1.) 2.) National Data Likely Underestimate the Number of Children Who Died from Maltreatment and Provide Incomplete Information on Circumstances

		More Children Have Likely Died from Maltreatment than Are Counted in National Data

More children have likely died from maltreatment than are reflected in the  national estimate of 1,770 child fatalities for fiscal year 2009. Some  children may not have been previously maltreated, or their earlier  maltreatment may not have been noticed or reported to CPS agencies. The NIS is a congressionally  mandated, periodic effort of HHS to estimate the incidence of child abuse  and neglect in the United States. HHS Collects but Does Not Report Some Useful Information on the Circumstances Surrounding Child Fatalities

NCANDS collects more data on the circumstances surrounding child  fatalities than are reflected in HHS’s annual Child Maltreatment report— information that could be useful for prevention. However, HHS does not report some information it collects on  the circumstances surrounding child fatalities. Local Investigative Challenges and Limited Coordination Hinder States’ Efforts to Collect Child Maltreatment Fatality Data and Report to NCANDS

		Investigative Difficulties Can Hamper Local Data Collection Efforts

Challenges faced by local investigators, such as law enforcement  officials, medical examiners, and CPS staff, in determining whether a  child’s death was caused by maltreatment make it difficult for states to  collect complete data on child maltreatment fatalities.   Lack of definitive medical evidence: Without definitive medical  evidence, it can be difficult to determine that a child’s death was  caused by abuse or neglect. Inconsistent interpretations and application of maltreatment  definitions. HHS Provides Assistance to States in Reporting on Child Maltreatment Fatalities, but States Would Like Additional Help

		HHS Provides Technical Assistance to States in Reporting Data on Child Maltreatment

HHS provides assistance to states in several ways to help them report  information on child maltreatment to NCANDS. Although NCCDR regularly collaborates with federal organizations to  analyze child fatality data and develop strategies to prevent child deaths,  there has been little routine information sharing between NCCDR and  NCANDS on child maltreatment fatalities. States Would Like Additional Assistance in Collecting and Using Data on Child Fatalities and Near Fatalities from Maltreatment

Although HHS provides a variety of assistance to states on how to report  data to NCANDS, state officials indicated a need for additional assistance  collecting child fatality as well as near-fatality data to use for prevention  efforts. Conclusions

In conclusion, children’s deaths from maltreatment are especially  distressing because they involve a failure on the part of adults  responsible for protecting them. 3. Estimate the costs and benefits of collecting national data on near  fatalities and take appropriate follow-up actions. DOJ and NCCDR provided technical comments,  which we incorporated as appropriate. In its comments, HHS also raised concerns about the nationwide Web- based survey of child welfare administrators—one of several  methodologies used for this report—noting that it had several limitations. At that time, we will send copies of this report to relevant  congressional committees, the Secretary of Health and Human Services,  the Attorney General of the United States, and other interested parties. The survey included questions  about state laws related to child maltreatment, child welfare department  coordination with other agencies or entities, state challenges related to  identifying and collecting information on child maltreatment fatalities and  reporting these data to NCANDS, child death review teams, state  challenges related to collecting information on child maltreatment near  fatalities, and federal assistance from HHS to states on data collection  and reporting. Both states and NDACAN take steps to protect confidentiality. NCCDR Data Analysis

To examine the extent to which HHS collects and provides  comprehensive information on child fatalities from maltreatment, we  requested and obtained state child death review team data from  NCCDR’s Child Death Review (CDR) Case Reporting System. Appendix III: Information from States Not Reported in NCANDS

	State Data on Child Fatalities Not Reported to NCANDS

Thirty-two states also collected information on child maltreatment fatalities  that were not reported to NCANDS in fiscal year 2009, according to our  survey of state child welfare officials.
Why GAO Did This Study

Children's deaths from maltreatment are especially distressing because they involve a failure on the part of adults who were responsible for protecting them. Questions have been raised as to whether the federal National Child Abuse and Neglect Data System (NCANDS), which is based on voluntary state reports to the Department of Health and Human Services (HHS), fully captures the number or circumstances of child fatalities from maltreatment. GAO was asked to examine (1) the extent to which HHS collects and reports comprehensive information on child fatalities from maltreatment, (2) the challenges states face in collecting and reporting this information to HHS, and (3) the assistance HHS provides to states in collecting and reporting data on child maltreatment fatalities. GAO analyzed 2009 NCANDS data--the latest data available--conducted a nationwide Web-based survey of state child welfare administrators, visited three states, interviewed HHS and other officials, and reviewed research and relevant federal laws and regulations.

What GAO Found

More children have likely died from maltreatment than are counted in NCANDS, and HHS does not take full advantage of available information on the circumstances surrounding child maltreatment deaths. NCANDS estimated that 1,770 children in the United States died from maltreatment in fiscal year 2009. According to GAO's survey, nearly half of states included data only from child welfare agencies in reporting child maltreatment fatalities to NCANDS, yet not all children who die from maltreatment have had contact with these agencies, possibly leading to incomplete counts. HHS also collects but does not report some information on the circumstances surrounding child maltreatment fatalities that could be useful for prevention, such as perpetrators' previous maltreatment of children. The National Center for Child Death Review (NCCDR), a nongovernmental organization funded by HHS, collects more detailed data on circumstances from 39 states, but these data on child maltreatment deaths have not yet been synthesized or published. States face numerous challenges in collecting child maltreatment fatality data and reporting to NCANDS. At the local level, lack of evidence and inconsistent interpretations of maltreatment challenge investigators--such as law enforcement, medical examiners, and child welfare officials--in determining whether a child's death was caused by maltreatment. Without medical evidence, it can be difficult to determine that a child's death was caused by abuse or neglect, such as in cases of shaken baby syndrome, when external injuries may not be readily visible. At the state level, limited coordination among jurisdictions and state agencies, in part due to confidentiality or privacy constraints, poses challenges for reporting data to NCANDS. HHS provides assistance to help states report child maltreatment fatalities, although states would like additional help. For example, HHS hosts an annual NCANDS technical assistance conference, provides individual state assistance, and, through NCCDR, has developed resources to help states collect information on child deaths. However, there has been limited collaboration between HHS and NCCDR on child maltreatment fatality information or prevention strategies to date. State officials indicated a need for additional information on how to coordinate across state agencies to collect more complete information on child maltreatment fatalities. States are also increasingly interested in collecting and using information on near fatalities from maltreatment.

What GAO Recommends

GAO recommends that the Secretary of HHS take steps to further strengthen data quality, expand available information on child fatalities, improve information sharing, and estimate the costs and benefits of collecting national data on near fatalities. In its comments, HHS agreed with GAO's findings and recommendations and provided technical comments, which GAO incorporated as appropriate.