The CDC calls the infant mortality rate — which measures how often children die before their first birthday — “an important marker of the overall health of a society.” So when the rate increased in 2022 for the first time in 20 years, national media and the public took note. Increases in child and adolescent deaths due to drug use, suicide and gun violence have also received significant attention and remain a focus of prevention efforts.
But in the face of what appears to be a real, and sustained, national increase in deaths due to child abuse and neglect (a trend that continues as states begin to release data for 2023-2024), there remains strong resistance among child welfare scholars, advocates and national leaders to discussing maltreatment fatalities.
Nearly a decade has passed since the first hearing of the National Commission to Eliminate Child Abuse and Neglect Fatalities. Its report, Within Our Reach, called to “improve collection of data about child abuse and neglect fatalities.” But little progress has been made. Information about how and why children died remains scattered across various sources — media articles, state-released fatality reports, and death reviews from other entities. States continue to vary greatly in how they investigate child deaths — and what information they release.
We are part of a new project, Lives Cut Short, that seeks to re-energize efforts to prevent maltreatment fatalities through improved data collection, timely notifications of child deaths and greater transparency. Unfortunately, efforts to make fatalities a significant part of the conversation are often met with resistance. This opposition is founded on several inaccurate perceptions — and a misguided belief that we can reduce stigma by keeping conversations about child safety behind closed doors.
Are Child Maltreatment Deaths Rare?
The reality is that we do not know how often fatalities caused by maltreatment occur, because there is no reliable national count. The most commonly cited number — of roughly 2,000 deaths each year — comes from the National Child Abuse and Neglect Data System (NCANDS). Their count is widely known to be unreliable due to delays in determining the cause of death, different reporting standards across states, variation in which deaths are examined by child welfare agencies and other factors. Citing multiple studies, The National Commission to Eliminate Child Abuse and Neglect Fatalities concluded: “We know that the number of fatalities is higher than reported by NCANDS”.
But even if one considers death to be a numerically rare outcome of child abuse and neglect, that is hardly a reason not to study the incidents that occur and make serious efforts to prevent them. Any number of rare but severe events have led to meaningful changes in social policy because it is unjustifiable to allow them to persist if they can be prevented. Policy efforts to prevent rare child deaths are prolific — consider laws requiring car seats, gates around swimming pools, safeguards on apartment windows, or safe storage of weapons.
Can We Learn Anything from Child Maltreatment Deaths?
Some have argued that maltreatment fatalities are a “needle in the haystack,” far too random to learn from. But perhaps they are better understood as a canary in the coal mine — a sign of poor or deteriorating standards for identifying and responding to children at risk of serious harm.
We know that children who die of maltreatment have risk factors that distinguish them from children who do not. We also know that children who are reported to CPS have significantly elevated rates of inflicted fatal injuries, accidental injuries and other types of death. Because of limitations to existing data, however, we do not know whether the actions of the child welfare system, law enforcement or other professionals that interacted with the family prior to the child’s death were aberrant or practice as usual.
The high-profile cases that receive media coverage may indeed be anomalous, involving torture or abuse over many years, often of older children with past system involvement. An analysis by the Detroit News found that only around 10% of child maltreatment deaths received media coverage. Examined in isolation, each death may appear uniquely tragic and random, with unclear policy implications. This realization is what led to the development of Child Death Review Teams (CDRTs). But CDRTs conduct their work behind closed doors and, at least in recent years, with limited community engagement. They release only aggregated data, typically years after the deaths occurred. As one advocate concluded: “There’s no practical information. There’s no good data.” Only with greater transparency and a willingness to examine child deaths will we begin to identify patterns and develop strategies to prevent future deaths.
Do We Overreact to Child Maltreatment Deaths?
Some argue that, by focusing on fatalities, we risk a “foster care panic”, where caseworkers arbitrarily and unnecessarily remove large numbers of children out of fear that one might die. A recent study suggests that increases in foster care entries following high-profile child deaths may be better understood as a course correction rather than a panic. As the author described, subsequent changes in removal rates were “concentrated among children at high risk of maltreatment,” and the shift was associated with a decrease in hospitalizations for injuries.
That is only one study, of course. But the findings make intuitive sense, and are timely to consider. In Washington, the media has observed that while the number of children placed in foster care is “shrinking fast”, the number of deaths and critical incidents among families involved in the child welfare system has almost doubled since 2019. Likewise, data from Kentucky indicate that “as child maltreatment reports have declined over the past five years, fatality and near-fatality reports have been on the rise.” We should be circumspect in assuming that agency reactions to child maltreatment deaths are disproportionate, unwarranted or haphazard.
Do Child Maltreatment Deaths Lead to Bad Policies?
There is also concern that sweeping policy changes resulting from the death of a single child may be unproductive or impose unintended consequences, such as increased workload for a system already facing high turnover and burnout. This claim is not without merit. But perhaps legislative changes that are unresponsive to child safety emerge because we permit the public a very partial view of only a fraction of child fatality cases, sometimes not until years after an incident occurred. The result is that those cases that do receive extensive media and public attention become the focus of legislatures that are keen to do something — anything — to respond.
Earlier this year, 12-year-old Gavin Peterson of Utah died after prolonged abuse and starvation, despite repeated efforts by concerned community members to engage CPS. Rather than examining investigation standards or policies surrounding safety plans, Utah legislators proposed expanding free school lunch programs. But Gavin’s parents were not struggling to access the free lunch program — instead, they were prohibiting the school from providing him food.
Absent greater transparency and more complete information, legislators will continue to draft policies that are unlikely to prevent future deaths, while also leveraging tragedies for their own agenda.
What Should the Public Know When a Child Dies of Maltreatment?
New York City’s child welfare commissioner Jess Dannhauser recently stated: “I don’t believe that discussing the details of individual families’ lives is the best way to drive system change. When it’s important, when the public needs to know if we get something terribly wrong, I’ll make sure that they know.” But just a few decades ago, leadership in NYC viewed transparency very differently, stating that the release of information is “excellent for holding our people accountable, us accountable, and maintaining credibility for the public.”
In the face of other tragedies involving governmental agencies, such as officer-involved shootings, the public is not content to let the agency investigate itself, on its own timeline, and then decide whether and what information to release. Likewise, we should not let agencies decide what their constituencies “need to know” when a child has died from possible abuse or neglect.
But agency leaders should also welcome fewer restrictions on what can be shared. As Child Welfare League of America CEO Linda Spears once explained, confidentiality “makes it more difficult for the public to understand the complexity of the work, the challenge of the work, and what it really takes to accomplish the work.”
Closing Thoughts
The silence on child deaths reflects a broader shift away from talking about child safety. The current “strategic plan” for the U.S. Administration for Children and Families and the “Current issues and priorities” for the Children’s Bureau include no mentions of child abuse, safety, maltreatment or fatalities. The U.S. Children’s Bureau’s annual National Conference on Child Abuse and Neglect — the only research conference routinely attended by child welfare administrators and professionals — released a call for proposals with five learning tracks, none of which mention child safety, child abuse or child fatalities.
This message is clearly being heard by organizations that have historically sought to prevent and treat victims of child abuse and neglect. The North Carolina state chapter of Prevent Child Abuse America recently re-named itself The Positive Childhood Alliance — literally erasing the very mention of that which it is funded to prevent. In many jurisdictions, children exposed to substances no longer receive a “Plan of Safe Care,” but instead an ostensibly less stigmatizing “Family Care Plan.”
Our federal and foundation leaders can talk about “thriving,” “positive childhood” and ”well-being“ because their daily work does not force them to see children who are abused, neglected and killed. Similarly, because the vast majority of children who die from maltreatment are unnamed and unknown to the public, it becomes easy to look away.
Reducing child abuse and neglect fatalities must reemerge as a U.S. policy priority, starting with timely data, public accountability, national leadership, and candid discussions about child safety.