Multi-System Perspectives on Child Fatality Determinants and Prevention Strategies

Background and purpose: The majority of child deaths in the United States are caused by accidental and intentional injuries, and most of these deaths are preventable. As a result, federal policies and many child welfare organizations have increasingly moved toward a primary and secondary prevention framework in connection with child fatalities. The effectiveness of those prevention efforts rests not only on understanding the most common types of fatalities (e.g., sleep-related, maltreatment-related, etc.) but also the underlying determinants or causes of those fatalities and strategies for remediation prior to death. Professionals across systems serving children and families come into close contact with families that experience a preventable child fatality, providing them with rich insights into the context of what transpired. The purpose of the current study was therefore to explore the perspectives of multi-system professionals around the leading determinants of child maltreatment-related fatalities, and to identify a set of prevention strategies to be empirically tested.

Methods: Data for the current study were obtained through 69 semi-structured interviews and 7 focus groups with a total of 101 participants across the following systems: child fatality review teams, child welfare agencies, public health, health, mental health, early education, youth agencies, schools, and youth and parents with lived experience in the child welfare system. Participants worked at leadership, supervisory, and frontline levels. Experience working with the child welfare system ranged from 4 years to 39 years. Text data from interview and focus group transcripts were coded using thematic analysis (constructivist research).

Findings: Through inductive analysis, we identified a set of determinants for preventable child fatalities at family, community, and systems levels. The seven identified family-level determinants that contribute to preventable child fatalities were: unsafe infant sleep behaviors, substance misuse, mental health issues, domestic violence, caregiver stress, lack of parenting and coping skills, and lack of adequate childcare and social support. At the community level, we identified three primary determinants: inaccessible resources and supports, poor quality of services, and environmental barriers to accessing support. That is, families were either unable, unaware, or chose not to access services and resources that would mitigate fatality risk. At the systems level, a lack of collaboration and coordination among local, regional and state agencies was the main determinant identified. Proposed solutions to addressing the identified determinants included targeted interventions, enhanced community involvement in prevention efforts, and public awareness campaigns that deliver consistent safe sleep messaging to change parenting behaviors.

Conclusions and implications: Our findings highlight the urgent need to enhance the collaboration and coordination across systems and develop an integrated and comprehensive service continuum based in a public health approach that provide destigmatized supports, resources, and connection to families to prevent child fatalities. Beyond addressing service gaps, it is necessary to design and implement culturally responsive targeted interventions and a statewide safe sleep campaign that addresses information deficits and promotes behavioral change. Promoting family-strengthening policies and family-supportive attitudes in communities are also necessary for a paradigm shift in child and family services and to help all children realize their potential.