Public health surveillance of fatal child maltreatment: analysis of 3 state programs

Objectives. We sought to describe approaches to surveillance of fatal child maltreatment and to identify options for improving case ascertainment.Methods. Three states—California, Michigan, and Rhode Island—used multiple data sources for surveillance. Potential cases were identified, operational definitions were applied, and the number of maltreatment deaths was determined.Results. These programs identified 258 maltreatment deaths in California, 192 in Michigan, and 60 in Rhode Island. Corresponding maltreatment fatality rates ranged from 2.5 per 100000 population in Michigan to 8.8 in Rhode Island. Most deaths were identified by child death review teams in Rhode Island (98%), Uniform Crime Reports in California (56%), and child welfare agency data in Michigan (44%). Compared with the total number of cases identified, child welfare agency (the official source for maltreatment reports) and death certificate data underascertain child maltreatment deaths by 55% to 76% and 80% to 90%, respectively. In all 3 states, more than 90% of cases ascertained could be identified by combining 2 data sources.Conclusions. No single data source was adequate for thorough surveillance of fatal child maltreatment, but combining just 2 sources substantially increased case ascertainment. The child death review team process may be the most promising surveillance approach.Child maltreatment causes a significant number of fatalities in the United States, and accurately determining the number of maltreatment-related deaths each year remains a challenge. With data from child protective services agencies, the National Child Abuse and Neglect Data System estimated there were nearly 1500 child abuse–related or neglect-related deaths in 2004 (2.0 per 100 000 children).1 However, child protective services data are known to underestimate maltreatment deaths for a variety of reasons including difficulties identifying, investigating, and reporting deaths to child protective services; lack of standard definitions of child maltreatment; and differing legal standards for substantiation of maltreatment.2^,3In the United States, a death certificate is the official record of death. Death certificates include a determination of the cause and manner of death and are often used to summarize the mortality burden of injuries and diseases. It is, however, well documented that these vital records underestimate the magnitude of fatal child maltreatment.3^–6 In fact, 50% to 60% of all child maltreatment deaths are not identified as such by death certificates,3^,5^,6 with 1 report estimating that 85% of deaths related to child maltreatment are recorded on the death certificate as attributable to other causes.7The combination of data from multiple sources to obtain more accurate identification of individuals with the condition under surveillance (i.e., case ascertainment) has enhanced public health surveillance of injuries and violence8^–11 and has shown promise as a method for obtaining more accurate estimates of mortality related to child maltreatment.3^,6 In September 2001, the Centers for Disease Control and Prevention (CDC) funded programs in 3 states—California, Michigan, and Rhode Island—to develop and evaluate public health surveillance of fatal child maltreatment through the use of multiple data sources for case ascertainment. We describe the approaches taken in these programs and summarize the epidemiology of fatal child maltreatment. Because underascertainment of fatal child maltreatment by both child protective services and death certificate data are well documented, we focused on the relative utility of additional data sources available for surveillance and explored various options for improving case ascertainment. Four of the authors took part in the state programs (T. M. C. and V. J. P. in Michigan, S. J. W. in California, and W. V-O. in Rhode Island). By summarizing options for surveillance based on their experiences, we hope to provide useful information to other states interested in establishing surveillance for fatal child maltreatment.