Within Our Reach

How Prevention is the Best Model for Addressing Child Abuse and Neglect Fatalities

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September 23, 2022

By: Amy Templeman

There is a shift taking place across the nation regarding child abuse and neglect fatalities. These tragedies, long considered inevitable, make headlines across every community and jurisdiction, with a focus on why systems failed our children and how these children fell through the cracks.

One finding points to the fact that child welfare systems have historically been focused on addressing harm only after it has occurred. Now imagine a system that works collaboratively across multiple agencies to provide the resources and supports that families need to prevent abuse and neglect before it can occur. That is the shift taking place today, with demonstration projects taking place across the United States, including Indiana, that are identifying risk factors and moving resources upstream to address the stressors that families face and with an emphasis on prevention.

The Indiana Department of Health (IDOH) is one of five sites nationwide participating in a Department of Justice demonstration initiative known as Child Safety Forward. With support from a broad range of technical assistance providers, IDOH has conducted research that identifies unsafe sleep-related deaths as the leading cause of death due to external causes for children ages 0-18 years old, when excluding medically expected fatalities.


Their findings, which focused on Clark, Grant, Delaware and Madison Counties, highlighted the fact that infants are at a heightened risk for sleep-related deaths and that those deaths were being underreported throughout the state based on inconsistent and incomplete child fatality reviews. Furthermore, they found that inconsistent and incomplete documentation of Sudden Unexpected Infant Deaths (SUIDs) had the potential to limit knowledge of the true rates of SUIDs and the risk factors. High quality, accurate fatality data enables jurisdictions to better understand and address risk factors, promoting the effectiveness and actionability of recommendations.


It is important to note that, in 107 of 140 of the cases identified, children were unknown to Child Protective Services (CPS) before the fatality, pointing to the fact that CPS alone cannot address these deaths and supporting the need for a public health approach to child maltreatment-related fatalities.

Based on these findings, IDOH took several important steps. They developed Community Action Teams in each of the four counties to create avenues for distribution of safe sleep information and resources through pediatricians, vaccination sites, and other channels. They connected with Family Resource Centers and Prevent Child Abuse chapters to share information and identify resources for families.


They also shared their data with government leaders and policymakers, which helped lead to improved SUID policies in Governor Holcomb’s 2022 Next Level Agenda. On July 1, 2022, House Enrolled Act 1169 went into effect, establishing consistent standards for investigations into SUIDs, aligning with the Centers for Disease Control and Prevention best practices. This alignment will ensure that coroner investigations into deaths among healthy children who die suddenly and unexpectedly are handled consistently across the state and include imaging, pathology and toxicology.

Child abuse and neglect fatalities, including unsafe sleep deaths, are not inevitable. They are preventable, solvable and an issue that we all have a stake in addressing. For more information on safe sleep guidelines, visit the Indiana Department of Child Services website on Safe Sleep.


A version of this article previously appeared in the Indiana Herald Bulletin on September 15, 2022.

Disclaimer: This product was supported by cooperative agreement number 2019-V3-GX-K005 Reducing Child Fatalities and Recurring Injuries Caused by Crime Victimization, awarded by the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this product are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice.

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