on the circumstances of child  maltreatment near fatalities, such as the child’s age and ethnicity, the  child’s relationship to the perpetrator, and whether the child was receiving  foster care or family preservation services.
States predominantly use child maltreatment fatality and near-fatality data  to develop strategies for preventing these occurrences, and state officials  told us they would like more assistance to use this information for  prevention. States reported in our survey that child maltreatment fatality  data are often used to inform prevention strategies, make state-level child  welfare policy changes, and allocate funding or other resources for  prevention activities. In addition, states reported using the information  they collect on child maltreatment near fatalities to inform or implement  strategies for preventing maltreatment fatalities and to allocate funding or  other resources for prevention activities. For example, as a result of  trends associated with fatal maltreatment and crying infants, many states  have developed public awareness campaigns, resources for parents, and  other interventions to prevent shaken baby syndrome (see sidebar).
HHS officials confirmed that states were increasingly interested in  receiving technical assistance on how to use child fatality data to  meaningfully inform prevention efforts. State officials also reported  wanting more information from other states on best practices in general  and on using data for prevention efforts in particular.
section_title: Conclusions
paragraphs: In conclusion, children’s deaths from maltreatment are especially  distressing because they involve a failure on the part of adults  responsible for protecting them. Child welfare policymakers and  practitioners rely on child maltreatment fatality data—voluntarily reported  by states—to understand the extent and circumstances of these tragic  deaths and to develop strategies to prevent them. At the state level,  obtaining comprehensive data on child maltreatment fatalities is very  challenging and requires information sharing among state and local  agencies—each with its own policies, types and levels of expertise, and  concerns. Yet such cooperative efforts are a work in progress, and  assistance from HHS to help states collect and report more  comprehensive child fatality data is important. At the federal level, to the  extent that HHS collects but does not publish information on child  maltreatment fatalities, or does not routinely share information on child  fatality data analyses, opportunities may be lost to identify effective  means of preventing child maltreatment deaths in the future. Finally,  without national data on children’s near fatalities from maltreatment, we  are unable to have a clear picture of the extent of near fatalities and the  risk factors associated with such maltreatment, making it difficult to  develop prevention strategies. As a society, we should be doing  everything in our collective power to end child deaths and near deaths  from maltreatment, and the collection and reporting of comprehensive  data on these tragic situations is an important step toward that goal.
section_title: Recommendations for Executive Action
paragraphs: To improve the comprehensiveness, quality, and use of national data on  child fatalities from maltreatment, the Secretary of HHS should take the  following four actions  1.  Identify ways to help states strengthen the completeness and  reliability of data they report to NCANDS. These efforts could include  identifying and sharing states’ best practices, particularly those that  foster cross-agency coordination and help address differences in state  definitions and interpretation of maltreatment and/or privacy and  confidentiality concerns. 2.  Expand, as appropriate, the type and amount of information HHS  makes public on the circumstances surrounding child fatalities from  maltreatment. 3.  Use stronger mechanisms to routinely share analyses and expertise  with its partners on the circumstances of child maltreatment deaths,  including insights that could be used for developing prevention  strategies. 4.  Estimate the costs and benefits of collecting national data on near  fatalities and take appropriate follow-up actions.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS for review and comment, and  HHS’s comments are reproduced in appendix IV. We also provided a  draft of this report to the Department of Justice (DOJ) and pertinent  excerpts to NCCDR. DOJ and NCCDR provided technical comments,  which we incorporated as appropriate.
In its comments, HHS agreed with our recommendations to improve the  comprehensiveness, quality, and use of national data on child fatalities  from maltreatment. HHS also provided technical comments and additional  information about activities under way or planned, which we incorporated  as appropriate. For example, HHS stated that it has initiated  conversations with the states to improve the identification of cases that  involve near fatalities and that it plans to include two additional analyses  on child fatalities in the Child Maltreatment report in 2013. While we  recognize that HHS has some activities under way pertinent to issues  raised in our report, more can be done to address these issues, such as  by using stronger mechanisms to routinely share information and  expertise on child fatalities from maltreatment. For example, although  HHS cites the Federal Inter-agency Work Group on Child Abuse and  Neglect as a mechanism already in place for sharing information, HHS  officials previously told us that this workgroup has not often discussed  child fatalities from maltreatment. Since having mechanisms is a starting  point for information sharing, we clarified our recommendation to  emphasize the importance of putting such means to routine use. HHS  also noted that NCANDS data collection has always been voluntary, as  our report acknowledges.
In its comments, HHS also raised concerns about the nationwide Web- based survey of child welfare administrators—one of several  methodologies used for this report—noting that it had several limitations.  According to HHS, survey completion was typically delegated to  subordinates, which can create inconsistencies in the types of  respondents and data collected; the staff person responding may not  have considered information from other divisions; and finally, states  provided self-reported information and thus GAO cannot validate it. For  the most part, these observations would apply to any survey in which the  respondent is answering the survey questions as a representative of an  organization rather than as an individual. We took several precautions to  minimize these limitations. For example, before activating the survey, we  confirmed that the state officials listed were correct for completing the  survey; obtained comments on the survey draft from three experts, in  addition to conducting pretests with state officials; and provided  respondents ample time for consultation with other state officials as  needed. We received responses from all states. While survey data are  not typically verified independently, in our judgment the precautions taken  to address survey limitations are sufficient for our purposes. (App. I  provides information on our survey methodology.).
As agreed with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days from its  issue date. At that time, we will send copies of this report to relevant  congressional committees, the Secretary of Health and Human Services,  the Attorney General of the United States, and other interested parties.  The report will be available at no charge on GAO’s Web site at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7215 or brownke@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Key contributors to this report are listed in  appendix V.
section_title: Appendix I: Scope and Methodology
subsections: section_title: Survey of States
paragraphs: To obtain state perspectives on our objectives, we conducted a Web- based survey of child welfare administrators in the 50 states, the District  of Columbia, and Puerto Rico. The survey was conducted using a self- administered electronic questionnaire posted on the Web. HHS provided  us with names and contact information for state child welfare  administrators. We contacted child welfare administrators via e-mail  announcing the survey and sent follow-up e-mails to encourage  responses. The survey data were collected between October and  December 2010, with child welfare officials from every state, the District  of Columbia, and Puerto Rico responding. The survey included questions  about state laws related to child maltreatment, child welfare department  coordination with other agencies or entities, state challenges related to  identifying and collecting information on child maltreatment fatalities and  reporting these data to NCANDS, child death review teams, state  challenges related to collecting information on child maltreatment near  fatalities, and federal assistance from HHS to states on data collection  and reporting.
We worked with agency officials and experts to develop the survey.  Because this was not a sample survey, there are no sampling errors.  However, the practical difficulties of conducting any survey may introduce  errors, commonly referred to as nonsampling errors. For example,  differences in how a particular question is interpreted or in the sources of  information that are available to respondents can introduce unwanted  variability into the survey results. We took steps in the development of the  survey, data collection, and data analysis to minimize these nonsampling  errors. For example, prior to administering the survey, we pretested the  content and format of the survey with four states (Arizona, Kansas, New  York, and Wisconsin) to determine whether (1) the survey questions were  clear, (2) the terms used were precise and accurate, (3) respondents  were able to provide the information we were seeking, and (4) the  questions were unbiased. We chose these pretest states based on a  number of factors, including recommendations from HHS officials or  experts, whether the state collected information on near fatalities from  maltreatment, whether the state had a state-level child death review  team, and overall child population, among others. We made changes to  the content and format of the final survey based on pretest results.  Because this was a Web-based survey in which respondents entered  their responses directly into our database, there was a reduced possibility  of data entry error. We also performed computer analyses to identify  inconsistencies in responses and other indications of error. In addition, an  independent analyst verified that the computer programs used to analyze  these data were written correctly.
section_title: Literature Review
paragraphs: To identify research that estimated the number of child deaths from  maltreatment in the United States and the extent to which these deaths  are accurately captured, or undercounted, we searched ProQuest, Dialog  Social Science Databases, NTIS, SocAbs, Nexis Statistical Master File,  and MEDLINE. We also asked researchers and subject matter experts to  identify studies. We selected 19 studies that had been published after  2000; had a focus on the child fatality data collection process in the  United States; had a state or national, rather than county-level, focus; and  focused on child maltreatment fatalities, not abuse and neglect. For each  selected study, we determined whether the study’s findings were  generally reliable. Two GAO social science analysts assessed each  study’s research methodology, including its research design, sampling  frame, selection of measure, data quality, limitation, and analytic  techniques for its methodological soundness and the validity of the results  and conclusions that were drawn.
section_title: NCANDS Data Analysis
paragraphs: To identify the extent to which HHS collects and provides comprehensive  information on child fatalities from maltreatment, we obtained and  analyzed NCANDS data from the National Data Archive on Child Abuse  and Neglect (NDACAN) at Cornell University. NDACAN prepares data  and documentation for secondary analysis, and disseminates the  datasets to researchers. We obtained the NCANDS datasets for federal  fiscal year 2009 from NDACAN for our analysis. The NCANDS datasets  consist of files in three formats: the child file, the agency file, and the  summary data component (SDC). The child file dataset is the case-level  component of NCANDS that contains child-specific data of all state CPS  investigations or assessments of alleged child maltreatment that received  a disposition during fiscal year 2009. Fifty states submitted the child file in  fiscal year 2009, including the District of Columbia and Puerto Rico. The  agency file is the NCANDS state-level component, which is submitted by  states that submit the child file. The agency file contains aggregated  state-level data that have been requested by CAPTA that are not able to  be collected at the case level. This includes data on preventative  services, CPS workload, and child fatalities not reported at the case level  in the child file. For fiscal year 2009, 50 states submitted the agency file.  States that are unable to submit case-level data submit the SDC file. The  SDC consists of aggregated state-level statistics of key items in the child  file and agency file. (Two states submitted the SDC for fiscal year 2009.)
Both states and NDACAN take steps to protect confidentiality. States  encrypt all identification variables submitted to NCANDS to prevent  tracing a child file record back to the record in the state’s child welfare  information system. For records involving a fatality, NDACAN recodes  certain variables to mask information, including the state, county of report,  information about the child, and perpetrator identification.
We analyzed a subset of fiscal year 2009 NCANDS child file cases in  which a child maltreatment fatality had occurred (i.e., those in which the  maltreatment death data element was equal to 1 or “yes”). Data elements  that were analyzed included age, sex, maltreatment type, and perpetrator  characteristics. In addition to the analysis of fiscal year 2009 child file  cases in which a maltreatment death had occurred, we analyzed four  variables each from the fiscal year 2009 agency file and SDC. These four  variables were the number of child maltreatment fatalities, foster care  deaths, children whose families had received family preservation services  in the 5 years prior to fiscal year 2009, and children who had been in  foster care and were reunited with their families in the 5 years prior to  fiscal year 2009. These agency file and SDC variables were summed with  the equivalent child file variables to yield complete totals.
We assessed the reliability of the NCANDS data provided by NDACAN by  conducting electronic testing; reviewing documentation on the NCANDS  data; and interviewing officials from NDACAN, the NCANDS contractor  (Walter R. McDonald & Associates), and the Children’s Bureau of HHS to  clarify data elements and procedures for data collection and reporting. To  verify the number of unduplicated fatalities due to child maltreatment, we  compared our assessment with the analysis done by NDACAN  researchers. The NCANDS data were found to be sufficiently reliable for  the purposes of this engagement.
section_title: NCCDR Data Analysis
paragraphs: To examine the extent to which HHS collects and provides  comprehensive information on child fatalities from maltreatment, we  requested and obtained state child death review team data from  NCCDR’s Child Death Review (CDR) Case Reporting System. The CDR  Case Reporting System is a Web-based application that allows local and  state users to enter case data and access and download their data via the  Internet on a continual and voluntary basis. In 2009, state and local child  death review teams in 26 states submitted data to the CDR Case  Reporting System. These data contain detailed information on the child  welfare history of victims, including the number of CPS referrals and  substantiations per child, whether there was an open CPS case at the  time of death, and whether any siblings were ever put in foster care. The  database contains extensive information on the incident that led to the  death, including the place of the incident, such as the child’s home, and  the type of injury that caused the death, such as a weapon or drowning.  The system also collects information on acts of commission or omission  for every death entered into the system, regardless of cause or manner.  To confirm the reliability of these data, social science methodologists at  GAO reviewed documentation about the collection and reporting of  NCCDR data. We also interviewed several NCCDR officials who were  responsible for these data and HHS officials responsible for the  cooperative agreement with NCCDR. In addition, we compared NCCDR  data on child fatalities with NCANDS data on child fatalities in the NCCDR  states. Although these data were not sufficiently reliable to support a  finding, they were reliable for providing background context and examples  of the possible data elements not available from NCANDS.
section_title: Site Visits
paragraphs: To gather additional information about challenges states face in collecting  and reporting information on child maltreatment fatalities to NCANDS,  including challenges at the local level, and federal assistance to states,  we conducted site visits to California, Michigan, and Pennsylvania and  met with state officials and officials from selected localities within those  states between July and December 2010. Specifically, we met with local  officials from Calaveras, Los Angeles, and Sacramento counties in  California; Bay, Genessee, Ingham, Lincoln, Oakland, and Wayne  counties in Michigan; and Berks, Lehigh, and Philadelphia counties,  among others, in Pennsylvania.
We selected these states based on recommendations from HHS officials  and experts, child population, collection of information on child  maltreatment near fatalities, type of child welfare program administration  (state-administered and county-administered with state supervision), and  geographic diversity. We worked with state officials to select counties that  were located in both urban and rural areas to ensure that we captured  any related differences in data collection and reporting processes and  federal assistance. During these visits, we interviewed state child welfare  officials and officials from the department of health or other body  coordinating the child death review process, and collected relevant state  laws, policies, procedures, and reports. At the local level, we interviewed  CPS officials, law enforcement personnel, and medical examiners or  coroners in charge of investigating child deaths in each state. Through  these interviews, we collected information on state and local processes  for collecting and reporting data on child maltreatment fatalities and the  associated challenges officials face. We conducted some of these  interviews via telephone to limit travel costs.
Information we gathered on our site visits represents only the conditions  present in the states and local areas at the time of our site visits. We  cannot comment on any changes that may have occurred after our  fieldwork was completed. Furthermore, our fieldwork focused on in-depth  analysis of only a few selected states. On the basis of our site visit  information, we cannot generalize our findings beyond the states we  visited.
section_title: Expert Interviews
paragraphs: For all three objectives, we interviewed HHS officials and other experts on  child maltreatment fatalities and near fatalities. We identified child  maltreatment researchers through our literature review and through  recommendations from stakeholders knowledgeable about child  maltreatment fatalities and near fatalities. For this study, we interviewed  HHS and other officials knowledgeable about NCANDS, NCCDR, and  NIS-4 data. We also interviewed researchers and experts affiliated with  the following centers and associations: the American Academy of  Pediatrics (AAP), the American Bar Association’s (ABA) Center on  Children and the Law, the Child Welfare League of America, the National  Coalition to End Child Abuse Deaths, the Interagency Council for Child  Abuse and Neglect/National Center on Child Fatality Review, and  NCCDR. (The National Coalition to End Child Abuse Deaths includes  officials from the Every Child Matters Education Fund, the National  Center for Child Death Review, the National District Attorneys  Association/National Center for Prosecution of Child Abuse, the National  Association of Social Workers, and the National Children’s Alliance.)
We conducted this performance audit from April 2010 through July 2011  in accordance with generally accepted government auditing standards.  These standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Selected Information on Child Fatalities from Maltreatment
paragraphs: Appendix II: Selected Information on Child  Fatalities from Maltreatment Selected NCANDS results on child fatalities from maltreatment reported by HHS for  fiscal year 2009   Forty-six percent of fatalities were children younger than 1 year, and 81 percent were 3  years old or younger.  Boys had a slightly higher child fatality rate than girls, at 2.36 per 100,000 boys in the  population, and girls had a rate of 2.12 per 100,000 girls in the population.    Of all child fatalities, 39 percent were White children, 29 percent were African- American, and 17 percent were Hispanic. Children of American Indian or Alaska Native,  Asian, Pacific Islander, or multiple race categories collectively accounted for 3.6  percent, and 11.2 percent were children of unknown race.  Thirty-seven percent of child fatalities were caused by multiple forms of maltreatment.    Neglect accounted for about 36 percent of fatalities and physical abuse for 23 percent.
Seventy-six percent of child fatalities were caused by one or more parents.  Twenty-seven percent of child fatalities were perpetrated by the mother acting alone,  and 23 percent were caused by both parents.  Foster parents and legal guardians accounted for less than 1 percent of perpetrators  (foster parents were reported as the perpetrator in 5 child fatalities from maltreatment).   Twelve percent of children who died from maltreatment were from families who had  received family preservation services in the previous 5 years.  Two percent of children who died from maltreatment had been in foster care and were  reunited with their families in the previous 5 years.    HHS’s Child Maltreatment 2009 report did not provide information on these data  elements for children who died from maltreatment.
Child risk factors include having an intellectual disability, physical disability, learning disability, and  visual or hearing impairment.
Risk factors associated with the caregiver include alcohol or drug abuse, domestic violence,  emotional disturbance, and financial difficulties.
Preventive services are provided to parents whose children are at risk of maltreatment and include  family support, child day care, education and training, employment, and housing.
subsections: section_title: Information from NCCDR on Child Maltreatment Fatalities
paragraphs: Following are selected results from our analysis of child maltreatment  data in the CDR Reporting System:   Manner of death: Homicide was the manner of death on the death  certificate for 57 percent of child maltreatment fatality victims reported to  NCCDR in calendar year 2009.
Cause of death: Injury was the primary cause of death for 79 percent of  children who died from maltreatment, and just over half of those children  were killed with a weapon.
Child welfare history: Of the 417 reported child maltreatment fatality  victims:    Thirty-one percent had a documented history of maltreatment.    Thirteen percent had an open CPS case prior to the incident causing  the child’s death.   Fourteen percent of children who died had at least one CPS referral  prior to their deaths.   Eight percent were placed in foster care prior to their deaths.
section_title: Appendix III: Information from States Not Reported in NCANDS
subsections: section_title: State Data on Child Fatalities Not Reported to NCANDS
paragraphs: Thirty-two states also collected information on child maltreatment fatalities  that were not reported to NCANDS in fiscal year 2009, according to our  survey of state child welfare officials. For example, 27 states reported that  they collected data on the child’s family characteristics that they did not  report to NCANDS in fiscal year 2009. (See table 4.) Data that states  collect but do not report to NCANDS could represent additional, more  detailed information on children who die from maltreatment (such as  information on siblings’ prior contact with the child welfare system) or data  that states collect but cannot report for technical reasons. For example, in  explaining this condition, two states noted that much of the data was  captured in narrative or case logs—not in reportable data fields—while  another state noted that it collects additional information on child  maltreatment fatalities reported by local county child welfare agencies.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Contact
section_title: Staff Acknowledgments
paragraphs: Brett Fallavollita, Assistant Director, and Deborah A. Signer, Analyst-in- Charge, managed this assignment and made significant contributions to  all aspects of this report. Katherine Berman, Amanda D. Cherrin, Alison  Gerry Grantham, and Marcella Wagner, Analysts, also made important  contributions to this report. Katherine van Gelder and James E. Bennett  provided writing and graphics assistance. Hiwotte Amare, Lorraine R.  Ettaro, Stuart M. Kaufman, and Monique B. Williams provided data  analysis and methodological assistance; and Julian P. Klazkin provided  legal assistance. Almeta J. Spencer provided administrative support.