Child Fatality Review

Overview

Death is a universal experience of all living creatures. At one time, many children died from diseases and conditions that are now treatable. The expectation for most parents in the 21st century is that their children will outlive them. Unfortunately, this is not always true.

The creation of child death review teams (CDRTs) is foremost a formal attempt to answer the question, “Why?” The question comes from the perceived unnaturalness of a child dying, intellectual curiosity about how this could be so, and grief-inspired anguish. Additional questions include “What could have prevented this?” and “What could we have done better?” It is in the structure of CDRTs, the issues they face, and their commitment to children that prevention recommendations are made.

The inspiration for child death review arose primarily from the concern about child abuse. While questions periodically arise about possible clusters of birth defects and deaths, environmental toxicology has not been the stimulus for the formation of child fatality review (and may indeed be underappreciated if or when it does exist). Motor vehicle–related fatalities are major causes of childhood death, yet this did not serve as the inspiration for the spread of CDRTs. Therefore, it was not the fact of child fatalities alone that caused such teams to arise but rather concerns about the occurrence of undetected homicide caused by child abuse.

Child abuse first received attention in 1962 with the publication of “The Battered Child Syndrome” in the Journal of the American Medical Association.1 This article described physical abuse, particularly cases with multiple and recurrent injuries. As a result of this publication, within the next 5 years all 50 states enacted child abuse reporting laws. Indeed, the Journal of the American Medical Association has cited this article as one of its “landmark” articles acknowledging its pioneering importance in shaping the field of child abuse.²

These early descriptions of child abuse focused on physical abuse; sexual abuse and neglect were better appreciated later. Although much physical abuse is overt (eg, skin injuries) and potentially easily recognizable, there are some forms of physical abuse that may be very difficult to detect. For example, the findings of shaken baby syndrome were first linked with shaking as a mechanism of action in the early 1970s.^3-5 In these early descriptions, cases were identified as being shaken baby syndrome only if there were no signs of impact to the head. A child would be seen who had no apparent external signs of trauma but considerable brain injury. Shaken baby syndrome injuries (brain injury and swelling, intracranial bleeding, and retinal hemorrhages in most cases) are internal and, thus, they can be missed in cases of sudden death without an autopsy. Later, coexisting impact trauma to the head^6,7 and elsewhere on the body⁸ was better characterized. Nevertheless, many cases of shaken baby syndrome have no external signs of physical abuse.

Likewise, abusive abdominal trauma often leaves no external signs. When hit, the skin of the abdomen is not trapped against adjacent underlying bone as is the case with skin over the tibia, forehead, cheekbones, or other sites commonly seen with accidental bruising. Punching, stomping, or impacts with blunt objects (eg, knee, baseball bat) are not high velocity mechanisms such as slaps, which can leave bruising on areas of skin without underlying bone. Unless these mechanisms of injury drive with such force and depth that they trap the skin against the spine and cause bruising, the skin of the abdomen is usually clear, even with considerable internal injury.

Mandatory autopsy laws and much of the motivation of CDRTs have stemmed from the fact that a child with no signs of external trauma (eg, shaken baby syndrome, abdominal trauma) might not be correctly diagnosed as being a victim of child abuse. The victim might then be buried with an incorrect diagnosis such as sudden infant death syndrome (SIDS). The consequences of this mistake could be considerable in allowing a perpetrator of fatal child abuse to remain in a position to hurt or kill other children. Underascertainment of specific causes of child fatality cases results in incorrect death certificates and a distorted picture of how children die.^9,10 Although fear of missing a child abuse death may have been the initial rationale for the establishment of most CDRTs, the key charge to all such teams is prevention. With each death that is reviewed, many teams explicitly consider the degree to which the child’s death was preventable. Consider Case Study 1-1.

Definitions of preventability vary, but many are similar to this: “A preventable death is one in which an individual or a community could reasonably have done something that would have changed the circumstances that led to the death.”¹¹ Three options of relative preventability are preventable, possibly preventable, or unpreventable. Teams may use other terminology but commonly face the issue that preventability is not “all or none.” The compilation of recommendations across cases comprises the reports made by state and local teams in an effort to reduce child deaths, and the degree of preventability helps with the prioritization of such recommendations. In Case Study 1-1, preventability is high with regard to the mother’s actions in trying to go around a railroad gate. This does not obviate the need for proper child restraint in other cases in which such restraint might make a difference in survival.

THE HOMICIDES OF CHILDREN AND YOUTH*

Murders of children and youth are the ultimate form of juvenile victimization and have received a great deal of deserved public notoriety in recent years. (Strictly speaking, murder and homicide are not identical; however, in this chapter the terms are sometimes used interchangeably to improve readability.) Even though the images of Amber Hagerman or the students at Columbine High School are vivid in the public’s mind, the statistics on child murder victims are not. Substantial misunderstandings exist about magnitudes, trends, and which children are at risk This chapter is intended to give a brief statistical portrait of the various facets of child and youth homicides in the United States. It draws heavily on homicide data from the Federal Bureau of Investigation’s (FBI) Supplementary Homicide Reports (SHR).¹ Among the highlights of the findings are the following:

• In 1997, there were slightly more than 2000 juvenile homicide victims or a rate of 3 per 100 000, a rate substantially larger than any other developed country.
• Juvenile homicide is unevenly distributed geographically and demographically. Rates are substantially higher for black and Hispanic juveniles, for certain jurisdictions (eg, District of Columbia, Nevada), and certain counties; at the same time, 85% of all US counties had no juvenile homicide at all.
• The homicides of teenagers, young children, and children in middle childhood appear to be different on a number of dimensions, suggesting they need to be analyzed separately.
• The homicides of teens rose dramatically in the late 1980s and early 1990s but have declined sharply since 1993. These homicides mostly involve male victims and offenders and usually involve firearms.
• The homicides of young children are committed largely by family members using beatings and suffocation. Boys and girls are victimized about equally. A disproportionate number of offenders are women. These homicides may be seriously undercounted.
• Middle childhood is a time of life when homicide risk is low. The homicides in this age group show a mixed pattern, including cases involving child maltreatment, firearms, sexual motivation, and multiple family homicides.
• Types of juvenile homicide victimization that deserve special attention include child maltreatment homicides, multiple victim family homicides, female offender

According to FBI data, 2087 persons younger than 18 years were victims of homicides in 1997. That rate of 3 per 100 000 (over 5 children per day) makes the United States first among developed countries in juvenile homicide. In fact, the US rate is dramatically out of line, nearly double the rate of the country with the next highest rate.² The United States’ lead in child homicide is related to the generalized American prowess in lethal violence: The homicide rate for all persons is 6.8 per 100 000, 3 times higher than any other developed country.

Murder is a crime that does not have higher rates in childhood than adulthood, unlike other violent crimes such as rape, robbery, and assault.³ However, homicide is the only major cause of childhood death to have increased in incidence in the last 30 years. Although deaths due to accidents, congenital defects, and infectious diseases fell over the last generation, during much of the period up until the 1990s, growing numbers of children were being murdered. Homicide is currently high among the 5 leading causes of childhood mortality, accounting for 1 out of 23 deaths for those younger than 18 years. More young children (birth through 4 years) now die from homicides than from infectious disease or cancer, and homicides claim the lives of more teenagers than any other cause except accidents. However, since 1993, juvenile homicide joined the general trend of homicide since 1991 and began to drop (Figure 3-1).

Overall, juvenile homicides are among the most unequally distributed form of child victimization, with certain groups and localities experiencing the overwhelming brunt of the problem. Minority children are particularly affected, with nonwhites making up 52% of all child homicide victims.⁴ Even after the recent decline, overall rates for black children (9.1 per 100 000) and Hispanic children (5 per 100 000) dwarf the rate for whites (1.8 per 100 000) (Figure 3-2). The distribution is uneven geographically, as well. The states with the highest rates (Nevada, Illinois, and Louisiana) have rates 6 times higher than those with the lowest rates (Table 3-1). The District of Columbia has 9 times more child murders than the national average.

International Child Death Review Teams: Australia, Canada, and the United Kingdom

Child death review in the United States is discussed in detail throughout this text. This chapter provides an overview of child death review in 3 English-speaking countries outside the United States: Australia, Canada, and the United Kingdom. These countries have cultural similarities and differences, and their legal systems have evolved in slightly different ways over the years, leading to unique child death review processes in each country.

Australia

Australia has a landmass almost 32 times greater than that of the United Kingdom and 85% of that of the United States. However, the population is relatively small at 20 264 082,¹ which is just 7% of the population of the United States. Most of the population is concentrated in the coastal regions, especially the east coast, with 72% of the population living in state or territory capital cities. For example, Sydney and Melbourne, on the east coast, have populations of 4 million and 3 million, respectively. Twenty-five percent of the Australian population comprises children and young people aged 17 years and younger.

Indigenous settlement occurred over 40 000 years ago, leading to a very sophisticated culture appropriate for survival in areas where the climate can be hostile and the terrain barren. European settlement did not occur until just over 200 years ago. As a result of immigration, Australia is a multicultural society, with 25% of the population having been born outside Australia.

The 2 most established child death review teams (CDRTs) in Australia are in the states of New South Wales (capital Sydney) and Victoria (capital Melbourne). The Victoria Child Death Review Committee was established in 1996 with a particular focus on reviewing the deaths of child protection service clients. New South Wales also established a child death review team in 1996. It is the most comprehensive in Australia, because it looks at every death in New South Wales through the age of 17 years.

After an inquiry into how government agencies respond to complaints of family violence and violence in Aboriginal communities, the government of Western Australia established a child death review committee in 2003. It has the task of reviewing all deaths of children known to the Department of Community Development. Later that year, an Advisory Council of the Prevention of Deaths in Children and Young People was established with the aim of reporting on current trends in child deaths in Western Australia and identifying gaps in knowledge so as to make recommendations about preventing such deaths.

Queensland has a child death review process that allows the director-general of the Department of Families to appoint a review of the death of a child known to the department, but it does not have a comprehensive child death review team. South Australia and the Australian Capital Territory have recommended that a process for reviewing child deaths be set in place, modeled on the New South Wales Child Death Review Team. The Northern Territory and the state of Tasmania do not currently have a formal mechanism for reviewing child deaths.

The Victorian Child Death Review Committee was established as a government ministerial advisory committee and first met in 1996. Membership was drawn from health, welfare, law enforcement, legal, and academic fields, with appointments being made by the minister for the Department of Human Services. Its duties include²:

• Review departmental inquiry reports of children and young people who died while current or recent clients of the child protection service in Victoria and advise the minister for children and minister for community services of the committee’s deliberations.
• Identify particular groups of child deaths that may benefit from further investigation or research.
• Analyze and comment on any themes, trends, or patterns that emerge from the review of inquiry reports.
• Comment on service and system responses to children and families arising from the review of inquiry reports and receive feedback on the implementation of service system reforms.
• Provide advice to the minister for children and minister for community services on the child death inquiry process.
• Prepare an annual report.
• Perform other functions in relation to child deaths as directed by the minister for children and minister for community services.

The Victorian Child Death Review Committee’s task is not to look at all deaths in the state or even at all deaths secondary to abusive injury. Rather, it is a means of carefully reviewing deaths of children who have been known to child protective services, recognizing the complexity of the needs of many of these children and their families (such as parental drug addiction, family violence, mental illness, disability, and past child abuse). The committee is then able to advise the minister about child protection services and the system responses to children and families considered to be at risk and to make recommendations for providing responses.

The Role of Mental Health Professionals

Historically, the mental health profession has provided leadership and set structure for the development of the child fatality review process. The first large-scale, systematic child death review team (CDRT) was created in 1978 by a child psychiatrist, Dr. Michael Durfee, in Los Angeles County.^1,2 Led by Durfee, this team set the standard for CDRTs by gathering a multidisciplinary group of professionals to review child fatalities associated with suspicious, vague, or violent circumstances. Since then, CDRTs have expanded across the country and internationally, all with the same universal goal: to understand how and why children die and to prevent future fatalities.³

Although the goals of CDRTs are generally the same, the specific review process varies from state to state. For example, in 47 states CDRTs review all child abuse and neglect deaths; 41 states also review selected categories of deaths involving children due to other homicides, accidents, suicides, and natural causes. The reviews can be conducted at local and/or state levels; 2 states have only local reviews, 17 states conduct reviews at the state level, and 37 states have local and subsequent state reviews. States conduct reviews based on chosen age ranges with the maximum age ranging from 14 years (n = 1) to 25 years (n = 1). The majority of states (n = 40) review deaths from birth through the age of 17 years.⁴ The role of mental health professionals may differ based on the functions of teams. Teams that conduct selective reviews could benefit from having mental health professionals with specialized training in those selected areas. For example, teams that only review deaths of children younger than 1 year would benefit from having mental health professionals who specialize in infant development, infant-parent attachment, postpartum maternal depression, and prenatal substance abuse. For teams that primarily review cases of child maltreatment deaths, having mental health professionals with specialized knowledge and training in the area of child abuse and neglect would be useful. The majority of CDRTs are involved in reviews after the legal investigation of children’s deaths have occurred; however, 7 states have teams that are involved during the initial investigation process. For teams actively involved in the legal investigative phase of cases, mental health professionals with experience in forensic assessment and forensic mental health would be helpful.

National surveys of CDRTs report that state and local teams are universally multidisciplinary and typically include representatives from the mental health field.^3,4 Various professionals from the mental health field may be involved with CDRTs, including psychiatrists, psychologists, social workers, counselors, and therapists, with a range of specialties in the areas of families, children, adults, forensics, and child welfare. Mental health professionals on CDRTs may be from the private practice sector, academic or medical institutions, or specific agencies such as child advocacy organizations, hospital child protection teams, child abuse prevention programs, community mental health centers, domestic violence programs, substance abuse treatment programs, school districts, or state departments of health or mental health.

The professionals within the mental health field have a range of contributions they can offer to CDRTs. Some of these contributions are universal to all mental health professionals, such as backgrounds and experience in mental health disorders, treatment, and diagnoses. Through graduate education, psychologists, psychiatrists, social workers, and other mental health professionals are exposed to research methods and statistics. This research background can be critical to establishing data systems that document cases and manners of death. Mental health professionals with these skills can help establish computer-tracking databases that use statistical methods so teams can identify child fatality trends over time.

Mental health professionals have many skills and expertise to contribute to CDRTs. Their unique contributions will vary based on their specific disciplines and specialized training. Psychiatrists have backgrounds in medicine and mental health and are in positions to provide information on the connections between them. They have knowledge about mental illness and psychotropic medications that can help CDRT members understand important aspects of cases. Psychiatrists have extensive training in identifying and diagnosing symptoms of mental illness, which can be useful in reviewing child fatalities.

Like psychiatrists, psychologists have training and experience in mental health assessment and diagnosing mental illness. By reviewing case records, psychologists can identify symptoms associated with mental illness and provide perspectives on how this may have contributed to children’s deaths. Psychologists have knowledge about clinical treatments and interventions and can provide information related to these topics.

Social workers and counselors have focused training in family dynamics and family systems and may be able to identify critical aspects related to cases. Social workers are traditionally well trained in child welfare policies and can be excellent sources of information in this area. In many cases, social workers on CDRTs may represent child protective services (CPS) and can offer information specific to the field of social work and the child protection system.

This chapter will review the contributions of mental health professionals to the following 4 areas: the CDRT process, the members of CDRTs, other professionals, and communities. The chapter will also discuss ethical considerations for mental health professionals working with child fatalities and CDRTs.

The role of mental health professionals on CDRTs can vary and include a range of areas that contribute directly to CDRTs, specifically in understanding various factors related to children and families, child development, and forensics.

Based on their training and expertise, mental health professionals possess the following qualities:

• A distinct understanding of family dynamics, mental illness, individual motivation, and parent-child relationships
• Advanced clinical knowledge of psychological factors that may be associated with infant and child homicide or fatal neglect, such as maternal depression, parental mental illness, and substance abuse
• Knowledge related to the psychological correlates of child abuse and neglect