Origins and clinical relevance of child death review teams - includes related material

Children Today,  March-April, 1992  by Michael J. Durfee,  George A. Gellert,  Deanne Tilton-Durfee

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Interagency child death review teams have emerged in response to the increasing awareness of severe violence against children in the United States. Since 1978, when the first team originated in Los Angeles, Calif, child death review teams have been established across the nation. Approximately 100 million Americans or 40% of the nation's population now live in counties or states served by such teams; most have been formed since 1988. Multiagency child death review involves a systematic, multidisciplinary, and multiagency process to coordinate and integrate data and resources from coroners, law enforcement, courts, child protective services, and health care providers. This article provides an introduction to the unique factors and magnitude of suspicious child deaths, and to the concept and process of interagency child death review. Future expansion of this process should lead to more effective multiagency case management and prevention of future deaths and serious injuries to children from child abuse and neglect.

(JAMA 1992;267:3172-3175)

Over 1000 American children the each year of intentional injuries at the hands of a caretaker (P.W. McClain, MS, J.J. Sacks, MD, MPH, R.D. Froehlke, MD, A. D. Ewigman, MD, oral communication, April 1992)[1] Most are infants or young toddlers.[2-4] No single health, social service, law enforcement, or judicial system exists to track and comprehensively assess the circumstances of child deaths.[5] This article describes the expanding national implementation of interagency multidisciplinary child death review teams in response to the critical need for systematic evaluation and case management of suspicious child deaths.

Magnitude of the Problem

It is difficult to estimate the incidence of fatal child abuse using traditional data systems.[6] Available statistics reflect varied levels of competence in detection, evaluation, and recording of child deaths and variation in definitions used by different agencies. The National Committee for Prevention of Child Abuse, which annually surveys all states, reported a national incidence of 1383 child abuse facilities for 1991.[1] The National Committee for Prevention of Child Abuse survey does not utilize a rigorous case definition and excludes cases not known to social service departments or other child abuse agencies. The Centers for Disease Control uses vital statistics and Federal Bureau of Investigation Uniform Crime Reports to arrive at an annual national figure of about 2000 child fatalities from abuse or neglect (P.W. McClain, MS, J.J. Sacks, MD, MPH, R. D. Froehlke, MD, A.D. Ewigman, MD, oral communication, April 1992). In Los Angeles County, California, 14 years of multiagency child death review suggests that the numbers will increase as abuse-related fatalities are more accurately identified and reported.

Unique Factors in Child Death

Death scene investigators evaluating adult victims may follow protocols fairly objectively. First responders to an imminent or actual child death scene, however, may be swept up in an intense focus on providing life support for the victim and emotional support for the victim's family. Even when it becomes apparent at the hospital that the circumstances of death are suspicious, delays may occur before an investigator returns to the scene of the event, or investigators may visit only the hospital and request that the medical staff interpret the death.

Criminal investigation of a child death caused by a caretaker is unique for investigators, since the perpetrator is legally responsible for the child and has continuous access to the victim. This contrasts with the majority of adult homicides where the victim and perpetrator are not cohabiting at the time the injury causing death is perpetrated. Child deaths may also result from the neglect of children by caretakers who are expected to provide for the child victim's biological needs. The concept of not feeding, protecting, or otherwise providing for the unique needs of, a young child may be difficult to comprehend for a homicide detective with no child abuse training.

Most suspicious child deaths occur among very young children. Studies of "fatal child abuse" or of "homicide by caretaker" indicate that 50% of the victims are under 1 year of age.[2-4] These young victims may have no previous records or only medical records that are not frequently accessed as part of the death investigation. Autopsies of young children require a specialized understanding of pediatrics, pathology, child abuse, and forensic investigation. Few jurisdictions have such experts. Autopsies may be conducted by physicians with no formal pathology training, much less specialization in forensic pathology.[7] Radiological and laboratory equipment for clinical or forensic tests may make a diagnosis possible,[8,9] but these tests may be unavailable locally or may not be ordered to reduce costs.

The above factors contribute to inappropriate surveillance, potential under-reporting, misclassification, and mismanagement of child deaths. Case management is further confounded by problems in interagency communications. An extreme example of a case lost in multiple systems involved a 10-month-old infant whose family had 52 agency contacts before the child was eventually beaten to death. Contacts included law enforcement, child protective services, hospital emergency departments, public health nurses, and a psychiatric emergency team. Most individual agency actions appeared reasonable, but no single agency had a comprehensive and collective record of contacts with the family.