Child Maltreatment:

Strengthening National Data on Child Fatalities Could Aid in Prevention

GAO-11-599: Published: Jul 7, 2011. Publicly Released: Jul 12, 2011.

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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.

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. 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. 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.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

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

    Agency Affected: Department of Health and Human Services

    Status: Open

    Comments: In 2011 and 2013, HHS stated that it believes adequate mechanisms exist for sharing information on child fatalities from maltreatment. In September 2011, HHS cited as examples the Federal Interagency Work Group on Child Abuse and Neglect and the annual National Conference on Child Abuse and Neglect. GAO acknowledged these and other mechanisms in its report. However, GAO also noted that child maltreatment fatalities were not often discussed at such interagency meetings and there was little routine information sharing between federal NCANDS officials and national child death review team experts on child maltreatment fatalities. In 2013, HHS reiterated the adequacy of its mechanisms. HHS held two roundtables at the annual meeting for state liaisons and members of the NCANDS data team that discussed sources of child fatality data and lessons learned from child fatality reviews to prevent fatalities and near fatalities. Such information sharing among HHS and state NCANDS officials are important steps and GAO looks forward to HHS making routine use of its interagency, multidisciplinary partners to share analyses and expertise about child maltreatment deaths, particularly focusing on the circumstances surrounding these deaths so as to aid in prevention.

    Recommendation: To improve the comprehensiveness, quality, and use of national data on child fatalities from maltreatment, the Secretary of HHS should expand, as appropriate, the type and amount of information HHS makes public on the circumstances surrounding child fatalities from maltreatment.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: For 2011, HHS's annual Child Maltreatment report made public additional information about child fatalities from maltreatment than in its earlier 2009 report: A new table provides information on child fatalities among caregivers with selected risk factors, such as alcohol abuse, and another table provides data on child fatalities by single-year age rather than by age group. HHS previously noted that some NCANDS information is not provided in the report when there is insufficient data from the states. In FY13, as part of its review of NCANDS child maltreatment data, the Office Of Management and Budget approved the addition of one fatality-related data element: the exact date of death. In addition, the program instructions to the states also revised HHS's public disclosure policy: HHS now requires states to provide the public with a minimum of information about child fatalities and near-fatalities. Specifically, states are to release, when appropriate, with certain exceptions, information about the cause and circumstances about the fatality or near-fatality, and any previous investigations, reports, or services. This new information and public disclosure policy should help strengthen the comprehensiveness of data and understanding of the circumstances surrounding child fatalities from maltreatment.

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

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: On September 30, 2011, the Child and Family Services Improvement and Innovation Act (42 USC 1305) was passed into law. The Act requires states to describe the various sources of data on child fatalities and, if applicable, why information is not included from other relevant agencies, such as state vital statistics, child death review teams, law enforcement agencies, and offices of medical examiners or coroners. The additional information required by the Act will assist in improving the comprehensiveness and quality of national data on child fatalities from maltreatment. HHS noted the new act's requirements for state reporting in the most recent Child Maltreatment report for 2011, and issued Program Instructions (ACYF-CB-PI-13-04) in April, 2013, requiring states as part of their 2013 Annual Progress and Services Report to address the sources of information used to report child fatality data and to describe efforts to expand the sources of information used to report such data. HHS stated that this information will be used to continue discussions with states in improving the quality and completeness of fatality information reported through NCANDS. These new program instructions and any related discussions with states should help strengthen the completeness and accuracy of child fatality data by fostering states' use of cross-agency data sources.

    Recommendation: To improve the comprehensiveness, quality, and use of national data on child fatalities from maltreatment, the Secretary of HHS should estimate the costs and benefits of collecting national data on near fatalities and take appropriate follow-up actions.

    Agency Affected: Department of Health and Human Services

    Status: Open

    Comments: In 2011 and 2013, HHS noted that it had initiated conversations with the states to improve the identification of cases that involve children's near-fatalities. In 2013, members of the Children's Bureau and the NCANDS Technical Team sought input and recommendations from the states through webinars, working groups, and annual technical assistance meetings about collecting near fatality data. HHS stated that it had not yet added a new data element to NCANDS because of state officials' concerns about their ability to capture and report near-fatality data that would be consistent across states. HHS noted that discussions with states are continuing on this topic: For example, at the State Liaison Officers meeting in April 2013, Children's Bureau and data team members conducted a presentation on Applying Lessons Learned from Child Fatality Reviews to Preventing Fatalities and Near Fatalities that included group discussions on 2-year goals for improving the identification, data tracking, and critical action steps related to near-fatality cases. GAO believes HHS should continue to explore the possibility of collecting near-fatality data, including developing an analysis or assessment of the issues so as to determine appropriate followup actions.

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