- CAN —
- child abuse and neglect
- CECANF —
- Commission to Eliminate Child Abuse and Neglect Fatalities
- CPS —
- child protective services
The death of any child is a tragedy. When that death is caused by abuse or neglect, sorrow is often coupled with anger: How could this have happened? More importantly, was this preventable? A federal commission, the Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF), is working to turn anger into action to stop these tragedies.1
At least 1500 children die every year at the hands of those who are supposed to care for and protect them. We say “at least” because we do not have reliable data about the number of deaths from child maltreatment. There is no national standard for counting these deaths, and the data about child fatalities come from multiple sources that do not coordinate or share data. Most experts, including the US Government Accountability Office, believe that child abuse and neglect (CAN) fatalities are significantly undercounted.2,3
Recognizing that even 1 death from CAN is 1 too many, Congress passed the Protect Our Kids Act that created CECANF in 2012.4 CECANF, a 12-member panel appointed by the president and Congress, began its work in February 2014. Commissioners have 2 years to study the extent and causes of CAN fatalities and to submit a report to Congress that includes concrete recommendations for a national strategy to eliminate CAN fatalities.
In June 2014, CECANF began a series of public hearings across the country. Commissioners reached out to experts from a broad range of disciplines. Local legislators, child welfare leaders, law enforcement officials, federal policy experts, data experts, community leaders, tribal representatives, child and parent advocates, former foster children, and pediatricians have been among those who have testified and offered recommendations to the commission. Their testimony is available on the CECANF Web site.1
CAN Fatalities as a Public Health Crisis
After a child dies or almost dies from abuse or neglect, the lay press and others often focus on what child protective services (CPS) should have done or not done. The reality is that a significant proportion of children are known to CPS before the incident that led to their death or near-death. Part of the reason is that child maltreatment fatalities occur predominantly in young children whose first contact with CPS may be the fatality itself; in 2013, nearly three-quarters of child maltreatment fatalities were in children <3 years of age. Almost half of all deaths were in children <1 year old.5 Testimony provided to CECANF has emphasized that the factors leading to a CAN fatality are complex and that prevention cannot come from any single agency. CAN fatalities and near-fatalities are a public health crisis, not just a CPS crisis.
Most families in which there is a CAN fatality are known to some system. Almost all children are born in a hospital and are therefore known to the medical system because a pediatrician examined them in the newborn nursery and an insurance company paid for the delivery. Law enforcement may know families with a history of domestic violence, the behavioral health system may be involved for parental mental illness, and the education system is aware of families with preschool- or school-aged children. Finally, community and faith organizations are often aware of neighborhood families in crisis. The need for all these systems to work together to eliminate CAN fatalities has been discussed at length by CECANF.
Difficulty sharing information between the agencies listed here can lead to critical information being held in silos and not being available to on-the-ground CPS caseworkers, pediatricians, law enforcement personnel, or other social service providers. If agencies cannot or do not share information, it is difficult to protect children. Although the Health Insurance Portability and Accountability Act explicitly allows physicians to provide child abuse–related information to CPS, it does not allow CPS to share information with the very physicians who have raised concerns and provide medical care to the child. The American Academy of Pediatrics recently submitted testimony to the commission and emphasized the importance of communication between CPS and pediatricians for identification, treatment, and prevention of future abuse and recommended “strong and funded health care liaisons with the child welfare system” to ensure a “coordinated approach to preventing and treating child abuse and neglect.”6 Importantly, there is now precedent for legislation to mandate this type of information sharing. Senate Bill 27, which recently passed in Pennsylvania, established formal 2-way communications between certified medical practitioners and CPS during child abuse investigations and in circumstances that affect the medical health of the child.7
The number of infants and young children who nearly die of CAN, often called near-fatalities, have also been discussed by the CECANF because causes and etiologic characteristics of near-fatalities closely mirrors those of fatalities; strategies designed to prevent CAN fatalities therefore will probably also prevent near-fatalities.8 Twenty states review near-fatality cases in a way that is similar to Child Death Review teams. Dr Joanne Wood, a pediatrician at Children’s Hospital of Philadelphia, testified before the CECANF about near-fatalities and the pediatrician’s role in the diagnosis and evaluation of these cases.9
Looking Ahead and a Call to Action
The CECANF must submit its recommendations to the president and Congress by early 2016. In the time between now and then, >1500 children will die of abuse or neglect. That is more children than will die during this time from all childhood cancers.10 Success in the treatment of pediatric cancer came when multiple groups came together in a unified front. It is time to create that type of unified front to prevent CAN fatalities and near-fatalities. The importance of the medical system, specifically pediatricians, in this effort cannot be overemphasized. Because children who die of abuse or neglect are often young, physicians may be the only people outside the family who routinely see them. Multiple pediatricians9,11,12 testified to the CECANF that pediatricians want to be part of a multidisciplinary approach to accomplish this goal. There are many ways for pediatricians to do so, including following the progress of CECANF, submitting testimony via the CECANF Web site, participating in child death review and near-fatality review teams, encouraging states to collect data about near-fatalities, continuing to collaborate with local and state CPS agencies, advocating for legislation that removes the barriers to sharing information, and finding out where the need is for physician expertise in the community. But as we await the outcomes of such advocacy, there are more immediate opportunities for action. As health care systems move toward integration of services for families, including with the community services, simply screening parents and children for depression or adverse childhood experiences and telling them to seek care if screened positive is not enough. Rather, we will be increasingly accountable to provide more direct links to services in behavioral health for both parents and children, whether through direct partnership with providers or more efficient processes of referral. If pediatricians can engage with community providers in a more fundamental way, we will be further along the road toward building a safe and healthy future for children.
We thank Joanne Edgar and Janet Fromkin, MD, for their help preparing this piece.
- Accepted August 12, 2015.
- Address correspondence to Rachel P. Berger, MD, MPH, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224. E-mail:
Dr Berger contributed to the conception of this piece and drafted the article; Drs Sanders and Rubin contributed to the interpretation of the data contained in the piece and revised the piece critically for important intellectual content; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: Dr Berger’s salary is partially paid for by the Commission to Eliminate Child Abuse and Neglect Fatalities. The other authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- 1.↵Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF) Web site. Available at: https://eliminatechildabusefatalities.sites.usa.gov/
- 2.↵US Government Accountability Office. Strengthening national data on child fatalities could aid in prevention. Report to the chairman, Committee on Ways and Means, House of Representatives. Available at: www.gao.gov/new.items/d11599.pdf
- 3.↵Child abuse and neglect deaths in America. 2012. Available at: www.everychildmatters.org/storage/documents/pdf/reports/can_report_august2012_final.pdf
- 4.↵The Protect Our Kids Act of 2012. Available at: www.gpo.gov/fdsys/pkg/PLAW-112publ275/pdf/PLAW-112publ275.pdf
- 5.↵Children’s Bureau (Administration on Children, Youth and Families, Administration for Children and Families) of the US Department of Health and Human Services. Child maltreatment 2013. Available at: www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf
- Hassink S
- 7.↵Improving the exchange of child abuse information among medical practitioners and county agencies 2013–2014. Available at: www.legis.state.pa.us/CFDOCS/billInfo/billInfo.cfm?syear=2013&sInd=0&body=S&type=B&bn=27
- Sanders D
- Wood J
- 10.↵American Cancer Society. Cancer in children. 2012. Available at: www.cancer.org/Cancer/CancerinChildren/DetailedGuide/cancer-in-children-key-statistics. Accessed June 5, 2015
- Palusci V
- Wells K
- Copyright © 2015 by the American Academy of Pediatrics