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Investigating and Addressing Child Maltreatment as a Cause of Infant Mortality

Investigating and Addressing Child Maltreatment as a Cause of Infant Mortality. Steve Wirtz, PhD Safe and Active Communities Branch California Department of Public Health Jaspreet Samra, MPH California Epidemiological Investigation Service Fellow California Department of Public Health

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Investigating and Addressing Child Maltreatment as a Cause of Infant Mortality

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  1. Investigating and Addressing Child Maltreatment as a Cause of Infant Mortality • Steve Wirtz, PhD • Safe and Active Communities Branch • California Department of Public Health • Jaspreet Samra, MPH • California Epidemiological Investigation Service Fellow • California Department of Public Health • CityMatCH Perinatal Periods of Risk (PPOR) • Learning Network Webinar • October 25, 2011

  2. Overview • Child maltreatment (CM) numbers • Focus on fatal CM • Inconsistent definitions, reporting & numbers • Creating consistent definitions • Role of Child Death Review Teams (CDRTs) • Fatal Child Abuse and Neglect Surveillance (FCANS) Program • FCANS CM Fatality Reconciliation Audit • Results • Infant mortality • Conclusions • Prevention and intervention strategies

  3. Child Maltreatment Numbers • National • National Child Abuse and Neglect Data System • ~ 900,000 children victims of CM (12.1 per 1,000)) • ~1,770 child deaths due to CM (2.34 per 100,000) • 46% < 1 year & 81% < 4 years of age • National Incident Study – 4 (NIS-4) • 1.25 million (Harm); 2.9 million (Endangerment) • California • FCANS Program • Department of Social Services • California Child Welfare System - Case Management System (CWS-CMS) • SB 39 reporting system

  4. Child Maltreatment Surveillance Pyramid for California • CAN Fatalities (~190) • Serious and Severe Hospitalization (~500) • CAN Incidences (~93,000) • Reported CAN (~472,000) • Unreported Cases Prepared by CDPH SAC Branch from FCANS Program Reconciliation Audit, 2007-8, OSHPD Hospital In-patient Discharge Data, 2006, and Child Welfare Services Reports for California, 2009; retrieved 5/11/11 from UCB Ctr for Social Services Research website http://csrr.berkeley.edu/ucb_childwelfare

  5. Definitions Child Maltreatment: Federal Laws & Standards • Federal Public Law 108-36, 2003 - Child Abuse Prevention and Treatment Act • Federal standards & data sources • National Child Abuse and Neglect Data System (http://www.acf.hhs.gov/programs/cb/pubs/cm06) • National Incidence Study-4 (NIS-4) (https://www.nis4.org/DefAbuse.asp) • Child Maltreatment Surveillance: Uniform Definitions for Public Health http://www.cdc.gov/ncipc/dvp/CM_Surveillance.pdf) • Each state has its own legal definitions of child abuse and neglect based on minimum standards set by Federal law

  6. Definitions of Child Maltreatment:Legal Framework • Legal and statutory concepts of CM reflect conflicting social and political values • State power to use coercive interventions and expend societal resources • Protect the “best interests” of the child • Parental rights to family privacy and autonomy • U.S. preference for familial or marketplace provision (“family bubble”) • Principle or standard of “minimum intrusion” • Demonstrable injury or harm • Endangerment – potential for immediate and predictable injury or harm

  7. Tracking Child Maltreatment Deaths: Challenges • Definitions of CM (i.e., child abuse & neglect) represent social judgments • Negotiated settlements between a society’s diverse cultures and current scientific knowledge • Community minimal standard of care articulated through social-moral-legal processes • Knowledge as expressed by “professional experts” • Different definitions of CM based on legal mandates and agency policies and guidelines • Results in different identification & reporting rates of CM deaths and non-comparability of findings across agencies, geographic locations, and over time

  8. Classification of Caregiver CM Deaths Components of CAN Operational Definition Agent Action Causal Recipient Types of Impacts Linkage Consequence Parent(s) Commission Direct causal Child 0-17 Actual harm Death Caregiver(s) Omission chain Contribution Framework for Creating a Consistent CAN Definition for CDRTs

  9. Operational Definition of Caregiver CM Death • The death of a child under the age of 18 directly or indirectly caused by a caregiver’s act(s) of commission or omission that are judged by a CDRT as CM, weighing risk of harm and level of social acceptability • That means FOUR conditions need to be met • Causal link • Caregiver agent • Child’s age/live birth • CM behavior

  10. Different Standards for Child Maltreatment • Standard of care model • Adult sexual contact with a child is considered sexual abuse regardless of intent or outcome (child-focused) • Violates a widely accepted community standard - minimum standard of care • Standard of consequences model • Corporal punishment is “acceptable” in the U.S • Physical abuse is judged based on being “too harmful” – an assessment of risk

  11. Different Standards for Child Maltreatment • Standard for neglect • Balance of assessments of risk (degree of harm) and of social acceptability (minimum standard of care) • Use of infant safety seats in cars in the U.S. • Prevents 2/3 of injuries & 90% of deaths • Laws, awareness, & social norms • “Neglect” regardless of motivation or consequence (e.g., most unprotected children are not injured)

  12. Different Standards for Child Maltreatment • Basic needs model – Dr. Howard Dubowitz • Neglect occurs when a child’s basic need is not adequately met, and • Unmet need results in actual or potential harm • Basic needsinclude: adequate food, clothing, health care, supervision, protection from hazards, education, nurturance, & shelter • http://www.chadwickcenter.org/CD/SDConference/Presentations/H2Docs.pdf/ hdubowitz@peds.umaryland.edu

  13. Advantages of a Child-focused,Public Health Definition of Neglect • Fosters a comprehensive view of contributors to neglect, not just parents • Encourages consideration of a broad spectrum of interventions, including population-based primary prevention • Emphasizes a constructive approach, not just finding “blame” • Fits with a broad mandate to ensure the health, safety & well-being of children (e.g., United Nations Convention on the Rights of the Child)

  14. California’s Fatal Child Abuse and Neglect Surveillance (FCANS) Program • Mandate to establish & maintain fatal child maltreatment tracking system (P.C. 11174.34) • Established standards & tracking system for CDRTs • Provides online case reporting system to CDRTs • Currently using National Center for Child Death Review’s Case Reporting System v2S (www.childdeathreview.org) • Provides training and technical assistance • Conducts Reconciliation Audit using information from all available sources • Promotes public health approach to prevention

  15. Fatal Child Maltreatment in California: Inconsistencies and Undercounts • Vital Statistics – Death Certificates • Department of Justice • Supplemental Homicide Records (SHR) • Child Abuse Central Index (CACI) • Department of Social Services (DSS) • CWS-CMS • SB 39 (new reporting system) • FCANS Program • Need consistent, valid & comprehensive surveillance system for CM fatalities

  16. Tracking Child Maltreatment Deaths: Opportunities • Critical role for Child Death Review Teams (CDRTs) • Multi-agency, multi-disciplinary local review teams • Investigate, protect, prosecute & prevent CM deaths • Identify and collect systematic data on causes and circumstance of child deaths • Disseminate and use data for surveillance, planning, interventions, and prevention of CM and other childhood injuries and preventable deaths. • Reconcile data from multiple sources (FCANS Audit) to produce the most comprehensive & valid statewide estimate

  17. FCANS Fatality Child Maltreatment Reconciliation Audit 2007-8 • Reconcile fatal CM data from 5 state data sources using CDRTs as “relative gold (alloy) standard” • Sources: - Vital Statistics Death Statistical Master - Supplemental Homicide Reports - Child Abuse Central Index - DSS CWS/CMS - FCANS Program

  18. Audit Methods • Prepare 2007-8 data from 5 sources for audit • Identify CM cases based on each source’s case definition (including quality control for complete case capture) • Create a single list of “unduplicated” cases • Identify contacts in each county for CDRTs • Distribute cases to respective County CDRT’s • Ask teams to respond to Audit questions • Was team aware of case & did team review it? • Did team consider case a homicide? • Did team consider case a CM-related fatality? • If not, why not? • Is team aware of any additional CM cases?

  19. Methods (continued) • Follow up with CDRTs to collect responses • Conduct quality control with CDRTs to clarify and complete audit • Clarify team role in review & classification (e.g., LA County screening & review process) • Discuss criteria with CDRTs and resolve questionable cases • Create final unduplicated list with CM classifications (e.g., Confirmed, No, No answer) • Apply positive predictive values of confirmed cases to “not reviewed” or “no answer” cases • Calculate estimated total number of fatal CM • Conduct univariate analyses of case characteristics

  20. Fatal Child Maltreatment Audit California, 2007-2008 • Responses received from 56/58 counties • Total of 510 unduplicated “potential” CM cases identified, including newly reported cases • FCANS Reports – 273 • CWS/CMS – 212 • SHR – 157 • VS – 149 • CACI – 112 • New cases reported by CDRTs – 20

  21. Results of Fatal Child Maltreatment Audit California, 2007-2008

  22. Fatal Child Maltreatment by Source California, 2007-8 Reconciliation Audit Total N=338 CDPH FCANS N=191 CDSS CWS/CMS N=153 CDPH VS N=134 N=20 DOJ SHR N=136 DOJ CACI N=76

  23. Confirmed Fatal CM Cases by SourceCalifornia, 2007-8

  24. Positive Predictive Values for CM by Number of Sources

  25. Calculated Estimate of Fatal CM CasesCalifornia, 2007-2008

  26. Characteristics of CM FatalitiesCalifornia, 2007-2008 1Rates are estimated for total N=379 based on given percentages

  27. Infant Mortality, California, 2009 • California’s Infant Mortality Rate Reaches Historic Low in 2009 (CDPH News Release 10-20-2011) • 4.9 per 1,000 births • 2,593 infant deaths • Child maltreatment • Small portion of infant deaths (~ 3%) • But larger percent of injury deaths (~ 1/3) • Suffocation - Unintentional • Homicide/assaults • Motor Vehicle Crashes - Unintentional

  28. Infant Maltreatment–related Deaths • Unsafe Sleep – 13% • Child asleep on chest of relative that is under influence • Abusive Head Trauma/SBS – 11.5% • Child suffered several head injuries by biological father • Perinatal Substance Exposure – 7% • Prematurity; PSE-meth listed as contributing • Abandoned Baby/Concealed Pregnancy – 3% • Mom hid pregnancy & intentionally strangled baby • Motor Vehicle Crashes – 3% • Unrestrained decedent in mother’s lap

  29. Characteristics of Infant Maltreatment Fatalities, California, 2007-2008 1Rates are estimated for total N=166 based on given percentages

  30. Characteristics of Infant Maltreatment Fatalities, California, 2007-2008 1Rates are estimated for total N=166 based on given percentages

  31. Characteristics of Infant Maltreatment Fatalities, California, 2007-2008

  32. Characteristics of Child Maltreatment Fatalities, California, 2007-2008

  33. 2007-8 Fatal CM Reconciliation Audit Conclusions • ~190 CM fatalities per year in California • 1.9/100,000 children 0-17; Lower than national estimate – 2.3 • 15.2/100,000 - infant maltreatment-related • Maltreatment type: ~ 50/50 Neglect & Abuse • Risk characteristics: Male & Black infants • Infant maltreatment-related types • Unsafe sleep • Abusive Head Trauma/SBS • Perinatal Substance Exposure • CDRTs play a critical role

  34. 2007-8 Fatal CM Reconciliation Audit Conclusions • CM fatalities are undercounted in current data sources • Single sources only capture ~24%-59% of cases • More sources = higher accuracy of the predictive value • Audit produces a more comprehensive and accurate estimate • Need for a more comprehensive CM fatality surveillance system • Standardized case definitions • Improved reporting systems for agencies • Effective prevention recommendations

  35. Developing Effective Recommendations • After determination that a death (or group of deaths) was preventable, use the Guidelines for Writing Effective Recommendations to identify and prioritizepotential prevention opportunities, taking into account • Magnitude of the problem • Existence of effective interventions • Capacity and feasibility of taking action (available resources, political climate, etc.) • Practical and feasible recommendations are made and follow up progress is tracked

  36. Prevention Strategies • Role of CDRTs • Identification & Classification • Effective recommendations & reports • Promote “best practice” solutions • Harvard Center on the Developing Child www.developingchild.harvard.edu • Build on existing local capacities (individual, systems, community coalitions & policies) • Prevention strategies • Comprehensive & integrated support systems • Strengthening families through home visitation & family resources centers • Make the public case for prevention

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