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.  

By: Sheila Boxley  

When the federal Commission to Eliminate Child Abuse and Neglect Fatalities released its groundbreaking report in 2018, one of the key concepts that informed its recommendations was the need for multi-disciplinary support for families. In other words, keeping children safe is a job that child welfare systems and child protective services (CPS) cannot do alone. 

On the heels of the release of the Commission’s report, the U.S. Department of Justice funded a demonstration initiative to develop and test multidisciplinary strategies and responses to address fatalities or near-death injuries as a result of child abuse and neglect. Known as Child Safety Forward, the initiative has spent the subsequent four years developing strategies to support a public health approach to reducing abuse and neglect fatalities. 

The Child Abuse Prevention Council of Sacramento (CAPC) was one of five demonstration sites in the nation chosen for this grant. Systems partners across Sacramento County began the work with an understanding that child safety and well-being was not solely a “child welfare responsibility,” and recognized the need for all child- and family-serving agencies and organizations to partner together. While collaboration across systems in Sacramento County was already strong, the initiative furthered a sense of shared responsibility and accountability for child safety to fully implement a public health approach to prevent child maltreatment through systems change.  

Through the development of a Prevention Cabinet comprised of local system and community leaders, the Sacramento Child Safety Forward team leaned into  the collective impact approach, which is often utilized to support and engage multi-disciplinary players to work together to solve complex problems. 

What is collective impact? Practitioners define it as “a network of community members, organizations, and institutions that advance equity by learning together, aligning, and integrating their actions to achieve population and systems-level change.” It involves a structured process that integrates the following: a common agenda; shared measurement; mutually reinforcing activities; continuous communication; and a backbone team.  

Engaging community and centering equity are essential elements to the success of collective impact. The Sacramento team approached the work by elevating families into relationships of equal power in the development of a strategic plan with the goal of aligning with community needs.  

They achieved this by appointing Community Representatives to infuse the initiative with the stories, voices, and life experiences of those who have had contact with any child- and family- serving system or agency in Sacramento County. Seven community listening sessions, developed in partnership with the Community Representatives, provided additional community feedback. 

Shifting the way people think and understand the connection between prevention and child safety takes time. It requires moving decision makers and practitioners from focusing on how to work within the constraints of their current system to envisioning a new way for the system to operate. There were core elements of the Child Safety Forward design that helped accelerate some of the necessary transformations. These included: 

Child Safety Forward enabled Sacramento County to create a robust governing structure through its Prevention Cabinet for this work. This entity now consists of more than 30 cross-systems leaders from public systems, private nonprofits, and the community who have come together to co-create a strategic plan focused on systems change that promotes positive outcomes for children and families. 

The demonstration initiative has afforded Sacramento County the opportunity to participate in peer-to-peer learning and connect with subject-matter experts to support planning and implementation of a cross-systems strategic plan using a public health 21st century child welfare system approach. This has included the development of strategic ten-year plan to eliminate child abuse and neglect fatalities by 2030 that the team will be presenting to the Sacramento County Board of Supervisors. 

Child Safety Forward Sacramento’s Prevention Cabinet has become the advisory body and collaborative partner for other child safety initiatives in the county. Because the Prevention Cabinet has such a widespread reach across county agencies and organizations, the Prevention Cabinet has been selected as the governing body of the county’s efforts to implement the Family First Sacramento Comprehensive Prevention Plan.   

This approach to collective impact is uniting cross-sector and community leaders under a common cause and will ultimately help leaders engage and collaborate across systems that touch families with a common goal and collective responsibility for keeping children safe.  

___________________ 

Sheila Boxley is the President & CEO of the Child Abuse Prevention Center, a local and state organization which provides services, training, research, and advocacy and serves as the association for the 500 family resource centers in California. 

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.  

Reports highlight findings in multi-year effort to develop strategies to reduce child abuse and neglect.

WASHINGTON, DCChild Safety Forward (CSF) today released the final evaluation report of its four-year demonstration initiative funded by the Department of Justice (DOJ) with technical assistance led by Social Current. CSF, which was launched in October 2019 by the DOJ’s Office for Victims of Crime, engaged five sites across the U.S. in the demonstration initiative, which included research, planning and implementation around strategies aimed at reducing child injury and fatality from abuse and neglect.

The CSF demonstration sites include: The Indiana Department of Health; St. Francis Hospital in Hartford, Connecticut; Cook County Health in Illinois; the Michigan Department of Health and Human Services; and the Sacramento County Child Abuse Prevention Council. Final reports from the sites are available here.

Through CSF, the five demonstration sites received technical assistance from a team of national experts to help plan and implement an all-systems approach to respond to and reduce child maltreatment fatalities and child crime victimization. Technical assistance focused on collecting and analyzing data using a safety science approach; developing strong community collaboratives; engaging persons with lived experience; developing and implementing a communications strategy; addressing systemic bias, racism, and issues of power; and using a developmental evaluation approach.

“Each of the strategies identified and implemented by the five sites were unique and specific to their communities,” commented Amy Templeman, director of Within Our Reach and senior director of child and family well-being at Social Current. “However, they all shared a common trait – they all pivoted away from an approach that only took into account risk factors and broadened their focus to protective factors, which is ultimately at the heart of a public health approach that engages voices of those with lived experience as experts in finding the solutions that will make all lives better.”

Demonstration sites conducted retrospective reviews of child fatality data and/or collected additional community-level and system-level data to inform their implementation plans. The following summarizes the key strategies and learnings from each site:

Some of the key lessons learned and takeaways from the initiative include:

Parent engagement strategies often end up being transactional and unidirectional. To address this, we must unlearn, test new infrastructures and ways to building partnerships with parents, and relearn as a system how to effectively address the existing power imbalance that makes it difficult for the system and parents to be united in their commitment to keeping children safe and at home.

“Child Safety Forward’s ability to evolve over time is one of the keys to its success,” noted Stacy Phillips, Victim Justice Program Specialist with the Office for Victims of Crime (OVC) within the U.S. Department of Justice. “The technical assistance team worked to create a culture of learning around the many strategies developed by the sites and were able to support sites in building flexibility into their approach. OVC was proud to support this work and contribute toward an extensive community of learning across the field with regard to reducing child maltreatment and fatalities.”

About the Within Our Reach Office 

Within Our Reach is an office established within Social Current to further the recommendations of the federal Commission to Eliminate Child Abuse and Neglect Fatalities. The goal of Within Our Reach is to equip policymakers, practitioners, and advocates with the tools they need to fundamentally reform child welfare. Based on the commission’s national strategy, desired reform includes a proactive public health approach—a shared family and community responsibility to keep children safe. Within Our Reach is made possible through collaboration with Casey Family Programs, whose mission is to provide, improve, and prevent the need for foster care.   

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. 

By: Dr. Daniel P. Hall Riggins and Verleaner Lane

According to the Center for Disease Control and Prevention, each year, there are nearly 3,500 sudden unexpected infant deaths (SUID) in the United States. In 2020, 27% of those deaths occurred in infants under the age of one due to an unsafe sleep environment.

The American Academy of Pediatrics understood the dangers of unsafe sleep nearly three decades ago, resulting in the launch of their Safe to Sleep, (formerly Back to Sleep) campaign in partnership with the National Institute of Child Health and Human Development. The campaign advocated for parents to place children on their backs to sleep and to remove loose bedding. As a result, child death rates from SUIDs dropped precipitously, but in the early 2000s those advances stalled, with infant mortality rates remaining stagnant at around 85-100 deaths per 100,000 births each year.

Since then, researchers have recognized that rates of infant death remain high in American Indian/Alaska Native and Black communities, leading child health experts to examine the role that race may play in these health disparities.

AAP updated its safe sleep guidance last year, with a focus on addressing disparities by contextualizing safe sleep behavior within broader societal and cultural factors, including the impact of poverty, lack of access to prenatal and well-childcare, and lack of culturally appropriate messaging around safe sleep. As a result, communities nationwide are taking a fresh look at sleep-related infant deaths through the lens of a population health approach.

That was one of the goals of Cook County Health Project CHILD’s participation in the Child Safety Forward initiative — one of five sites that was selected for a Department of Justice-funded grant to reduce child abuse and neglect fatalities and injuries through a collaborative, community-based approach.

An initial data review showed that Cook County’s SUID rate is twice the national rate and the Cook County incidence of SUID in Black infants was over 10 times higher compared to Non-Hispanic White infants, based on data from 2019.

Project CHILD began its efforts by using geospatial risk analysis mapping to demonstrate neighborhood “hot spots” of SUIDs. We discovered noted clusters of deaths on the Westside of Chicago in neighborhoods like Garfield Park, Humboldt Park, and North Lawndale; on the Southside in neighborhoods like Englewood, Pullman, and Woodlawn; and in Southern suburbs like Chicago Heights, Harvey, Hazel Crest, Olympia Fields, and Park Forest.

Project CHILD also approached the issue with an understanding that child welfare cannot do this work alone. In fact, data indicates that 50 percent of infants and children who die from fatal injuries caused by maltreatment, including unsafe sleep practices, are unknown to the child welfare system. This led to Project CHILD convening a multi-disciplinary group of stakeholders comprised of healthcare providers, community health workers, maternal infant health providers, educators, social service providers, and law enforcement – all those who come into contact with children and families.

We then partnered with the Child Protection Training Academy, (CPTA) located on the University of Illinois campus, which had created a simulation training model for DCFS Child Protection Investigators. The simulation was structured around training to recognize elements of unsafe sleep practices based on a fictional family with numerous underlying conditions including domestic violence, mental health concerns, substance use disorder and suspicions of sexual & physical abuse.

The simulation developed a home that was designed to draw attention to unsafe sleep practices, with the environment staged with a pack and play that was cluttered with clothing, bedding, and other objects. The simulation’s life-like doll was placed on a soft couch, to draw attention to other risk factors for unsafe sleep. Though the training was conducted on Zoom the teams were able to “investigate” the environment through the use of the “proxy” who walked through the home with a camera enabling the participants to see the home and its contents. Team members could ask for close up examination of particular items in order to determine what questions they might need to ask to gather additional evidence. Additional risk factors were added within the house, such as a premature infant and evidence of smoking.

What the simulation training revealed was that safe sleep issues were often not the primary concerns of members of the MDT as they observed the family’s home. Law enforcement, for example, is often called to homes for other reasons but are rarely trained to look for unsafe sleep practices.

It’s also important for members of the MDT to hear from families and parents with lived experience about the other factors that can influence sleep practices. Project CHILD met with families and heard from them about conflicting messaging coming from older generations who are respected for their wisdom, beliefs about the importance of skin-to-skin bonding, and, in communities where violence is prevalent, thoughts on family beds as perhaps one of the safer places for infants. We also heard loud and clear that families often do not trust public agencies and that the child safety messaging they do receive appears punitive and reactive.

Based on the insights from our geospatial mapping, simulation training and parent insights, we hope to create more advanced safe sleep trainings and guides for all stakeholders, not just those across the child welfare system. This information can also be used to assist in planning targeted messaging to hot spot communities, and the implementation of services and greater awareness, education and outreach to those communities.

Ultimately, we hope that, through the collaboration with key partners, such as Be Strong Families, EverThrive Illinois and the MDT teams, we can apply these learnings in new ways to enhance community understanding and action around safe sleep practices to reduce child fatalities.


Daniel P. Riggins, MD is a pediatrician with Cook County Health. Verleaner Lane is the project director for Project CHILD of Cook County Health, one of five Child Safety Forward sites.

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.

Child Safety Forward is a national demonstration initiative funded by the Department of Justice, Office for Victims of Crime (OVC) to reduce child abuse and neglect fatalities and injuries through a collaborative, community-based approach. Social Current’s Within Our Reach office is the lead technical assistance provider for the initiative, which is wrapping up its final year. Along with final reports from the five sites, Child Safety Forward is releasing two new briefs with funding from Casey Family Programs.

The first brief, A Reflection Guide to Shape Provider Conversations about Infant Sleep, focuses on Safe Sleep conversations. This is offered to providers as a tool based on the learnings from the sites on how bias shows up at the individual, relational, and institutional levels. The brief reflects strategies adapted by the sites to prioritize conversations and listening to community to better understand how together we can shape environments for children that support health and well-being.

Based on initiative findings and learnings, the second brief on Sustainability focuses on how to overcome resource interruptions and other challenges that stand in the way of producing lasting and effective change. This brief learning memo examines how Child Safety Forward was set up to encourage demonstration sites to apply a more comprehensive definition of sustainability during implementation. It also presents our recommendations for how funders and technical assistance teams can support sustainability.

By: Verleaner R. Lane

April has long been recognized as Child Abuse Prevention Month. This year, the conversation around prevention has broadened to include family strengthening, in recognition of the importance of families and communities having access to resources that can lessen family stressors and prevent child abuse and neglect before it occurs.

Science shows us that children are more likely to thrive when their families have the economic and social supports that they need. Enabling these positive childhood experiences requires that we reimagine child welfare and focus instead on child and family well-being with upstream resources that can prevent child abuse and neglect before it occurs.

Federal and state policies that connect families to economic support services, such as Temporary Assistance for Needy Families (TANF), housing assistance, and nutritional supplements have been shown to strengthen families and reduce child welfare interactions.

By shifting to a preventative child and family well-being system that offers upstream resources for families, the goal is to provide families with more services rather than more surveillance.

Federal policy is supporting this shift by authorizing more funding and more flexible funding for family-strengthening services through the Family First Prevention Services Act and the proposed reauthorization of the Child Abuse Prevention and Treatment Act (CAPTA).

What does a family-strengthening approach to child safety look like in practice? Answering that question is the impetus behind a national demonstration initiative launched by the Department of Justice’s Office for Victims of Crime in 2019.

The project, Child Safety Forward, engaged five sites across the United States in a multi-year focus that included research, planning, and implementation around strategies aimed at reducing child injury and fatality from abuse and neglect. The sites selected are Cook County Health in Illinois; Indiana Department of Health; Michigan Department of Health and Human Services; Saint Francis Hospital in Hartford, Connecticut; and Sacramento County, California’s Child Abuse Prevention Council. 

Each site is developing strategies that are unique and specific to their communities, honoring and reflecting the data they collected in the first year to identify community-led solutions that support resilient families and keep children safe in their homes. Each site is also working with a collaborative body of stakeholders and partners, including those with lived experience, to guide the work and is reviewing short- and long-term goals through an equity and diversity lens.

Our strategy includes bringing together a diverse group of community stakeholders that work with the most affected families in a variety of different settings. Our work has been focused on three Illinois counties: Cook, Peoria, and Vermilion, to identify the highest-risk geographic areas and target resources in these communities.

We began our efforts by using a data collection process that had been established earlier by Cook County Health in partnership with the Cook County Medical Examiner. The process automates data exchange between these two Cook County agencies allowing for the linkage of clinical data to mortality events among specific populations as determined by the medical examiner. Data sharing across these agencies is automated to identify risk factors for mortality among individuals experiencing homelessness, those impacted by the opioid epidemic, those with justice involvement, and the intersection of these experiences.

For Cook County, we reviewed approximately 300 sudden unexpected infant deaths over the past five years likely related to unsafe sleep conditions. We identified specific neighborhoods that had a higher rate of sudden unexpected infant death.

Based on these lessons learned, we are now able to appropriately target resources and educational interventions to protect families from these catastrophic events by creating the Safety for Children 0-5 self-paced educational curriculum and adding scenarios to the Simulation Labs and the MDT Training. We worked with pediatricians and community organizations to develop safe sleep messaging and interventions targeted to these high-risk neighborhoods. The program, led by 12 government and community agencies, including Project CHILD, aims to address sudden unexpected infant death (SUID), one of the leading causes of infant mortality.

Illinois Safe Sleep Support will focus on outreach and education to expand the community-based promotion of safe sleep practices, promote resources to improve safe sleep environments, identify SUID disparities, and address opportunities for improvement. The investments of this year-long campaign will continue to position Illinois as a leading state for children, families, and the early childhood workforce that supports them.

All of the strategies across the five Child Safety Forward sites share one common trait – they are predicated on demonstrating a public health approach to child and family well-being called for by the federal Commission to Eliminate Child Abuse and Neglect Fatalities. With a focus on increasing equity in systems that serve families, elevating parents into relationships of equal power, building protective factors, and supporting families who are having trouble weathering one or more of the storms impacting our country right now, each of the demonstration sites is working to create a body of knowledge about what works to reduce child fatalities.

As we celebrate Child Abuse Prevention, let us not forget that addressing community needs by giving families support prevents traumatic events from happening, has much more impact, and costs much less, than removing children from families and/or attempting to address the consequences of adversity after a child has grown up. 

We all have a stake in our kids’ future and shifting our focus from child welfare to child and family well-being will help us create a future where every child can thrive and reach their full potential.


Verleaner R. Lane, MA. is the Project Director for Project Child as a Visiting Project Specialist contracted employee within the Institute for Legal, Legislative, and Policy Studies (ILLAPS) at the University of Illinois at Springfield. Cook County Health established Project CHILD in 2019 to better understand and address infant deaths due to unsafe sleep conditions, or from abuse or neglect.

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. 

By: Regina Dyton and Chavon Campbell

When Saint Francis Hospital in Hartford, Conn. was chosen by the U.S. Department of Justice for a demonstration initiative to develop strategies and responses to address child fatalities from abuse or neglect, we didn’t expect the transformative nature of this project.

We began our efforts on the Child Safety Forward initiative three years ago with research and data analysis that showed that Hartford was an outlier when compared to Conn. and national child maltreatment rates. From 2015-2017 Hartford averaged 17.6 substantiated cases of child maltreatment per 1,000 children, nearly double the state and national rates during the same period. This and other disparities evident in the data demonstrated the need for a greater understanding of the underlying causes of disparities and risks for child maltreatment, particularly around prevention messaging for communities of color.

With a guiding principle of “those closest to the problem are closest to the solution,” we sought to bring parents together to form a Parent Engagement Work Group that would work closely with a multidisciplinary team of stakeholders composed of state agencies and community-based organizations to better understand the underlying issues.

 We recruited parents from existing relationships in the community, with the Greater Hartford Family Advocacy Center at Saint Francis Hospital, and with members of the Hartford Parent University (HPU), a grassroots organizing agency that trains and supports parents to advocate for quality education. We met with state agency leaders, child abuse pediatricians, and community agency directors to review the data and better understand the risks for child maltreatment that contributed to injuries and fatalities.

Perhaps the greatest area of learning on this topic was the parents’ perceptions of risks. Early in the formation of the Parent Engagement Work Group, parents made it clear that they wanted to address issues beyond child abuse and neglect by caregivers, noting that there are many environmental, systemic, and other types of threats to the safety of children. Examples included non-caregiver abuse and exploitation, drugs, suicide, and community violence, in short, all threats to child safety and well-being.

This led parents to focus on the ways in which they receive child safety education, which in most cases, was only mandated by child protection agencies after an allegation of abuse or neglect, leading parents to view child safety education as reactive and punitive. They wondered if other communities or families had better access to comprehensive and preventative child safety education.

The biggest impact came when the parents were presented with the data that showed that the death rate of Black children due to abuse and neglect was two times that of white children.

They asked how people who were not members of their communities (not just racially/ethnically but socio-economically and culturally) knew more about their collective reality than they themselves and made plans for them without communicating with those directly affected.

And while child fatality data is released publicly by state agencies, for a variety of reasons, including a lack of trust between families and state agencies, that data rarely reaches the populations who need it most.

Parents asked if and how they could be more involved in planning and carrying out research on their own communities and then using that data to plan improvements for child, family, and community well-being.

Based on their findings, the parents came together to develop a comprehensive educational guide to teach parents about multiple topics related to child well-being. Entitled “From Pain to Parenting,” the guide outlines a series of training workshops, led by parents, on a range of topics related to child well-being, including unsafe sleep, domestic violence, sexual abuse and assault, mental health, firearm safety and gun violence, and disabilities.

The Child Safety Forward Hartford initiative will serve as a springboard for establishing ongoing planning and action on preventing child maltreatment fatality and near fatality. The project will transfer from Saint Francis Hospital to the Institute for Community Research (ICR) as the lead agency, with Voices of Women of Color and Hartford Parent University as partners. ICR will train a group of parents to design and implement their own research and will conduct sessions to help parents understand data and advocate for data-sharing with communities. 

Hartford Parent University will provide ongoing training on topics identified by parents as they relate to Hartford Public Schools, especially regarding children with disabilities and children belonging to other marginalized communities. Voices of Women of Color will provide training in community organizing and advocacy and will lead the recruitment of a parent engagement group for each of Hartford’s thirteen neighborhoods.

The Hartford Child Safety Forward site was unique among the other demonstration sites in focusing on parent and community organizing and the purposeful shifting of power to those most affected. By combining the disciplines of research, community organizing, and prevention education, we were able to engage parents in a meaningful dialogue about the things that matter to them most – the safety and well-being of their children.

By elevating their voices and experiences and authentically shifting power to these parents, we ultimately learned far more from them about how to prevent abuse and neglect and build a Child and Family Well-being System that can strengthen families and enable all children to thrive. Our field will be all the richer for it.

Regina S. Dyton, MSW, served as principal investigator and project manager for the Child Safety Forward Project in Hartford. Chavon Campbell, MBA, is director of compliance for Hartford Communities That Care and project manager for the Pain to Parenting Project.

 This commentary 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 are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice.

Social Current was pleased to be included at the in-person event to recognize the fifth anniversary of the Family First Prevention Services Act (FFPSA), hosted by the Administration for Children and Families (ACF) at the U.S. Department of Health and Human Services (HHS) in Washington, DC. To mark the occasion, on March 1, 2023, HHS and ACF leadership gathered stakeholders, delivered remarks, and brought together panels of legislators, national experts, and state and tribal leaders. The event featured videos from families with lived expertise in the child welfare system. The conversations reflected a rich understanding of why the legislation was created, what it has accomplished, its challenges, and where we go from here to better support families. The recording for this event is available here.

Five years ago, FFPSA was enacted to enhance upstream and supportive services for families to help children remain safely at home with their caregivers, reduce the unnecessary use of congregate care, and build the capacity of communities to support children and families. At the anniversary event, Social Current observed five takeaways that will help to shape future opportunities to support thriving families and communities.

Achieving these reforms will require a tremendous shift in resources, both at the federal funding level to redirect funding to more front-end resources, through policies that adapt to a more preventative approach, and in the way that place-based services are delivered by community-based organizations. Passage of FFPSA is a first step in that journey for child welfare. Too many of our social systems were structured to respond only after harm occurs – by realigning our nation’s social service delivery systems and reimagining the power and impact of the social sector, we can deliver on the promise of equitable access to health and well-being for all people.

By: Susana Mariscal and Bryan Victor

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

As the U.S. Commission to Eliminate Child Abuse and Neglect Fatalities notes, child welfare systems have historically been focused on addressing harm only after it has occurred. Fortunately, federal and state agencies along with local nonprofits and community leaders are beginning to work collaboratively and create a multi-system service continuum to provide the resources that families need beforehand, preventing abuse and neglect before it occurs. We can see evidence of that shift, with demonstration projects across the U.S., including Indiana, that are identifying risk factors (e.g., contributing factors) for child fatalities, moving resources upstream to support families, and building on protective factors 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 (CSF). With support from technical assistance providers and multidisciplinary child fatality review teams, IDOH has conducted research focusing on Clark, Delaware, Grant, and Madison counties that identified unsafe sleep-related deaths as the leading cause of death due to external causes (e.g., sleep-related, drowning) for children ages 0-18 years old, excluding medical reasons. The findings from IDOH – based on a 5-year retrospective review – highlighted that Black infants are at a heightened risk for sleep-related deaths (55.9%t; 19 of 34 deaths) and that sleep-related deaths have been underreported throughout the state due to inconsistent and incomplete documentation of Sudden Unexpected Infant Deaths (SUIDs). High quality, accurate fatality data enables jurisdictions to better understand and address risk factors, improving the effectiveness and actionability of recommendations.

Based on these findings, IDOH took several steps to expand the state’s ability to prevent child fatalities. They developed Community Action Teams to implement prevention initiatives, and are working collaboratively with Prevent Child Abuse Indiana chapters and Family Resource Centers run by the Strengthening Indiana Families project to educate the public about safe sleep practices. Family Resource Centers are a one-stop-shop for families, providing tailored resources to address their needs and build on their strengths. IDOH has also developed videos providing safe sleep information and stories of parents who lost a child in unsafe sleep environments. (For more information on safe sleep, visit the IDOH website.)

Informed by findings from the CSF initiative, Indiana legislators passed House Enrolled Act 1169 — which went into effect on July 1, 2022 — establishing consistent standards for SUID investigations and data collection, aligning with the Centers for Disease Control and Prevention best practices, including pathology and toxicology.


It is important to note that, in 2020, in 95 of 168 cases identified (56.5 percent), children were unknown to Child Protective Services before the fatality, indicating that government agencies like the Indiana Department of Child Services alone cannot prevent these deaths. The work of fatality prevention lies with all of us: neighbors, community members, and the full range of professionals that serve children and families. To increase our effectiveness at preventing these fatalities and reducing racial disparities, the multiple systems that serve families must collaborate and share information to provide coordinated, holistic services. Communities also need to increase their formal and informal supports for families, so that all parents in the community have equitable access to the resources they need to be connected and safe. Every parent needs help at some point and -as the Family Resource Centers’ motto says- “Kids don’t come with instructions. We’re here to help.” Let’s all join in the nationwide shift toward prevention by supporting families in our communities so that children can develop their full potential. Imagine what a difference we all can make in the lives of children in our community when we work together proactively to keep the most vulnerable among us safe.


A version of this article appeared previously in the Indianapolis Star on October 6, 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 and by the Children’s Bureau, Administration for Children, Youth and Families, Administration for Children and Families, USDHHS, under grant 90CA1864. 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 and the Children’s Bureau.

By Amy Templeman, director of Within Our Reach at Social Current

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.