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. 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. 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. 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.