Within Our Reach

A Public Health Approach to Reducing Child Fatalities in Indiana 

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November 7, 2023

By: Susana Mariscal and Bryan Victor 

One of the most challenging and complex responsibilities of the child welfare system is understanding and investigating the death of a child. As difficult as they are, these investigations are an essential part of a public health process that helps explain why child deaths occur and the strategies that can prevent future deaths.  

Child Fatality Review (CFR) teams are assigned the hard task of reviewing all deaths of children under the age of 18 that are sudden, unexpected, or unexplained, including children known to child protective services, and deaths that are determined to be the result of homicide, suicide, accident, or are undetermined. While many local CFR teams are comprised of individuals who are committed to protecting children and families in their local communities, for some states, including Indiana, CFR teams are volunteer positions and members are not compensated for their participation.  

When the Indiana Department of Health (IDOH) was selected in 2019 by the Department of Justice Office for Victims of Crime as one of five sites in the nation to participate in a demonstration initiative to apply a public health approach to reducing child abuse and neglect fatalities and injuries, a focal area was the CFR process. The initiative, known as Child Safety Forward, gave us the opportunity to apply support from a national technical assistance team to our long-term aim of ensuring that processes, such as fatality review, are used consistently and effectively to generate data-informed recommendations to support prevention.  

For the first phase of Child Safety Forward Indiana, CFR teams undertook a five-year retrospective review of data corresponding to child deaths in four counties that experienced the highest number of child fatalities in the state, along comparison counties. We also conducted interviews with parents and child-serving professionals involved with CFR, such as child welfare, public health, education, mental health, criminal justice, and others to learn about barriers and facilitators related to identification and prevention. The findings were significant, both in what they revealed about causes of child death, and in what they revealed about gaps in the system. 

One of the findings identified inconsistencies around the implementation and operation of CFR teams around the state. For instance, instead of focusing on determining factors that could help identify prevention strategies, local review teams were often oriented toward assigning responsibility for death in individual cases—which reinforced the notion that CFR is a punitive process. To improve policy, IDOH developed data-driven recommendations that informed two state legislative changes. The first proposed policy change was to eliminate restrictions on who could initiate a CFR team, opening the door to a broader set of practitioners and community members to take the lead. The second proposed policy change was to mandate certain types of evidence and data to be collected during a death scene investigation in Sudden Unexpected Infant Death (SUID) cases–often related to unsafe sleep conditions. 

Since the passage of these bills, the Child Safety Forward Indiana team has continued to implement several other changes that strengthened the CFR infrastructure across the state. The biggest change is the increase in the number of CFR teams, which for the first time in the history of the program, now cover all 92 counties in the state. The Department of Child Services (DCS) has taken on the responsibility of initiating teams in many of these areas. With this rapid expansion, training and resources for teams were needed, and Child Safety Forward Indiana has created a hub and toolkit for this purpose, along with coordinators to provide support at the regional level. 

Over the course of the initiative, the improvement in the quality of the CFR process was one aspect of a multi-dimensional effort, including multidisciplinary team training.  The team also worked to improve cross-system collaboration in partnership with Strengthening Indiana Families (SIF), a primary child maltreatment project that is implementing Family Resource Centers in central Indiana to provide support and build on families’ protective factors through community collaboration. SIF also convened a Parent Advisory Group to emphasize the voices and representation of parents in shaping prevention programs, advancing racial equity and inclusion, and improving children and family outcomes.  

Community Action Teams, consisting of a group of stakeholders, were established to implement CFR team recommendations. IDOH also developed and launched a data-informed statewide infant safe sleep campaign, including videos which have garnered over 1.5 million views. 

While no direct causal inferences can be made, all of these and other prevention efforts have had a meaningful collective impact in the four target counties, which has seen decreases in SUID rates and in the rates of child fatalities due to external injury.  

These efforts demonstrate that, while difficult, the work of those who conduct child fatality reviews are a vital and necessary tool in a public health approach that is geared toward providing the resources and knowledge that can prevent future tragedies, so that all children fulfill their promise. 


Susana Mariscal is an associate professor at the Indiana University School of Social Work. She is the lead evaluator of Child Safety Forward Indiana and project director of Strengthening Indiana Families, a strengths-based primary child maltreatment prevention program funded by the U.S. Children’s Bureau. Mariscal is a community-engaged scholar focused on violence prevention and resilience promotion among children and families. 

Bryan Victor is an assistant professor at Wayne State University School of Social Work. His research examines community-based approaches to violence prevention with a particular focus on child maltreatment. Victor is a co-investigator on the Child Safety Forward Indiana evaluation team and co-leads the Strengthening Indiana Families project with Dr. Susana Mariscal. 

Disclaimer: This product was supported by cooperative agreement number 2019-V3-GX-K005, 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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