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United States Government Accountability Office: 
GAO: 

Report to the Chairman, Committee on Ways and Means, House of 
Representatives: 

July 2011: 

Child Maltreatment: 

Strengthening National Data on Child Fatalities Could Aid in 
Prevention: 

GAO-11-599: 

GAO Highlights: 

Highlights of GAO-11-599, a report to the Chairman, Committee on Ways 
and Means, House of Representatives. 

Why GAO Did This Study: 

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. 

What GAO Found: 

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. 

Figure: General Process for Reporting Child Maltreatment Fatalities 
That Are Known to Child Protective Service (CPS) Agencies to NCANDS: 

[Refer to PDF for image: illustration] 

(1) Local CPS workers document child fatalities from maltreatment. 

(2) Local CPS submits details of those deaths to the state. 

(3) State child welfare department collects and validates data. 

(4) State child welfare department sends data to NCANDS. 

Source: GAO analysis of site visit information. 

[End of figure] 

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. 

What GAO Recommends: 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-11-599] or key 
components. For more information, contact Kay Brown at (202) 512-7215 
or brownke@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

National Data Likely Underestimate the Number of Children Who Died 
from Maltreatment and Provide Incomplete Information on Circumstances: 

Local Investigative Challenges and Limited Coordination Hinder States' 
Efforts to Collect Child Maltreatment Fatality Data and Report to 
NCANDS: 

HHS Provides Assistance to States in Reporting on Child Maltreatment 
Fatalities, but States Would Like Additional Help: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Selected Information on Child Fatalities from 
Maltreatment: 

Appendix III: Information from States Not Reported in NCANDS: 

Appendix IV: Comments from the Department of Health and Human Services: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Differing State Definitions of Medical Neglect: 

Table 2: States' Use of Standards of Evidence for Substantiation of 
Maltreatment: 

Table 3: Information Collected by NCANDS on Child Maltreatment 
Fatalities: 

Table 4: Types of Child Fatality Data States Collected but Did Not 
Report to NCANDS: 

Figures: 

Figure 1: Child Fatalities by Type of Maltreatment, Fiscal Year 2009: 

Figure 2: General Process for Reporting Child Maltreatment Fatalities 
Known to CPS to NCANDS: 

Figure 3: Potential Sources of State and Local Data on Child 
Maltreatment Fatalities: 

Figure 4: State Child Welfare Agencies That Did and Did Not Use 
Information from External Sources for Reporting Child Fatalities to 
NCANDS: 

Figure 5: Challenges Investigators Face Identifying Child Maltreatment 
Fatalities: 

Figure 6: Challenges States Face Coordinating among Jurisdictions and 
Agencies: 

Figure 7: Challenges States Face with Data Systems: 

Figure 8: State Variation in Defining and Collecting Information on 
Child Maltreatment Near Fatalities: 

Abbreviations: 

AAP: American Academy of Pediatrics: 

ABA: American Bar Association: 

ACF: Administration for Children and Families: 

CAPTA: Child Abuse Prevention and Treatment Act: 

CDC: Centers for Disease Control: 

CDR: Child Death Review: 

CFSR: Child and Family Services Review: 

CPS: child protective services: 

CRS: Congressional Research Service: 

DOJ: Department of Justice: 

EVAA: Enhanced Validation and Analysis Application: 

FBI: Federal Bureau of Investigation: 

HHS: Department of Health and Human Services: 

HIPAA: Health Insurance Portability and Accountability Act: 

HRSA: Health Resources and Services Administration: 

NCANDS: National Child Abuse and Neglect Data System: 

NCCDR: National Center for Child Death Review: 

NCHS: National Center for Health Statistics: 

NCIPC: National Center for Injury Prevention and Control: 

NDACAN: National Data Archive on Child Abuse and Neglect: 

NIS: National Incidence Study of Child Abuse and Neglect: 

NRC: National Resource Center: 

NRC-CWDT: National Resource Center for Child Welfare Data and 
Technology: 

OMB: Office of Management and Budget: 

SDC: summary data component: 

SIDS: sudden infant death syndrome: 

SUID: sudden unexplained infant death: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

July 7, 2011: 

The Honorable Dave Camp: 
Chairman: 
Committee on Ways and Means: 
House of Representatives: 

Dear Mr. Chairman: 

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.[Footnote 1] 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,[Footnote 2] 
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.[Footnote 3] 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.[Footnote 4] 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.[Footnote 5] 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 appendix 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. 

Background: 

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). 
[Footnote 6] 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.[Footnote 7] Of all children who died in fiscal year 2009, 
NCANDS estimates that 1,770 children died from various types of 
maltreatment.[Footnote 8] (See figure 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. 

Figure 1: Child Fatalities by Type of Maltreatment, Fiscal Year 2009: 

[Refer to PDF for image: pie-chart] 

Multiple maltreatment: 36.7%; 
Neglect: 35.8%; 
Physical abuse: 23.2%; 
Medical neglect: 1.8%; 
Sexual abuse: 0.4%; 
Psychological maltreatment: 0.1%; 
Other: 2.0%. 

Source: Data from HHS Child Maltreatment 2009 report. 

Note: This analysis is based on 1,343 child deaths reported by 44 
states through child-specific, case-level data. Because of this, the 
total number is smaller than the 1,770 NCANDS estimate for child 
fatalities from maltreatment. Fatalities can be attributed to more 
than one type of maltreatment. 

[End of figure] 

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.[Footnote 9] 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.[Footnote 10] 
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. 
[Footnote 11] (See figure 2.) 

Figure 2: General Process for Reporting Child Maltreatment Fatalities 
Known to CPS to NCANDS: 

[Refer to PDF for image: illustration] 

(1) Local CPS workers document child fatalities from maltreatment. 

(2) Local CPS submits details of those deaths to the state. 

(3) State child welfare department collects and validates data. 

(4) State child welfare department sends data to NCANDS. 

Source: GAO analysis of site visit information. 

[End of figure] 

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).[Footnote 12] 

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.[Footnote 13] 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,[Footnote 14] 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." 
[Footnote 15] 

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.[Footnote 16] 
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. 

Near Fatalities of Children from Maltreatment: 

CAPTA defines the term "near fatality" as "an act that, as certified 
by a physician, places the child in serious or critical 
condition."[Footnote 17] 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.[Footnote 18] 

Child Maltreatment Data Collected by NCANDS: 

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.[Footnote 19] 

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). 
[Footnote 20] Finally, NCANDS data are used to help assess the 
performance of several HHS programs in accordance with the Program 
Assessment Rating Tool. 

National Data Likely Underestimate the Number of Children Who Died 
from Maltreatment and Provide Incomplete Information on Circumstances: 

More Children Have Likely Died from Maltreatment than Are Counted in 
National Data: 

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.[Footnote 21] 

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. 
[Footnote 22] Some children may not have been previously maltreated, 
or their earlier maltreatment may not have been noticed or reported to 
CPS agencies.[Footnote 23] 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 figure 3),[Footnote 24] and in Federal Bureau of 
Investigation (FBI) Uniform Crime Reports at the federal level. 

Figure 3: Potential Sources of State and Local Data on Child 
Maltreatment Fatalities: 

[Refer to PDF for image: illustration] 

Potential sources of state and local data on child maltreatment 
fatalities: 

Local law enforcement; 
Medical examiner or coroner’s office; 
Child protective services; 
Vital statistics offices; 
Multidisciplinary state and local child death review teams. 

Source: GAO analysis of state survey data. 

[End of figure] 

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.[Footnote 25] 
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.[Footnote 26] More specifically, for example, 43 
states responded that their NCANDS data did not include child fatality 
data from the vital statistics department. (See figure 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. 

Figure 4: State Child Welfare Agencies That Did and Did Not Use 
Information from External Sources for Reporting Child Fatalities to 
NCANDS: 

[Refer to PDF for image: horizontal bar graph] 

Agency: Vital Statistics Department; 
Did not use data from state agency or entity: 43 states; 
Used that data: 4 states. 

Agency: Prosecutor/Attorney General Office; 
Did not use data from state agency or entity: 42 states; 
Used that data: 7 states. 

Agency: State Child Death Review Team; 
Did not use data from state agency or entity: 41 states; 
Used that data: 8 states. 

Agency: Health Department; 
Did not use data from state agency or entity: 41 states; 
Used that data: 8 states. 

Agency: Juvenile Justice Department; 
Did not use data from state agency or entity: 41 states; 
Used that data: 6 states. 

Agency: Law Enforcement; 
Did not use data from state agency or entity: 40 states; 
Used that data: 9 states. 

Agency: Medical Examiners’ Office; 
Did not use data from state agency or entity: 39 states; 
Used that data: 10 states. 

Source: GAO analysis of state survey data. 

Note: Data reflect state child welfare officials' responses to 
question about data reported to NCANDS through the agency file. The 
total number of states responding varies by item number. 

[End of figure] 

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.[Footnote 27] 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.[Footnote 28] 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.[Footnote 29] The NIS is a 
congressionally mandated, periodic effort of HHS to estimate the 
incidence of child abuse and neglect in the United States.[Footnote 
30] 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.[Footnote 31] 
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.[Footnote 32] 

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.[Footnote 33] 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.) 

Table 1: Differing State Definitions of Medical Neglect: 

Definition of medical neglect: Failing to provide any special medical 
treatment or mental health care needed by the child; 
States using this definition: Mississippi, North Dakota, Ohio, 
Oklahoma, Tennessee, Texas, and West Virginia. 

Definition of medical neglect: Withholding medical treatment or 
nutrition from disabled infants with life-threatening conditions; 
States using this definition: Indiana, Kansas, Minnesota, and Montana. 

Source: HHS analysis of state laws in use as of July 31, 2009. 

[End of table] 

Some experts we interviewed said that definitions need to be 
standardized nationally to improve the quality of NCANDS data. 
[Footnote 34] 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.[Footnote 35] 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.) 

Table 2: States' Use of Standards of Evidence for Substantiation of 
Maltreatment: 

Least strict: 

Level of evidence required for investigator to substantiate child 
abuse or neglect: Credible (or reasonable determination) that a child 
had been abused or neglected; 
Number of states with given level of evidence: 20; 
Victim rate (Victims per 1,000 children in given states) in fiscal 
year 2007: 13.3. 

More strict: 

Level of evidence required for investigator to substantiate child 
abuse or neglect: Preponderance of evidence supported a determination 
that a child was a victim of abuse or neglect; 
Number of states with given level of evidence: 28; 
Victim rate (Victims per 1,000 children in given states) in fiscal 
year 2007: 9.4. 

Strictest: 

Level of evidence required for investigator to substantiate child 
abuse or neglect: Clear and convincing evidence that a child had been 
abused or neglected; 
Number of states with given level of evidence: 2; 
Victim rate (Victims per 1,000 children in given states) in fiscal 
year 2007: 1.7. 

Source: Congressional Research Service analysis based on data provided 
in HHS, Child Maltreatment 2008. 

[End of table] 

* 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;[Footnote 36] 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. 

HHS Collects but Does Not Report Some Useful Information on the 
Circumstances Surrounding Child Fatalities: 

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.[Footnote 37] 
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. 
[Footnote 38] 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.[Footnote 39] However, HHS does not report some information it 
collects on the circumstances surrounding child fatalities.[Footnote 
40] 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.[Footnote 41] 

* Perpetrators:[Footnote 42] 

- 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. 
[Footnote 43] 

* 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.[Footnote 44] 

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).[Footnote 45] 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.[Footnote 46] Nearly all states have child death review 
teams comprising CPS workers, prosecutors, law enforcement, coroners 
or medical examiners, public heath care providers, and 
others.[Footnote 47] 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).[Footnote 48] 

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.[Footnote 49] 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. 
[Footnote 50] (The sidebar describes the CDR data-reporting form.) 

[Side bar: 
NCCDR’s Child Death Review Case Reporting Form: 

NCCDR developed the Child Death Review Case Reporting Form to collect 
comprehensive information on child fatalities from state and local 
teams that conduct child death reviews. This case reporting form was 
developed in cooperation with 30 state child death review leaders and 
advocates. The case reporting form documents detailed information 
about the circumstances involved in the child’s death, such as the 
manner of death (e.g., homicide or accident), the cause of death 
(e.g., injury or neglect), the child welfare history of children who 
die from maltreatment, the investigative actions taken, services 
provided or needed, and key risk factors. The system collects 
comprehensive information on the history of the child, primary 
caregivers, supervisors, and perpetrators of acts of omission and/or
commission. It also collects further details about the method of death 
(such as by fire, weapon, asphyxia, poisoning, or drowning) and 
collects details on subtypes of physical abuse deaths (e.g., abusive 
head trauma, chronic battered child syndrome, beating, scalding, or
burning) and neglect deaths (e.g., failure to protect from hazards, 
failure to provide necessities, failure to seek or follow treatment,
or abandonment). The case reporting form collects information on 
actions recommended or taken by states’ child death review teams to
prevent similar deaths and improve agency systems. It also allows for 
the collection of information on near deaths of children as well as 
fatalities. 
Source: GAO analysis of NCCDR information. End of side bar] 

Local Investigative Challenges and Limited Coordination Hinder States' 
Efforts to Collect Child Maltreatment Fatality Data and Report to 
NCANDS: 

Investigative Difficulties Can Hamper Local Data Collection Efforts: 

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.[Footnote 51] (See figure 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. [Footnote 52] 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.[Footnote 53] 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. 

Figure 5: Challenges Investigators Face Identifying Child Maltreatment 
Fatalities: 

[Refer to PDF for image: horizontal bar graph] 

Challenge: Medical issues in identifying or documenting child 
maltreatment; 
Not a challenge: 7 states; 
Some to moderate challenge: 37 states; 
Great to very great challenge: 6 states. 

Challenge: Resources available to identify or investigate child 
maltreatment fatalities; 
Not a challenge: 14 states; 
Some to moderate challenge: 29 states; 
Great to very great challenge: 7 states. 

Challenge: Access to or availability of training provided on 
identifying or investigating maltreatment; 
Not a challenge: 16 states; 
Some to moderate challenge: 29 states; 
Great to very great challenge: 6 states. 

Challenge: Level of agreement on the application or interpretation of 
state definitions of child abuse and/or neglect; 
Not a challenge: 21 states; 
Some to moderate challenge: 27 states; 
Great to very great challenge: 2 states. 

Source: GAO analysis of state survey data. 

[End of figure] 

* 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.[Footnote 54] 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.[Footnote 
55] 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 figure 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.[Footnote 56] 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 figure 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.[Footnote 57] 

[Side bar: 
CDC Sudden Unexplained Infant Death (SUID) Investigation Reporting 
Form: 

In 1996, CDC developed the SUID Investigation Reporting Form to 
establish a standard death scene investigation protocol for all sudden 
unexplained infant deaths. A revised version of this protocol, in 
addition to guidelines and training materials, is available on CDC’s 
Web site, and some investigators use this tool to meet their data 
collection needs. The protocol guides investigators through the steps
involved in an investigation, including questions to ask when 
interviewing witnesses, and provides a means to document findings. 
According to CDC, by standardizing data collection, this protocol 
improves the classification of SIDS and other unexplained infant 
deaths. Two of the three states we visited had standardized protocols-—
similar to CDC’s SUID Reporting Form—-for investigating sudden 
unexplained infant deaths. One of these states also had a standardized 
protocol for conducting autopsies that medical examiners and coroners 
use for infants whose deaths are sudden and unexplained. 
Source: GAO analysis of information from CDC and California and 
Michigan site visits. End of side bar] 

* 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 figure 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. 

Limited Coordination and Data Access Issues Pose Reporting Challenges: 

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 figure 
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. 

Figure 6: Challenges States Face Coordinating among Jurisdictions and 
Agencies: 

[Refer to PDF for image: horizontal bar graph] 

Challenge: Level of coordination or cooperation among different 
jurisdictions; 
Not a challenge: 12 states; 
Some to moderate challenge: 33 states; 
Great to very great challenge: 4 states. 

Challenge: Level of coordination or cooperation among different state 
agencies; 
Not a challenge: 18 states; 
Some to moderate challenge: 30 states; 
Great to very great challenge: 2 states. 

Challenge: Agencies involved do not generally or easily share 
information; 
Not a challenge: 22 states; 
Some to moderate challenge: 19 states; 
Great to very great challenge: 5 states. 

Challenge: Confidentiality or privacy issues related to child 
maltreatment; 
Not a challenge: 27 states; 
Some to moderate challenge: 21 states; 
Great to very great challenge: 1 state. 

Source: GAO analysis of state survey data. 

[End of figure] 

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.[Footnote 58] (See figure 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). 

[Side bar: 
California’s Reconciliation Audit: 

California uses a “reconciliation audit” to generate an estimate of 
child fatalities for NCANDS. The audit compares data from five 
sources-—homicide files and child abuse central index files from the 
state department of justice, child welfare agency records, state 
department of health records, and files from county child death review 
teams. This audit is made possible by a state law that requires the 
state department of health to track child maltreatment deaths in 
California and requires multiple agencies to share data for the 
purpose of establishing accurate information on the nature and extent 
of these deaths (Cal. Penal Code § 11174.34 (Deering 2008)). According 
to the California official in charge of conducting the audit, the 
number of deaths estimated by this process is usually two-thirds 
higher than the number produced by any one data source. In the most 
recent audit, in 2008, the child welfare agency recorded 24 known 
cases of child maltreatment fatalities, but the reconciliation audit, 
which was submitted to NCANDS, found an estimated 185 cases. 
Source: GAO analysis of California state information. End of side bar] 

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 figure 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 figure 7.) 

Figure 7: Challenges States Face with Data Systems: 

[Refer to PDF for image: horizontal bar graph] 

Challenge: The information tracking systems of multiple agencies are 
not electronically linked; 
Not a challenge: 16 states; 
Some to moderate challenge: 12 states; 
Great to very great challenge: 16 states. 

Challenge: Data entry errors; 
Not a challenge: 16 states; 
Some to moderate challenge: 26 states; 
Great to very great challenge: 1 state. 

[End of figure] 

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. 

HHS Provides Assistance to States in Reporting on Child Maltreatment 
Fatalities, but States Would Like Additional Help: 

HHS Provides Technical Assistance to States in Reporting Data on Child 
Maltreatment: 

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.[Footnote 59] 
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.[Footnote 60] 

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.[Footnote 61] 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. 

States Would Like Additional Assistance in Collecting and Using Data 
on Child Fatalities and Near Fatalities from Maltreatment: 

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. 

Assistance Collecting Fatality Data: 

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. 

Collecting Maltreatment Data on Near Fatalities: 

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.[Footnote 62] 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 figure 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. 

Figure 8: State Variation in Defining and Collecting Information on 
Child Maltreatment Near Fatalities: 

[Refer to PDF for image: illustrated U.S. map] 

Selected state definitions of a maltreatment near fatality: 

California: a severe childhood injury or condition caused by abuse or
neglect that results in the child receiving critical care for at least
24 hours following the child’s admission to a critical care unit. 

Indiana: a situation where a child has been admitted to the intensive 
care unit or a neonatal intensive care unit and has been placed on a 
ventilator because of injuries sustained from alleged abuse and/or 
neglect. 

New Jersey: a serious or critical condition, as certified by a 
physician, in which a child suffers a permanent mental or physical 
impairment, a life-threatening injury, or a condition that creates a 
probability of death within the foreseeable future. 

State definition and data collection of near-fatality information: 

State has defined near fatality in state law, statute, or policy but 
does not collect data: 
Connecticut; 
Delaware; 
Georgia; 
Hawaii; 
Iowa; 
Kansas; 
Missouri; 
Nebraska; 
North Carolina; 
Oregon; 
South Carolina; 
Virginia; 
Texas
Wisconsin. 

State has defined near fatality and collects data: 
Arkansas; 
Arizona; 
California; 
Indiana; 
Kentucky; 
Louisiana; 
Maryland; 
Massachusetts; 
Minnesota; 
Nevada; 
New Jersey; 
Oklahoma; 
Pennsylvania; 
Puerto Rico; 
Tennessee; 
Utah; 
Washington; 
West Virginia; 
Wyoming. 

State has no definition or data collection: 
Alabama; 
Alaska; 
Colorado;
District of Columbia; 
Florida; 
Idaho; 
Illinois; 
Maine; 
Michigan; 
Mississippi; 
Montana; 
New Hampshire; 
New Mexico; 
New York; 
North Dakota; 
Ohio; 
Rhode Island; 
South Dakota; 
Vermont. 

Source: GAO survey of states and state near-fatality definitions; 
MapInfo (map). 

Note: State definitions may be included in a regulation or action by a 
state administrative agency. Calif. Dept. of Social Services, ACL No. 
08-13 (March 14, 2008), p.1, fn.1; Indiana Dept. of Child Services, 
Child Welfare Manual, p.5 (Aug. 1, 2010); N.J. Admin. Code § 10:133-
1.3 (2011). 

[End of figure] 

Assistance on Using Data for Prevention: 

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). 

[Side bar: 
State Shaken Baby Campaigns: 

Shaken baby syndrome, which is associated with the violent shaking of 
an infant or young child, usually occurs when a caretaker becomes 
frustrated with a crying child. Prevention efforts typically include 
educating new parents on the dangers of shaken baby syndrome and 
offering coping mechanisms to resolve parental anger or frustration. 
Many states, including California, New York, and Wisconsin, currently 
have prevention campaigns that specifically target new parents at 
hospitals, places of birth, or other health care facilities. Ten 
states have statewide public awareness campaigns, and two states have
passed legislation to include education in public schools on parental 
skills and responsibility, including the dangers of shaking infants,
according to the National Conference of State Legislatures. 
Source: GAO analysis of information from NCSL. End of side bar] 

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. 

Conclusions: 

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. 

Recommendations for Executive Action: 

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. 

Agency Comments and Our Evaluation: 

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. (appendix 
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 [hyperlink, 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. 

Sincerely yours, 

Signed by: 

Kay E. Brown: 
Director, Education, Workforce, and Income Security Issues: 

[End of section] 

Appendix I: Scope and Methodology: 

Survey of States: 

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. 

Literature Review: 

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. 

NCANDS Data Analysis: 

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. 

NCCDR Data Analysis: 

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. 

Site Visits: 

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.[Footnote 63] 

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. 

Expert Interviews: 

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. 

[End of section] 

Appendix II: Selected Information on Child Fatalities from 
Maltreatment: 

Table 3: Information Collected by NCANDS on Child Maltreatment 
Fatalities: 

Type of child maltreatment data collected by NCANDS: Information about 
the child; 
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. 

Type of child maltreatment data collected by NCANDS: Type(s) of 
maltreatment[A]; 
Selected NCANDS results on child fatalities from maltreatment reported 
by HHS for fiscal year 2009: 
* 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. 

Type of child maltreatment data collected by NCANDS: Information about 
perpetrators[B]; 
Selected NCANDS results on child fatalities from maltreatment reported 
by HHS for fiscal year 2009: 
* 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). 

Type of child maltreatment data collected by NCANDS: Child welfare 
contact; 
Selected NCANDS results on child fatalities from maltreatment reported 
by HHS for fiscal year 2009: 
* Twelve percent of children who died from maltreatment were from 
families who had received family preservation services in the previous 
5 years[C]; 
* Two percent of children who died from maltreatment had been in 
foster care and were reunited with their families in the previous 5 
years[D]. 

Type of child maltreatment data collected by NCANDS: Child's risk 
factors[E]; Risk factors associated with the caregiver[F]; Preventive 
services provided to families[G]; 
Selected NCANDS results on child fatalities from maltreatment reported 
by HHS for fiscal year 2009: 
* HHS's Child Maltreatment 2009 report did not provide information on 
these data elements for children who died from maltreatment. 

Source: HHS, Child Maltreatment 2009. 

Notes: States report these data on a child-specific level through 
NCANDS child files. 

[A] Maltreatment types include neglect, physical abuse, sexual abuse, 
psychological maltreatment, and medical neglect. 

[B] NCANDS defines a perpetrator as a person determined to have caused 
or knowingly allowed the maltreatment of a child. 

[C] Family preservation services are activities designed to help 
families alleviate crises that might lead to out-of-home placement of 
children, maintain the safety of children in their own homes, support 
families preparing to reunify or adopt, and assist families in 
obtaining services and other supports necessary to address their 
multiple needs. 

[D] This information is provided through aggregated agency files 
rather than individual case-level child files. Data are for fiscal 
year 2009. HHS also collects data on children who died from 
maltreatment while in foster care. However, the foster care data 
element is ambiguous because child deaths while in foster care can 
reflect earlier maltreatment by parents that led to the child's 
removal from the home, deaths from other causes such as disease or 
accidents, or deaths from maltreatment by foster parents. Perpetrator 
information is more useful: In fiscal year 2009, foster parents were 
reported as the perpetrator in 5 child fatalities from maltreatment. 

[E] Child risk factors include having an intellectual disability, 
physical disability, learning disability, and visual or hearing 
impairment. 

[F] Risk factors associated with the caregiver include alcohol or drug 
abuse, domestic violence, emotional disturbance, and financial 
difficulties. 

[G] 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. 

[End of table] 

Information from NCCDR on Child Maltreatment Fatalities: 

Following are selected results from our analysis of child maltreatment 
data in the CDR Reporting System: [Footnote 64] 

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. 
[Footnote 65] 

* 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. 
[Footnote 66] 

[End of section] 

Appendix III: Information from States Not Reported in NCANDS: 

State Data on Child Fatalities Not Reported to NCANDS: 

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. 

Table 4: Types of Child Fatality Data States Collected but Did Not 
Report to NCANDS: 

Types of child fatality data elements not reported to NCANDS in fiscal 
year 2009: Child information (e.g., maltreatment history, mental 
health, criminal history); 
Number of states collecting data: 29. 

Types of child fatality data elements not reported to NCANDS in fiscal 
year 2009: Child's status in relation to the child welfare system 
(e.g., foster care or prior substantiated maltreatment); 
Number of states collecting data: 29. 

Types of child fatality data elements not reported to NCANDS in fiscal 
year 2009: Incident information (e.g., date, time, place); 
Number of states collecting data: 28. 

Types of child fatality data elements not reported to NCANDS in fiscal 
year 2009: Primary cause of death; 
Number of states collecting data: 27. 

Types of child fatality data elements not reported to NCANDS in fiscal 
year 2009: Family characteristics (e.g., sibling information, 
siblings' prior contact with child welfare system); 
Number of states collecting data: 27. 

Types of child fatality data elements not reported to NCANDS in fiscal 
year 2009: Information about person responsible for supervising child 
at time of near death if the supervisor was not the primary caregiver 
(e.g., demographic, criminal history); 
Number of states collecting data: 26. 

Types of child fatality data elements not reported to NCANDS in fiscal 
year 2009: Information about child's primary caregiver (e.g., 
employment, education level, criminal history); 
Number of states collecting data: 25. 

Source: GAO survey of state child welfare officials. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Department of Health and Human Services: 

Department of Health & Human Services: 
Office of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

June 20, 2011: 

Kay Brown: 
Director, Education, Workforce and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Ms. Brown: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled, "Child Maltreatment: Strengthening 
National Data on Child Fatalities Could Aid in Prevention" (GAO-11-
599). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

General Comments Of The Department Of Health and Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled, 
"Child Maltreatment: Strengthening National Data On Child Fatalities 
Could Aid In Prevention" (GA0-11-599): 

The Department appreciates the opportunity to review and comment on 
this draft report. 

GAO Recommendations: 

To improve the comprehensiveness, quality, and use of national data on 
child fatalities from maltreatment, the Secretary of HHS should: 

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. Establish routine mechanisms for HHS agencies and their partners to 
share analyses and expertise 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. 

Administration for Children and Families (ACF) Response: 

GAO's recommendations essentially suggest ACF's Administration on 
Children, Youth and Families (ACYF) continue activities currently 
under way and activities that will continue into the future. ACYF is 
in agreement with the GAO recommendations and the comments below 
elaborate on the work already under way or planned. 

Several processes and forums are in place for furthering these 
dialogues. The Children's Bureau (CB) continues to provide detailed 
annual reports on child maltreatment that identify and address 
interpretation issues. Thus readers can use the information to conduct 
their own research or form their own interpretations. 

The annual publication of Child Maltreatment is updated and expanded 
each year. The full data file is available from the National Data 
Archive on Child Abuse. There are approximately 56 tables planned for 
the Child Maltreatment 2010 report, compared to 51 tables in the 2009 
report. Two additional tables on fatalities have been planned for some 
time and will be included in the report. The full data file is 
available from the National Data Archive on Child Abuse and Neglect at 
Cornell University for researchers to use after the annual report is 
released. 

Two relevant issues are: 1) CB does not have statutory authority to 
require States to provide this data; it has always been a voluntary 
effort and, under the Child Abuse Prevention and Treatment Act 
(CAPTA), "to the extent practicable," and 2) the data reported is 
meant to be nationally representative, that is, reflective of what is 
happening in all of the States. Some data elements are not discussed 
at length in the report when there is not sufficient input from the 
States. 

Several mechanisms are already in place for sharing of information. 
The Federal Inter-Agency Work Group on Child Abuse and Neglect serves 
as a coordinating group. CB manages the Children's Justice Act (CJA) 
under CAPTA. One of the key tenets of CJA is that funds be spent on 
improving the handling of abuse-related fatalities. Many of the States 
have used their funding over the years to establish and support local 
and State child fatality review teams, which include a data collection 
component. CB hosts the CJA grantees meeting as well as the State 
Liaison meeting annually, and the National Child Abuse and Neglect 
Data System (NCANDS) data team members participate in those meetings. 
The 18th National Conference on Child Abuse and Neglect will be hosted 
by CB in April 2012. At this Conference, as well as in many previous 
years of the Conference, opportunities exist for workshops, roundtable 
discussions, exhibit area and poster session interaction on these 
topics. Finally, the CB enjoys a positive working relationship with 
the Health Resources and Services Administration (HRSA) and the 
National Center for Child Death Review (NCCDR), which it funds. 

CB has already initiated conversations with the States to improve the 
identification of cases that involve near fatalities. With the support 
of the States, it is anticipated that the Child File of NCANDS will be 
modified to include an additional data element identifying such cases. 

National Child Abuse and Neglect Data System: 

The national data reported to the Department via NCANDS is the most 
comprehensive data on child maltreatment that our Nation has ever had. 
This is also true for the data on child fatalities. For 2009, case-
level data for more than 3.5 million records of child abuse and 
neglect were reported and analyzed by HHS. This includes case-level 
data for more than 1,300 fatalities. We consider this a major 
achievement given the following factors: 

* Participation by the States in NCANDS is voluntary. The combined 
effort of the States and CB results in an annual report each year. 

* States do not receive additional funding for participation in 
NCANDS, and yet contribute staff time each year, as their resources 
allow. 

* Definitions of child abuse and neglect and procedures for responding 
to allegations of maltreatment are established by state legislative 
and departmental authority. 

* Reporting of child maltreatment and child fatalities is the 
responsibility of the public by both professional and community 
members. Each year, more than 1 million professionals undertake the 
responsibility for reporting alleged abuse and neglect. 

CB routinely coordinates the reporting of improved data to NCANDS with 
the efforts of States to develop and improve their information system 
through the Division of State Systems; to respond to Federally 
mandated state reporting requirements for foster care and independent 
living through the Division of Program Implementation; to receive a 
wide range of technical assistance through 10 national resource 
centers overseen by the Division of Child Welfare Capacity; and to 
receive grant funding for prevention activities. Additionally, CB has 
created a number of quality improvement centers to further innovation 
in child protective services throughout the United States. The Office 
of Child Abuse and Neglect serves as the link between the CB and other 
initiatives, which address child maltreatment. 

While it is commonly believed that the reported number of children who 
were known to have died due to child abuse and neglect is an 
undercount, we are making considerable progress in closing the gap 
between deaths due to child maltreatment and those that are not 
identified as such. HHS supports States in their use of primary 
prevention to help parents be more aware of the dangers of co-
sleeping; unsecured weapons and medications; and unsupervised play. 
The 18th National Conference on Child Abuse and Neglect in 2012, which 
is likely to draw more than 2,000 attendees, will include several 
sessions related to preventing and addressing child fatalities and 
near fatalities. Additionally, the annual Child Maltreatment report in 
2013 will have two additional analyses in the chapter about child 
fatalities. The additional analyses will examine caregiver risk 
factors of children who died and the total number of reported 
fatalities by state during the previous five years. 

Adding new data elements for the States to report as part of the 
NCANDS data file is undertaken in a systematic manner. All potential 
new data fields are discussed with the States for the feasibility of 
collecting and reporting the data via NCANDS. Each potential new data 
field must go through the Office of Management and Budget review and 
approval cycle before it can be implemented as a reportable field in 
the NCANDS data file. Consultations with the States have already been 
initiated to determine how to best address data collection on near 
fatalities of children. The feasibility of collecting and reporting 
data on Shaken Baby Syndrome (also known as inflicted traumatic brain 
injury) will be discussed with States this summer. 

National Resource Center on Child Protective Services: 

It is important to clarify the current involvement of the National 
Resource Center (NRC) on Child Protective Services (CPS). NRC has on 
occasion received requests for technical assistance on improving a 
State's child fatality review system, and has responded to those 
requests. In addition, there is one consultant at NRC specifically 
designated to respond to queries from Citizen Review Panels. NRC has a 
good working relationship with the National Center on Child Death 
Review and often refers constituents to the Center. Additionally, NRC 
is often called in to help States after a child fatality has occurred, 
to review their CPS system and determine if the fatality could have 
been prevented. In a recent example, one State has decided to redesign 
its system, particularly in the area of safety decision making, which 
is a critical first step in the CPS response process. 

Limitations of the GAO Review: 

GAO conducted a nationwide web-based survey of State child welfare 
administrators as part of their data collection and analysis to 
complete the report and provide recommendations. This type of data 
collection and analysis has methodological limitations to include: I) 
In many States, Commissioners/Directors do not complete the survey. 
Completion of the survey is typically delegated to subordinates, which 
results in 50 States selecting different staff at different levels of
experience, with different backgrounds and from different divisions to 
complete the survey. This creates inconsistencies in respondents and 
the data collected. 2) The staff person responding to the survey may 
not have considered input from various divisions such as the IT 
division, Critical Review/Child Death Unit, etc. Some agencies have 
both an internal review unit and a statewide multidisciplinary review 
unit and including both perspectives would be critical. 3) The survey 
data collected is self-report, with no ability for the GAO to validate 
information provided. 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

Contact: 

Kay E. Brown, Director (202) 512-7215 or brownke@gao.gov: 

Staff Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] In this report, we use the term "maltreatment" to refer to both 
abuse and neglect, unless noted otherwise, which is also consistent 
with the Department of Health and Human Service's use of the term in 
its annual report, Child Maltreatment. 

[2] In this report, we use the terms "child fatalities" and "child 
deaths" interchangeably. 

[3] Child Abuse Prevention, Adoption, and Family Services Act of 1988, 
Pub. L. No. 100-294, sec. 101, § 6(b)(1), 102 Stat. 102, 107. 

[4] Throughout this report, references to state survey responses 
include the District of Columbia and Puerto Rico. 

[5] We selected our site visit states based on expert recommendations 
and variations in demographics, child welfare program administrative 
structure, and other factors. During these site visits, we interviewed 
state child welfare officials and state child death review team 
officials, as well as county or local officials from child protective 
services, law enforcement, coroner or medical examiner offices, and 
others involved in child death investigations or review processes. 

[6] CDC's National Center for Health Statistics (NCHS) collects 
information from death certificates. This figure includes deaths of 
children from birth to age 19. 

[7] The perinatal period refers to the weeks immediately before and 
after birth; a congenital anomaly is a health problem or a physical 
abnormality that a baby has at birth. 

[8] Fiscal year 2009 data are the most recent information on child 
maltreatment from NCANDS. With regard to child fatalities, 49 states 
reported a total of 1,676 child fatalities from maltreatment to HHS. 
Of those 49 states, 44 reported child-specific, case-level data on 
1,343 fatalities, and 40 reported aggregate data on an additional 333 
fatalities. On the basis of these data, HHS estimates that 1,770 
children died from maltreatment in fiscal year 2009. Alaska, 
Massachusetts, and North Carolina did not report data on child 
fatalities for fiscal year 2009. 

[9] In the majority of states, child welfare programs are state 
administered through state and local offices, while in a minority of 
states, they are state supervised and county administered, according 
to HHS. 

[10] After investigation or assessment, the allegations are either 
"substantiated" or "founded" or "unsubstantiated/unfounded," according 
to HHS. In some states, CPS focuses on the service needs of the family 
if the child is considered at low or medium risk of harm rather than 
investigating allegations of maltreatment. This approach is called 
"alternative response" or "differential response." 

[11] In the case of child deaths in which there has been no previous 
contact with child welfare services, law enforcement officials and 
medical examiners or coroners may conduct investigations without CPS. 
The results of these investigations may or may not be reported to CPS 
agencies. 

[12] HHS's Children's Bureau in the Administration for Children and 
Families (ACF) sponsors 10 NRCs that provide individualized training 
and technical assistance to states and localities, by request, on 
various topics. 

[13] 42 U.S.C. §§ 5104, 5105. CAPTA Reauthorization Act of 2010, Pub. 
L. No. 111-320, 124 Stat. 3459. 

[14] Under this grant, each eligible state receives a base allotment 
of $50,000. Remaining funds are distributed in proportion to each 
state's relative share of the child population under 18 among all 
states that apply for a grant. 42 U.S.C. § 5106a(f)(2). CAPTA funding 
is included in the $8.4 billion in federal funds provided for child 
welfare programs in fiscal year 2010. 

[15] 42 U.S.C. § 5106a(b)(1), (2), and § 5106g(2). 

[16] See 42 U.S.C. § 5106a(c). 

[17] CAPTA also defines "serious bodily injury" as "bodily injury 
which involves substantial risk of death, extreme physical pain, 
protracted and obvious disfigurement, or protracted loss or impairment 
of the function of a bodily member, organ, or mental faculty." 42 
U.S.C.§ 5106a(b)(4)(A), (B). 

[18] Citizen review panels are authorized to review near fatalities. 
42 U.S.C. § 5106a(c)(4)(A)(iii)(II). 

[19] 42 U.S.C. § 5106a(d). Three CAPTA data items refer to child 
fatalities from maltreatment. 

[20] Under CFSRs, established in 2000, states are assessed for 
substantial conformity with certain federal requirements for child 
protection, foster care, adoption, family preservation and family 
support, and independent living services. The CFSRs enable the 
Children's Bureau to (1) ensure conformity with federal child welfare 
requirements, (2) determine what is actually happening to children and 
families as they are engaged in child welfare services, and (3) assist 
states with enhancing their capacity to help children and families 
achieve positive outcomes. 

[21] There is no separate file for child fatalities in NCANDS. A 
child's fatality is recorded as a data element in a child's individual 
case-level file that is maintained by state child welfare departments. 
State CPS agencies generally report data to NCANDS. 

[22] NCANDS collects information on all children who were referred or 
reported to CPS because of alleged maltreatment and whose maltreatment 
was investigated or otherwise assessed. Such information is largely 
reported through individual case-level "child files." States that are 
unable to provide case-level data provide aggregated counts of key 
indicators through "agency files." As we note, states are also 
encouraged to go beyond CPS data in reporting child fatalities to 
NCANDS. 

[23] In addition, some states do not report data on child maltreatment 
for residential treatment facilities to NCANDS, as we noted in our 
earlier work. Residential treatment facilities are boarding schools, 
academies, boot camps, and wilderness camps that provide services for 
children with behavioral or emotional challenges. Because many states 
lack authority under state law to gather data from some residential 
treatment facilities, such as exclusively private facilities, we found 
that NCANDS data may understate the number of fatalities and other 
kinds of maltreatment occurring in such facilities. GAO recommended 
that HHS determine the barriers for states that do not report case-
file data for residential facilities to NCANDS and explore options to 
help states address existing barriers. GAO, Residential Facilities: 
State and Federal Oversight Gaps May Increase Risk to Youth Well-
Being, [hyperlink, http://www.gao.gov/products/GAO-08-696T], 
(Washington, D.C.: Apr. 24, 2008), and Residential Facilities: 
Improved Data and Enhanced Oversight Would Help Safeguard the Well-
Being of Youth with Behavioral and Emotional Challenges, [hyperlink, 
http://www.gao.gov/products/GAO-08-346] (Washington, D.C.: May 13, 
2008). 

[24] Nearly all states and some counties have a "child death review 
team" comprising CPS workers, prosecutors, law enforcement, coroners 
or medical examiners, public health care providers, and others. These 
multidisciplinary teams review cases of child deaths for the purpose 
of follow-up and prevention. 

[25] According to HHS officials, agency files were established in part 
to enable states to report information about child maltreatment 
obtained from non-CPS agencies that also investigate child 
maltreatment, such as state health and justice departments and, in the 
case of fatalities, medical examiners' offices. Agency files also 
contain information on funding sources for preventive services; 
information on referrals and reports to CPS, including CPS staffing; 
and contacts with court representatives. Child-specific case-level 
details are not available for fatality data gathered from external 
departments that are reported in the agency file. In fiscal year 2009, 
all but two states submitted agency files. 

[26] This response reflects the number of states (24) that responded 
"no" to questions about whether they used any non-CPS data sources in 
reporting NCANDS data, using agency files. According to HHS, 40 states 
reported data to NCANDS in their agency files on child maltreatment 
fatalities that HHS officials believe were obtained from non-CPS 
agencies. (See table 4-1 in HHS, Child Maltreatment 2009.) Sixteen of 
these 40 states reported zero child fatalities in the agency file for 
fiscal year 2009, and HHS officials said these agencies consulted with 
external agencies to determine the zero count. However, our survey 
question specifically asked state child welfare officials whether 
their state's NCANDS agency file for fiscal year 2009 includes 
information on child maltreatment fatalities from specific state 
agencies or entities, and 24 states responded "no" to all agencies or 
entities. States responded similarly as to whether they used any non-
CPS data sources in reporting NCANDS data using child files (23 
responded "no"). HHS officials acknowledged that gathering information 
on child maltreatment fatalities from multiple sources needs attention. 

[27] See appendix I for a description of the scope and methodology for 
this study, including information about our review of relevant 
literature. 

[28] P.G. Schnitzer et al, "Public Health Surveillance of Fatal Child 
Maltreatment: Analysis of 3 State Programs," American Journal of 
Public Health, February 2008, Vol. 98, No. 2. 

[29] The small number of fatalities in the sample size limits the 
reliability of the NIS estimate for child fatalities from 
maltreatment. Because the sample size is small, the estimate has a 
large standard error. Taking this variance into account, the 95 
percent confidence interval around the incidence of child maltreatment 
fatalities estimated by the NIS-4 indicates that the number of 
children who died from maltreatment in 2005-2006 is likely between 
1,541 and 3,318. 

[30] The next report is due no later than Dec. 20, 2014. 42 U.S.C. § 
5105(a)(3). 

[31] The NIS applies two definitional standards: the Harm Standard and 
the Endangerment Standard. The Harm Standard generally requires that 
an act or omission result in demonstrable harm in order to be 
classified as abuse or neglect. (The incidence of child fatalities was 
reported under the Harm Standard.) The Endangerment Standard includes 
all children who meet the Harm Standard but adds children who were not 
yet harmed by abuse or neglect if a trained reporter thought that the 
maltreatment endangered the children or if a CPS investigation 
substantiated or indicated their maltreatment. 

[32] In addition to the main study, the NIS-4 included several 
supplementary studies designed to enhance interpretations of NIS 
findings, such as surveys of CPS agencies. HHS is currently comparing 
the methodologies, including definitions, used by NIS-4 and NCANDS. 
This comparison analysis--which will not address child maltreatment 
fatalities--will be issued as a supplementary study to the NIS-4. 

[33] Definitions of child abuse and neglect and procedures for 
responding to allegations of maltreatment are established by state 
legislative and departmental authority, according to HHS. 

[34] In January 2008, CDC published definitions of child maltreatment 
and included recommended data elements designed to promote public 
health departments' voluntary use of consistent terminology for data 
collection related to child maltreatment. Reviewers and panelists 
involved in developing these definitions included NCANDS staff and 
consultants and the director of the National Center for Child Death 
Review. See CDC, National Center for Injury Prevention and Control 
(NCIPC), Child Maltreatment Surveillance: Uniform Definitions for 
Public Health and Recommended Data Elements (January 2008). 

[35] The data-mapping process helps states define and align state data 
elements with NCANDS data elements and format. The process has been an 
integral part of state reporting since 1998, according to HHS 
officials. 

[36] As HHS notes, NCANDS data are influenced by the states that 
report information over the years, and even small fluctuations in the 
data can affect the total numbers. The populations of the reporting 
states in fiscal year 2009 were different enough compared with the 
populations in fiscal year 2008 to affect both the national estimate 
and the national rate. See HHS, Child Maltreatment 2009. 

[37] The term "circumstances" in this report refers to the factors 
surrounding and contributing to incidents of fatal child maltreatment. 
These factors include information on the child, the perpetrator, and 
the context for the child's death, such as its cause, location, date, 
type of maltreatment, and caregiver characteristics. 

[38] For selected NCANDS data results on child fatalities, see 
appendix II. 

[39] In addition to data that states report to NCANDS, 32 states 
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. See appendix III for more information 
on data that states collected that were not reported to NCANDS. 

[40] In commenting on a draft of this report, HHS noted that the 
annual Child Maltreatment report for 2013 will include additional 
analyses of caregiver risk factors of children who died and the total 
number of reported fatalities by state during the previous 5 years. 

[41] The term "indicated" refers to a report disposition that 
concludes that maltreatment cannot be substantiated under state law or 
policy, but there is reason to suspect that the child may have been 
maltreated or was at risk of maltreatment. This is applicable only to 
states that distinguish between substantiated and indicated 
dispositions. 

[42] In January 2005, the Office of the Assistant Secretary for 
Planning and Evaluation, HHS, issued a study on Male Perpetrators of 
Child Maltreatment: Findings from NCANDS utilizing an 18-state dataset 
of perpetrators identified by the CPS system during 2002. This study 
focused on perpetrators of child maltreatment generally but did not 
discuss child fatalities specifically. See U.S. Department of Health 
and Human Services, Office of the Assistant Secretary for Planning and 
Evaluation, Male Perpetrators of Child Maltreatment: Findings from 
NCANDS (Washington, D.C.: 2005). 

[43] Unmarried partners pose higher risks of maltreatment: Compared 
with children living with married biological partners, those whose 
single parent had a live-in partner had more than eight times the rate 
of maltreatment overall, according to the NIS-4. 

[44] Children with disabilities are likely undercounted since not 
every child receives a clinical diagnostic assessment from a CPS 
agency worker that is confirmed by a physician or other expert. NCANDS 
includes this as a limitation to its disability data. 

[45] For selected results from our analysis of child maltreatment data 
in the CDR Reporting System, see appendix II. 

[46] Follow-up may include providing services to surviving family 
members, providing information to assist in prosecuting perpetrators, 
and developing recommendations to improve child protection systems. 
Many states received initial funding for child death review teams 
through CAPTA formula grants, commonly called Children's Justice Act 
grants, to improve the prosecution and handling of child abuse and 
neglect cases. (CAPTA § 107.) 

[47] According to NCCDR, 49 states have a child death review program: 
37 states have a state-level panel and teams in local communities, 
mostly at the county level; and 12 states have only state-level review 
teams. 

[48] Although NCCDR is funded by HRSA, the Office of Management and 
Budget does not consider the NCCDR data reporting system a federal 
database because HRSA does not review or approve child death reviews 
and no data are submitted directly to HRSA. 

[49] In defining maltreatment, NCCDR limits perpetrators to parents 
and caregivers, while NCANDS does not limit the definition in this way. 

[50] In commenting on a draft of this report, HHS noted that NCCDR 
recently established a data dissemination plan to allow NCCDR data to 
be studied and published at the national level. 

[51] For the purposes of this report, medical issues include those 
related to the determination of maltreatment by medical professionals, 
including identifying cases of abuse or neglect, and properly 
documenting those cases. 

[52] According to CDC, shaken baby syndrome is a leading cause of 
child abuse deaths in the United States, and at least one of four 
babies who are violently shaken dies from this form of maltreatment. 
Although babies with shaken baby syndrome may display some outward 
signs, these injuries are not always visible. 

[53] HHS Child Maltreatment 2009 report. 

[54] According to the International Association of Coroners and 
Medical Examiners, the cost of an autopsy ranges from several hundred 
dollars to several thousand, depending on the extent of the postmortem 
examination and other tests, such as X-rays, which incur additional 
costs. 

[55] Committee on Identifying the Needs of the Forensic Sciences 
Community, National Research Council. Strengthening Forensic Science 
in the United States: A Path Forward. A special report prepared at the 
request of the Department of Justice. Washington, D. C.: August 2009. 

[56] Forensic pathology is a subspecialty of medicine devoted to the 
investigation and physical examination of persons who die a sudden, 
unexpected, suspicious, or violent death. 

[57] Training on death scene investigation--supported by the 
Department of Justice's (DOJ) Office of Juvenile Justice and 
Delinquency Prevention--is also available at the national level for 
professionals involved in the child death investigation process, such 
as medical personnel, law enforcement, and child welfare workers. This 
week-long, multidisciplinary training covers techniques for 
investigating child fatalities, including examples of common and 
uncommon fatal child maltreatment cases and injuries specific to 
children. Additionally, training and technical assistance resources 
for multidisciplinary professionals may be requested and funded 
through DOJ's Office for Victims of Crime's Training and Technical 
Assistance Center. 

[58] Confidentiality and privacy issues include the 1996 Health 
Insurance Portability and Accountability Act's (HIPAA) privacy rule, 
which provides protections for personal health information. See 
generally 45 C.F.R. pt. 164, subpts. A and E (2010). In addition, 
states that receive CAPTA basic grants must provide assurance that 
they have a statewide program that includes provisions or methods to 
(1) maintain the confidentiality of all records and reports related to 
their child abuse and neglect investigations; (2) release information 
from these confidential records to any federal, state, or local 
government entity, or an agent of these entities that need this 
information to carry out their responsibilities under law to protect 
children from abuse and neglect; and (3) release to the public 
information concerning a child abuse and neglect case when it resulted 
in the death (or near death) of a child. 

[59] The NCANDS State Advisory Group is composed of members from 
Alaska, California, Connecticut, District of Columbia, Indiana, 
Kentucky, Louisiana, Massachusetts, Michigan, Missouri, New Mexico, 
New York, North Dakota, Oklahoma, Oregon, Puerto Rico, South Carolina, 
South Dakota, Tennessee, and Vermont. 

[60] The goal of the National Resource Center for Child Welfare Data 
and Technology (NRC-CWDT) is to improve the quality of data reported 
to the federal government in the Adoption and Foster Care Analysis and 
Reporting System, NCANDS, Statewide Automated Child Welfare Systems, 
and the National Youth in Transition Database. In addition, according 
to HHS, the National Resource Center on Child Protective Services has 
often been called in after a child fatality has occurred to review 
state CPS systems and determine if the fatality could have been 
prevented. States may request on-site technical assistance through 
their Administration for Children and Families Regional Office. 

[61] The HHS Office on Child Abuse and Neglect leads and coordinates 
the Federal Interagency Workgroup on Child Abuse and Neglect, which 
represents over 40 federal agencies. The overall goals of the 
workgroup are to provide a forum through which staff from relevant 
federal agencies can communicate and exchange ideas concerning child 
maltreatment-related programs and activities, to collect information 
about federal child maltreatment activities, and to provide a basis 
for collective action through which funding and resources can be 
maximized. However, HHS officials told us that the topic of child 
maltreatment fatalities has not often been discussed at these 
quarterly meetings. 

[62] The Paperwork Reduction Act requires that federal agencies obtain 
OMB approval before collecting information from the public (such as 
forms, general questionnaires, surveys, instructions, and other types 
of collections). 44 U.S.C. § 3507. 

[63] In Pennsylvania, we also met with county CPS officials from 
Franklin, Lycoming, Montgomery, and Sullivan counties. 

[64] This analysis was conducted by NCCDR for our study using data for 
calendar year 2009. Results are based on data from 20 states. 

[65] In addition to CPS records, documentation could include 
information on prior abuse obtained from law enforcement reports, 
medical records, or autopsy reports. 

[66] The child could have died from maltreatment that occurred prior 
to placement in foster care, and not necessarily by maltreatment 
inflicted by the foster parent. 

[End of section] 

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