State Child Abuse Death Review Committee

1. State Child Abuse Death Review Committee State Child Abuse Death Review Committee Florida Department of Health Michelle Akins, BSW Child Abuse Death Review Quality Improvement Coordinator

2. History of Child Abuse Death Review Teams in U.S. • 1980’s: grass roots organization of teams throughout the U.S. • Early 1990’s: Following landmark Missouri study of fatal abuse deaths, national and state efforts lead to models of CDR to improve child abuse reporting and services • Mid 1990’s: U.S. Department of Justice, OCAN and American Academy of Pediatrics funding of efforts to support states & national CDR training. MCHB begins effort to encourage review of all preventable deaths.

3. History of Child Abuse Death Review Teams in U.S. • Late 1990’s: Most states have some form of CDR, but with wide variations in scope & process. • States form regional support coalitions, including South East Coalition and Midwest region. These two groups organize annual/bi-annual conferences. • MCHB promotes efforts to coordinate CDR with other review processes, including FIRM, Maternal mortality & SIDS. • Domestic Violence Review starts to organize. • MCHB funds the National MCH Resource Center with a goal to support expansion of CDR to all preventable deaths.

4. Objectives of Child Abuse Death Review Teams • Accurate identification and uniform reporting on every child death. • Improved investigative systems. • Improved services for families and community. • Improved communication and linkages among agencies. • Understanding of risks & protective factors in child deaths. • Changes in legislation, policy and practice, to prevent deaths and improve health and safety.

5. GAO: US tracking of child-abuse deaths is flawed America uses flawed methods to tally and analyze the deaths of children who have been maltreated, and the latest annual estimate of 1,770 such fatalities is likely too low, the Government Accountability Office says in a new report to Congress. Better data, says the GAO, would aid in developing strategies that could save many children's lives in the future. The GAO report, the subject of a House Human Resources subcommittee hearing Tuesday, says state agencies and the Department of Health and Human Services should broaden the scope of data collection, improve coordination, and seek uniform definitions of abuse and maltreatment. "We need to do a much better job working together at the local, state and national level," said Theresa Covington, director of the National Center for the Review and Prevention of Child Deaths, in testimony prepared for the hearing. In his opening remarks, the chairman of the House subcommittee, Rep. Geoff Davis, R-Ky., evoked the death of 2-year-old Caylee Anthony, whose mother, Casey, was acquitted of murder last week in a trial that drew worldwide news coverage. "Sometimes the death of a child from maltreatment does not make headlines at all, possibly because it is not recorded as a death from maltreatment," Davis said. "It is hard to know which child deaths are more tragic — those we know about, or those we do not," he added. "Our role is to be the voice for the voiceless — especially those children whose deaths are missing from official data today." The main source of nationwide data on child-maltreatment deaths is the National Child Abuse and Neglect Data System (NCANDS), which issues an annual report based on information submitted voluntarily by the states. NCANDS' latest report, for the 2009 fiscal year, estimated that 1,770 children had died from abuse or neglect, up from 1,450 in 2005. The GAO notes that many state officials believe that increase stems at least in part from new procedures and better reporting, rather than a surge in abuse of children. But reporting standards differ widely from state to state. Some of the problems highlighted by the GAO: —Nearly half of states included data only from child welfare agencies in reporting maltreatment deaths to NCANDS. Yet not all children who die from maltreatment have had contact with these agencies, likely leading to incomplete counts due to lack of data from coroners' offices, law enforcement agencies and other sources. One study cited by the GAO found that maltreatment deaths in three states were undercounted by 55 to 75 percent. —

6. DAVID CRARY | AP National Writer | 07/12/11 Continued • HHS collects some information about maltreatment deaths, such as perpetrators' previous abuse of children, yet does not report it. And the federally funded center for child death review does not synthesize or publish the detailed data that it collects from states about maltreatment deaths. • —At the local level, lack of medical evidence and inconsistent interpretations of maltreatment challenge investigators in determining whether a child's death is caused by maltreatment. At the state level, limited coordination among jurisdictions and state agencies, in part due to confidentiality or privacy constraints, poses challenges for reporting data. • According to the GAO, state officials said that better data on maltreatment deaths would enable them to craft more effective prevention strategies — comparable to already widespread efforts to curtail the problem known as shaken-baby syndrome. • "As a society, we should be doing everything in our collective power to end child deaths and near-deaths from maltreatment," the report concluded. "The collection and reporting of comprehensive data on these tragic situations is an important step toward that goal." • It recommended that HHS expand the range of data that it distributes, while also helping states gather more complete and reliable information. • HHS, in a formal response, said it agreed with the recommendations and was taking steps to implement them. • Witnesses at Tuesday's hearing, in their prepared remarks, acknowledged that state and federal budget difficulties complicated any push for more funding to curtail child abuse. However, Michael Petit of the advocacy group Every Child Matters nonetheless called for up to $5 billion in additional federal spending. • Jane Burstain of the Center for Public Policy Priorities, a think tank in Austin, Texas, asked politicians to at least maintain current levels of spending on programs aimed at preventing abuse. • "As families struggle and stress levels rise, child maltreatment becomes more of a risk," she said. "To cut programs that support struggling families in tough economic times is the very definition of penny wise and pound foolish and is a choice our children will pay for with their lives." • Dr. Carole Jenny, a pediatrician and child-abuse expert at Brown Medical School in Providence, R.I., urged federal support for training more doctors in child-abuse pediatrics. • "When a child does die from abuse or neglect, these pediatricians can help police, forensic, and social service agencies make the correct diagnosis, by doing the appropriate medical work up in the hospital and by ruling out conditions that mimic abuse or neglect," she said in her testimony. • Another expert on child welfare, Richard Wexler of the National Coalition for Child Protection Reform, said the GAO report — by detailing the inconsistency of child-fatality data — highlighted the potential flaws in trying to rank states in this area. • "Phony 'scorecards' claiming state X or Y is 'worst' when it comes to child abuse deaths penalize states that are rigorous in ferreting out such deaths and reward states that ignore them," Wexler said.

7. Models Vary • State & Local Teams: Local teams conduct intensive case reviews and state boards review findings of local teams. • State-only teams conduct case reviews of selected cases, usually fatal abuse & neglect. • Local teams review cases independently without any state-supported program or board.

8. Models Vary • Almost half of the states review deaths - all causes; • Of the limit reviews, 92% exclude deaths from natural causes. • All review maltreatment. • 48 states review deaths through at least age 17. • One state to age 15 and one state even reviews up to age 24 (New Mexico). • States vary greatly on time frames for the review.

9. Florida the most restrictive State In reviewing Child deaths

10. Florida Child Abuse Death Review Committee • Established by statute in 1999 (Section 383.402) • Requires review of the death of a child who: • died as a result of child abuse or neglect and • is verified by Department of Children and Families

11. Confidentiality- FS.383.412 • Any information that reveals the identity of the surviving siblings, family members, or others living in the home of a deceased child who is the subject of review by and which information is held by the State Child Abuse Death Review Committee or a local committee is confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. • (b) Information made confidential or exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution that is obtained by the State Child Abuse Death Review Committee or a local committee shall retain its confidential or exempt status. • (3)(a) Portions of meetings of the State Child Abuse Death Review Committee or a local committee at which information made confidential and exempt pursuant to subsection (2) is discussed are exempt from s. 286.011 and s. 24(b), Art. I of the State Constitution. The closed portion of a meeting must be recorded, and no portion of the closed meeting may be off the record. The recording shall be maintained by the State Child Abuse Death Review Committee or a local committee. • (b) The recording of a closed portion of a meeting is exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

12. Why reporting is important • Child abuse death data is only identified through the Dept of Children and Families’ Florida Abuse Hotline • No other agency’s data specifically identifies child abuse deaths • We will not know why children die in Florida • We will not be able to give an accurate number of how many • We will not be able to determine what prevention efforts are needed

13. What case qualifies for a Review • History- children who had a prior with DCF and a verified death • Currently- 2004 law was passed after recommendation from the State Committee that all children who have a verified death • This means from 2003 on an average the committee reviewed around 35 cases a year

14. Florida Statistics for 2009 • 2,638 children died according to Vital Statistics • 217,382 reports of abuse and neglect • 513were reports involving child deaths • 192 were verified for abuse

15. Florida Child Deaths

16. National, Vital Statistics, Hotline calls and verified for 2009

17. 2004-2009 Verified deaths

19. History • 1985-HRS Task force subsequent to the death of Cory Greer • 1987-Protecting Florida’s Children Task Force: A Blue Print for the next decade • 1990_Child Welfare League of America Salary Study subsequent to the death of Bradley McGee • 1991-Study commission on Child Welfare (Barkett Commission) • 1995-Governor’s Panel on Child Protection Issues: A Review of the Lucas Ciambrone Case • 1996_Task force on Family Safety • 1997-Governor’s Child Abuse Task Force • 1998-DCF QA Review subsequent to the death of Kayla Mckean • 1999-District 7 Child Safety Strike Force • 2002-Blue Ribbon Task Force (Rylia Wilson) • 2002-Jamie Cotter Death Review • 2003- I-75 Child Death (Alfonzo Montes) • 2005- Hillsborough Kids Inc (Ronnie Parrish) • 2009 – Gabriel Myers workgroup • 2010 – Sub-Committee on Safe Families

20. CADRHow does it work? • A group of local concerned citizens, agencies, professionals get together and review the death of the child • A belief that environmental, social, economic, health and behavioral factors impact the risk, manner and investigation of death • It is a simple process of sharing data on the surface; but a complex process of “Group Thinking” and shared responsibility for getting it right

21. What is the purpose • Preventing future deaths • Preventing further risk to siblings • Educating the public • Training needs for agencies • Legislative changes • Policy changes • Practice changes

22. A Public Health Approach • Knowing where and how often the occur • Understanding who is most at risk and why • Creating effective interventions • Immunizing other children from harm

23. Intervention Options • Involve others…………Engagement • Change Behaviors……Education • Change Technology…..Engineering • Change Systems………Enactment • Change Laws…………..Enforcement

24. Department of Health Department of Legal Affairs Department of Children and Families Department of Law Enforcement Department of Education Florida Prosecuting Attorneys Association Florida Medical Examiners Commission (must be a forensic pathologist) Team Representation: Agency Appointments

25. Pediatrician Public health nurse Children’s mental health professional CPT medical director DCF child protective investigations supervisor Member of a child advocacy organization Private provider of child abuse/neglect prevention program Social worker(experience working with victims and perpetrators) Paraprofessional (experience in child abuse prevention) Law enforcement officer(experienced in children’s issues) Florida Coalition Against Domestic Violence Team Representation: Secretary of Health Appointments

26. HEALTHY START COALITION DIRECTORY OF FIMR AND CADRS • Jan-Mar 2010 Quarterly Report • Prevention Objective 2.3, Tactic 2.3.3: Healthy Start, Fetal and Infant Mortality Review. By 30 June, 2015, Healthy Start will have secured sufficient funding to establish the Fetal and Infant Mortality Review process statewide and will continue to collaborate in collaboration with the State Child Abuse Death Review Team regarding mutual strategies to reduce child deaths. • 2.3.3.2 By 31 December 2010, 100% of the 30 HS coalitions will have explored local funding opportunities. • 2.3.3.4.2 By 29 June 2012, 100% of the HS Coalitions will have completed plans for collaboration with their CADR Teams.

27. Local Committee’s 22 Active Local 2 Inactive

29. Flow chart

30. Other Review Types • Domestic Violence Committee • FIMR • PAMR

31. Annual Report 2010 www.flcadr.org

32. Abuse vs. Neglect 2004-2009

33. Age of Child at Death

34. Race and Gender of Child

35. Relationship of Caretaker

36. Race of Perpetrator

37. Age of Perpetrator

38. Age and Gender of Perpetrator

39. Physical Injury Murder/Suicides Abandoned Newborns Sexual Assault related Poisoning/Drugs Fire Furniture Firearm Suicide Traffic related Back over Roll over Left in vehicle Drowning Unsafe sleep Medical Neglect Dehydration/malnutrition Neglect-Supervision Animal related Types of Child Deaths

40. Top 3 Deaths , Findings, and Recommendations • Drowning- 59 (31%) • Physical Abuse- 52 (27%) • Unsafe sleep environment- 42 (22%)

41. Key Recommendations • # 1 -Review All Child Deaths- Amend §383.402 (1), F. S to expand the State Child Abuse Death Review Committee’s authority related to the review of child deaths in Florida to have a better understanding of why children die in Florida.  • # 2 -Fully Fund Healthy Families Florida - Support the Department of Children and Families 2011-12 Legislative Budget Request to restore Healthy Families Florida funding to the 2009-10 funding Level. • # 3 – Prioritize Assessment of Substance Abuse in Child Abuse and Neglect Cases –Substance abuse, the illegal or excessive use of alcohol or drugs, should be strongly considered when evaluating and investigating all cases of child abuse and neglect.  The presence of substance abuse should also be given a higher priority in the risk assessment activities of child protection organizations that come into contact with children and their families. 

42. Priority Issues and Recommendations • Drowning - Children continue to die from drowning at an alarming rate as a result of inadequate supervision. • Recommendation:  Implement a systemic approach to prevent drowning of children in Florida, with a focus on those under 5 years of age. • Physical Abuse - An alarming number of infant and toddler homicides are attributed to common triggers and risk factors for physical abuse. • Recommendation:  Any entity providing federal or state funded services, whether it be child protection investigations or case management, child care, home visiting or other services, should be trained to identify the common triggers and risk factors that contribute to child abuse.  • Unsafe Sleep Environments - Sudden unexplained infant deaths associated with unsafe sleep are tragic, but must be investigated thoroughly and consistently in order to prevent future infant deaths • Recommendation:  Improvements in the investigation of child deaths and heightened public awareness and education should be implemented for the prevention of infant suffocation deaths related to unsafe sleeping conditions.

43. Continued • Quality Assurance Review - Understanding the thinking and decision-making process of the legal decisions made and/or the court action taken would assist in educational opportunities resulting in better outcomes for children. • Recommendation: There is a need for a Quality Assurance review as it pertains to the legal involvement when any child dies as a result of abuse.  • Judicial Involvement - Informing judges, magistrates and court staff on the process and findings from the child death reviews will assist them to recognize key indicators of child endangerment. • Recommendation: Increase judicial awareness of Child Abuse Death Review Committee findings and trends through targeted training initiatives. • Public Awareness Campaigns - Research-based public awareness campaigns are effective in educating the public on strategies and actions that work to prevent child abuse and neglect before it ever occurs in the first place. • Recommendation: Enhance targeted public awareness campaigns related to child health, safety, and welfare, and other mechanisms for preventing child deaths. • The State Committee believes that implementing these recommendations for each priority issue will improve the child protection system by providing the knowledge, skills, and

44. Continued • Accessible and Affordable Childcare - Waiting lists for subsidized child care are growing. Subsidized child care enables low income parents to work, but only 30% of eligible families were served 2009-10, leaving more than 90,000 children on waiting lists. • Recommendation: Support The Policy Group for Florida’s Families and Children to expand child care subsidies by 20% annually until all eligible children have the opportunity to enroll in a child care program or family child care home, allowing parents to work. • Enhanced Data Collection and Analysis on Economic Factors- Without additional data and analysis by the State Committee on economic factors present in death review cases, a determination of whether these factors directly or indirectly contributed to these factors is unknown.     • Recommendation:  Economic factors should be considered as a part of the risk assessment and documented in the Florida Safe Families Network (FSFN) data system so they can be analyzed both locally and on a statewide level to determine the impact they have on child deaths. • Consistency and Communication - Communication between agencies and consistent evidence gathering protocol are crucial to the child death investigation and protection of other remaining children that are at risk. • Recommendation:  Improved consistency, communication and coordinated response during investigations are needed among the various agencies involved in child abuse/neglect and child death investigations. • Public Awareness Campaigns - Research-based public awareness campaigns are effective in educating the public on strategies and actions that work to prevent child abuse and neglect before it ever occurs in the first place. • Recommendation: Enhance targeted public awareness campaigns related to child health, safety, and welfare, and other mechanisms for preventing child deaths.

45. The State Committee believes that implementing these recommendations for each priority issue will improve the child protection system by providing the knowledge, skills, and public awareness needed to reduce tragic child abuse and neglect deaths.

46. Wrap up • Challenges • Lessons learned • Experiences

47. Remember!! • “The world is not an evil place because of the people who are in it, but because of the people who refuse to do anything about it!” – Albert Einstein

48. We are guilty of many errors and many faults, but our worst crime isabandoning the children, neglecting the fountain of life. Many of the things weneed can wait. The child cannot. Right now is the time… we cannot answer‘Tomorrow’; his name is today.” Gabriela Mistral (pseudonym of Lucila de María del Perpetuo Socorro GodoyAlcayaga), 1945 Nobel Laureate for Literature

49. Thanks for caring for our most precious citizens • ?’s • Michelle Akins, BSW • Michelle_Akins@doh.state.fl.us • 1701 S 23rd Street • Ft. Pierce, Fl 34950 • 772-467-6012 x 114 office • 863-697-3981 Cell • Florida State Child Abuse Death Review Committee • www.flcadr.org