Sounding Board Questions and Answers

ALABAMA
Submitted by Bob Hinds

Q: How is 100% participation from all local Child Death Review (CDR) Teams in Alabama achieved?

A: Although Alabama has not achieved this 100% participation goal as yet, we are getting much closer. We have climbed from a 64% case review rate in 1998 to a rate of more than 80% in 2003 and 2004. Many endeavors, some painful, some not, have worked together to achieve this progress. Our State CDR law requires that every District Attorney (DA) in our State form a CDR Team. The statute also requires each Team to meet a minimum of once per year. The great majority of our DA’s conform to this requirement. They do so because the law requires it, but also because they believe in what we are doing and are seeing the benefits of CDR. However, there is a very small minority who, for whatever reason, has not chosen to comply. And since there are no “or else” provisions in our law, there are no “teeth” in the statute to force compliance; therefore, we’ve had to adopt “other” measures to try to achieve full participation. Because publicity seems to be our best tool in this fight, the following “other” measures involve public awareness issues of some sort and have proven to be at least somewhat effective.

First we began publishing monthly and/or quarterly “Status of Cases Reports” that we send to each Team detailing the status of all cases that all Teams are obligated to review. In addition we began publishing a year-end “Status of Cases Report” in all of our Annual Reports. We use a color-coded, county-by-county, state map to show how well (or how poorly) each Team is performing.

In addition, we have found that having at least one State legislator on our State CDR Team (our “Board of Directors”) always comes in handy. A personal letter from a State Senator/Representative to the inactive DA usually generates some sort of reaction...sometimes a good reaction and sometimes a not so good reaction.

Finally, a personal visit from the CDR Director to offer assistance and answer questions has helped clear up many misconceptions. When we first began CDR, many DA’s felt threatened by CDR, but these personal visits and time-generated exposure to the beneficial results of CDR have helped to dispel, though not entirely eliminate, many of these fears.

As we have said, Alabama has not reached the goal of 100% team participation…but that will always be our goal! Of course it goes without saying that, regardless of the goal or the method used to attain the goal, it is very important to always maintain a cordial relationship…or as cordial as possible…with all Team members.

Q: How do you ensure that a quorum of members attends the statute-required quarterly State CDR Team meeting?

A: This again is not something that the Alabama CDR has achieved 100% of the time. But our record is improving in this area as well. Alabama’s CDR State Team is required by law to meet quarterly. Our law also requires fifteen of the twenty-eight member Team to be in attendance to achieve a quorum. By design the State Team is made up of many different people from many different agencies, including nine private citizens who are appointed by the Governor. These twenty-eight members come from varied backgrounds and live in all areas of our state. Only nine of these members are allowed to send a “proxy” to attend in their place. All these factors make it difficult to achieve the attendance required.

We attempt to achieve our quorum through several measures: 1) Immediately following our current meeting we post a notice on our web site announcing the date of our next meeting; 2) We send out e-mail and fax “Save the Date” notices 5-6 weeks prior to each meeting; 3) We mail the minutes of our last meeting with details of the coming meeting one month prior to our next meeting; 4) One week prior to the meeting, we call each member and see who is coming and who is not; and finally, 5) We keep a list of all members who are authorized to send proxies. If needed, we call those non-attending, proxy-authorized members back and have the non-attending member appoint someone to vote on matters in his/her absence.

In addition, because our statute permits it, we have recently started making use of video conferencing equipment to allow members to attend our meetings without having to face the long drive to our main location. We have also started moving our meeting site to different regions of the State so that the same people are not always forced to make the long drive to our meetings.
The challenge of achieving a quorum is a continuing problem for us, particularly when Team vacancies are not filled in a timely manner. It helps tremendously to have Team members who are willing and able to use their personal contacts to complete our State Team.

CALIFORNIA
Submitted by Craig Pierini

Q: What is the role of the California State Child Death Review Council (SCDRC) and what agencies make up its membership?

A: The role of the SCDRC is to oversee the statewide coordination and integration of state and local efforts to address fatal child abuse and neglect and to create a body of information to prevent child deaths. In order to fulfill these responsibilities, the SCDRC produces a directory of local teams, and an annual report that includes information on local Child Death Review Teams, data on child deaths in the state, and data from the Fatal Child Abuse and Neglect Surveillance Program (FCANS).

FCANS was implemented by the California State Department of Health Services and is monitored by the SCDRC. In addition, the SCDRC supports training and technical assistance to local teams through funding from state agencies and by a current grant with the Inter-Agency Council on Child Abuse and Neglect. The SCDRC does not review individual cases.

The current membership of the SCDRC consists of representatives from the California Department of Justice, California Department of Health and Social Services, the Governor's Office of Emergency Services, County Welfare Director's Association, California Homicide Investigator's Association, California District Attorney's Association, California State Coroner's Association, Maternal, Child and Adolescent Directors, California Conference of Local Health Department of Nursing Directors, Prevent Child Abuse-California, Inter-Agency Council on Child Abuse and Neglect and two regional representatives.

Q: Do local child death review teams receive any funding from the SCDRC or other state agencies?

A: All California child death review teams exist primarily through contributions from local resources. However, at the current time, teams do receive some compensation for each FCANS form they submit to the California Department of Health Services. FCANS was designed to gather relevant data to assist local teams in reducing the likelihood of future child abuse deaths and other preventable causes. In addition, a grant from the Governor's Office of Emergency Services was recently released that provides support for team functioning and development. This one-year allocation is made available to local teams on a regional basis, with the possibility of additional future funding, if available.

EMERGENCY MEDICAL SERVICES
Submitted by Paul Maxwell and Josh Krimston

Q: Why should EMS professionals be on CFR Teams?

A. CFR teams are tasked with looking at different parts of a "puzzle" to determine the whole picture. When children are injured or killed, fire department and emergency medical services (EMS) personnel are dispatched to the scene. These "first responders" are, in most cases, the first professionals to make contact with the victim, family members and others. We believe that EMS professionals are often overlooked and consider them to be a crucial source of potentially useful information.

Paramedics and EMTs are, by nature, investigators. Paramedics and EMTs are trained to, within seconds of arrival, sift through a barrage of information and prioritize the most important details related to the history of the event. EMS professionals that sit on a CFR team can offer insight into field medical treatment including local protocols and policies. This can be useful in determining why a patient was transported or pronounced, intubated or not, etc… CFR team members with an EMS background can guide the team to sources of often overlooked first hand information, including paramedic patient care reports, and help interpret their findings.

Nearly every community in the United States has a local component of EMS personnel. These professionals, with backgrounds in emergency medicine, mechanism of injuries, scene assessment, abuse recognition and injury prevention are likely to be major contributors in a CFR team’s quest for the truth.

ILLINOIS
Submitted by Sherrie Barr

Q: What should occur when a member has professional or personal involvement in the case being reviewed by the child death review team upon which they sit. Should that member be involved in the review?

A: As of July 2004 the Illinois Child Death Review Executive Council passed Ethic guidelines to be included in their Best Practice regarding this issue. The following is a excerpt of these guidelines:

1. The avoidance of real or perceived conflict of interests is essential to the integrity of the work of child death review teams. To avoid real or perceived conflicts of interest team members will recuse themselves from case reviews, and not have access to case material related to the case (through the CDRT team review process), after having been retained by legal counsel on that case. Alternatively, team members will refrain from being hired to serve as a consultant on cases that they have reviewed.

2. Team members are asked to discuss any possible ethics concerns, including potential conflicts of interest, with the Chairperson of their team. Likewise, Chairpersons are asked to bring any ethics concerns to the Executive Council for discussion. Violation of ethics guidelines (CDRT, State of Illinois or professional guidelines), as related to the work of child death review, may lead the Executive Council to recommend to the Director of DCFS that the team member be removed.

Q: What occurs once the CDRT makes and submits their official recommendations?

A: Per Illinois, CDRT legislation all recommendations are sent to the Director of the Illinois Department of Children and Family Services (DCFS). The Director is mandated to respond to these recommendations. DCFS has a committee that conducts research into the recommendations and the responses. The committee is comprised of Associate Deputy Directors from many different divisions within the Department thus providing a holistic approach to the responses. These responses are then sent to the Director's Office for final approval. Once approved these responses which includes the course of action that the Department will take regarding the issue are sent out to the appropriate team chair person.

INDIANA
Submitted by Suzanne O’Malley

Q: My child died but the prosecutor only charged Battery. Why isn’t it Murder?

A: In the State of Indiana we have several potential charges for the death of a child. One of our newest charges is Battery causing the death of a child under the age of fourteen (14), which is a class A felony. This carries a penalty of 20-50 years and is probably charged most often in cases where a child was killed by inflicted injury. This charge on its face doesn’t sound as serious as Murder to many families, but in some cases can carry an equally substantial penalty.
Battery causing the death of a child is a strong charge and is more likely to result in a conviction than Murder. The requirements a prosecutor must prove are that a particular person who is at least eighteen years old, knowingly or intentionally touched another person in a rude, insolent or angry manner that resulted in the death of a person less than fourteen (14) years old. To prove the charge of Murder, a prosecutor must show that the defendant intended to kill the child or was aware by a substantial certainty that their actions would kill the child.
Proving the “Intent to Kill” aspect of Murder is extremely difficult in cases where the child died from means that are not normally associated with a deadly weapon. In other words, when you shoot someone with a gun, a jury is more likely to believe you wanted them dead than when you use your fist. However, jurors will accept that striking, kicking or shaking a child is a battery, making it a charge for which it is much easier to convict.

Q: When a child dies due to bad parenting, why aren’t those parents charged with a crime?

A: Bad parenting isn’t against the law, Neglect of a Dependant is. The difference between the two is the intent of the caretaker. There are many times when a parent uses poor judgment that doesn’t rise to the level of Neglect.
Here in Indiana, the most used portion of our Neglect statute states a caretaker must knowingly or intentionally place a child in a situation that does endanger their life or health. The intent element is based on the perception of the caretaker and not on what a reasonable person might think. To illustrate this point, let me give you two examples.

Example one: A parent puts their two year old in a second story bedroom. The room has a window which is located a foot off the floor but the window is closed and locked. Is this neglect? Probably not.

Example two: Same scenario as example one, but this time the parent sees the two year old walk over to the window, flip the lock, push open the window, and throw out a toy. The parent closes the window. The two-year-old walks over, opens the window again, and throws out another toy. The parent shuts the window and leaves the two year old alone in the room. The two year old opens the window, throws out a toy, loses his balance and falls out.

Under the second scenario the parent has the knowledge that his child can open a locked window, that the child is fascinated by the window, that the child likes to throw things out the window, and that the window is a foot off the floor. The parent also knows that this is a second story window and that a fall from this window could injury his child, yet the parent still leaves the child unattended.

The intent of the caretaker is what makes seemingly bad parenting rise to the level of a crime.

MONTANA AND BUREAU OF INDIAN AFFAIRS
Submitted by John Oliveira

Q: Do child fatality investigations differ on reservations?

A: Yes and no. While the procedures for processing a death scene are consistent with national practices, cultural dynamics do play a role in some areas of the investigation. Often, investigators must be familiar with cross-cultural issues such as religion, customs or traditional rituals, like smoking out a house, not speaking of the dead or a no autopsy belief. These all may affect the outcome of an investigation or integrity of a scene. In most cases investigators will have to balance ethical and legal responsibilities with cultural sensitivity.

Q: Are there higher rates of child fatalities in Indian Country compared to the rest of the United States?

A: Unfortunately, there is insufficient data to provide a clear answer as to whether there is a higher rate of child fatalities in Indian Country. However, it could be deduced that because existing data pertaining to those risk factors most common with high rates of child fatalities such as substance abuse, child abuse, domestic violence, use of restraint systems and driving under the influence are all significantly higher on reservations than the rest of the U.S., the fatality rates are higher. Other factors such as isolation and lack of adequate medical facilities may also contribute to a potentially higher rate of child deaths.

Currently the U.S. Bureau of Indian Affairs is in the process of establishing Child Fatality Review Programs throughout Indian Country to better understand the child death issues on the reservations and potential preventive strategies to reduce the current numbers.

NORTH CAROLINA
Submitted by Marcia Herman-Giddens

Q: Are children in military families where one or both parents in active duty at higher risk of being a victim of a child abuse homicide?

A: Data from NC show children in these families living in the two counties with the largest installations have over twice the risk (~5.0 per 100,000 per year) than children in the state as a whole (2.2 per 100,000). Unfortunately, there are no data from other states and military installations. It is important that further research be conducted. Obtaining child abuse fatality data requires individual record review and is, therefore, time and labor intensive. Data is required for a number of years to provide numbers adequate for statistical stability. Some states may have now collected data for 5 years or more and could begin to look at this. As of December 2004, there is no indication that the Department of Defense is undertaking such a study.

Q: Do states' child protective services (CPS) check national criminal records (especially for violent crimes) for caretakers of children in their investigations?

A: Probably not ,according to an informal inquiry through a child abuse list-serv. There is no legal access to records from other states that the caretaker may have lived in by CPS workers. In North Carolina, we know from fatality reviews that some children have been killed after being left with or placed with a parent who had a history of violent crimes committed in other states. There was and is no way for CPS to check at this point. It is likely that some fatalities of children in other states are related to this lack. Federal legislation needs to be enacted to not only allow for a system of checking but to mandate checks. A bill, HR 3972 was introduced last year by Rep Foley from Florida. Unfortunately, it is still sitting in the House Subcommittee on Crime, Terrorism, and Homeland Security. Every state needs to help with this bill by getting their representatives to sign on and support it. Other measures are needed as well to get this enacted.

NORTH CAROLINA AND MILITARY
Submitted by Ray Sanders

Q: When should a child death be reviewed?

A: A child death should be reviewed at the local level as soon as possible (ASAP) after the death. It should be recommended that all reviews be done the month immediately following the death. This presents a unique multi layer approach to problem solving.

• This time frame allows for all reports (LE, Coroner/ME, DSS, Mental Health and any other lingering report to be done). If we are talking about identifying systemic problems we don't want to make the "review process" one of them.

• This manner of review allows for a quicker response time to develop and implement prevention strategies while the topic is hot.

• It empowers the local agencies to fix those systemic problems that may have gone awry during the life of the child. The longer you wait to review the more imbedded the problem gets in the system. The next child death may have similar issues that could have been resolved at an earlier moment.

• The quicker we can educate the public to an ongoing issue the quicker we can save the next life.

• Ongoing LE/DSS-CPS investigations may benefit from important discussions during the review and improve or enhance overall investigation procedures.

Q: What should be done to better work with neighboring states?

A: Follow this procedure:

• Contact and meet with the sate coordinator from your bordering states

• Discuss those issues that are common to you all

• Develop some achievable goals that can be done quickly

• Get your superiors involved in discussing ways to helping to develop some MOA's/MOU's that may assist in cross border investigation and collaboration of agencies

• Develop some cross border prevention strategies

• Look at data in each state and find some similarities or differences in approaches to systemic issues. This will also allow some common standardization of data, language and investigative processes

• Develop some type of coalition so as to be able to meet regularly to keep some of the above items n the forefront

• Touch base with the national offices in California and Michigan to assist you in developing plans and strategies for a more efficient Child Fatality Review Process

OKLAHOMA
Submitted by Tricia Gardner

Q: What is a Near Death Review, how were the criteria established and what is the review protocol?

A: On April 6, 2000 the legislation that created the Oklahoma Child Death Review Board (OCDRB) was amended to include the following information: “conduct case reviews of deaths and near deaths of children in the state.” In addition, the legislation also included the statement “As used for this section, the term [near death] means a child is in serious or critical condition, as certified by a physician, as a result of abuse or neglect.” As a result of this amended legislation, the OCDRB approached the mandate to review Near Deaths by creating a committee to determine what cases should be reviewed. It was determined that the focus would be on children who are injured due to child abuse and neglect and as a result of that injury are admitted into intensive care. The local hospitals have been informed of these criteria and have been asked to pass information onto the OCDRB when an event occurs. The OCDRB created a Near Death Form to be used when reviewing these cases. The information gathered is similar the data collected on child deaths. A copy of this form is also attached.

Q: Do the availability of services for mental health and substance abuse services effect the rate of child fatalities?

A: Oklahoma had the highest rate of serious mental illness (11.4%) in 2002 based on a survey conducted by SAMHSA entitled the National Survey on Drug Use and Health. There are approximately 3.6 million people in Oklahoma – 11.4% of the total population equals 410,400. Yet in a report released by SAMHSA based on 2003 data, there were only 9,373 patients who received treatment that year (including inpatient, outpatient and hospital stays for both mental health and substance abuse issues). The Oklahoma Department of Human Services recently reported that 88% of the child welfare cases in the state involve substance abuse, mental health issues, or both. In the State Infant Homicide Data: A Comparison by Population conducted by NCFR, Oklahoma ranks 5th among all states. In addition, Oklahoma is consistently listed by the National Clearinghouse on Child Abuse and Neglect Information as among the states with the highest rates of fatalities due to neglect. While this is not a full-research study, and there are no resources available at this time to conduct such a study, this information would lead one to believe there is a correlation between services available and the number of child deaths in a state, especially those due to neglect circumstances.

SOUTH CAROLINA
Submitted by Sherry Henne-Stieber

Q: What is the Mission of the Citizen Review Panels?

A: The mission of the Citizen Review Panels is to assure that children and families in the community are provided the best possible services within the context of available resources and that children are protected from maltreatment. This mission will be achieved when the broader community has an understanding of, and a voice in 1) evaluating and assessing the child welfare system, 2) advocating for the effective discharge of the responsibilities of the Child Protective Services system (and those of other community agencies that support the child welfare system), 3) advocating for the strengthening of necessary resources, 4) recommending and advocating for policies and procedures that promote high quality practice, and 5) emphasizing cross-system problem-solving to enable effective changes.

Q: What is the Purpose of Citizen Review Panels?

A: The purpose of Citizen Review Panels is to provide independent, unbiased oversight to the State’s child protective services system, identify system strengths and weaknesses and make recommendations for change. The intent of the program is to integrate the work of local citizens, consumers and child welfare professionals representative of agencies and groups involved with the child welfare system to work on the problems of child abuse and neglect, including prevention and treatment services to children and families. The creation of the Citizen Review Panel Program is an acknowledgement that protection of our children is the responsibility of the entire community, not a single agency. As such, the CPS system is the interactions of numerous agencies and individuals. While the Department of Social Services may be the primary focus of oversight, the Citizen Review Panels shall take into consideration the impact of these other entities and assess whether they support or hinder the state’s efforts to protect children from abuse and neglect. The entire community has a stake in protecting the safety of its children.

Each Citizen Review Panel is charged with developing methods by which to conduct a systemic review of:

• The Child Protective Services Agency’s compliance with the state

• CAPTA Plan. CAPTA is the federal Child Abuse Prevention and Treatment Act governing grants to States to improve the state and local Child Protective Services system. Financial support from CAPTA is contingent upon the State’s meeting the requirements outlined in the CAPTA legislation and its amendments

• The coordination of child protection programs with the foster care and adoption programs

• The review of child fatalities and near fatalities, and

• Any other criteria the panel considers important

TENNESSEE
Submitted by Clark Flatt, The Jason Foundation, Inc.

Q: With youth suicide being the THIRD leading cause of death for our youth ages 15-24 and the SECOND leading cause of death for college-age youth, why have we not heard more about this tragedy, and how we can address this national health problem?

A: Part of the problem lies in the stigma of mental health treatment in our nation. Parents and youth both are hesitant to ask for mental health treatment. Secondly, related to the stigma associated with mental health treatment, is the stigma and darkness that surrounds the “S” word – Suicide.

The Jason Foundation, Inc. (JFI) utilizes a national awareness campaign that strives to de-stigmatize mental health treatment as well as bringing to light the problem of youth suicide as a national health problem. JFI’s program includes PSA’s – both television and print – as well as “Awareness” seminars. JFI has an aggressive advocacy program working through key political and social/athletic individuals. By addressing the “S” word in an informational/educational manner, we take away some of its myths.

Q: How do we get programs of awareness and prevention to students, educators/youth workers, and parents?

A: JFI believes in a national campaign through “grassroots” organizations. In the past three years, we have developed with support form our National Clinical Affiliate Ardent Health Services a network of twenty-five regional offices. These offices coordinate JFI’s mission with local political and educational individuals/organizations as well as to build a collaborative effort with local organizations such as crisis centers, mental health organizations, and others who work toward youth suicide prevention. JFI firmly believes that only through collaboration will we – our nation – be successful in the fight against youth suicide. By building these collaborative efforts on a local basis, we are able to provide our programs on the grass-root level in coordination with other groups – working and supporting each other.