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United States Government Accountability Office: 
GAO:  

Testimony: 

Before the Subcommittee on Human Resources, Committee on Ways and 
Means, House of Representatives: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT:
Tuesday, July 12, 2011: 

Child Fatalities From Maltreatment: 

National Data Could Be Strengthened: 

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

GAO-11-811T: 

Chairman Davis, Ranking Member Doggett, and Members of the 
Subcommittee: 

Thank you for the opportunity to participate in today's discussion of 
child fatalities from maltreatment. 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 
this estimate and that there are inconsistencies and limitations in 
the data that states collect and report to NCANDS. In addition, many 
more children are severely harmed and may nearly die from 
maltreatment, but NCANDS does not collect data specifically on near-
fatalities. The Department of Health and Human Services (HHS) 
maintains NCANDS, which is a voluntary state data-reporting system. 
[Footnote 2] HHS provides oversight of state child welfare systems, 
and in all states, child protective services (CPS) is part of the 
child welfare system. When state CPS investigators determine that a 
child's death is considered maltreatment under state laws or policies, 
CPS documents the case, and the state's child welfare department 
reports it to NCANDS. 

My testimony today is based on our July 2011 report, which is being 
publicly released today and addresses three issues: (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. 
[Footnote 3] To address these questions, we assessed the methodology 
of published research on the number of child fatalities; analyzed 
fiscal year 2009 NCANDS data; and interviewed HHS officials 
responsible for NCANDS child maltreatment data, child welfare 
practitioners, and other experts. We also conducted a nationwide Web- 
based survey of state child welfare administrators in 50 states, the 
District of Columbia, and Puerto Rico; and conducted site visits to 
California, Michigan, and Pennsylvania. Finally, we reviewed HHS 
documents on child maltreatment fatalities and near-fatalities as well 
as CAPTA and related laws, including pertinent state laws. We 
conducted our work 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 in this product. 

The following summarizes our findings on each of the three issues 
discussed in our report: 

* National estimate of the number of children who likely have died 
from maltreatment. More children have likely died from maltreatment 
than are reflected in the national estimate of 1,770 child fatalities 
for fiscal year 2009. Undercounting is likely due to nearly half the 
states reporting 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 4] HHS encourages 
states to obtain information on child maltreatment fatalities from 
other non-CPS sources of information, but 24 states reported in our 
survey that their 2009 NCANDS data did not include child fatality 
information from any non-CPS sources.[Footnote 5] Synthesizing 
information about child fatalities from multiple sources--such as 
death certificates, state child welfare agency records, or law 
enforcement reports--can produce a more comprehensive picture of the 
extent of child deaths than sole reliance on CPS data. For example, 
one peer-reviewed study[Footnote 6] found that more than 90 percent of 
the child fatality cases could be identified by linking any two of the 
data sources.[Footnote 7] Furthermore, inconsistent state definitions 
of maltreatment, differing state legal standards for substantiating 
maltreatment, and missing state data can complicate the ability to 
obtain comprehensive information on child fatalities from maltreatment 
across states or over time. In addition to collecting the number of 
child fatality deaths, NCANDS collects data on the circumstances 
surrounding these deaths, which could be useful for prevention, but 
not all of this information is synthesized or published in HHS's 
annual Child Maltreatment report. For example, for children who had 
died from maltreatment, HHS's 2009 report did not provide data on 
child risk factors and caregiver risk factors. When we analyzed 
unpublished fiscal year 2009 state data reported to NCANDS on 
children's deaths from maltreatment, we found that 16 percent of 
perpetrators of fatal child maltreatment were previously involved in 
an incident of child maltreatment. 

* Challenges to collecting and reporting child maltreatment fatality 
data to NCANDS. Local child death investigators, such as law 
enforcement officials, coroners and medical examiners, and CPS staff, 
face several challenges in determining whether a child's death was 
caused by maltreatment. One challenge is that without definitive 
medical evidence, it can be difficult to determine that a child's 
death was caused by abuse or neglect rather than natural causes. In 
our survey, 43 states indicated that medical issues were a challenge 
in determining child maltreatment. For example, investigators in 
California told us 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. State and local resource constraints can also limit 
investigators' ability to conduct testing, such as autopsies, to 
determine how a child died. Another challenge in determining cause of 
death is that the level of skill and training for coroners and medical 
examiners can vary greatly, according to the National Academy of 
Sciences.[Footnote 8] Child death investigators can also differ in 
their interpretation and application of maltreatment definitions, 
which can lead to inconsistent determinations of the cause of death. 
For example, law enforcement officials and coroners sometimes disagree 
on the manner or cause of death when the death is suspected to be from 
natural causes but there is some indication of abuse or neglect, 
according to California law enforcement officials we interviewed. 
Finally, states reported challenges coordinating among geographic 
jurisdictions and with other state agencies, such as health 
departments, to obtain information on child fatalities from 
maltreatment. For example, 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, according to Michigan officials. 

* Assistance by HHS to help states report on child maltreatment. HHS 
provides ongoing assistance to states for reporting child maltreatment 
fatality data through an NCANDS technical assistance team that hosts 
an annual technical assistance meeting, provides Web-based resources, 
and uses an NCANDS Listserve to share information with states and 
facilitate peer-to-peer assistance. States can obtain individualized 
NCANDS technical assistance upon request from an assigned NCANDS 
technical team liaison, and an NCANDS State Advisory Group meets 
annually to review and update NCANDS collection and reporting 
processes. In addition, HHS provides assistance to states' child death 
review teams through the National Center for Child Death Review 
(NCCDR), which helps states share information by publishing their 
child death review teams' contact information, data, and annual 
reports on its Web site.[Footnote 9] The NCCDR Web site also offers 
best practices for preventing the leading causes of children's injury 
and death and other information. NCCDR and NCANDS officials 
acknowledged that, to date, they have not routinely coordinated on 
child maltreatment fatality data or prevention strategies. In 
responding to our survey, state officials indicated a need for 
additional assistance collecting data on child fatalities and near-
fatalities from maltreatment and using this information for prevention 
efforts. 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. States also reported wanting assistance to collect 
and use information on near fatalities, which CAPTA defines as "an act 
that, as certified by a physician, places the child in serious or 
critical condition," but NCANDS does not collect near fatality data. 
[Footnote 10] 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 from maltreatment. In 
comments on a draft of this report, HHS stated that it is considering 
adding a field to identify these specific cases. 

In the report we released today, we recommended, as summarized here, 
that the Secretary of HHS take steps to: 

* further strengthen data quality, such as by identifying and sharing 
states' best practices and helping address differences in state 
definitions and interpretation of maltreatment; 

* expand available information on the circumstances surrounding child 
fatalities from maltreatment; 

* improve information sharing on the circumstances surrounding child 
fatalities from maltreatment; and: 

* estimate the costs and benefits of collecting national data on near 
fatalities. 

We provided a draft of the report we drew on for this testimony to HHS 
for its review, and copies of HHS's written responses can be found in 
appendix IV of that report.[Footnote 11] In its comments, HHS agreed 
with our recommendations to improve the comprehensiveness and quality 
of national data on child fatalities from maltreatment and pointed out 
activities under way that are consistent with our recommendations. 
However, 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. 

Chairman Davis, Ranking Member Doggett, and Members of the 
Subcommittee, this concludes my statement. I would be pleased to 
respond to any questions you or other Members of the Subcommittee may 
have. 

GAO Contacts and Acknowledgments: 

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 statement. Individuals who made key 
contributions to this testimony include Katherine C. Berman, Lorraine 
R. Ettaro, Brett S. Fallavollita, Julian P. Klazkin, Sheila R. McCoy, 
Deborah A. Signer, Kate van Gelder, and Monique B. Williams. Almeta J. 
Spencer provided administrative assistance. 

[End of section]  

Footnotes:  

[1] In this testimony, we use the term "maltreatment" to refer to both 
abuse and neglect.  

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

[3] GAO, Child Maltreatment: Strengthening National Data on Child 
Fatalities Could Aid in Prevention, [hyperlink, 
http://www.gao.gov/products/GAO-11-599] (Washington, D.C.: July 7, 
2011). 

[4] 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.  

[5] 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.  

[6] 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. 

[7] HHS's most recent National Incidence Study of Child Abuse and 
Neglect (NIS-4)--issued in January 2010--estimated 2,400 child deaths 
from maltreatment in the study year spanning portions of 2005 and 
2006. The NIS is a congressionally mandated, periodic effort of HHS to 
estimate the incidence of child abuse and neglect in the United 
States. 42 U.S.C.  5105(a)(2). Unlike NCANDS, which relies primarily 
on CPS data reported by states, the NIS-4 relies on multiple sources 
of child death information. 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.  

[8] 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. 

[9] NCCDR is a nongovernmental organization funded by HHS that 
provides resources to state child death review teams. These 
multidisciplinary teams review cases of child deaths for follow-up and 
prevention. 

[10] 42 U.S.C.  5106a(b)(4)(A).  

[11] We provided a copy of the draft report to the Department of 
Justice (DOJ) and pertinent excerpts to NCCDR. DOJ and NCCDR provided 
technical comments which we incorporated as appropriate.  

[End of section]