MASSACHUSETTS DEPARTMENT OF CHILDREN AND FAMILIES 2010 Analysis of Child Fatalities & Near Fatalities Angelo McClain, Ph.D., LICSW Commissioner July 2013 MASSACHUSETTS DEPARTMENT OF CHILDREN AND FAMILIES 2010 Analysis of Child Fatalities & Near Fatalities Prepared by: Antone C. Felix III, Data Analyst Office of Management, Planning & Analysis Scott P. Scholefield, Director Case/Special Investigations Unit Rosalind M. Walter, Director Data Management Unit Information Technology Department of Children and Families 600 Washington Street, 6th floor Boston, MA 02111 TABLE OF CONTENTS Section Page Introduction …….. .............................................................................................................................. 1 I. Summary of Child Fatalities and Near Fatalities in 2010 ......................................... 3 A. Child Near Fatalities ................................................................................................ 3 B. Child Fatalities.......................................................................................................... 6 II. Analysis of DCF Child Fatalities (Open or Recently Open Cases): 1989 - 2010 .......................................................... 12 A. Manner of Death and Contributing Factors ........................................................ 14 B. DCF Involvement ................................................................................................... 19 1. Placement Status ................................................................................................ 19 2. Case Status.......................................................................................................... 23 3. Custody Status.................................................................................................... 24 4. Reports of Child Maltreatment ........................................................................ 25 C. Family Demographics ............................................................................................ 26 1. Age and Sex of Children .................................................................................... 26 2. Age of Parents .................................................................................................... 27 3. Marital Status of Mothers ................................................................................. 28 4. Mothers: Age at First Birth, DCF Placement History, and Mental Illness ..................................................................................................... 28 5. Caretakers Actively Involved in DCF Casework ............................................ 29 6. Race and Hispanic Origin of Deceased Children and Their Parents ................................................................................................................ 29 7. Family Residence ............................................................................................... 32 8. Family Size.......................................................................................................... 33 D. Substance Abuse..................................................................................................... 34 1. Substance Abuse and Child Maltreatment ...................................................... 34 2. Parent/Caretaker’s Past and Current Use of Drugs/Alcohol ......................... 35 3. Mother’s Prenatal Care and Use of Substances during Pregnancy ........................................................................................................... 36 E. Domestic Violence .................................................................................................. 37 1. Prevalence of Domestic Violence in Families................................................... 37 F. Special Groups of Children ................................................................................... 38 1. Adolescents ......................................................................................................... 38 2. Medically-Involved/Physically-Challenged Children ..................................... 39 III. Child Maltreatment-Related Fatalities: 2001 – 2010……………….………………40 IV. Death Rates..……………..…………………………………………………………...46 A. Age-Specific Death Rates Summary: 2004 – 2010...............................................46 B. 2010 Death Rates Computations…………….. ………………………………….47 1. All Child Fatalities……………………………………………………………..47 2. Maltreatment-Related Child Fatalities……………………………………….48 Introduction Massachusetts has one of the lowest child death rates in the nation,1 yet between 500 and 700 children die each year.2 Their deaths are attributable to natural causes, accidents, suicide, and homicide. The Department of Public Health (DPH) gathers information on all recorded deaths that occur in Massachusetts.3 In contrast, the statistics compiled in this analysis by the Department of Children and Families (DCF) -- the Massachusetts child welfare agency -- are limited to the following groups of deceased children: (1) children whose families had open cases or cases that had been closed for six months or less at the time of the child’s death; and (2) children with maltreatment-related deaths whose families had cases closed more than six months or no previous DCF history (deaths reported to DCF pursuant to M.G.L. ch. 119, sec. 51A which resulted in supported allegations of abuse or neglect). The Department works collaboratively with DPH (Registry of Vital Records and Statistics) to ascertain child death certificate findings. The release of death certificates impacts production of this report.  All child deaths in families open or recently involved (“known”) to DCF are reported to the Case Investigation Unit (CIU), regardless of how the child died.4 CIU staff conduct investigations that focus on a review of the services provided to the family and the circumstances surrounding the death. Each investigation includes, but is not limited to, a comprehensive review of the case record and a visit to the DCF Area Office to interview social work staff involved with the case. Before a CIU report is finalized, a member of the Professional Advisory Committee5 reviews the report to provide an external perspective. The purpose of this review is to determine if DCF needs to address any case practice or policy issues. Since its formation in the late 1980s, the CIU has collected information on deceased children whose families had the following status with DCF: • families with an open case; • families being investigated as the result of a 51A report6 received prior to the child’s death; • families with cases that closed within the six months preceding the child’s death; and 1 Annie E. Casey Foundation. Kids Count 2010 Data Book online http://datacenter.kidscount.org/data/acrossstates/rankings.aspx?ind=22 2 Number of child deaths from printouts for years 2000 to 2010 generated by the Massachusetts Registry of Vital Records and Statistics (DPH). 3 DPH reports on Massachusetts Deaths http://www.mass.gov/eohhs/docs/dph/research-epi/death-full-09.pdf 4 The manner of death may be natural causes, unintentional injuries, homicide, suicide, pending investigation/autopsy, or undetermined following an autopsy. 5 The Professional Advisory Committee has a multi-disciplinary membership including legal, educational, medical, mental health, law enforcement, social service, and child welfare professionals not employed by DCF. 6 Massachusetts Laws, Chapter 119, Section 51A (reporting of abuse and neglect of children). 1 • families who had a supported 51A report within six months preceding the child’s death, but the case was not opened for services. In 2001, the CIU began collecting information on all deceased children for whom a 51A report was filed including those from families previously unknown to DCF and families with cases closed more than six months prior to the child’s death. This group of children is limited to those children where abuse/neglect was the direct cause of death or was a contributing factor to the cause of death. The data collected on these maltreatment deaths are not as comprehensive as the data collected on families with current or recent DCF involvement (see bulleted items on page 1). Data are gathered via phone calls to area office staff and a review of case information in the DCF case management information system (FamilyNet). The CIU also receives notification of all reports of abuse or neglect that meet the definition of “near fatality.” DCF defines a “near fatality” as any case where a doctor or hospital has filed a 51A report and determined the child named in the report to be in “serious” or “critical” condition as a result of physical and/or sexual abuse or neglect, and that the condition is considered to be life threatening. Upon receiving notification of a near fatality from an area office, CIU staff review all information about the case contained in FamilyNet. This preliminary data collection serves as the basis for their investigation. The CIU process for near fatalities is a paper review; there are no meetings with area office managers or staff. However, CIU investigators may call area office managers or staff for additional information. If the CIU review of a fatality or near fatality reveals any clinical or case practice issues, a corrective action plan is developed. There are three main sections in this report. Section I consists of a summary of all fatalities and near fatalities that occurred during 2010. Section II contains a statistical analysis of the data collected on all deceased children whose families were open or recently closed with DCF. Statistics cover all manner of death during the years 1989-2010. This section describes what happened to all deceased children, regardless of the cause of death. Section III includes a statistical profile focused solely on maltreatment-related deaths that occurred from 2001-2010. In 2001, the count of children who died from abuse/neglect was expanded to include deceased children whose families were unknown to DCF or were closed more than six months prior to the child’s death. The statistics presented in this report are based on information obtained from the DCF Case Investigation Unit and FamilyNet. Additional information on the manner of death and related medical diagnoses was obtained from the Registry of Vital Records and Statistics (Massachusetts Department of Public Health). 2 I. Summary of Child Fatalities and Near Fatalities in 2010 A. Child Near Fatalities There were 27 near fatalities reported to DCF during 2010 (15 boys and 12 girls). Abusive head trauma injuries7 were diagnosed in 16 of the 27 near fatalities. Eight of the 16 children had additional injuries such as bone fractures, bruises, internal injuries, bite marks, and burns. In 7 other cases of severe physical abuse, children suffered bodily injuries that were similar to those inflicted on the head trauma victims with the following exceptions: severe burns from immersion in hot water, cardiac arrest associated with food asphyxiation, and massive abdominal trauma. The remaining 4 near fatalities were cases of neglect: 2 children were severely injured in auto accidents, 1 child nearly drowned (pool), and 1 two-year-old child consumed narcotic medication. Neglect was a factor in the near fatalities of 4 children, physical abuse was a factor for 4 children, and both physical abuse and neglect were factors for 17 children. Two children were sexually abused as well as neglected and physically abused. The victimized children included 15 infants, 6 one-year-olds, 5 two-year-olds, and 1 four-year-old. Mothers were the primary perpetrators of neglect. “Unknown” person was the leading perpetrator category of physical abuse. Allegations of neglect were supported on 19 mothers, 9 fathers, 4 boyfriends, and 3 unrelated caretakers. Physical abuse was supported on 6 boyfriends, 5 fathers, 4 mothers, and 11 unknown perpetrators. (See Tables A1 and A2 on pages 4 and 5) Of the 27 families, 12 were known to DCF (5 open protective and 7 closed cases) and 15 were unknown (no prior history). None of the children were in DCF custody and none were in placement. Median ages of mothers and fathers were 25.5 and 29 years, respectively. Thirteen mothers were less than 20 years old when they gave birth to their first child. Eight mothers were married and 16 had a prior history with DCF. Seven fathers had a previous history with DCF. Current family issues were mental illness (12), domestic violence (8 families), and substance abuse (6). Seventeen of the children were White, 3 were Black, 2 were Asian, and 1 was multiracial. Race was unknown for 4 children. Eleven of the 27 children with near fatal injuries were identified as Hispanic. (See Tables A1 and A2) 7 Abusive head trauma is defined as brain, skull, and spinal injuries associated with shaking and other injuries inflicted on infants (new terminology from the American Academy of Pediatrics) (Christian, C.W. and R. Block. 2009. Abusive Head Trauma in Infants and Children. Pediatrics 123: 1409-1411). 3 Table A1. CY2010 Child Near Fatalities: 27 Children from Families Known and Unknown to DCF CHILD'S AGE FAMILY CASE STATUS DURATION OPENED/CLOSED INJURIES ABUSE/ NEGLECT DCF PLACEMENT CUSTODY TYPE <1 day no previous history ----- brain injury, multiple bruises and abrasions from fall (2nd floor) PHYS/NEG NO NIP 25 days closed more than 6 mos. multiple fractures and bruises PHYS NO NIP 38 days no previous history ----- abusive head trauma, multiple fractures PHYS/NEG NO NIP 38 days no previous history ----- abusive head trauma, multiple fractures PHYS/NEG NO NIP 65 days no previous history ----- abusive head trauma, multiple fractures PHYS/NEG NO NIP 89 days no previous history ----- abusive head trauma PHYS/NEG NO NIP 104 days no previous history ----- abusive head trauma PHYS/NEG NO NIP 127 days closed more than 6 mos. abusive head trauma, rib fracture PHYS NO NIP 132 days no previous history ----- abusive head trauma PHYS/NEG NO NIP 211 days no previous history ----- injuries from MVA NEG NO NIP 250 days open protective 6 mos. or less skull fractures, multiple bruises, abdominal perforation PHYS/NEG NO NIP 264 days closed 6 mos. or less multiple bruises and fractures, failure to thrive PHYS/NEG/SEX NO NIP 265 days open protective more than 6 mos. abusive head trauma PHYS/NEG NO NIP 334 days no previous history ----- abusive head trauma, internal injuries, multiple bruises PHYS/NEG NO NIP 343 days no previous history ----- severe burns from immersion hot water, rib fractures PHYS/NEG NO NIP 1 year closed 6 mos. or less abusive head trauma PHYS/NEG NO NIP 1 year no previous history ----- abusive head trauma, bruises and bite marks PHYS NO NIP 1 year no previous history ----- abusive head trauma PHYS NO NIP 1 year open protective more than 6 mos. cardiac arrest from food asphyxiation, multiple bruises/abrasions PHYS/NEG NO NIP 1 year no previous history ----- abusive head trauma PHYS/NEG NO NIP NIP 1 year no previous history ----- near drowning (pool) NEG NO 2 years open protective 6 mos. or less abusive head trauma, bruises, burns PHYS/NEG NO NIP 2 years open protective more than 6 mos. abusive head trauma PHYS/NEG NO NIP 2 years closed 6 mos. or less massive abdominal trauma (internal injuries) PHYS/NEG/SEX NO NIP 2 years closed 6 mos. or less abusive head trauma, multiple fractures PHYS/NEG NO NIP 2 years 4 years closed no previous history more than 6 mos. ----- ingestion of Suboxone pills (narcotic medication) injuries from MVA (pedestrian) NEG NEG NO NO NIP NIP CODES: NEG = neglect; PHYS = physical abuse; SEX = sexual abuse; NIP = not in placement NOTE: Abusive Head Trauma = brain, skull, and spinal injuries associated with shaking and other head injuries inflicted on infants (American Academy of Pediatrics). 4 Table A2. CY'2010 Child Near Fatalities: Perpetrators (27 Children from Families Known or Unknown to DCF) CHILD'S AGE PERPETRATOR <1 day 25 days 38 days mother unknown mother father mother boyfriend father mother father mother father unknown mother father unknown mother father mother boyfriend mother boyfriend father unknown mother father unknown mother boyfriend mother unknown unknown mother boyfriend unknown mother boyfriend mother mother godmother unknown babysitter unknown mother boyfriend mother unknown mother father unrelated caretaker 38 days 65 days 89 days 104 days 127 days 132 days 211 days 250 days 264 days 265 days 334 days 343 days 1 year 1 year 1 year 1 year 1 year 1 year 2 years 2 years 2 years 2 years 2 years 4 years NEGLECT PHYSICAL SEXUAL ABUSE ABUSE X ----X X X ----X X X X X ----X X ----X X X ----X X X ----X X ----X X X --------X X ----X ----X X X ----X ----X X X ----X X X X X X X ----X X ----X ----X X --------X ------------X X X ----X --------X ----X X X X --------X ----X ------------X ----X X X ----X ------------- ----- INJURIES CURRENT TEENAGE FAMILY MOTHER ISSUES AT 1ST BIRTH brain injury, bruises, abrasions fractures, bruises abusive head trauma, fractures MI MI DVMI YES YES YES abusive head trauma, fractures ----- ----- abusive head trauma abusive head trauma ----SA/DV/MI --------- abusive head trauma MI ----- abusive head trauma, fracture abusive head trauma DV ----- YES ----- injuries from MVA ----- YES fractures, bruises, abdominal injury ----- ----- fractures, bruises, failure to thrive SA/DV/MI YES abusive head trauma MI ----- abusive head trauma, internal injuries, bruises ----- ----- X severe burns from hot water immersion, fractures SA/DV abusive head trauma abusive head trauma, bruises, bite marks abusive head trauma cardiac arrest from food asphyxiation, bruises, abrasions SA MI --------- YES YES ----YES abusive head trauma, bruises, abrasions DV/MI ----- near drowning (pool) abusive head trauma, bruises, burns ----DV/MI ----YES abusive head trauma X X ----------------- YES abusive head trauma, fractures MI ----- ingestion of narcotic medication SA ----- injuries from MVA (pedestrian) ----- ----- NOTE: Ommisions under "Current Family Issues" indicate "None" or "Unknown." Issues apply to the child's caretaker(s). Abusive Head Trauma = brain, skulll, and spinal injuries associated with shaking and other head injuries inflicted on infants (American 5 YES massive abdominal trauma (internal injuries) SA/DV/MI CODES: DV = domestic violence; MI = mental illness; SA = substance abuse Academy of Pediatrics). ----- B. Child Fatalities Thirty (30) children in families with an open or recently8 closed DCF case status died in 2010. Nine (9) of these children died from natural causes, 9 were homicides, and 4 died in accidents. For the remaining 8 children, the manner of death was “undetermined” following an autopsy by a medical examiner.9 Child maltreatment (physical abuse/neglect) was found to be the cause or contributing factor in 8 of the 30 deaths. Forty-three percent (43%) of these deceased children were infants (less than one year old), 27% were 1-10 years old, and 30% were adolescents (12-17 years old). Four (4) of the 30 children were in DCF custody. Of those children in DCF custody, 2 were hospitalized infants who died 2-9 days after birth and 2 were foster children with multiple medical conditions (congenital) who died from natural causes. (See Table A3 on page 9) The deaths of an additional 10 children were reported to DCF and found to be maltreatment-related. Five (5) children were from families not previously known to DCF and the remainder were from families whose cases had been closed for more than six months at the time of death. (See Table A4 on page 10) The decline from 50 deaths in 2009 to 30 deaths in 2010 (-40%) marked a return to the 30-38 range recorded during 2002-2008. Other co-occurring annual declines were: an 80% decrease in 5-11 year old children (from 10 to 2 children); a 36% decrease in adolescents (14 to 9 children); a 62% decrease in deaths from natural causes (24 to 9 children); an 88% decrease in infant co-sleeping deaths (8 to 1 child). Over the past 22 years, there has been a dramatic reduction in DCF child deaths. Counts of fatalities have declined from a peak of 89 in 1990 to a leveling-out of 30-38 in 2002-2010. Since 1989-1990 there has been a significant decrease in the number of infant deaths. Typically, these children died from medical problems originating at birth. The decline in death-related factors such as congenital conditions, prematurity, low birth weight, Sudden Infant Death Syndrome (SIDS), and drug exposure may explain the drop in infant deaths (Table 3 on page 18). Even though drug and alcohol abuse have decreased as factors in child fatalities, these are still major contributors to a family’s involvement with DCF. Children of substance abusing parents are at greater risk of neglect, physical abuse, sexual abuse, and emotional abuse compared to children of non-substance abusing parents. 10 8 Families with cases that closed within the six months preceding the child’s death The medical examiner has performed a full forensic evaluation (toxicology screens, investigation of the scene at death, autopsy, etc.) but cannot determine if the manner of death was due to natural causes or an accident. 10 National Clearinghouse on Child Abuse and Neglect Information. 2003. Substance Abuse and Child Maltreatment. Children’s Bureau, ACF, U.S. DHHS (http://nccanch.acf.hhs.gov). 9 6 There were 7 SIDS-related deaths in 2010 (includes families known and unknown to DCF). In 6 of these 7 fatalities, the manner of death was undetermined (See table below and Tables A3 and A4 on pages 9-10). “Undetermined” is used for cases in which it is impossible to establish, with reasonable medical certainty, the circumstances of death after a thorough investigation. From the available information, it was not clear how many of the SIDS deaths involved unsafe sleeping conditions. CF investigators supported neglect as a contributing factor in 2 SIDS deaths (table below). Cause of Death (Families Known and Unknown to DCF) Year & Manner of Death SIDS SIDS/ Co-Sleeping Asphyxiation/ Co-Sleeping Ill-Defined & Unspecified Cause/ Co-sleeping 2007: Natural Causes 1 --- --- --- Accident --- 1 (1 neglect) --- --- Undetermined/Pending 1 4 (3 neglect) --- --- 1 --- --- --- 2008: Natural Causes Accident --- --- 3 (2 neglect) --- Undetermined/Pending --- 4 (1 neglect) --- --- Natural Causes 2 --- --- --- Accident --- --- --- --- Undetermined/Pending 1 7 (3 neglect) --- 3 (1 neglect) 1 --- --- --- 2009: 2010: Natural Causes Accident Undetermined --- --- --- --- 4 (1 neglect) 2 (1 neglect) --- --- Note: (# neglect) = number of neglect-related deaths During 2010, there were 18 fatalities (6 in families open with DCF) with supported allegations of neglect or physical abuse (Tables A3 and A4). Neglect was a factor in 10 deaths, physical abuse was a factor in 2 deaths, and both physical abuse and neglect were factors in 6 deaths. Some of the deaths involved multiple perpetrators (Table A5 on page 11). Perpetrators of neglect included 13 mothers, 6 fathers, 1 babysitter, and 1 male partner. Perpetrators of physical abuse were 4 mothers, 3 fathers, 1 male partner, 1 babysitter, and 1 unknown person. Maltreatment-related deaths have ranged from 7 to 19 since 2001 (Table 25 on page 43). There is no apparent trend in the annual fluctuations in maltreatment-related deaths. 7 Twenty-five (25) of the 30 children (83%) known to DCF who died in 2010 were not in placement (Table A3 on page 9). Of the 5 children (17%) in “placement,” 3 died in the hospital shortly after birth (2-9 days) and 2 succumbed to multiple medical conditions (congenital) at the ages of 1 and 15 years while in foster care. Regardless of location, most deaths have been due to natural causes and to a lesser degree accidents. In the 10 years (2001-2010), there have been 2 maltreatment-related fatalities in foster care and none in residential care. There was an accidental death in 2001 when a child died while in unrelated foster care (neglect). In 2005, a child in unrelated foster care was a homicide victim (physical abuse and neglect). 8 Table A3. CY'2010 Child Fatalities: 30 Children from Families with an Open or Recently Open DCF Case Status AGE (YEARS) <1 <1 <1 <1 <1 <1 <1 <1 <1 <1 <1 <1 <1 1 1 1 2 2 2 7 10 13 15 15 15 16 16 16 17 17 FAMILY CASE STATUS open protective open protective open protective open protective open protective open protective case closed open protective open protective open protective open protective open protective open protective open protective open protective open protective open protective open protective case closed open protective open protective open protective open protective open protective open protective case closed case closed case closed case closed open protective DURATION MANNER OPENED/CLOSED OF DEATH more than 6 months A 6 months or less NC more than 6 months NC 6 months or less NC 6 months or less U more than 6 months U 6 months or less U 6 months or less U 6 months or less NC more than 6 months U 6 months or less U 6 months or less H more than 6 months U 6 months or less H more than 6 months U more than 6 months NC more than 6 months H 6 months or less H 6 months or less H 6 months or less NC 6 months or less NC 6 months or less NC more than 6 months NC more than 6 months A more than 6 months H 6 months or less A 6 months or less H 6 months or less H 6 months or less H more than 6 months A FACTORS CAUSING OR CONTRIBUTING TO DEATH extreme immaturity (placental separation and hemorrhage) Edwards Syndrome/Trisomy 18 (genetic disorder), congenital; terminal illness prematurity, prenatal drug exposure (cocaine, heroin) congenital CPT 2 deficiency (inherited metabolic disorder), terminal illness SIDS; birth asphyxia SIDS SIDS (co-sleeping w/parents) SIDS, medical neglect SIDS ill-defined and unspecified cause SIDS, acute upper respiratory infection, bronchopneumonia abusive head trauma, fractures of all extremities asphyxiation, unsafe sleeping conditions bodily injuries ill-defined and unspecified cause multiple medical complications (congenital) blunt force trauma to head w/injuries to brain gunshot wounds abusive head trauma, mother's substance abuse (alcohol, cocaine), bodily injuries heart condition (congenital mitral stenosis) cardiomyopathy (heart disease), cardiac arrhythmia seizure seizure, multiple medical conditions (congenital) drowning (reservoir) stab wounds, drug deal motor vehicle accident (passenger), drunken driving gunshot wounds stab wounds gunshot wounds motor vehicle accident (pedestrian), hit and run NEGLECT/ DCF PLACEMENT ABUSE CUSTODY TYPE NEG NEG PHY/NEG NEG PHY/NEG PHY/NEG PHY/NEG NEG TEMP NO NO TEMP NO NO NO NO NO NO NO NO NO NO NO PERM NO NO NO NO NO NO PERM NO NO NO NO NO NO NO HOSP NIP HOSP HOSP NIP NIP NIP NIP NIP NIP NIP NIP NIP NIP NIP PRE-ADOP NIP NIP NIP NIP NIP NIP UNREL NIP NIP NIP NIP NIP NIP NIP CODES: NC = natural causes; A = accident; H = homicide; U = undetermined by medical examiner; NEG = neglect; PHYS = physical abuse; TEMP = temporary custody; PERM = permanent custody; NIP = not in placement; HOSP = hospital; PRE-ADOP = pre-adoptive foster home; UNREL = unrelated foster home 9 Table A4. CY'2010 Child Fatalities: 10 Children from Families Unknown to DCF or with Cases Closed more than Six Months AGE (YEARS) FAMILY CASE STATUS DURATION OPENED/CLOSED <1 case closed more than 6 months <1 unknown family ---------------<1 unknown family ---------------<1 unknown family ---------------1 unknown family ---------------1 unknown family ---------------2* case closed more than 6 months 2* case closed more than 6 months 4* case closed more than 6 months 4* case closed more than 6 months (* Two sets of twins from different families) MANNER OF DEATH FACTORS CAUSING OR CONTRIBUTING TO DEATH U H H H H A A A A A SIDS (co-sleeping w/mother) head injury (multiple skull fractures) asphyxiation, abusive head trauma, bodily injuries abusive head trauma, bodily injuries abusive head trauma, blunt trauma to abdomen fall from window (25 ft.), head injury (skull fractures) drowning (pool) drowning (pool) drowning (pool) drowning (pool) NEGLECT/ ABUSE DCF CUSTODY PLACEMENT TYPE NEG PHY PHY/NEG PHY PHY/NEG NEG NEG NEG NEG NEG NO NO NO NO NO NO NO NO NO NO NIP NIP NIP NIP NIP NIP NIP NIP NIP NIP CODES: NC = natural causes; A = accident; H = homicide; U = undetermined by medical examiner; NEG = neglect; PHYS = physical abuse; NIP = not in placement 10 TABLE A5. CY'2010 Child Fatalities: Perpetrators of Child Maltreatment (18 Children from Families Known or Unknown to DCF) CHILD # 1 2 3 4 5 AGE PERPETRATOR NEGLECT PHYSICAL FACTORS CAUSING OR CONTRIBUTING TO DEATH OF ABUSE CHILD 6 days 40 days 42 days 65 days 111 days mother x mother x unknown mother x mother x father 6 158 days mother x father x 7 197 days father 8 227 days mother x 9 1 year mother x 10 1 year babysitter x 11 1 year mother x father x 12 2 years mother x male partner x 13 2 years mother x father x 14 &15* 2 years mother x father x 16 & 17* 4 years mother x father x 18 16 years mother x father x (* Two sets of twins from different families) (** Applies to child's caretaker (mother, father, other) x x x x x x x x x x prematurity, prenatal drug exposure (cocaine, heroin) SIDS (co-sleeping w/mother) head injury (multiple skull fractures) SIDS asphyxiation, abusive head trauma, bodily injuries CURRENT** MANNER TEEN FAMILY OF MOTHER ISSUES DEATH AT 1ST BIRTH SA/MI/DV abusive head trauma; fractures of all extremities NC U H U H NO NO YES NO UNKNOWN H NO abusive head trauma, bodily injuries asphyxiation, unsafe sleeping conditions bodily injuries abusive head trauma, blunt trauma to abdomen fall from window (25 ft.), head injury (skull fractures) MI DV MI/DV H U H H A NO YES YES UNKNOWN UNKNOWN blunt force trauma to head w/injuries to brain MI/DV H YES abusive head trauma, mother's substance abuse (alcohol, cocaine), bodily injuries drowning (pool) drowning (pool) drowning (pool) drowning (pool) motor vehicle accident (passenger), drunken driving SA/MI H YES A UNKNOWN A UNKNOWN A UNKNOWN CODES: NC = natural causes; A = accident; H = homicide; U = undetermined by medical examiner; SA = substance abuse; DV = domestic violence; MI = mental Ilness 11 II. Analysis of DCF Child Fatalities: 1989 – 2010 (Open or Recently Closed Cases) Thirty (30) children “known” to DCF died in 2010. This annual count of fatalities marked a return to the 30-38 range of deaths recorded in 2002-2008 (Table 1). The relatively stable period from 2002-2008 was followed by 50 deaths in 2009—the highest number of deaths since 1996 (Table 1). From 2009 to 2010, the largest change in fatalities occurred in the 5-11 year-old age group (Table 1). In 2009, there were more 5-11 year-old children than usual (60% of them died from natural causes). Table 1. Age of Children (1989 – 2010): Counts of Children Calendar Year 1989: 1990: 1991: 1992: 1993: 1994: 1995: 1996: 1997: 1998: 1999: 2000: 2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010: No. % Less than 28 days 16 19% 10 11% 8 12% 8 12% 10 15% 1 2% 8 15% 3 5% 6 14% 4 10% 6 15% 5 12% 3 7% 1 3% 3 8% 4 13% 5 16% --4 12% 6 16% 4 8% 6 20% 28 days to < 1 yr. 26 31% 30 34% 21 32% 23 34% 17 25% 25 38% 21 40% 14 25% 11 26% 5 12% 9 23% 6 15% 12 26% 9 28% 10 28% 6 20% 10 32% 11 35% 13 38% 15 39% 13 26% 7 23% Age of Children 1 yr. to < 2 2 yrs. to < 5 yrs. yrs. 5 9 6% 11% 7 12 8% 13% 4 6 6% 9% 8 8 12% 12% 11 6 16% 9% 7 9 11% 14% 6 5 11% 9% 3 6 5% 11% 3 5 7% 12% 5 6 12% 15% 1 4 3% 10% 7 3 17% 7% 1 4 2% 9% 4 8 12% 25% 4 3 11% 8% 2 4 7% 13% 1 2 3% 6% 2 5 6% 16% 2 2 6% 6% 1 2 3% 5% 4 5 8% 10% 3 3 10% 10% 12 5 yrs. to < 12 yrs. 10 12% 9 10% 9 14% 5 7% 6 9% 8 12% 10 19% 13 24% 2 5% 4 10% 4 10% 5 12% 8 17% 6 19% 5 14% 4 13% 4 13% 4 13% 5 15% 2 5% 10 20% 2 7% 12 yrs. or Older 18 21% 21 24% 18 27% 15 22% 18 26% 15 23% 3 6% 16 29% 15 36% 17 41% 15 38% 15 37% 18 39% 4 12% 11 31% 10 33% 9 29% 9 29% 8 24% 12 32% 14 28% 9 30% Total 84 100% 89 100% 66 100% 67 100% 68 100% 65 100% 53 100% 55 100% 42 100% 41 100% 39 100% 41 100% 46 100% 32 100% 36 100% 30 100% 31 100% 31 100% 34 100% 38 100% 50 100% 30 100% In 2010, there were 13 infants (less than 1 year old), 8 children 1-11 years old, and 9 adolescents (Table 1). Since 1990 there has been a large decrease in the number of infant/young child deaths (Table 1, Fig. 1). Many of these young children died from medical conditions originating at birth. Adolescent deaths were more prominent from 1989-2001 (median 16 deaths) than from 2002-2010 (median 9 deaths) (Table 1, Fig. 1). Fatalities Figure 1. Child Fatalities by Age: 1989 - 2010 90 80 70 60 50 40 30 20 10 0 09 20 07 20 05 20 03 20 01 20 99 19 97 19 95 19 93 19 91 19 89 19 Calendar Year < 1 yr 1 - <5 yrs 5 yrs - <12 yrs. 12 yrs. or Older The median age of deceased children was 1.6 years11 in 2010 (see table below). Fortythree percent of these children were infants and 30% were adolescents (Table 1). The low median age in 1995 and 2008 were due to the high proportions of infants—55% each year (Table 1). The occurrence of the high median age in 2001 (9.0 years) was due to an upward shift in the number of children 12 years or older. Beginning in 2002, the Department’s reporting on fatalities has been limited to children less than 18 years old. From 1990 to 2001, there were several years when the annual count of children included one or two children 18 years or older. YEAR MEDIAN AGE (YRS) YEAR MEDIAN AGE (YRS) 11 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 1.8 2.0 1.4 1.7 1.4 0.7 5.6 2.4 5.1 5.0 4.1 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 9.0 2.5 2.1 4.1 1.2 3.2 1.0 0.5 3.5 1.6 Half the children are younger than the median age and half are older. 13 A. Manner of Death and Contributing Factors The total number of fatalities has always been a reflection of its major component-natural causes (See table below and Table 2 and Fig. 2 on pages 15-16). However, in 1998, 2007, 2008, and 2010, deaths from natural causes were exceeded by the combined deaths from accidents and homicides (Table 2, Fig. 2). Manner of Death Natural Causes Accidents Homicides Suicides Undetermined/Pending* Proportions Median Range 1989 - 2010 1989 - 2010 59.5% 27% - 68% 20.5% 13% - 44% 13% 3% - 32% 3% 0% - 8% 3% 0% - 27% * Children whose manner of death could not be determined following an autopsy by a medical examiner. In 2010, 9 deaths (30%) were from natural causes and 9 deaths were from homicides (Table 2 on page 15). Homicide deaths (9) were due to: head trauma/bodily injuries (4 deaths), gunshot wounds (3), and stab wounds (2). Accidental deaths (4) in 2010 were attributed to: motor vehicle accidents (2 deaths), premature birth (1),12 and drowning (1). There was a higher proportion of fatalities with an “undetermined” manner of death than in any prior year (27%) (Table 2). The manner of death could not be determined for 8 fatalities during 2010 (Table 2, Table A3 on page 9). Seven of these children were infants and 1 was a one year old. In 5 of these fatalities, the medical diagnosis was SIDS. Two other fatalities had a diagnosis of “ill-defined and unspecified cause.” The diagnosis of the remaining fatality was asphyxiation. It was not clear what role unsafe sleeping conditions played in these deaths. The finding of “undetermined” is used when the information pointing to one manner of death is no more compelling than one or more other competing manners of death considering all available information. “Undetermined” is intended for cases in which it is impossible to establish, with reasonable medical certainty, the circumstances of death after a thorough investigation. 12 While fleeing from police, the pregnant mother sustained injuries which resulted in the premature birth (placental separation and hemorrhage) of her baby. 14 Table 2. Manner of Child’s Death (1989 – 2010): Counts of Children Calendar Year Manner of Death Unintentional Homicide Suicide Undetermined* Injury 1989: No. 57 13 6 5 3 % 68% 15% 7% 6% 4% 1990: 50 24 9 2 4 56% 27% 10% 2% 4% 1991: 35 15 11 1 4 53% 23% 17% 2% 6% 1992: 41 12 11 3 --61% 18% 16% 4% --1993: 45 10 9 4 --66% 15% 13% 6% --1994: 41 13 8 1 2 63% 20% 12% 2% 3% 1995: 36 10 5 1 1 68% 19% 9% 2% 2% 1996: 29 14 7 4 1 53% 25% 13% 7% 2% 1997: 28 9 4 1 --67% 21% 10% 2% --1998: 11 18 9 2 1 27% 44% 22% 5% 2% 1999: 23 9 3 2 2 59% 23% 8% 5% 5% 2000: 24 12 3 1 1 59% 29% 7% 2% 2% 2001: 29 9 6 2 --63% 20% 13% 4% --2002: 15 11 4 1 1 47% 34% 12% 3% 3% 2003: 23 5 5 3 --64% 14% 14% 8% --2004: 18 8 4 ----60% 27% 13% ----2005: 17 5 4 2 3 53% 17% 13% 7% 10% 2006: 21 4 1 1 4 68% 13% 3% 3% 13% 2007: 11 7 11 --5 32% 21% 32% --15% 2008: 15 10 6 3 4 39% 26% 16% 8% 11% 2009: 24 7 6 1 12 48% 14% 12% 2% 24% 2010: 9 4 9 --8 30% 13% 30% --27% * Undetermined following an autopsy by a medical examiner. Notes: Totals may not equal 100% due to rounding-off. The manner of death for maltreated children could be accident, homicide, or natural causes. An example of natural causes would be an infant death attributed to prematurity/congenital conditions resulting from maternal substance abuse. Natural Causes 15 Total 84 100% 89 100% 66 100% 67 100% 68 100% 65 100% 53 100% 55 100% 42 100% 41 100% 39 100% 41 100% 46 100% 32 100% 36 100% 30 100% 31 100% 31 100% 34 100% 38 100% 50 100% 30 100% Figure 2. Child Fatalities by Manner of Death: 1989 - 2010 60 Fatalities 50 40 30 20 10 0 10 20 09 20 08 20 07 20 06 20 05 20 04 20 03 20 02 20 01 20 00 20 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 Calendar Year Natural Causes Accident Homicide Suicide Specific factors causing or contributing to child fatalities from 1989 through 2010 are listed in Table 3 on page 18 (See Fig. 2 above). These factors were identified from information gathered by CIU staff during their investigations, case information from the DCF database (FamilyNet), and printouts from the Massachusetts Registry of Vital Records and Statistics.13 In 2010, the leading factors contributing to child fatalities were neglect, congenital conditions, and SIDS (Table 3). Death-related factors that have shown the most distinct declines over the past 22 years are drugs/alcohol, prematurity, low birth weight (LBW), congenital conditions, and SIDS (Table 3). Drug/alcohol use by mothers during pregnancy has been associated with prematurity, congenital deformities, and LBW. Substance abuse by parents/caretakers is discussed in more detail on pages 34-36. In this report, drug/alcohol-related cases are defined as those where a parent/caretaker/child’s use of drugs or alcohol was a contributing factor in the death. Some examples are: a teenage homicide involving the dealing of drugs; an adolescent overdosing on drugs; a child’s accidental death from neglect while the parents/caretakers were intoxicated; a child contracting AIDS at birth from a heroin-addicted mother; a motor vehicle accident where the driver was a teenager or parent under the influence of drugs/alcohol; and an infant death due to congenital conditions/prematurity that resulted from the mother’s use of illegal substances during pregnancy. For drugs/alcohol to be considered a contributing factor in the last example, there must be a supported report of neglect and a medical diagnosis that the baby’s death from congenital conditions was a direct result of the mother’s use of illegal substances during pregnancy. 13 Information from death certificates (manner of death and medical diagnoses for cause of death). 16 In 2010, 4 fatalities were identified as being drug and/or alcohol involved (Table 3 on next page). One of the drug/alcohol-related deaths involved a premature infant whose mother used cocaine and heroin during her pregnancy. Other deaths involved: a 16 year old who died in a drunken-driving accident; a 15 year old who was stabbed during a drug deal; and a 2 year old whose mother was under the influence of alcohol and cocaine when she physically abused him. In 12 of the 30 fatalities, it was unknown whether drugs or alcohol were factors. Although drugs and alcohol have been declining as factors in child fatalities, they are still a major contributor to a family’s involvement with DCF. The pervasiveness of drugs/alcohol in these fatality cases is shown on page 35. Statistics are presented on the past and current use of substances by parents and other primary caretakers. A description of the type of drugs and their prevalence is also provided. From 1989 to 2010, the proportion of mothers with deceased children and a history of substance abuse fluctuated between 39% and 65%--median 47.5% (see following table). During the same time span, the proportion of mothers with an unknown history of substance abuse decreased—a high of 41% in 1990 to a low of 3% in 2008. Calendar Year and Proportion of Mothers with a History of Substance Abuse: 1989-1999 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 51% 41% 41% 57% 53% 65% 47% 48% 39% 58% 51% Calendar Year and Proportion of Mothers with a History of Substance Abuse: 2000-2010 2001 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 44% 42% 53% 43% 52% 55% 43% 39% 58% 40% 43% When neglect and physical abuse are contributing factors to a child’s death, each is counted in both of the categories displayed in Table 3. Consequently, the number of deaths involving neglect and physical abuse cannot be determined by adding the counts for each category. The following table gives the number of children with abuse- and/or neglect-related deaths during 1989-2010. In 2010, there were 8 maltreatment-related deaths: 4 deaths involved neglect and 4 deaths involved both neglect and physical abuse. Deaths involving maltreatment ranged from a high of 15 in 1992 to a low of 1 in 1997 (see table below). It should be noted that these counts only include deceased children whose families had open cases or cases closed six months or less at the time of death. 1989 13 Calendar Year and Number of Maltreatment-Related Deaths: 1989-1999 1990 1991 1992 1993 1994 1995 1996 1997 1998 14 9 15 10 3 11 5 1 13 1999 3 2000 4 Calendar Year and Number of Maltreatment-Related Deaths: 2000-2010 2001 2002 2003 2004 2005 2006 2007 2008 2009 7 9 5 3 4 3 13 11 7 2010 8 17 Table 3. Factors Causing or Contributing to Child’s Death (1989 - 2010) Specific Factors Drug/Alcohol Related Congenital Condition Prematurity Low Birth Weight Sudden Infant Death Abusive Head Trauma Terminal Illness HIV- Related Infections Other Infectious Disease Fire Motor Vehicle Accident Drowning Other Accident Neglect Physical Abuse Firearms Stabbing Beating TOTAL FACTORS TOTAL DEATHS INFANT DEATHS 1989 26 26 16 15 15 NA NA 2 -5 5 1 -11 2 3 NA NA 127 84 42 1990 25 13 17 13 16 NA NA 4 3 9 6 3 10 12 4 5 NA NA 140 89 40 1991 13 15 7 5 8 NA NA 6 2 1 6 4 3 5 4 4 NA NA 83 66 29 1992 12 13 8 7 5 NA NA 5 -6 4 2 -12 3 6 NA NA 83 67 31 1993 19 21 11 5 12 NA NA 3 -2 4 2 3 5 5 3 NA NA 95 68 27 1994 12 9 5 1 19 NA NA 6 --5 3 2 5 2 1 6 NA NA 76 65 26 1995 7 12 11 3 9 NA NA 4 -2 -2 4 7 6 1 NA NA 68 53 29 1996 3 13 3 -8 NA NA 4 3 -5 5 3 2 4 2 NA NA 55 55 17 1997 3 9 5 3 8 NA NA 1 3 4 1 1 5 1 1 4 NA NA 49 42 17 1998 3 6 3 2 4 NA NA -1 2 5 6 5 11 5 5 NA NA 58 41 9 Calendar Year 1999 2000 3 1 9 12 4 5 2 2 6 3 NA NA NA NA 1 1 1 --2 4 7 2 2 4 2 2 3 1 1 2 1 NA NA NA NA 41 42 39 41 15 11 2001 5 12 5 3 5 1 7 -2 1 4 2 1 7 2 1 2 -60 46 15 2002 3 5 1 -5 -2 -1 2 4 3 3 7 3 1 2 1 43 32 10 2003 2 8 5 2 5 1 6 2 3 -3 -1 5 2 2 1 1 49 36 13 2004 4 6 5 4 4 -1 -4 -4 -1 3 -4 1 -41 30 10 Note: The summation of factor counts does not equal the number of deaths because multiple factors may have contributed to a child’s death. Physical abuse only includes abusive head trauma, stabbing, and beating when the perpetrator is a caretaker. 18 2005 5 4 8 6 4 -3 -3 -1 1 3 4 1 3 -1 47 31 15 2006 1 14 7 4 4 -3 -4 -2 1 2 3 ----45 31 11 2007 2 6 5 2 4 3 3 -2 -2 2 -10 6 6 -2 55 34 17 2008 5 7 8 5 4 -1 -3 4 2 2 5 10 3 3 --62 38 21 2009 2 16 4 2 9 1 5 -4 -3 -2 5 4 2 1 1 61 50 17 2010 4 7 2 2 6 3 2 ---2 1 1 8 4 3 2 2 49 30 13 B. DCF Involvement 1. Placement Status The proportion of deceased children in placement at the time of their death has been at its lowest level for the past four years (2007-2010)—14% to 18% of all deaths (Table 4 on page 20). In 2010, 17% (5) of all deceased children were in out-of-home locations: hospital (3 children), unrelated foster home (1), and pre-adoptive foster home (1) (Table 5 and Table 6 on page 21). All 5 children had multiple medical conditions at birth. The 3 hospitalized children lived 2-9 days (2 premature, 1 with a genetic disorder/terminal illness). As was the case with the 3 infants, the 2 foster children (1year-old and 15-year-old) succumbed to major medical complications (Table A3 on page 9). From 1991 to 2010, the proportion of deceased children who were in placement at the time of their death ranged from 14% to 49% (32% median) (Table 4). The relatively large proportions of children who died while in placement during 1993-1995 (42-49%) were mainly attributable to fatalities in unrelated foster homes and institutional settings (mostly hospitals) (Table 5). Many of these children died shortly after birth; others were hospitalized for a relatively short period of time with a terminal condition; and some spent most if not all of their lives in hospitals or pediatric nursing homes. Most of the children who died while placed with relatives or unrelated foster parents had serious illnesses or disabilities. From 1996 to 2006, there was a shift towards lower proportions of deceased children in placement (Table 4). During these years, the proportion of children who died while in placement ranged from a high of 39% to a low of 23% (Table 4). In 2007-2010, the proportion of deceased children in placement stabilized at 14-18% (Table 4). Four of the 6 deaths in unrelated foster care during 2007-2010 (Table 5) were due to natural causes. The 2 remaining deaths were due to street shootings. The vast majority of the children receiving services from the Department are living at home with parents. Regardless of location, most deaths have been due to “natural causes” and to a lesser degree accidents (Table 2 on page 15). The only time accidents exceeded natural causes was in 1998 (Table 2). This singular occurrence was attributed to the high number of adolescent deaths and low number of infant deaths (Table 1 on page 12). Another anomalous year was 2007 when the number of deaths from homicides and natural causes were equal (Table 2). The year 2007 was distinguished by a relatively high number of adolescent homicides and a relatively low number of infant deaths from natural causes. 19 Table 4. Child’s Placement Status at Time of Death (1991 - 2010) Location of Child Not in In Placement Total Placement 1991: No. 44 22 66 % 67% 33% 100% 1992: 53 14 67 79% 21% 100% 1993: 35 33 68 51% 49% 100% 1994: 37 28 65 57% 43% 100% 1995: 31 22 53 58% 42% 100% 1996: 35 20 55 64% 36% 100% 1997: 29 13 42 69% 31% 100% 1998: 26 15 41 63% 37% 100% 1999: 26 13 39 67% 33% 100% 2000: 30 11 41 73% 27% 100% 2001: 26 20 46 57% 43% 100% 2002: 23 9 32 72% 28% 100% 2003: 26 10 36 72% 28% 100% 2004: 23 7 30 77% 23% 100% 2005: 19 12 31 61% 39% 100% 2006: 19 12 31 61% 39% 100% 2007: 28 6 34 82% 18% 100% 2008: 31 7 38 82% 18% 100% 2009: 43 7 50 86% 14% 100% 2010: 25 5 30 83% 17% 100% Note: The relative percentages may not sum to 100% due to rounding-off. Calendar Year 20 Table 5. Child’s Placement Status at Time of Death (1991 - 2010) Location of Child Calendar Year Kinship Foster Home Unrelated Foster Home Institution (hospital) Residential Care 1991 3 12 5 1992 2 10 2 1993 3 12 16 1994 8 11 8 1995 3 10 9 1996 6 8 1 1997 3 9 -1998 2 6 1 1999 2 5 2 2000 -3 5 2001 1 6 6 2002 2 3 3 2003 -2 5 2004 --6 2005 1 3 7 2006 -4 6 2007 -3 2 2008 -1 4 2009 1 1 1 2010 -1 3 Note: Institution includes hospitals and pediatric nursing homes. Preadoptive Home -----1 ---2 -1 1 -1 1 1 1 -1 2 --1 --1 2 3 -4 -2 --1 --2 -- Supervised Independent Living -----1 --------------- On the Run from Placement --2 --3 -4 1 1 3 --1 ---1 2 -- Total 22 14 33 28 22 20 13 15 13 11 20 9 10 7 12 12 6 7 7 5 Table 6. Child’s Placement Status and Manner of Death (2010) Location of Child Not in Placement In Placement: Kinship Foster Home Unrelated Foster Home Residential Care Institution (hospital) Pre-Adoptive Foster Home Supervised Independent Living On-the-Run from Placement Total Natural Causes 5 -1 -2 1 --9 Manner of Death Accident Suicide 3 ----1 ---4 --------- Homicide 9 Undetermined 8 Total 25 -------9 -------8 -1 -3 1 --30 During the period 1993-2010, approximately 110,700 children spent time in DCF placement. Of these, an estimated 109,400 were placed in foster and/or residential care. The remaining children were placed in “other” locations such as hospitals, pediatric nursing homes, and with other Massachusetts state agencies. Of the 762 children known to DCF who died during 1993-2010, a total of 146 children died in foster or residential care (Fig. 3 on next page). The deaths of 15 of the 146 children were maltreatment-related; 4 of these 15 children died from physical abuse/neglect14 that occurred prior to placement in unrelated foster care (Fig. 4 on next page). Of the 11 children who died from maltreatment that took place while the child was in foster or residential care: neglect was a contributing factor in 8 deaths; physical abuse was the cause of death for 2 children; and both 14 Three of the children died from injuries (physical abuse) inflicted in their parent’s home and one child succumbed to medical problems related to prenatal cocaine use by his mother (neglect). They died after they were placed in unrelated foster care. 21 physical abuse and neglect were factors in the remaining child’s death. In other words, 11 of the 146 children who died while placed in foster or residential care during an 18-year period were victims of maltreatment (where the neglect or abuse occurred in the placement setting). Of the remaining 131 children15 who died while in foster or residential care, 91 died from natural causes, 30 died in accidents, 6 were suicides, 3 were homicides (shooting by an unknown/non-caretaker), and 1 was undetermined (Fig. 4, Table 7 on next page). Natural causes can be broken down into 18% sudden infant death, 14% AIDS, and 68% other medical problems (often congenital in origin) (Table 7). Figure 3. Child Fatalities 1993 - 2010 Placement Status 11% 2% ** 762 Children: 19% 67% No. % Not in Placement 512 67% Foster and Residential Care 146 19% Institutions* 85 11% On the Run from Placement 18 2% Supervised Independent Living 1 ** * Hospitals and pediatric nursing homes ** Less than 1% after rounding-off Figure 4. Child Fatalities in Foster and Residential Care 1993 - 2010 8% 3% 1% No. 146 Children: Natural Causes 91 Accident 30 Suicide 6 Homicide (non-caretaker perpetrator) 3 Maltreatment occurred in Placement * 11 Maltreatment occurred prior to Placement ** 4 Undetermined 1 2% 4% 62% 21% * Maltreatment occurred in foster or residential care. ** Maltreatment occurred in home of parents prior to placement in unrelated foster care where child died. 15 % 62% 21% 4% 2% 8% 3% 1% Note: The summation of relative percentages does not equal 100% due to rounding-off. The 131 children does not include 4 deaths where the maltreatment occurred in the parents’ home prior to placement in unrelated foster care (see Fig. 4, Table 7). 22 Table 7. Manner of Death: Children in Foster and Residential Care (1993 – 2010) Total Fatalities 146 Natural Causes: 91 Sudden Infant Death 16 AIDS 13 Other medical (often congenital in origin) 62 Accidents: 30 Involving a motor vehicle 9 Drowned (2 in pools, 4 in river/lake/ocean) 6 Asphyxiation/Suffocation (soft bedding, choking, etc.) 8 Other (fire, drug overdose, fall, shooting) 7 Suicide: 6 Homicide (shooting by an unknown/non-caretaker): 3 Neglect/Physical Abuse: (9 accidents, 4 homicides, 2 natural causes) 15 Occurred in Foster/Residential Care 11 Occurred in home of parent(s) prior to placement in Foster/Residential Care 4 Undetermined: 1 Note: This table represents children who died in foster and residential homes/facilities; it does not include children who died while in institutions (hospitals), supervised independent living, or on the run from placement. 2. DCF Case Status In 2010, child deaths summarized in this report occurred primarily in open protective cases (24 of 30 or 80%) (Table 8 on next page). Over the past 20 years, the proportion of deaths in protective cases has ranged from 61% to 96% (77.5% median). During 2010, 12 protective cases were open for more than six months and 12 protective cases were open for six months or less at the time of the child’s death. The remaining 6 cases were closed less than 6 months when the child died. Of the 24 children who died while in open protective cases: 5 were homicide victims, 3 were accident victims, and 9 died from natural causes (Table A3 on page 9). Manner of death could not be conclusively determined for the remaining 7 children in open protective cases. Manner of death for the 6 children from families with a closed case status was homicide (4), accident (1), and undetermined (1). (Table A3) 23 Table 8. Family’s Case Status at Time of Child’s Death (1991 - 2010) Calendar Year 1991: 1992: 1993: 1994: 1995: 1996: 1997: 1998: 1999: 2000: 2001: 2002: 2003: 2004: 2005: 2006: 2007: 2008: 2009: 2010: No. % Current Protective < 6 mos. 10 15% 17 25% 13 19% 19 29% 11 21% 11 20% 10 24% 4 10% 11 28% 11 27% 8 17% 8 25% 10 28% 9 30% 8 26% 10 32% 13 38% 16 42% 10 20% 12 40% Case Status at Time of Death Current Current Current Protective > Voluntary CHINS 6 mos. Request Referral 42 7 1 64% 11% 2% 41 4 1 61% 6% 1% 45 5 2 66% 7% 3% 27 5 4 42% 8% 6% 40 --75% --31 3 3 56% 5% 5% 21 2 1 50% 5% 2% 21 4 5 51% 10% 12% 18 1 3 46% 3% 8% 21 1 2 51% 2% 5% 30 1 1 65% 2% 2% 20 -1 62% -3% 20 -3 56% -8% 16 -2 53% -7% 16 1 2 52% 3% 6% 14 2 2 45% 6% 6% 12 2 7 35% 6% 21% 10 4 3 26% 11% 8% 28 2 1 56% 4% 2% 12 --40% --- Case Closed < 6 mos. Totals 6 9% 4 6% 3 4% 10 15% 2 4% 7 13% 8 19% 7 17% 6 15% 6 15% 6 13% 3 9% 3 8% 3 10% 4 13% 3 10% --5 13% 9 18% 6 20% 66 100% 67 100% 68 100% 65 100% 53 100% 55 100% 42 100% 41 100% 39 100% 41 100% 46 100% 32 100% 36 100% 30 100% 31 100% 31 100% 34 100% 38 100% 50 100% 30 100% Note: The relative percentages may not sum to 100% due to rounding-off. 3. Custody Status of Children Four of the 30 children who died during 2010 were in DCF custody—2 in temporary custody and 2 in permanent custody. DCF seeks court ordered custody of a child when remaining in the home is contrary to the child’s welfare. Courts can also grant custody to DCF as part of CHINS, divorce, or paternity petitions among others. DCF can accept voluntary care of a child at a parent’s request. Courts grant DCF permanent custody of a child upon finding the child is in need of care and protection. The 2 children in permanent custody (unrelated foster home and pre-adoptive foster home placements) died from natural causes—multiple medical conditions (congenital). One of the children in temporary custody died from natural causes; the other child’s death was accidental. Both of these children had been hospitalized (2-day-old and 9-day-old infants). 24 4. Reports of Child Maltreatment Reports of abuse or neglect made pursuant to M.G.L. ch. 119, sec. 51A are screened-in when there is reason to believe that a child has been maltreated or may be at risk of maltreatment by a caretaker. The DCF differential response system allows reports to be screened-in for an investigation or initial assessment. Not all reports of abuse and neglect require the same type of intervention. DCF is able to engage families more quickly in an initial assessment when the reported concern does not warrant the formal investigation of an allegation. An investigation is required when there has been an allegation of sexual abuse, serious physical abuse, or serious neglect. Depending on the urgency, a report screened-in for investigation is designated an emergency or non-emergency. For screened-in emergency reports, an investigation must be initiated within 2 hours and completed within 5 business days after receiving the report. Investigations prompted by non-emergency reports must be initiated within 2 business days and completed within 15 business days after receiving the report. The reported allegations are investigated by DCF staff who determine whether the report should be supported or unsupported. Reports alleging child maltreatment were filed on the deaths of 17 of the 30 children known to DCF during 2010: 7 reports were unsupported and 10 were supported. Neglect was supported for 6 deaths; it was a factor in 4 of the deaths. In the other 2 deaths, a 51A was filed and supported on the mother for neglect; however, the neglect was not a factor in the death (filthy conditions in home, drug dealing from home, etc.). In the remaining 4 deaths, both physical abuse and neglect were contributing factors (Table A3 on page 9). The 4 neglect deaths involved 3 infants and a teenager. SIDS, medical neglect, motor vehicle accident, unsafe sleeping conditions, and prematurity related to prenatal drug exposure were factors in their deaths. Both physical abuse and neglect were factors in the deaths of 2 infants and 2 two-yearold children who succumbed to abusive head trauma and bodily injuries. (Table A3) Two of the 8 children with maltreatment-related deaths in 2010 were the subjects of 51A reports in the three months preceding their deaths. One child had an initial assessment finding of concern (medical neglect) and the other child had a supported finding of physical abuse by an unknown perpetrator. In the first case, allegations of neglect due to the mother having used marijuana during her pregnancy were screened-out. Supported allegations of neglect in the second case involved domestic violence (first report) and attempted suicide (second report). 25 C. Family Demographics 1. Age and Sex of Children In 2010, 67% of the deceased children were male (Table 9). Over the years, the proportion of males has ranged from 49% to 80% (61.5% median) (Table 9). Table 10 shows 9 male and 4 female infants. Except for five years, infant deaths have been predominantly male. There were 7 male and 2 female adolescent deaths in 2010 (Table 10). In the past, males have accounted for most of the adolescent deaths; the exceptions were 2001 and 2005 when females outnumbered males by 2 to 1 and in 2009 when there were equal numbers. Table 9. Sex of Children (1989 - 2010) Sex of Children Male Female No. % No. % Year 1989 47 56% 37 44% 1990 54 61% 35 39% 1991 44 67% 22 33% 1992 39 58% 28 42% 1993 42 62% 26 38% 1994 37 57% 28 43% 1995 34 64% 19 36% 1996 37 67% 18 33% 1997 22 52% 20 48% 1998 27 66% 14 34% 1999 19 49% 20 51% 2000 28 68% 13 32% 2001 23 50% 23 50% 2002 23 72% 9 28% 2003 23 64% 13 36% 2004 24 80% 6 20% 2005 19 61% 12 39% 2006 20 65% 11 35% 2007 17 50% 17 50% 2008 21 55% 17 45% 2009 26 52% 24 48% 2010 20 67% 10 33% Table 10. Age and Sex of Children (2010) Sex Male Female Total < 1 yr. 9 4 13 1 - < 2 yrs. 1 2 3 Age of Children 2 - < 5 yrs. 5 - < 12 yrs. 2 1 1 1 3 2 26 12 - 18 yrs. 7 2 9 Total 20 10 30 2. Age of Parents Mothers of the children who died in 2010 ranged in age from 16 to 43 years old. The median ages of mothers and fathers, were 26.5 and 37.5 years, respectively. Thirty-seven percent of all mothers were 20-29 years old and 10% were less than 20 years old (Table 11). Compared to all mothers in the DCF caseload, a greater proportion of the mothers of deceased children were 20-29 year olds (Table 11). Over the past 19 years, the proportion of 20-29 year-old mothers of deceased children has ranged from 15% to 63% (median of 40%). The years 1993, 1996, and 1998 are the only years where the proportions of 20-29 year-old and 30-39 year-old mothers of deceased children approximated the corresponding caseload proportions. Table 11. Age of Parents at Time of Child’s Death (2010) Mothers of Deceased Mothers in the Fathers of Deceased Children DCF Caseload (*) Children No. % % No. % Parent’s Age (yrs.) 12 - 17 2 7% NA 1 3% 18 - 19 1 3% 3% --20 - 29 11 37% 30% 3 10% 30 - 39 9 30% 37% 3 10% 40 - 49 3 10% 23% 3 10% 50 - 59 --7% 1 3% 60 - 69 ---1 3% Unknown 4 13% -18 60% 30 100% 100% 30 100% Total (*) As of June 30, 2010, based on the number of females not in placement who were 18 to 59 years old with an open case status. NA = Not Available Note: The relative percentages may not sum to 100% due to rounding-off. 27 3. Marital Status of Mothers Sixty-six percent of the mothers of deceased children were known to be unmarried compared to 73% for the mothers in the general caseload (Table 12). In prior years, the proportion of unmarried mothers has been significantly higher for mothers of deceased children than for mothers in the DCF caseload. The proportion of unmarried mothers of deceased children has ranged from 66% to 97% (85% median) over the past 19 years. During these years, the proportion of unmarried mothers in the caseload has been stable. Table 12. Marital Status of Mothers at Time of Child’s Death (2010) Mothers of Deceased Mothers in the DCF Children Caseload (*) No. % % Marital Status Married 5 17% 23% Divorced --7% Separated 1 3% 5% Single (**) 19 63% 60% Widowed --1% Unspecified 5 17% 5% 30 100% 100% Total (*) As of June 30, 2010, based on the number of females not in placement who were 18 to 59 years old with an open case status. (**) Never married or single at time of child’s death (unknown marital history). Note: The relative percentages may not sum to 100% due to rounding-off. 4. Mothers: Age at First Birth, DCF Placement, Mental Illness Thirteen mothers (43%) were known to have been less than 20 years old when they gave birth to their first child. Eight mothers (27%) were known to have been placed in DCF foster or residential care as children. Thirteen mothers (43%) were known to have one or more of the following mental health issues: depressive disorder (5 mothers), bipolar disorder (3), anxiety disorder (3), suicidality (thinking and behavior) (3), post-traumatic stress disorder (1), self-inflicted injuries (1), schizophrenia (1), and panic disorder (1). 28 5. Caretakers Actively Involved in DCF Casework In 23 of the 30 families with deceased children, adult caretakers were known to be actively involved with DCF casework. Of the 23 involved families, 16 families had only one adult caregiver who was an active participant: 12 mothers, 3 fathers, and 1 foster mother. Seven families had two actively involved adult caregivers. In all 7 of these families, both caregivers were living together. (See chart below) Families Actively Involved with DCF Casework 30 Families Families with Adult(s) Actively Involved No Adult Involved 7 23 Mother 12 Mother & Stepfather 1 Mother & Father 6 Foster Mother 1 Father 3 6. Race and Hispanic Origin of Deceased Children and Their Parents Thirty percent of all children who died in 2010 were White, 30% were Black, 3% were Asian, and 10% were Multi-Racial (Table 13A on next page). Race could not be determined for 27% of the deceased children. Twenty-seven percent of the deceased children were identified as Hispanic/Latino16 (Table 13B on next page). A greater proportion of deceased children were Black (30%) compared to the DCF child caseload (17%) (Table 13A). Black children are over-represented in the child fatalities group. The proportions of deceased children and caseload children who were Hispanic were similar (27% and 31%, respectively) (Table 13B). 16 Children of any race who are identified as being of Hispanic/Latino origin. 29 Table 13A. Race of Children (2010) Deceased Children in DCF Children Caseload (*) No. % % Race White 9 30% 55% Black 9 30% 17% Asian 1 3% 2% Native American --*** Pacific Islander (**) --*** Multi-Racial 3 10% 5% Unspecified 8 27% 20% 30 100% 100% Total (*) As of June 30, 2010, children less than 18 years old with an open case status. (**) Native Hawaiian or other Pacific Islander *** = less than 1% after rounding-off Note: The relative percentages may not sum to 100% due to rounding-off. Table 13B. Hispanic/Latino Origin of Children (2010) Deceased Children in DCF Children Caseload (*) No. % % Origin Hispanic/Latino 8 27% 31% Not Hispanic/Latino 17 57% 62% Unspecified 5 17% 7% 30 100% 100% Total (*) As of June 30, 2010, children less than 18 years old with an open case status. The following table compares the proportions of Black children and Hispanic children in the fatalities group and the DCF caseload over a twelve-year period. Proportions of Black Children and Hispanic Origin Children: 1999 – 201017 Child Fatalities Proportion of Black Children Range: 16% - 40% Median 23.5% DCF Child Caseload Proportion of Black Children Range: 15% - 19% Median 17% Proportion of Hispanic Origin Children Range: 17% - 41% Median 26.5% Proportion of Hispanic Origin Children Range: 16% - 31% Median 27% The median proportion of Black children in the fatalities group (23.5%) exceeds the median proportion of Black children in the DCF caseload (17%) (see above table). There were similar median proportions of Hispanic children in the fatalities group (26%) and DCF caseload (27%). 17 Since 1999, Hispanic has been used as an “ethnicity” rather than a race. 30 For each racial category, Table 14 displays the proportion of deceased children in three age groups. Forty-three percent of all deceased children were infants, 27% were 1-11 years old, and 30% were adolescents. The age distributions are different for each race category: 44% of White children were infants and 44% of Black children were adolescents. Hispanic child fatalities were most prominent in the adolescent group (62%). Table 14. Age, Race and Hispanic Origin of Deceased Children (2010) Age Groups Race < 1 yr. 1 - 11 yrs. 12 - 18 yrs. White 4 (44%) 2 (22%) 3 (33%) Black 2 (22%) 3 (33%) 4 (44%) Asian 1 (100%) ------Native American ---------Multi-Racial 1 (33%) 2 (67%) ---Unspecified 5 (62%) 1 (12%) 2 (25%) 13 (43%) 8 (27%) 9 (30%) Total 2 (25%) 1 (12%) 5 (62%) Hispanic Origin 9 9 1 -3 8 30 8 Total (100%) (100%) (100%) --(100%) (100%) (100%) (100%) The racial distribution for mothers of deceased children is presented in Table 15. A racial comparison of mothers of deceased children to mothers in the DCF caseload is hindered by the high proportion of mothers of deceased children with unspecified race (43%) (Table 15). In 2010, White mothers of deceased children were under-represented and Black mothers were over-represented (Table 15). Twenty-three percent of the mothers of deceased children self-identified as being of Hispanic origin compared to 21% for all mothers in the DCF caseload. In most prior years, the proportion of mothers who were Black was greater in the fatalities group than in the overall DCF caseload; this was also true for Hispanic mothers. White mothers were under-represented in the fatalities group. Table 15. Race and Hispanic Origin of Parents (2010) Mothers of Deceased Mothers in the DCF Fathers of Deceased Children Caseload (*) Children No. % % No. % Race White 10 33% 58% 5 17% Black 6 20% 15% 2 7% Asian 1 3% 2% --Native American --*** --Pacific Islander (**) --*** --Multi-Racial --1% --Unspecified 13 43% 24% 23 77% 30 100% 100% 30 100% Total 7 23% 21% 4 13% Hispanic Origin (*) As of June 30, 2010, based on the number of females not in placement who were 18 to 59 years old with an open case status. (**) Native Hawaiian or other Pacific Islander (***) Less than 1% after rounding-off Note: The summation of relative percentages may not equal 100% due to rounding-off. 31 7. Family Residence Springfield was the family residence of 5 children who died in 2010. Cities with two or more child fatalities were: Pittsfield (3 children), Boston (2), and Lowell (2). On a county basis, 6 children were from Middlesex and 6 were from Hampden (Table 16). Comparing the DCF regional distributions of deceased children to all children in the caseload showed that the Western Region was the most over-represented (Table 17). The Central Region was the most under-represented. Table 16. Family’s County of Residence (2010) County Deceased Children Hampden 6 Middlesex 6 Berkshire 3 Essex 3 Hampshire 3 Plymouth 3 Suffolk 3 Bristol 2 Worcester 1 30 Total Table 17. Child’s DCF Service Region at Time of Death (2010) Deceased Children Children in DCF Caseload (*) No. % % DCF Region West 12 40% 23% Central 1 3% 16% Northeast 5 17% 16% Metro 4 13% 12% Southeast 5 17% 21% Boston (**) 3 10% 12% 30 100% 100% Total (*) As of June 30, 2010, children less than 18 years old with an open case status. (**) Brookline, Chelsea, Revere, and Winthrop are part of the Boston Region. 32 8. Family Size There were three or more siblings in 17 (57%) of the 30 families with a deceased child (Table 18). From 1993-2010, the proportion of families with three or more children has ranged from 46% to 74%. In contrast, 25% of the families in the overall caseload had three or more children (Table 18). Also, 47% of the families in the DCF caseload had one child versus 10% of the families with deceased children. The percentage of one-child families of deceased children has ranged from 5% to 26% over the past 18 years. Table 18. Family Size (2010) Deceased Children Family DCF Caseload Family Number of Children Count Count (*) in Family No. % % one 3 10% 47% two 10 33% 29% three 8 27% 16% four 5 17% 6% five 1 3% 2% six 1 3% 1% seven or more 2 7% ** 30 100% 100% Total Families (*) As of June 30, 2010, based on the number of children (less than 18 years old) with the same case identification number and an active case status. (**) Less than 1% after rounding-off 33 D. Substance Abuse 1. Substance Abuse and Child Maltreatment According to the Prevent Child Abuse America Fifty-State Survey18 (PCAA 2001), substance abuse was the most frequently cited problem affecting families reported for maltreatment. Other less frequently noted problems displayed by families reported for child maltreatment were poverty and economic strains, domestic violence, and lack of parental capacity and skills (PCAA 2001). Poverty, interpersonal violence, social isolation, the presence of unrelated substance-abusing adults in the home, and parental mental illness (particularly depression), that often co-occur with parental substance abuse are all associated with child maltreatment (Dore 1998).19 Estimates of 40% to 80% are given for the proportion of families in the child welfare system with alcohol/drug and abuse/neglect problems (studies cited by Young and colleagues 1998).20 In 80% of substance-abuserelated cases, the child’s entry into foster care was the result of severe neglect (U.S. Department of Health and Human Services 1999);21 addicted parents are often unable to meet the needs of their children. As stated above, there is a strong connection between parental substance abuse and child maltreatment. Children of substance-abusing parents are nearly three times as likely to be abused and more than four times as likely to be neglected as compared to children whose parents do not abuse alcohol and other drugs (studies cited by Banks and Boehm 2001).22 In addition to an increased risk of abuse and neglect, children of substance-abusing parents are also at risk for physical, academic, social, and emotional problems (Office on Child Abuse and Neglect 2009).23 The children’s needs often become secondary to the parents’ focus on obtaining, using, or recovering from the use of drugs and alcohol. 18 National Center on Child Abuse Prevention Research, a program of Prevent Child Abuse America. 2001. Current trends in child abuse prevention, reporting, and fatalities: the 1999 fifty-state survey. Working Paper Number 808, Chicago, IL. 26pp. 19 Dore, M.M. 1998. Impact and relationship of substance abuse and child maltreatment: risk and resiliency factors. Paper presented at conference on “Protecting Children in Substance Abusing Families” (9/28/98). Center for Advanced Studies in Child Welfare, Univ. of Minnesota School of Social Work, Minneapolis, MN. 25pp. 20 Young, N.K., S.L. Gardner, and K. Dennis. 1998. Responding to alcohol and drug problems in child welfare: weaving together practice and policy. Office of Juvenile Justice and Delinquency Prevention. CWLA Press, Washington, D.C. 179pp. 21 U.S. Department of Health and Human Services. 1999. Blending perspectives and building common ground: a report to Congress on substance abuse and child protection. U.S. Government Printing Office, Washington, D.C. 175pp. 22 Banks, H. and S. Boehm. 2001. Children’s Voice Article, September 2001, Substance abuse and Child Abuse. (http://www.cwla.org/articles/cv0109sacm.htm) 23 Office on Child Abuse and Neglect, Children’s Bureau (U.S. Department of Health and Human Services). 2009. Protecting children in families affected by substance use disorders. http://www.childwelfare.gov/pubs/usermanual.cfm 34 Among the abused and neglected children are infants who were prenatally exposed to drugs and alcohol. Nationwide, 550,000 – 750,000 children are born each year to women who used drugs or alcohol during their pregnancy (Office on Child Abuse and Neglect 2009). Many newborns exhibit severe physical impairments as a consequence of maternal substance abuse. Of those that survive, many are medically fragile and require intensive care (Office on Child Abuse and Neglect 2009). Children who were prenatally exposed to substances but show no apparent physical problems may manifest impairments as they become older including cognitive deficits, learning disabilities, and poor social adjustment. 2. Parent/Caretaker’s Past and Current24 Use of Illicit Drugs/Alcohol Table 19 shows the past and current use of substances by mothers and other primary caregivers in the household. The 16 other caregiving adults were: 13 fathers, 2 male partners, and 1 stepfather. It should be noted that the presence of another adult does not indicate that the adult is actively engaged in DCF casework (see page 29). Fourteen mothers (47%) had a documented history of abusing drugs and alcohol (Table 19). The proportion of mothers with a past history of substance abuse was lower in 2009 (40%). Since 1992, the proportion of mothers with a history of drugs/alcohol has ranged from 39% to 65%. At the time of the CIU investigation, 6 mothers were known to be using substances (Table 19). As was the case in prior years, most of the decline in substance-abusing mothers was due to a shift from “yes” in the past to “unknown” in the present. The principal substances used by mothers were marijuana, alcohol, and cocaine. Of those mothers known to have used substances at some time, 67% (8) used marijuana, 58% (7) used alcohol, and 33% (4) used cocaine. Seventy-five percent (9) of the mothers used more than one substance. The most frequently used combinations were: alcohol-marijuana and alcohol-cocaine. Other drugs used by the mothers of children who died in 2010 were: heroin (1 mother), methadone (1), oxycodone (1), and barbiturates (1). Table 19. Primary Caregiver Past and Current Use of Drugs/Alcohol (2010) Past History of Use Current Use Relationship to Child Yes No Unk Totals Yes No Unk Total Mother 14 13 3 30 6 15 9 30 Other Primary Adult 2 7 7 16 0 9 7 16 24 At the time of the CIU investigation. 35 3. Mother’s Prenatal Care and Use of Substances during Pregnancy Thirteen infants died in 2010: 4 deaths were due to “natural causes,” 1 was a homicide, 1 was an accident, and 7 were undetermined (Table 23 on page 38). Five of the infants were prenatally exposed to drugs/alcohol (Table 20). A determination of drug use was made at the time of delivery, either by the mother’s self report or from a positive toxic screen. Low numbers of infants and the paucity of information on drug/alcohol abuse preclude the drawing of conclusions about the use of substances during pregnancy and the frequency of selected medical conditions in Table 20. Table 20. Medical Conditions of Infants and Mother’s Use of Substances during Pregnancy (2010) Drug/Alcohol Use during Pregnancy Total Medical Condition (*) Yes No Unknown Prematurity 2 --2 Low Birth Weight 2 --2 Congenital Condition 1 2 -3 Sudden Infant Death 2 2 2 6 7 4 2 13 TOTAL CONDITIONS -1 2 3 No Medical Condition (**) 5 4 4 13 TOTAL INFANTS (*) An infant may have more than one medical condition; consequently, the summation of counts for each condition may not equal the total number of children. (**) Three infants had no medical conditions. As was the case with the above table, low counts of infants and a lack of information preclude any analysis of substance-abusing mothers and their level of prenatal care (Table 21). Table 21. Infant Deaths: Mother’s Prenatal Care and Use of Substances during Pregnancy (2010) Drug/Alcohol Use during Pregnancy Prenatal Care Yes No Unknown Total Routine 2 1 -3 Little 1 --1 None 1 --1 Unknown 1 3 4 8 5 4 4 13 TOTAL CHILDREN 36 E. Domestic Violence 1. Prevalence of Domestic Violence in Families It is widely known that adult domestic violence and child maltreatment often occur together. Domestic violence perpetrators not only victimize adults, but also harm their children, involve them in the abuse, and instill fear in them by exposing them to violence directed at their caregiver, usually the mother. Review of more than two decades of studies revealed that in 30 to 60 percent of the families where women were abused, their children were also maltreated.25 Domestic violence was reported in at least 11 of the 30 families where children died in 2010 (Table 22). If a past history with violence is included, the number of families increases to 16. A past history of violence includes mothers who were victims or perpetrators in a prior relationship. The prevalence of domestic violence among fatality cases for the past 18 years is presented in Table 22. Table 22. Prevalence of Domestic Violence among Fatalities (1993-2010) Prevalence of Domestic Violence in Families with Child Fatalities Total Families with Child Year Current Violence Past Violence Fatalities(*) No. % of Total No. % of Total No. 1993 24 35% 35 51% 68 1994 11 17% 23 37% 63 1995 18 34% 25 48% 52 1996 14 26% 19 35% 54 1997 5 12% 14 34% 41 1998 15 38% 22 55% 40 1999 7 18% 15 38% 39 2000 11 27% 23 56% 41 2001 14 30% 22 48% 46 2002 10 33% 17 57% 30 2003 13 37% 17 49% 35 2004 10 33% 17 57% 30 2005 8 27% 10 33% 30 2006 10 32% 15 48% 31 2007 12 39% 16 52% 31 2008 16 44% 20 56% 36 2009 17 35% 27 56% 48 2010 11 37% 16 53% 30 (*) Family counts for the following years are less than the number of fatalities because of sibling deaths (3 siblings in 1994; 2 in 1995; 2 in 1996; 2 in 1997; 2 in 1998; 2 pair in 2002; 2 in 2003; 2 in 2005; groups of 3 siblings and 2 siblings in 2007; 2 pair of siblings in 2008; 3 siblings in 2009). 25 National Council of Juvenile & Family Court Judges. 1999. Effective intervention in domestic violence and child maltreatment cases: guidelines for policy and practice. 37 F. Special Groups of Children 1. Adolescents Thirty percent of the children (9 of 30 children) who died in 2010 were 12 years old or older (Table 1 on page 12, Table 23). Over the past eight years (2003-2010), the proportion of adolescent deaths has ranged from 24% to 33% (Table 1). The 9 adolescents died from shootings (2), stabbings (2), motor vehicle accidents (2), medical problems (2), and drowning (1) (Table 23, Table A3 on page 9). Seven of the adolescents were male and two were female (Table 10 on page 26). Over the past 22 years, the counts of deceased adolescents by gender were: mostly male in 11 years; similar for the sexes in 9 years; and mostly female in 2 years. Table 23. Age of Children and Manner of Death (2010) Age of Children Manner of Death < 1 yr. 1 - < 2 yrs. 2 - < 5 yrs. 5 - < 12 yrs. Natural Causes 4 1 -2 Accidental 1 ---Homicide 1 1 3 -Undetermined (*) 7 1 --13 3 3 2 Total (*) Undetermined following an autopsy by a medical examiner. Total 12 - 18 yrs. 2 3 4 -9 9 4 9 8 30 Eight of the 9 adolescents were not in placement; one adolescent was in a specialized foster home (multiple medical conditions and intellectual/developmental disability) (Table A3). Three of the adolescents were known to have been involved with the Department of Youth Services (DYS) and one was involved with the Department of Mental Health. The following issues were identified for 5 of the 9 adolescents: criminal activities (3), substance abuse (2), exposure to domestic violence (1), mental illness (1), and special education (1). An adolescent may have more than one issue. Table 24 on the next page displays the type of services provided to 5 of the 9 adolescents. An adolescent may have received more than one service; consequently, the breakdown of services is based on the type of service not the number of children. Of the remaining 4 adolescents (not included above), 1 received support for medical issues; 1 died during the assessment period; and 2 children were in families that declined services. 38 Table 24. Type and Frequency of Services Provided to Adolescents (2010) Service Count of Adolescents Receiving Services (*) Tracking 3 Home-Based Treatment 3 Mental Health Counseling 2 Education Advocacy 2 Unrelated Foster Care 1 Group Home 1 Kinship Living Arrangement 1 Substance Abuse Treatment 1 Residential Substance Abuse Treatment 1 Job Core 1 16 Total Services 5 Total Number of Adolescents (*) An adolescent may have received more than one service; consequently, the summation of counts for each service does not equal the total number of children. 2. Medically-Involved/Physically-Challenged Children Of the 30 deceased children, 5 were medically-involved, 1 was physically-challenged, and 3 were both medically-involved and physically-challenged. These 9 children with health issues ranged from infants to adolescents: 4 were 2 to 9 days old, 1 was a year old, 1 was 7 years old, and 3 were teenagers. Their manner of death was natural causes (7), accident (1), and homicide (1). Three of the abovementioned infants never left the hospital due to congenital conditions related to premature births (2) and a terminal illness (genetic disorder) (1). The fourth infant, who was not in placement, also died from a genetic terminal illness. The locations of the remaining 5 “older” children were: living with parents or other family members (3), unrelated specialized foster home (1), and pre-adoptive foster home approved for the Special Kids/Special Care Program (1).26 26 The program provides intensive medical case management for children with complex medical needs who are in DCF custody and in foster care. 39 III. Child Maltreatment-Related Fatalities: 2001 – 2010 The following statistics only deal with child fatalities where maltreatment was a direct cause of death or a contributing factor to the cause of death. In 2001, DCF began compiling statistics on maltreatment-related deaths of children whose families were unknown to DCF and children whose families had their DCF cases closed more than six months prior to the child’s death. The following analysis includes the aforementioned maltreatment-related deaths and the maltreatment-related deaths from Section II (open or recently open cases). During 2010, there were 18 child fatalities with supported allegations of neglect or physical abuse by a caretaker (Table 25 on page 43). • Neglect was a factor in 10 deaths, physical abuse was factor in 2 deaths, and both neglect and physical abuse were factors in 6 deaths (Table 25). • Some of the deaths involved multiple perpetrators (Table A5 on page 11). Perpetrators of neglect included 13 mothers, 6 fathers, 1 male partner, and 1 baby sitter. Perpetrators of physical abuse were 4 mothers, 3 fathers, 1 male partner, and 1 baby sitter. (Table 26 on page 44) • Compared to 2007-2009, there were more deaths involving children 1 to 5 years old in 2010 (9 in 2010 vs. 3-4 in 2007-2009) (Table 25). • None of the 18 victims of maltreatment were in placement at the time of death (Table 25). • The case statuses of the 16 families (18 children)27 were: open protective for 6 months or less (3); open protective for more than 6 months (3); case closed 6 months or less (2); case closed more than 6 months (3); and family unknown to DCF (5). (Table 25) Summary of 18 Maltreatment-Related Child Fatalities in 2010 • 27 10 Neglect-Related Deaths: --There were two cases involving twin girls (2 years old and 4 years old) who drowned in the family’s backyard pool. --Two infants were at risk due to unsafe sleeping conditions. --A teenage boy was a passenger in a car driven by a drunken teenage driver. --A one-year-old child fell 25 feet from a window (unscreened, lack of supervision). --A premature infant had medical complications due to prenatal drug exposure (cocaine and heroin). --A case of medical neglect; the mother was not keeping medical appointments for her infant despite expressing concerns about the child’s health. In 2 families, there were 2 sibling deaths. 40 • 2 Physical Abuse-Related Deaths: --Infant: head injury (multiple skull fractures) from an unknown perpetrator. --Infant: abusive head trauma and bodily injuries from father. • 6 Physical Abuse- and Neglect-related Deaths: --Infant: abusive head trauma and fractures of all extremities from both mother and father (physical abuse and neglect) --Infant: asphyxiation, abusive head trauma, and bodily injuries from father (physical abuse) and mother (neglect) --One-year-old child: bodily injuries from mother (physical abuse and neglect) --One-year-old child: abusive head trauma and blunt trauma to abdomen from babysitter (physical abuse and neglect) --Two-year-old child: blunt force trauma to head with injuries to brain from both mother and male partner (physical abuse and neglect) --Two-year-old child: abusive head trauma and bodily injuries from mother (physical abuse and neglect) and father (neglect) Statistics pertaining to the deceased child’s age, race, gender, Hispanic origin, placement status, and manner of death are displayed in Table 25 (on page 43). In Table 26 (on page 44), the perpetrator’s relationship to the child is shown for each type of maltreatment. The family’s case status is also shown in Table 25. For comparison, statistics are given for each year from 2001 to 2010. Totals for the 10 years are also presented. Profile of Child Maltreatment-Related Deaths (Data Compiled on 129 Deaths from 2001 to 2010) • • • • • • • • 58% of the children were males 52% of the children were infants (less than 1 year old) 67% of the children were victims of neglect, another 18% were victims of neglect and physical abuse, 14% were victims of physical abuse 37% of the deaths were accidents and 33% were homicides 90% of the children were not in placement 65% of the families were known to DCF 59% of the perpetrators of neglect were mothers and 21% were fathers 33% of the perpetrators of physical abuse were mothers, 29% were fathers, and 17% were mothers’ male partners (see Fig. 5 on page 45, Tables 25 and 26) 41 As for race and Hispanic origin of the children, there were too many “unknowns” the first two years (Table 25 on next page). Removing the “unknown” counts from the race and Hispanic totals yielded: • • 47% of the children were non-White 28% of the children were Hispanic At the national level in FFY’2010, the proportion of children less than one year old with a maltreatment-related death was 47.7%.28 Adolescents accounted for 5.6% of the deceased children. DCF proportions in CY’2010 were 44% for infants and 6% for adolescents (Table 25). Nationally, one or both parents were responsible for 79.2% of the abuse/neglect-related deaths. DCF statistics show that most of the child fatalities are attributable to parents: 90% of all perpetrators of neglect and 70% of all perpetrators of physical abuse (Table 26). 28 U.S. Department of Health and Human Services, Administration on Children, Youth & Families, Children’s Bureau, 2012. Child Maltreatment 2010. (http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#can) 42 Calendar Year Table 25. Profile of Child Neglect/Physical Abuse Deaths 2001-2010 Total Child Maltreatment Fatalities Family Case Status: current protective case open 6 months or less current protective case open more than 6 months current CHINS case current voluntary open more than 6 months case closed 6 months or less case closed more than 6 months unknown to DCF Maltreatment: neglect physical abuse neglect and physical abuse Gender: male female Age (years): less than 1 1– 5 6 – 11 12 - 17 Race: White Black Asian multi-racial unknown Hispanic Origin: yes no unknown Placement Status: not in placement unrelated foster home institution (hospital/nursing home) Manner of Death: natural causes* accident suicide homicide undetermined/pending** 2001 19 3 3 --1 3 9 11 3 5 10 9 11 6 2 -3 2 -1 13 1 6 12 16 1 2 4 6 -8 1 2002 17 -7 --2 2 6 12 4 1 11 6 9 6 2 -3 2 -7 5 4 5 8 14 -3 3 7 -5 2 2003 16 1 4 ---4 7 10 1 5 9 7 6 6 2 2 12 -1 1 2 3 11 2 16 --3 7 1 5 -- 2004 8 1 1 --1 2 3 6 2 -7 1 6 --2 2 --1 5 3 2 3 7 -1 4 2 -2 -- 2005 7 2 ---2 1 2 5 1 1 6 1 4 2 1 -2 2 --3 -4 3 5 1 1 1 3 1 2 -- 2006 10 1 2 ---3 4 8 1 1 7 3 5 3 1 1 4 2 -1 3 3 7 -9 -1 2 4 -3 1 2007 19 4 6 3 --1 5 13 3 3 7 12 11 3 5 -6 4 -2 7 6 9 4 19 ---8 -7 4 2008 18 5 3 --3 2 5 15 1 2 8 10 10 4 1 3 8 2 1 1 6 4 11 3 14 -4 5 8 -3 2 * Premature babies dying from congenital conditions (neglect) or placental abruption (physical abuse) due to their mothers’ use of substances during pregnancy. ** Manner of death could not be determined following an autopsy by a medical examiner. 43 2009 15 2 4 -1 -2 6 9 3 3 9 6 7 3 3 2 5 4 2 1 3 4 11 -15 ---4 1 6 4 2010 18 3 3 --2 5 5 10 2 6 11 7 8 9 -1 6 4 -4 4 3 12 3 17 -1 1 6 -8 3 Total 147 22 33 3 1 11 25 52 99 21 27 85 62 77 42 17 11 51 22 4 19 51 31 78 38 132 2 13 23 55 3 49 17 Table 26. Perpetrators of Child Neglect/Physical Abuse 2001-2010 *Perpetrator: mother (Neglect) father stepfather mother’s boyfriend father’s girlfriend grandmother grandfather aunt uncle female legal guardian foster parent day care provider provider (after school program) baby sitter unrelated adult caretaker nursing home/rehab staff *Perpetrator: mother (Physical Abuse) father mother’s boyfriend father’s girlfriend uncle foster parent baby sitter **non-caretaker unknown 2001 10 2 --1 ---1 -1 -1 ---1 4 1 1 1 ---1 2002 11 3 --1 1 ---1 ------3 1 1 ------- 2003 13 6 ---2 -2 1 --1 -1 --2 1 2 -----1 2004 4 2 ------------1 -1 1 -------- Calendar Year 2005 2006 5 6 1 2 ------1 1 -------1 --------2 -1 1 ---------1 ------2 2007 15 3 -1 ------------2 1 3 ------- 2008 13 4 -1 -1 ---1 ---2 --1 ------2 -- * Perpetrators who neglect and physically abuse a child are counted under each category. If more than one perpetrator victimized a child, each perpetrator is counted under the appropriate category(ies). ** Non-caretaker was the mother’s former female partner (2 siblings died in arson fire). 44 2009 9 7 1 -1 2 1 ---------2 4 1 ------- 2010 13 6 -1 ---------1 --4 3 1 ---1 -1 Total 101 36 1 3 3 8 1 2 2 2 2 1 1 4 3 1 17 15 9 1 1 1 1 2 5 Figure 5. Profile of Child Maltreatment Fatalities: 2001 - 2010 7% 12% 147 Child Fatalities from Child Maltreatment 2001 - 2010 52% < 1 yr 52% 1 - 5 yrs 29% 6 - 11 yrs 12% 12 - 17 yrs 7% 29% Age (yrs) 18% Male 42% 58% Female 58% Neglect 67% 42% Physical Abuse 14% 14% 67% Neglect & Physical Abuse 18% Type of Maltreatment Gender 9% 1% 12% 37% 2% Accident Homicide Natural Causes Suicide Undetermined 16% 37% 33% 16% 2% 12% Not in Placement Institution (Hospital) Unrelated Foster Home 33% 90% Manner of Death Child's Placement Status Note: Percentages may not equal 100% due to rounding-off. 45 90% 9% 1% IV. Death Rates A. Age-Specific Death Rates Summary: 2004 - 2010 The following summary table presents child fatalities death rates for years 2004 through 2010 for all deceased children in the state and the DCF caseload (open cases). The table also displays annual death rates for maltreatment-related child fatalities in the nation, state, and DCF caseload. In addition to death rates for all children, rates were determined for two age categories—infants and children 1 year old or older. Statewide death rates for all child deaths were fairly stable over the seven years while DCF death rates fluctuated. Maltreatment-related death rates for the state and DCF rose from 2004 to 2007 then stabilized. In 2007, there was a rise in deaths of children in open cases (Table 25 on page 43). Annual changes in the nationwide maltreatment-related death rate were minor (nationwide rates are annually updated for the 5 most recent years).29 AGE-SPECIFIC DEATH RATES SUMMARY: 2004 – 2010* 2004 2005 2006 2007 2008 2009 2010 3.7 45.9 1.3 3.8 46.6 1.5 8.9 60.3 5.7 6.1 56.1 3.2 All Child Fatalities Massachusetts: All Children < 1 yr old (infants) 1 -17 yrs old 4.2 49.3 1.7 4.1 52.3 1.4 Child Deaths per 10,000 Resident Children in the State 3.9 4.2 4.1 48.2 52.0 50.5 1.5 1.6 1.5 Child Deaths per 10,000 Children in the DCF Caseload DCF Open Cases: All Children < 1 yr old (infants) 1 -17 yrs old 6.7 54.0 4.7 6.5 69.5 3.4 6.7 47.7 4.5 8.2 76.0 4.3 7.2 67.7 3.5 Maltreatment-Related Child Fatalities Nation:** .20 .20 Maltreatment-Related Deaths per 10,000 Children in the U.S.*** .20 .23 .23 .23 .21 Massachusetts: .05 .05 Maltreatment-Related Deaths per 10,000 Children in the State .07 .13 .12 .10 .13 Maltreatment-Related Deaths (Open Cases) per 10,000 Children in the DCF Caseload DCF Open Cases: .50 .50 .72 3.13 1.75 1.51 1.52 * State and DCF death rates are based on child deaths during the calendar year, whereas Nationwide rates are based on the Federal Fiscal Year. ** Most recent update of annual child fatalities death rates (Child Maltreatment 2010, Table 4-2. www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf) *** Converting to maltreatment-related deaths per 100,000 children in the U.S. yields: 2.07 in 2010, 2.34 in 2009, 2.28 in 2008, 2.28 in 2007, 2.00 in 2006, 1.94 in 2005, and 2.03 in 2004. 29 Most recent update of annual child fatalities death rates (Child Maltreatment 2010, Table 4-2. www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf) 46 Death rates for DCF caseload children were higher than the rates for Massachusetts and the United States. One might expect this given that DCF has a much greater proportion of families at risk. Supported reports of maltreatment are responsible for 80-90% of the children who enter the DCF system. Their families are beset by problems such as substance abuse, poverty and economic strains, domestic violence, and lack of parental capacity and skills. The use of alcohol and drugs by pregnant mothers and the lack of prenatal care are contributing factors to the birth of premature babies with severe medical problems. Poverty and the associated economic stresses are barriers to a healthy lifestyle and quality healthcare. Children are more susceptible to fatal accidents when parental oversight and decision-making are impaired as parents struggle with substance abuse, mental illness, poverty, and other problems. B. 2010 Death Rates Computations 1. All Child Fatalities According the Registry of Vital Records and Statistics, there were 539 child deaths in Massachusetts during January 1 - December 31, 2010.30 The deaths included 333 infants (less than 1 year old) and 206 children 1-17 years old. These counts of child fatalities were translated to age-specific death rates using the population of children less than 18 years old residing in Massachusetts from the 2010 U.S. Census.31 The age-specific death rate32 was 3.8 child deaths per 10,000 resident children in Massachusetts. The rate was 46.6 for infants and 1.5 for children 1-17 years old. Infants are defined as being less than one year old when they died. In 2010, there were 30 child deaths (all causes) in 30 DCF families; 24 deaths were in open cases and 6 were in closed cases. An age-specific death rate was determined using the 24 deceased children whose families had open cases and the 39,479 children33 in the DCF caseload (open cases) on June 30, 2010. The rate was 6.1 child deaths (open cases) per 10,000 children in the DCF caseload. Of the 24 deceased children (open cases) known to DCF, 12 were infants and 12 were 1-17 years old. Age-specific death rates for DCF infants and children 1-17 years old were 56.1 and 3.2, respectively. 30 Massachusetts Department of Public Health, Registry of Vital Records and Statistics, childhood deaths printout on May 29, 2012. 31 U.S. Census Bureau, American FactFinder (Advanced Search). Table QT-P2. Single Years of Age and Sex, Massachusetts. 2010 Census Summary File 1. [1,418,923 children less than 18 years old includes 71,434 infants and 1,347,489 children 1-17 years old] (http://factfinder2.census.gov) 32 The age-specific death rate was computed by dividing the number of deaths in 2010 for a specific age group by the mid-year resident population in that age group. For DCF, this meant dividing the number of children who died while in open cases during 2010 by the number of children less than 18 years old with open cases on 6/30/2010. Children with an open case are defined as children with an active case status who were in a case with an assessment for services or a service plan. 33 The 39,479 includes 2,138 infants, 37,585 children 1-17 years old, and 26 children age unspecified. 47 B. Maltreatment-Related Child Fatalities Across the nation, an estimated 1,560 children died from abuse and/or neglect in FFY’2010.34 Expressed as a rate, this count converts to 0.21 maltreatment-related deaths per 10,000 resident children in the United States.35 DCF recorded 18 maltreatment-related deaths36 in Massachusetts during 2010 – a rate of 0.13 maltreatment-related deaths per 10,000 resident children in Massachusetts. Thirteen of the 18 maltreated children were in families known to DCF. None of the 18 children were in placement. Of the 13 children from families known to DCF, 6 were in open cases and 7 were in closed cases. Based on the 6 children in open cases, the death rate was 1.52 maltreatment-related deaths (open cases) per 10,000 children in the DCF caseload. Neglect and physical abuse were contributing factors in 3 of the deaths. The remaining 3 deaths only involved neglect. It should be noted that the term maltreatment-related death is used because neglect and/or physical abuse were factors in the deaths; it does not necessarily mean they were the direct cause of the death. 34 Death of a child caused by an injury resulting from abuse or neglect, or where abuse or neglect was a contributing factor. 35 U.S. Department of Health and Human Services, Administration on Children, Youth & Families. 2012. Child Maltreatment 2010. (http://www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf) 36 Maltreated children are less than 18 years old and the perpetrators are caretakers. 48