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Hearing on Child Deaths Due to Maltreatment

July 12, 2011










July 12, 2011


Printed for the use of the Committee on Ways and Means

GEOFF DAVIS, Kentucky 


RICK BERG, North Dakota
TOM PRICE, Georgia
DIANE BLACK, Tennessee


JON TRAUB,  Staff Director
JANICE MAYS, Minority Staff Director 



Advisory of July 12, 2011 announcing the hearing


Kay E. Brown
Director Education, Workforce, and Income Security, U.S. Government Accountability Office

Tamara Tunie
Actor, Law and Order: SVU and Spokesperson, National Coalition to End Child Abuse Deaths

Theresa Covington
M.P.H., Director, The National Center for Child Death Review

Michael Petit
President and Founder, Every Child Matters Education Fund

Carole Jenny, M.D.
Director, Child Protection Program, Hasbro Children’s Hospital

Jane McClure Burstain, Ph.D.
Senior Policy Analyst, Center for Public Policy Priorities




Tuesday, July 12, 2011
  U.S. House of Representatives,
Subcommittee on Human Resources,
Committee on Ways and Means,
Washington, D.C.

The subcommittee met, pursuant to notice, at 10:02 a.m. in Room B‑318, Rayburn House Office Building, Hon. Geoff Davis [chairman of the subcommittee] presiding.

[The advisory of the hearing follows:]

     *Chairman Davis.  The hearing will now come to order.  But before we begin, I would like to yield to the chairman of the Ways and Means Committee, Dave Camp, who asked that the report from GAO that is the basis of our hearing be commissioned in the first place.  He as long been a champion of these issues regarding children.  And with that, I would like to yield to the distinguished chairman, Mr. Camp.

     *Chairman Camp.  Well, thank you very much, Chairman Davis.  I wanted to thank our witnesses for being here today, and also a special thanks go GAO for completing this report on abuse and neglect and maltreatment of children.  And having gotten a little bit of what the report may say, I understand that the reality is even more dramatic than the official estimates that we are getting.

     The purpose of this hearing, obviously, is to focus on child deaths due to maltreatment or abuse, neglect, however you want to describe it, and what government policies might be able to try to deal with this very critical issue.

     I want to thank all of our witnesses here, and Tamara, especially you, for highlighting this issue in a very public way and a very positive way, so we can hopefully make some progress on this.

     And I won’t delay the hearing any longer, but appreciate the hard work that you and Mr. Doggett are going to be doing today.  So thank you very much.  Thanks a lot.

     *Chairman Davis.  Thank you, Mr. Chairman.  With that, we will return to regular order.  I thank the distinguished gentleman from Minnesota for yielding his chair to the chairman, too.

     This is somewhat of a historic hearing in a couple of ways.  One, I think the topic is certainly important.  But for those of us that grew up in the era of black and white cathode ray TV tubes, this is the first Ways and Means Subcommittee hearing done in high definition.


     *Chairman Davis. I was told I had a great face for radio by my first media consultant.  So some of us are going to have a particularly challenging experience here today.

     But with that, I appreciate all of the witnesses who have come, those concerned citizens, advocates from many different streams of thought with one common concern.

     When children die from maltreatment, it makes international headlines, as in the Caylee Anthony case that drew the focus of millions around the world in recent months.  Unfortunately, the transience of the hype and passing interest of the population belies a much deeper challenge.

     And sometimes the death of a child from maltreatment gains attention due to the shocking details of the treatment while alive.  That is what happened in the case of 13‑year‑old Christian Choate, an Indiana boy killed in 2009 after years of abuse, including being allegedly locked in a 3‑foot‑high dog cage.

     After his death, police found letters he had written about how he wondered when anyone would check on him or give him food or water.  Christian asked why nobody liked him and how he just wanted to be liked by his family.  It is hard to fully comprehend the death or the sadness this boy must have experienced during his too‑short life. 

And sometimes the death of a child from maltreatment does not make headlines at all, possibly because it is not recorded as a death from maltreatment for a variety of reasons we will learn more about today.

     It is hard to know which child deaths are more tragic, those we know about or those we do not.  But our job today is to make sure that all deaths of children due to maltreatment are recorded, so we can learn from all of them and use that knowledge to work with state and local partners to prevent more of these tragedies from occurring in the future.

     Our role here today is to be a voice for the voiceless, especially those children whose deaths are missing from official data today.  The Federal Government estimates that 1,770 children died due to maltreatment in 2009, the most recent year of data we have.  But as we will learn today in today’s hearing, that official data understates the total number of children who die due to maltreatment each year for numerous reasons.  This undercount could be significant.

     GAO indicates that 24 states only report the deaths of children who had previous contact with a child welfare agency.  Another study found child welfare agency records undercounted deaths by 55 to 76 percent.  The bottom line is states are not reporting each child maltreatment death, and that makes it harder to prevent these deaths in the future.

     We welcome a range of experts today to help us understand how we currently count the number of children who die each year due to maltreatment, as well as to discuss flaws in the current system.  These experts will also help us to determine how these systems can be improved, and how better information can help us better protect children, which is our ultimate goal.

     I want to commend Chairman Camp, who last year asked GAO to review and report on these issues, based on his concern that we are unfortunately not getting it right today.  That GAO report is being released today, and is the backstop of GAO’s testimony this morning.

     We also welcome experts from the broader community who have worked for years to prevent child deaths due to maltreatment.  Our panel today includes Tamara Tunie, the spokesperson for the National Coalition to End Child Deaths, who has worked to raise the profile on this issue and better protect children.  We look forward to all of our witnesses’ comments, and thank them for their commitment to better protecting children from abuse and neglect.

     And I would say in the time that we have worked together on the subcommittee, Ranking Member Doggett and I have had a commitment to correcting broken information processes, to be able to integrate sources, to remove obstacles and silos.  And we are continuing to hold hearings like this to identify constraints that prevent the service providers, the care givers, from doing their very, very critical job.

     Without objection, each Member will have the opportunity to submit a written statement and have it included in the record at this point.

     And now I would like to yield to my friend and distinguished ranking member from Texas, Mr. Doggett, for an opening statement.

     *Mr. Doggett.  Thank you, Mr. Chairman.  Thank you for your commitment to this issue.  Each weekend that my wife and I are back in Texas, we try to devote a little time to our three preschool granddaughters.  The joy of being with them, their growth, their learning, their creativity, and also their innocence and vulnerability are in such contrast in homes where they are surrounded by love, with what we see played out in national TV with the abuse and death of too many young children.

     And so, today we conduct a bipartisan exploration of what we can do about the gap between those children, the many children in our country that are surrounded by loving and supporting families, and those who are not.  And I think we recognize that the death of even one child due to abuse or neglect is just too many.

     We are aware that there are so many, many children across the country who lose their lives or are permanently scarred by abuse or neglect from a caretaker.  We know that there are many reasons why this happens.  But the goal of today’s hearing must be to improve our understanding of these causes, and what we can do to prevent this kind of maltreatment of children.  Certainly poverty, teenage parenting, substance abuse, and mental health challenges are among the considerations.

     We must ensure that we don’t make matters worse than they are today by slashing services that are important to assure child protection, even though there are many gaps in those services.  Nor can we afford to slash the wider safety net for our families.

     As my neighbor in Austin, Dr. Jane Burstain, eloquently states in a written testimony, “To cut programs that support struggling families in tough economic times is the very definition of penny wise and pound foolish, and is a choice that our children could pay for with their lives.”

     Regrettably, the lives of children have not always gotten top priority.  They are not necessarily, despite the full house today and the many effective advocates who are here, they are not necessarily the best lobbied force in the country.  In my home state of Texas, the legislature just concluded with a 40 percent cut, actually more than 40 percent, in certain child abuse prevention programs, even though my home state of Texas has one of the highest rates of child abuse and neglect deaths in the country.

     Here in Washington, I have concern about the proposal here in the House, the House Republican Budget Resolution, to eliminate the Social Services Block Grant program, which provides some funding that is very important in child protective services.

     And I am also concerned that the child welfare programs that we studied in our last committee hearings, as well the TANF program, which is important in so many states for providing assistance to low‑income families — those programs are about to expire.  And we hopefully, as a result of the work of this committee, can come up with bipartisan legislation to continue them, and learn from the experience.

     I have just recently filed legislation concerning the TANF supplemental grants, which were part of the original 1996 law that are very important in Texas and 15 other states in providing services.

     So, I hope that out of today’s hearing we can gain more insight from our expert witnesses, and out of this can come together with effective legislation to try to respond to some of these matters that concern all of us so deeply.

     Thank you, Mr. Chairman.

     *Chairman Davis.  Thank you very much, Mr. Doggett.  Before we move on to our testimony, I would like to remind all of our witnesses to limit their oral statements to five minutes.  All of your statements will be entered into the record, and we will allow more time for discussion and for question.

     On our panel this morning we will be hearing from:  Kay Brown, Director of Education, Workforce, and Income Security, the U.S. Government Accountability Office; Tamara Tunie, actor from Law and Order:  Special Victims Unit, and spokesperson for the National Coalition to End Child Abuse Deaths; Theresa Covington, the Director of the National Center for Child Death Review; Michael Petit, President and Founder of Every Child Matters Education Fund; Carole Jenny, M.D., Director of the Child Protection Program at Hasbro Children’s Hospital in Providence, Rhode Island; and Jane Burstain, Senior Policy Analyst at the Center for Public Policy Priorities in Austin, Texas.

     Ms. Brown, please proceed with your opening statement.


     *Ms. Brown.  Chairman Davis, Ranking Member Doggett, and members of the subcommittee, thank you for inviting me here today to discuss our work on this very important topic of child deaths due to maltreatment.  My remarks are based on a GAO report that is also released today.  I plan to cover three issues:  the number of children who die from maltreatment; state reporting challenges; and HHS assistance to states.

     First, on the number of child deaths.  Every year, children in the United States die after being physically abused, severely neglected, or otherwise maltreated, frequently at the hands of their parents or other trusted caregivers.  Unfortunately, we don’t know for sure how many have died.  Based on data reported by state child welfare agencies to the National Child Abuse and Neglect Data System, or NCANDS, we know that there were at least 1,770 deaths in fiscal year 2009.

     But this is likely an undercount.  Almost half of these state agencies reported only those cases that were already known to them.  Yet these agencies don’t necessarily know about all children who die from maltreatment.  Some children may not have been previously maltreated, or their earlier maltreatment may not have been reported.

     However, these deaths may be known to other sources, such as law enforcement agencies, medical examiners, coroners, or health departments.  To illustrate this point, studies in a few states have combined information from several of these sources, and found that using the state child welfare records alone undercounted known fatalities by from 55 to 76 percent.  Further, a national sample of 122 counties across the country ‑‑ again, using multiple sources ‑‑ estimated 2,400 child deaths from maltreatment.

     Understanding the numbers and circumstances surrounding child fatalities from maltreatment can help inform prevention efforts.  HHS prepares annual reports on the NCANDS data, which include a wealth of information on the children who have died, the perpetrators, and many other factors.  However, we found that HHS does not include all of the potentially useful information it collects in its reports.

     In addition to NCANDS, state and local multidisciplinary child death review teams assess the causes of child fatalities, with an eye to improving investigations, services, and prevention.  These teams, found in all but one state, don’t review every death, but their reviews can provide more and richer detail on each case.  Many states are now submitting data from these reports to the HHS‑funded National Child Death Review Center, and the Center is beginning to analyze the data specific to fatalities from maltreatment.

     For my second point, states face multiple challenges that make it difficult to collect and report these data.  For example, without definitive evidence, it can be difficult to determine that a child’s death was, in fact, caused by maltreatment, rather than by natural causes.  Further, resources are limited for autopsies and other tests, which can be expensive.  Officials investigating fatalities may have differing skills, training, and experience, and coordination and data sharing across various agencies and jurisdictions may be hindered by concerns about privacy or confidentiality requirements, or by differing goals and cultures.

     On my third point, HHS provides a variety of technical assistance to states to help improve the data that they report to NCANDS.  However, in our survey, state officials asked for additional assistance on collecting child fatality data, using it for prevention, and collaborating across agencies.  We have made recommendations to HHS related to these and other issues.

     In conclusion, any child’s death from maltreatment is especially distressing, because it involves a failure on the part of the adults responsible for protecting them.  Policy‑makers and practitioners rely on data to understand the numbers and circumstances of these tragic deaths, and to learn from them to prevent other deaths.  Without improving upon and better sharing these data, we lose precious opportunities to protect our children.

     This concludes my prepared statement.  I am happy to answer any questions.

     [The statement of Ms. Brown follows:]

     *Chairman Davis.  Thank you very much, Ms. Brown.

     Ms. Tunie, if you could, give your testimony.


     *Ms. Tunie.  Good morning, Chairman Davis, Ranking Member Doggett, and members of the subcommittee.  My name is Tamara Tunie.  Many people know me in my role as Dr. Melinda Warner, the medical examiner on “Law and Order:  Special Victims Unit.”

     However, I am here today in my role as a concerned citizen, and as the spokesperson for the National Coalition to End Child Abuse Deaths.  The Coalition is made up of five national organizations that came together over a common concern for the growing number of child abuse and neglect deaths in the United States.  Those organizations are:  The National Association of Social Workers; National Children’s Alliance; National District Attorney’s Association; Every Child Matters Education Fund; and the National Center for Child Death Review.

     I am honored to be able to speak to you today.  On “Law and Order,” we investigate fictionalized crimes, and often have to deal with difficult story lines.  But nothing compares to the real and tragic cases that we hear about with increasing regularity in the national headlines:  Caylee Anthony in Florida; Marcella Pierce, from my home state of New York; and the gruesome story of Nubia Barahona, also in Florida.

     The unfortunate truths about these deaths is how common they are.  Since becoming the Coalition spokesperson, I have learned about the thousands of American children dying at the hands of those who are supposed to love and protect them, and I am here to say that the need for action is critical.

     Unfortunately, the most startling truth about death from child abuse is how common it is.  As we have heard and will hear today from the experts in this field, an estimated 2,500 children die each year from abuse and neglect; that is 7 children a day.

     It is not enough to feel saddened when hearing about the loss of innocent lives.  We have an obligation, as adults and citizens, to protect those who have no power to protect themselves, who have no voice to address the powers that be, and obligation to prevent these fatalities.

     The first step in ending child abuse and neglect deaths is awareness of the problem, including the accurate collection of data regarding the number and circumstances of child deaths from maltreatment.  We are all here today because Chairman David Camp, Chairman Geoff Davis, and Ranking Member Doggett, and the members of the Subcommittee on Human Resources believe that this important issue deserves attention.

     On behalf of the Coalition, I want to thank you for holding a hearing on child abuse and neglect fatalities, and for your efforts to bring an end to the preventable deaths of children like Caylee, Marcella, and Nubia in the United States.

     Thank you so much for hearing my testimony.

     [The statement of Ms. Tunie follows:]

     *Chairman Davis.  Thank you, Ms. Tunie.

     Ms. Covington?


     *Ms. Covington.  Thank you, Chairman Davis, Ranking Member Doggett, and members of the subcommittee, for providing me with this opportunity to speak to you.  I serve as the director of the National Center for Child Death Review, with funding from the maternal and child health bureau at HRSA, HHS.  We assist states in improving their child death review processes.

     CDR is a process in which profess ‑‑ in which professionals from many agencies come together to share case records, look at the facts in the deaths, and decide what they will do to prevent these deaths in the future.  Every state, except Idaho, tries to review all child abuse and neglect deaths at the state or community level.

     As described by the GAO, our center built and now maintains the national CDR case reporting system, which 39 states are using and submitting reports on all of the child deaths that they review.  This allows for the collection of comprehensive information on child deaths, because it is a compilation of the information shared by all the agencies at a review meeting.

     The system collects data on the child, their care givers, the supervisors, the perpetrators, the investigation, the circumstances in the death, and actions taken to prevent other deaths.  The report tool has over 1,800 data elements, and as of today we have 94,473 deaths in the system, of which 8.3 percent were due to child abuse and neglect, which is 7,894 little children like Casey Anthony’s.

     And the GAO report is right.  We know that more children die from abuse and neglect than is reported through NCANDS, from vital records, or law enforcement databases alone.  The CDC had funded a child maltreatment surveillance project in seven states, and I was the PI in Michigan.  In an average year, Michigan had reported 16 child abuse deaths through death certificates, law enforcement records, 26, child protective services, 40 deaths.  When child death review synthesized these multiple sources of data, the actual number was at least 100 deaths a year.

     And we just did a quick count of child abuse and neglect deaths reported through state child death review annual reports, and compared them to the NCANDS data for those same years:  15 states reported 1,029 states [sic], compared with 516 in the NCANDS report.

     I agree with the GAO findings on some of the reasons for the under‑reporting.  Deaths due to neglect are especially under‑reported, and most deaths from neglect happen when caregivers egregiously fail to protect a child from hazards:  toddlers drowning in bath tubs, children dying in house fires when left alone, children left in cars on hot days, infants suffocated while sleeping with their intoxicated parents.

     And different states have different definitions of abuse and neglect.  What Mississippi might call abuse, Connecticut might call a bad accident, or vice versa.  And states even differ on who makes the call, whether it is a CPS worker, the coroner, law enforcement, the prosecutor.  And states have different criteria for how they count the deaths into NCANDS, into our system, and into other systems.  There is also wide variation in the quality of child death investigations across the country, so that when the deaths aren’t well investigated, we don’t really know what happened.

     On a positive note, we know that when we count deaths right and do reviews well, prevention happens.  That is why it is so important that we investigate, count, and review all of these deaths.  I could spend all day here describing efforts implemented across the United States through child death review.  Some specific to your states include:  Kentucky implementing new fire safety education for families, because of deaths in which children died and adults survived.  Georgia, Louisiana, Michigan, Minnesota, New York, North Dakota, and Washington implemented major public awareness campaigns on shaken baby prevention and safe infant sleep.  North Dakota improved death reporting policies to CPS.  Tennessee developed evidence‑based home visiting programs.  Texas is training all CPS workers in infant death investigation.  A number of states have changed mandatory reporting policies to CPS, for example, requiring reports even if there are no survival siblings [sic].

     And I agree with the GAO recommendations to improve comprehensiveness, the quality, and the use of national data on maltreatment deaths.  And I look forward to being part of the solution, working with ACF, NCANDS and others, to identify how we can share and use all of our data to prevent these deaths.

     I also ask that you require national standards and child maltreatment definitions and in reporting.  And I ask that you call for a national commission to further study this issue.

     But our states also need additional resources.  States certainly need emergency help now, as ‑‑ for child protection, as their resource are dwindling while child abuse and neglect is increasing.  We should not be a nation that fixes its budget at the expense of abused and neglected children.  Other than the $600,000 in funds allocated for our resource center, there is no dedicated funding to states for child death review or for the reporting system.  Fortunately for us, a private company based near Goddard recently offered to build our new software for us.

     Chairman David, Mr. Doggett, and those of you on this committee, later tonight please think about the 7 or 8 or maybe even 10 children who will have died today because someone who is supposed to tuck them in at night killed them instead.  And then tomorrow, begin work on your committee to take action to keep our children alive.  Thank you.

     [The statement of Ms. Covington follows:]

     *Chairman Davis.  Thank you, Ms. Covington.

     Mr. Petit?


     *Mr. Petit.  Chairman Davis, Ranking Member Doggett, members of the subcommittee, thank you for convening this hearing and for the opportunity to testify on this issue.  I am Michael Petit, president of Every Child Matters Education Fund.

     I have been involved with child maltreatment fatalities for over 40 years, and I am sad to say that, despite great increases in our overall knowledge about child welfare, the situation facing these children has improved very little over that period of time.  I was formerly with the Child Welfare League of America for a dozen years.  I served as Maine’s human services commissioner, which had responsibility for child welfare and child protection.  I am also the author of a publication called, “We Can Do Better:  Child Abuse Deaths in America.”

     I will devote my testimony to an overview of child abuse fatalities.  Others will speak specifically to the data issues that are raised in the GAO report.

     To start with, child abuse rates are much higher in the U.S. than in other democracies, triple Canada’s rate, 11 times Italy’s rate.  The official tally of almost 1,800 deaths a year we believe is significantly undercounted, that there are, in fact, 2,500‑plus deaths a year, about 5 times the number of U.S. soldiers killed in 2 wars since the beginning of our study.

     Some 80 percent of the children killed are under the age of 4; 50 percent are under 1.  Black children are nearly three times more likely to be killed.  The vast majority of children are from low‑income, low‑education families.  And of the 51 children randomly selected for our report ‑‑ some of you may have seen this report; if not, we can make it available to you ‑‑ there are 51 children here.  In the course of our study period, going back to the start of the Afghan‑Iraq wars, there were 400 children behind each one of these pictures.  Of the 51 kids that we selected at random, only 1 was killed with a knife or a gun.  The other 50 were principally ‑‑ the principal cause of death was being beaten to death.

     Our collective systems of child protection are stretched too thin.  Too many troubled families, too few social workers and other staff, and too little community support.  Few of the thousands of child protective units in the states are adequately equipped to deal with all the families brought to their attention.  Consequently, protection for many children is a matter of geography.  Where a child lives may determine whether she lives or dies.  Some states appear to have a 10 times greater death rate than others.  Some states appear to spend five times more than others on child protection.  I say “appear,” because of a lack of acceptance of standard definitions in the field.  We don’t really know.

     Child abuse flows from extensive child maltreatment in the U.S., nearly three million reports a year, and preventable deaths are inevitable when we are drawing from such a large pool of vulnerable children.

     A major factor, lack of public awareness about the scope and size of the problem, directly related to restrictive confidentiality laws, which ‑‑ we hope one of the things that you will do is examine those laws and make modifications in them.  They shield the press, public officials, and the public from shortcomings.  And we made recommendations for ‑‑ in 2009 that have been presented in this committee; 150 child protection experts met for a couple of days.

     Let me say that I have had extensive personal experience in dealing with child fatalities where data interfered with the protection of a child.  During my stint as Maine’s commissioner of human services, we had a little girl that was presented to us by her family at 5:00 on a Friday afternoon.

     Our social worker called the local mental health center and said, “Is the father of this child taking his medications?  We know that he is a mentally ill individual, and he is not taking the medication.”  They said, “We are not going to share that information with you, there are confidentiality issues for the parent, and we are not going to give you the information.”

     One hour later, that child was put in an oven, the oven was turned on, and the child died in the oven.  It was a very tragic incident that put our whole state of Maine in a state of shock for weeks.

     And I have provided specific consultation to counties all across the country on this business of bringing together the information from law enforcement, child protection, the mental community, mental health.  And I am sad to say that, in most communities, there is not a sharing of that knowledge.  And, in many instances, the civil legal protection system for children is not enough.  The criminal justice system also needs to be brought into play, and we need to afford more progress in that.

     Let me say in my remaining moments that the adherence and development of national standards in this area is critical.  Are these children Texas children first, or are they Vermont children first, or are they American children first?  That is an issue, the national standards.

     The support of a commission to examine these child abuse deaths is critical, it is a very complex topic.  The increase in ‑‑ I mentioned.  And then, I think, a public education campaign is critical in this area.

     I will close my remarks with that, and I have submitted more detailed testimony elsewhere.

     Thank you.

     [The statement of Mr. Petit follows:]

     *Chairman Davis.  Thank you very much, Mr. Petit.

     Dr. Jenny?


     *Dr. Jenny.  Chairman Davis, Ranking Member Doggett, and members of the subcommittee, I thank you for the opportunity to testify on child deaths due to maltreatment.

     I am a professor of pediatrics at Brown Medical School, and the director of the child protection program at Hasbro Children’s Hospital in Rhode Island.  I have a unique perspective on this issue, because I may be the only person in this room who often has stood at the bedside in the emergency department or in the intensive care unit, and actually witnessed the deaths of infants and children from maltreatment.

     When the death of a child is the result of abuse or neglect, a sad event becomes an immense tragedy.  The 1,700‑yearly child maltreatment deaths officially reported are just the tip of the iceberg.  As the GAO report points out, counting and tracking the number of deaths from maltreatment is challenging.

     Sometimes it is very difficult to distinguish between accidental and non‑accidental death.  For example, when a child is purposely suffocated with a pillow or a plastic bag, it can be impossible to distinguish this act from a death by natural causes.

     In addition, many deaths from neglect are not counted as such.  In Rhode Island, a three‑year‑old was told by his drunken father to go across a busy street to retrieve a discarded lamp from a neighbor’s trash.  He was hit by a car and killed, and his death was ruled an accident.

     And what about deaths caused by the late effects of maltreatment?  If a teenage survivor of horrific sexual abuse commits suicide because of her severe depression and post‑traumatic stress, is that considered a child abuse death?  In my opinion, the root cause of death in that case is child maltreatment.

     My interest is in providing more accurate primary data to the agencies that track child maltreatment deaths.  These agencies cannot perform well if the cases they review have not been adequately investigated.  The pediatric profession has recently made a giant leap in improving this process.  The American Board of Pediatrics has established the board‑certified pediatric sub‑specialty of child abuse pediatrics.

     These pediatricians complete an additional three years of fellowship training in child maltreatment, becoming experts in the recognition, diagnosis, treatment, and prevention of child maltreatment.  When a child does die from abuse or neglect, these pediatricians can help police, forensic, and social service agencies make the correct diagnosis by doing the appropriate medical work‑up in the hospital, and by ruling out conditions that mimic abuse or neglect.

     There are ‑‑ there is currently no federal support for training pediatric sub‑specialists in child abuse pediatrics.  We need to expand the availability of fellowships, to make sure that these doctors are available to all hospitals around the country that care for children.  The National Association of Children’s Hospitals and Related Institutions has published recommended guidelines for the establishment of child protection teams at all children’s hospitals, but there are not enough trained, board‑certified pediatric specialists in the field to provide this expertise.

     Another way to increase the accurate counting of child maltreatment deaths is to increase the resources available to medical examiners and coroners, and to support their performance of quality death investigations.  Multiple studies have shown that only about half of the child maltreatment deaths are actually recognized and recorded on death certificates and in state vital statistics.

     In summary, in addition to improving our method of counting child maltreatment deaths, we need to improve our ability to recognize and discern when a death is due to child maltreatment.  And if we have the resources to diagnose abuse and neglect, and provide the necessary treatment and services to children and families, we can actually prevent the ultimate worst outcome, the death of a child.

     It is important to note that strengthening the quality of medical and death investigations in child abuse cases adds another protective factor.  That is, we will be better able to protect innocent parents from allegations of child abuse and neglect, and to preserve and promote families.

     Thank you.

     [The statement of Dr. Jenny follows:]

     *Chairman Davis.  Thank you, Dr. Jenny.  With that, I would like to defer to the distinguished ranking member to introduce the next witness.

     *Mr. Doggett.  I am very pleased to have join our panel Dr. Jane Burstain.  Dr. Burstain is responsible for child welfare and child protective service budget issues at the Center for Public Policy Priorities in Austin, Texas.  It is located in the same neighborhood that is my home in east Austin.  And CPPP is a non‑profit, non‑partisan think tank that has played a vital role in Texas, particularly on state legislative issues committed to improving the economic and social condition of low to moderate‑income Texans.

     Before she came to east Austin, Dr. Burstain served as an adjunct professor at Pepperdine, where she taught family policy classes.  And she worked as an attorney representing children in the Los Angeles child welfare system.  So we really have this coast‑to‑coast problem and insight offered by our panelists this morning.

     Thank you, Doctor.


     *Dr. Burstain.  Thank you.  Chairman Davis, Ranking Member Doggett, and members of the subcommittee; thank you for the opportunity to come testify on this important and tragic issue.

     As Representative Doggett mentioned, I have worked in the child welfare arena for more than a decade.  I started out as an attorney in Los Angeles, and during my six‑year tenure there representing thousands of abused and neglected children, I became interested in taking my experience and translating it into systemic improvement.  I earned my Ph.D., and in 2008 I joined the Center for Public Policy Priorities in Austin, Texas.

     At the Center, I conduct research, I participate in state and national coalitions, and I educate policy‑makers on how to improve and create better outcomes for children and families.

     Let me start by saying that I absolutely agree with Representative Doggett, that even one child death from maltreatment is too many.  It is the ultimate tragedy for the family and the community, and for the individuals who have to investigate it.  But every single day in the United States more than four children are reported to have died from abuse and neglect.  That is one death every six hours.  And those are just the ones that we know about.  As all the witnesses have testified here, the number of children dying from maltreatment is probably even higher.

     As discussed in my written testimony, and as adequately and extensively documented by the witnesses here, we do need to do a better job with states getting more quality, comprehensive, and consistent data on child maltreatment deaths.  But with children dying every day, we cannot wait for the data to be perfect before we act.  So I am going to focus on what we do know.

     We know that even taking reporting differences into account, some states have higher child maltreatment death rates than others.  We also know that poverty and having a teen parent are significant risk factors for abuse and neglect, and that those risk factors are more prevalent in certain states.

     So, I looked at states with high child poverty rates and high teen birth rates, which include many of the states represented on the panel today in this committee, and I looked to see if those states, on average, also had higher child maltreatment death rates.  I found that states with high child poverty had a 43 percent higher death rate, on average.  And I also found that states that had a high teen birth rate had a 61 percent higher death rate, on average.

     As families struggle and stress levels rise, child maltreatment becomes more of a risk.  And this risk is only growing.  The great recession has pushed more families into poverty.  As compared to 2008, the number and percentage of children living in poverty has increased nationwide in virtually every state.  And although the teen birthrate has dropped nationwide, some states still struggle with the issue.  In Texas, in 2008, there were 55,000 births to teenage girls.

     If we want to reduce child maltreatment, now is not the time to cut support to struggling families.  But as states grapple with huge budget deficits, that is exactly what is happening.  The number of children receiving child abuse and neglect prevention services has declined in 17 states, many of which are represented here on the subcommittee.

     In Texas, with more than 1.6 million children living in poverty and at risk for maltreatment, there is only funding for about 6,000 to receive direct child abuse and neglect prevention services.  Budgets are so tight that states are even cutting services to children who have been subjected to abuse and neglect.

     In 2009, in some states, 2 of every 3 children who are child abuse and neglect victims stayed in their home and did not receive any ongoing child welfare family support services.

     Early education and child care programs, which have been shown to reduce aggressive parenting behavior and maltreatment are being cut, as well.  Getting children out of the home and into daycare reduces parental stress, and makes the children more visible to reporters who can identify a problem before it escalates into something serious.  But in Texas’s most recent budget, the legislature cut grants to support pre‑kindergarten by 100 percent, and cut $.20 of every dollar that funds subsidized daycare to at‑risk children.  That is why federal programs which help support struggling families, like title IV‑B of the Social Security Act, the child care development block grant, and the supplemental TANF grant are so important.

     Expanded health insurance options for adults under the Patient Protection and Affordable Health Care Act is important, as well.  With health insurance, poor parents are struggling with substance abuse and mental health, can get access to services, and thereby reduce the risk factors for reduce and neglect, get healthy, and take care of their kids.

     I know that the budget crisis that is facing states extends to the Federal Government.  But to cut programs that support struggling families in tough economic times is the very definition of penny wise and pound foolish.

     And if we make that choice, our children will pay for it with their lives.

     [The statement of Dr. Burstain follows:]

     *Chairman Davis.  Thank you very much.  We will move to questions now.

     In today’s testimony we have heard a variety of numbers.  I know, from my professional experience, whether it was in the military, in business, and certainly in the morass of Washington, D.C., you can’t fix what you can’t measure.  And this is going to be one of the central questions, particularly numbers of how many children die due to maltreatment each year.

     States reported over 1,700 deaths in 2009 to HHS.  GAO cites this figure, and also a number from the HHS national incident study of child abuse and neglect that estimated 2,400 deaths over 2 years, from 2005 through 2006.

     Ms. Tunie mentions 2,500 deaths from maltreatment per year, as does Mr. Petit.  Ms. Covington speaks more generally about the undercount she witnessed in Michigan and reviewed in Nevada.

     Ms. Brown, your report details a number of reasons to believe current data understates the number of children who die from maltreatment.  In terms of scale, how many deaths do you believe were missing each year?  Tens?  Hundreds?  Thousands?  What is a better number if the HHS official estimate of 1,770 is an undercount?

     *Ms. Brown.  The challenge there is finding good research that actually measures these issues.  And we did a very careful literature review of all the research that looked at the numbers of child fatalities from maltreatment, and none of them are perfect.  That is the problem.

     You know, the one that has the relatively high percent of child welfare undercounts covers only three states.  The one that comes up with 2,400 reaches across a number of different partners, but it is such a small population that they captured, that it is hard to be really, really confident in the data.

     So, we know ‑‑ we have seen differences in hundreds.  We have seen as much as 1,000.  I would like to see a much better process for getting this information, so we can actually know.

     *Chairman Davis.  What were the states that ‑‑ the three states ‑‑

     *Ms. Brown.  In the study?

     *Chairman Davis.  Yes.

     *Ms. Brown.  California, Michigan, and Rhode Island.

     *Chairman Davis.  Okay, thank you.  Would anybody else care to comment on this issue?  Mr. Petit?

     *Mr. Petit.  Yes, I would just note that there are three peer‑reviewed articles that appeared in prestigious health and scientific journals that speak to the undercount being at least 50 percent.  One is the Journal of the American Medical Association, one is the Journal of Pediatrics, and one is the Journal of Public Health.  Each of them have extensive documentation they put forward that say the number appears to be at least a 50 percent undercount, which is how we arrive at the 2,500 figure.  But no one could defend that number as being precise, that being the whole purpose of the GAO study, is to help show just how deficient measuring is.

     *Chairman Davis.  Anybody else like to share?  Ms. Covington?

     *Ms. Covington.  I personally believe it is probably 100 percent undercount.  I think we should double the number, when you take into account neglect deaths.  Just looking at the 15 states that we did briefly before we came here, we doubled the number of states that actually reported ‑‑ you know, when you looked at that versus when was NCANDS, it was double.  And I think that that is probably true across the country.  So, I personally would double the number.

     *Chairman Davis.  Okay, thank you.  Any other ‑‑

     *Mr. Petit.  May I just say, as an example of what we get at ‑‑ we had a case one time in which it was an open child protective case.  They lived on a third or fourth floor.  The mother experienced an overdose.  The two‑year‑old child went down to the street, was run over by a car.  And in most states that is listed as a pedestrian accident, not the child abuse and neglect‑related death that it is.

     *Chairman Davis.  So you are saying, for example, connecting the different parts of the law enforcement investigation to collate that data would be helpful?

     *Mr. Petit.  Let me just say that when we have done that with law enforcement, the medical community, and others ‑‑ and district attorneys ‑‑ it is tremendously revealing to see what actually happens, the disposition of cases.

     Child welfare can say, “Here is 100 certified cases in which child sexual abuse,” for example, “occurred.”  Police might say, “We can identify 75 cases where there was a perpetrator.”  There may be 25 cases that are reported to the district attorney.  The district attorney may choose to prosecute 10, because they don’t think the data is good enough, in terms of supporting the evidence, and you may end up 5 convictions and 2 or 3 sentences to prison ‑‑ which I am not saying is the answer to this whole problem ‑‑ but they are not tracking those numbers.  They are keeping their information separately.  And when it is blended together they can see where the structural problems are in the system.

     *Chairman Davis.  Before I yield to Mr. Doggett, something I would throw open to the members of our panel, if you have suggested process improvement ideas ‑‑ particularly as we can tie a cost to them, or reduce that cost burden, to get this linkage of data.  We found, in many institutional settings, a great amount of success in removing error, unnecessary cost, and other problems ‑‑ or quality issues, in a more generic sense — but in this case it might lead to a solution to these problems.

     With that, I yield to Mr. Doggett.

     *Mr. Doggett.  Thank you, Mr. Chairman.  Dr. Burstain has put this in terms of one child losing a life every six hours.  Ms. Covington, I gather what you are saying is it could be as much as one every three hours, or one every two hours.  And that is what several of you have said with reference to the data, that those figures that are widely acknowledged are probably much greater than our understanding.  Right?

     And I ‑‑

     *Ms. Covington.  Yes, correct.

     *Mr. Doggett.  And I gather that for everyone here, if we could do something to prevent just one of these horror stories that will take place in the next six hours or the next three hours or the next two hours, we would want to do that.

     As policy experts looking more broadly across the country, beginning with you, Dr. Burstain, what can we do to prevent these tragedies?  We want to have an accurate count, certainly, and I think there are measures to get a better count.  But we are not counting beans here.  We are counting precious children’s lives.  What are the things that the Congress should be doing now, beyond getting a more accurate count, to be sure that that rate doesn’t go higher?

     *Dr. Burstain.  Thank you.  Well, in addition to funding the programs that support struggling families, I think one of the things that could really be helpful is the title IV‑E waiver program that has passed through the House.

     Basically, one of the problems with the child welfare system overall is, with the funding streams, you have title IV‑B, which is a block grant, and that is the money that states have flexibility to use for prevention programs, and to keep kids safe in their own home.  Title IV‑E basically covers foster care and adoption, so it covers the back end.  And that represents a much larger part of the federal financing on child welfare.

     And so, if you had a waiver program where states could take the money that they would have spent on foster care and spend that same money up front to keep kids safe, to prevent child abuse and neglect from occurring in the first place, I think it would go a long way towards really helping these families keep their children safe.

     I think funding child care is another really important issue.  Child care is something that can really help ‑‑ just getting the child out of the house relieves parental stress.  And I think, most importantly, the parents, when their kids are in child care, know that someone is going to be looking at that child.  And if there is a problem, and the child is coming with a bruise or seems to be unkempt, there is someone who can see that child every day and make a report and have the child protective services system intervene before a problem occurs.

     Because one of the problems with child maltreatment deaths is a lot of those deaths happen, and the child welfare system doesn’t even know about those kids.  And so it is not as if the child welfare system is investigating these difficult families and not doing a good job of intervening.  They don’t even have an opportunity to intervene, because most of these are young kids who are not in school, and so no one sees them.  And if you get child care for these struggling families, you eliminate that problem.

     *Mr. Doggett.  What will be the effect on this problem of child abuse, or child deaths, if the Social Services Block Grant is eliminated, if TANF supplemental grants in states like Texas are not continued, and they are set to expire within days, and if we don’t have unemployment benefits available for families?

     *Dr. Burstain.  Well, I can tell you with respect to the social security block grant and the TANF.  Those are programs that, I know in Texas, they use to directly support child welfare services.  So those are grants that are not only used to help generally families in poverty, but are specifically used to help families that are at risk of abuse and neglect, or have actually subjected their children to abuse and neglect, and they are in the system.

     *Mr. Doggett.  And you are saying ‑‑ just to interrupt you for a minute ‑‑ that in Texas the cuts have been so severe already, even without losing these programs, that some families already identified as actually having had cases of abuse or neglect no longer get the services?

     *Dr. Burstain.  Yes.  The services rate for child maltreatment victims in Texas is at about 45 percent.  So about 4 of every 10 children who have been identified as abuse and neglect victims receive ongoing child welfare services.  And, as I testified about earlier, in some states that rate is even lower, and you’ve got 7 of every 10 children staying in the home and not getting services.

     *Mr. Doggett.  Ms. Tunie, you represent an impressive coalition of social workers and others.  Are there recommendations that you have, with regard to what steps we can take to prevent this death rate from accelerating, from matters getting worse?

     *Ms. Tunie.  Yes.  In agreement with Dr. Burstain, to simplify it ‑‑ because I am not an expert on this issue ‑‑ funding is critical, and services are critical.  And the ability to collect the data accurately is critical.

     *Mr. Doggett.  Thank you.

     *Chairman Davis.  Thank you.  The gentleman’s time has expired.  I would like to share with Dr. Burstain that Mr. McDermott and I introduced the child welfare waiver bill addressing this IV‑E issue that passed out of the House in May.  I encourage you to call your friends in the United States Senate, and encourage them to move faster than their glacial pace to address these things.


     *Chairman Davis.  The chair now recognizes Mr. Paulsen from Minnesota.

     *Mr. Paulsen.  Thank you, Mr. Chairman.  Ms. Brown, may I ask you a question regarding the report?  The report explains the two primary sources of data that we have on child maltreatment fatalities, and the data reported to HHS and the data reported through state child death review teams.  What does HHS do with the data, exactly, other than just publish summaries of the information?

     *Ms. Brown.  The NCANDS data that HHS collects is used for ‑‑ because they oversee the state programs — it is used for things like checking to see if the states are abiding by their expectations when they do their reviews of each state program.

     They also use them to ‑‑ they have measures that they are expected to meet each year,for example, knowing the number of deaths from maltreatment and foster care.

     But the other thing, as far as the more on‑the‑ground information, is that they have some technical assistance centers, and there is one that deals specifically with child protective services.  And that center has done some training to try to push the information out.

     *Mr. Paulsen.  And then what do the states do with their child death review team data, the states, specifically?

     *Ms. Brown.  I am wondering if I am the right person to answer that.

     *Mr. Paulsen.  Ms. Covington is nodding her head.  Okay, please.

     *Ms. Covington.  Forty‑four states require that they use their data for a ‑‑ to publish a state annual report on their deaths, which would include child abuse deaths, as well as other deaths.  Most states are really getting smart about actually creating ‑‑ they ‑‑ almost all the states have a state‑level advisory board that reviews those findings before the report gets issued, and they make recommendations to their governors and their state legislatures on policy and practice.

     *Mr. Paulsen.  Okay.

     *Ms. Covington.  And some of them have been very successful, actually, in getting those things ‑‑ their recommendations implemented.

     *Mr. Paulsen.  Sure, Mr. Petit.

     *Mr. Petit.  Yes, Mr. Paulsen, if I may say, all together there is about $30 billion spent on the child welfare system, the formal child welfare system.  About 55 percent of that is state and local, mostly state.  About 45 percent of that is federal.

     There is a very weak federal oversight of the child welfare system.  They provide most of the money, and they actually ‑‑ the Federal Government actually provides the statutory framework within which most state child welfare systems operate.

     I would assert flatly that virtually every single state in the country right now is vulnerable to a successful class action litigation being brought against them, and states repeatedly lose those when, in fact, such class action litigation is brought against them.

     There are very few sanctions ever imposed by the Federal Government, even when states are out of compliance for many, many years, in contradiction to what federal standards and oversight requirements exist.

     *Mr. Paulsen.  And, Ms. Tunie, maybe you can just tell me.  What does your national organization do with the information in general, as you collect the info and get the data?

     *Ms. Tunie.  Well, our mission, basically, is to raise awareness of the issue, and also to urge Congress to take action.

     *Mr. Paulsen.  Okay.  And, by the way, thank you for helping raise awareness on this issue.  And, obviously, this hearing is a part of that effort.  And, I mean, what other recommendations do you have for us as individual members in our own districts, in our own states, to also help raise awareness about this issue, other than just going through numbers and data.

     *Ms. Tunie.  Yes.  You know, I think it is really important to put a face on it.  The book that Mr. Petit put together, where you really see the faces of these children, and it really becomes a personal, as opposed to just a number or a statistic.  I think that is a great way to raise awareness.

     *Mr. Paulsen.  Thank you, Mr. Chairman.

     *Ms. Tunie.  Thank you.

     *Mr. Paulsen.  Yield back.

     *Chairman Davis.  Thank you.  The chair recognizes the gentleman from Washington, Mr. McDermott.

     *Mr. McDermott.  Thank you very much.  I have watched these hearings since 1970, when I was in the state legislature.  And states always lurch forward after a horrible event.  It is over, and over, and over, and over again.

     And, Mr. Petit, you just sort of said that there is a tremendous problem, and most states would be vulnerable.  Let’s go on the positive side.  Tell me the states where they have the best system for getting these cases and preventing them.  Because it seems to me the problem is we are always coming in at the back end, looking at the problem, when it is already in the hands of the coroner.

     And so, what I am interested in is what states have had the best system in place to predict and deal with and prevent?

     *Mr. Petit.  Let me ‑‑ I think that is a more complicated question than I am going to spend time answering, in the sense that there are literally thousands of child protection offices across the country.

     *Mr. McDermott.  Yes.

     *Mr. Petit.  Many states run it through their county system.  And we have done studies looking at outcome measurements for the states, and they vary wildly, so that the differences between virtually any indicator you want to choose, removing children from their family, reports of child abuse, fatalities, foster care, et cetera, the variations between the bottom state and the top states may have multiples of five or tenfold.

     But I will tell you the states that do the best overall are the ones that have smaller, whiter populations.  So where ‑‑ which translates into less poverty and less complicated issues around domestic violence, around imprisonment issues, around substance abuse.  So all the states experience it, but some states experience much more than others.

     If you take a look at the overall distribution of these issues, they are concentrated especially most severely in the states with large minority populations.  And I say that, saying that that correlates, in turn, with high rates of poverty in those communities.

     But if you wanted to look at a state that probably has had a significant effect in dampening down the overall amount of child abuse to begin with, which is the ultimate goal that we all have, we would say, like, Vermont, where they have comprehensive health care services, where there is home visiting for virtually all children.  There is an extensive safety net that is built around welcoming a child and a family into the community, and people taking collective responsibility for overseeing what is happening with those children and families.

     There are a number of other states as well, but when you get into the big states ‑‑ Texas, Florida, California ‑‑ it is very, very challenging to manage the huge volume of cases that are brought to their attention in the first place.  Remember, that number now is about three million reports of child abuse.  HHS in their national incident study says the true number is closer to probably nine million cases of child abuse and neglect each year.

     *Mr. McDermott.  When you sit at the federal level, when you sit at this dais, and you look out on the United States, and you try and figure out what should we do, then the question that ‑‑ I mean, Dr. Jenny raises the question of more pediatric ‑‑ pediatricians trained in looking at the issue.  Where are the other gaps in training that we should put money or think about?

     I mean we get into these stovepipe things because we try and figure out how to deal with it.  But I would like to hear the other areas where you think there is a need.

     *Ms. Covington.  I think, without question, our death investigation system is ‑‑ really needs assistance throughout the country.  In my home state of Michigan there is a number of medical examiners that tell you if you die in the first half of the year you are going to get a really good autopsy and investigation.  If you die in the second half, it is going to not be so good, because they run out of money.  And that is a reality.

     And without really quality death investigations, we are just not getting the answers we need around these child abuse deaths.  So I think training and resources for improved death investigations would be one area.

     *Dr. Jenny.  I would like to say that the medical profession does a very bad job of recognizing abuse.  I did a study and I published in Journal of American Medical Association, where we looked at 131 abusive head trauma admissions to our hospitals, serious abuse.  And a third of those kids had a previous head injury from abuse, went to the doctor, and the doctor missed the diagnosis.  Eight of those kids died.

     And I think that there is very little education about family violence, about child abuse, in medical schools, in residencies.  And I think that that is a place where we could really ramp up the prevention by early recognition.

     *Mr. McDermott.  Is there a place for nurse practitioners in that kind of a thing?

     *Dr. Jenny.  Absolutely.  Nurse practitioners, PAs, even nurses.  I did a study in Colorado where we looked at the amount of time in nursing school curriculums that was spent on family violence.  It was less than two hours in a four‑year curriculum.

     So, I think that this is something that would be relatively easy to do, just by putting more emphasis on this in our professional societies and our curriculums in schools.

     *Chairman Davis.  Great, thank you very much.

     *Mr. McDermott.  Thank you.

     *Chairman Davis.  The gentleman’s time has expired.  Mr. Reed from New York.

     *Mr. Reed.  Thank you, Mr. Chairman.  Thank you to the panel.  I come at this issue ‑‑ when I first started my law practice we did a lot of law guardian work, and represented many abused and neglected children.  And there is nothing more touching than that experience, and frustrating, and emotional, and it creates a lot of anger in me, individually, to see parents abuse their children.

     So, that being said ‑‑ and I get the argument from all the testimony ‑‑ I was reading this last night, and I get the argument we need increased funding, we need to protect the funding.  You know, the environment we live in here in Washington, D.C., so ‑‑ and I don’t want to spend a lot of time on that issue, just to articulate that I get it, and I understand that.

     What I would be interested ‑‑ what I am interested in talking about today is kind of a new way of looking at this issue.  I think, from all the testimony that I have heard and I have read, each of the members of the panel here today would agree that poverty is a higher indication of child death from the parents from abuse and neglect of parents, and substance abuse ‑‑ would all agree is a higher indication of death of a child.

     That being said, I then ‑‑ does it not beg the question, a common sense question of targeting our resources by requiring parents who are on public assistance ‑‑ i.e. public assistance, the people that are in poverty are more likely to be on public assistance ‑‑ parents in that program, require them to be drug and alcohol tested?

     We are talking about the death of children.  And I understand there is going to be many parents that are going to be alcohol free and substance abuse free, and I get that.  But if we are talking about saving the death of children, does that not trump the benefit that we could receive from identifying the higher‑risk children through testing their parents for substance and alcohol abuse?

     Dr. Burstain, would you have any comment on that?

     *Dr. Burstain.  Well, first, I think that I completely agree with you, that we should be looking at ways that we can prevent child abuse and neglect deaths.

     I will say that drug and alcohol testing is expensive.  So if you are talking about not wanting the Federal Government and not wanting the states to have to spend more money ‑‑

     *Mr. Reed.  So if we can we get the cost taken care of ‑‑

     *Dr. Burstain.  Well ‑‑

     *Mr. Reed.  I mean you are asking for money elsewhere, so if you get the money ‑‑

     *Dr. Burstain.  Yes, absolutely.  And I would say that that money would be better spent, instead of drug and alcohol testing, all of the individuals who are receiving public assistance, I would say that money would be better spent actually getting drug and alcohol treatment.

     *Mr. Reed.  Well, not everyone that is on public assistance, just parents that have children in the home be tested.  I am talking about a very narrow program, trying to narrow it down ‑‑

     *Dr. Burstain.  Wait ‑‑

     *Mr. Reed.  Just parents.

     *Dr. Burstain.  I ‑‑

     *Mr. Reed.  Not all those on public assistance.

     *Dr. Burstain.  I believe the majority of people who are receiving public assistance have children.

     *Mr. Reed.  Okay.

     *Dr. Burstain.  And so the majority of those people would be tested.  And what I would say is that money that you would spend on testing ‑‑ because what are you going to do if they turn out positive?  The money would be ‑‑

     *Mr. Reed.  We would coordinate that information with CPS and with law enforcement, target those individuals, intervene, make sure that those parents are getting substance counseling, trying to lead them to a substance‑free life, and that will lower the risk of death to their children, which all of you agree has created a higher risk for those children that are living in that environment.

     *Dr. Burstain.  You would be ‑‑

     *Mr. Reed.  So that would be my ‑‑

     *Dr. Burstain.  You would be absolutely right, if there was money for treatment.  But there isn’t money for treatment.  And so, what I would say is, instead of spending your money on testing people who you have no basis to believe are actually abusing substances, I would spend the money on providing services to the people you know are abusing substances.

     *Mr. Reed.  And when they ‑‑

     *Dr. Burstain.  So once they become involved in the child welfare system, you need to get them access to substance abuse.  And, more importantly, mental ‑‑

     *Mr. Reed.  So we have to wait until they abuse their children before we get ‑‑ because once they abuse their children, they are in the CPS system ‑‑ then we can get them the substance abuse treatment that they need?

     *Dr. Burstain.  Absolutely you do not have to wait.  One of the things that I highlighted in my testimony is that, under the new Health Care Reform Act, getting people health insurance ‑‑ one of the reasons people don’t get treatment, and before they actually become involved in the child welfare system, is poor adults a lot of times don’t have health insurance.  And so the only way they can get treatment is become involved in the child welfare system, and get services through the child welfare system.

     *Mr. Reed.  Okay.  I notice my time is ‑‑ Mr. Petit, you are the commissioner of ‑‑

     *Mr. Petit.  Child welfare.

     *Mr. Reed.  Child welfare in Maine.

     *Mr. Petit.  I would just note that the Congress and the Senate had legislation introduced more than 10 years ago on making substance abuse treatment monies available to state child protective agencies whenever that was identified as being an issue.  And certainly there is a high relationship between the two.  But the Senate Finance Committee never held a hearing on the bill.  It was introduced in three consecutive legislative sessions to provide assistance in that case.

     Now, that little girl that was baked to death in an oven that I mentioned, I remember the governor saying to me, “Stop this.  Take these children from these families and get ‑‑ stop this issue.”

     I said to the governor, “This is the first death we have had in four years.  There are 12,000 children or so in our open protective custody in any given moment.  And in the course of a year, 1 or 2 might die, even though this problem that you just described exists maybe in 60, 70, 80 percent of the households.”

     So, I think there is a way to target this much more specifically, so that you get at what you are talking about.

     May I suggest ‑‑ I have been doing this for 40 years.  This is a panel that has been involved with this for a long time.  I cannot emphasize enough the need for a national commission that brings together all of the different disciplines.  We are talking about nothing less than healthy, human growth and development, which is a very complex topic, which hasn’t been looked at by this congress, by any Administration in decades.  The last that I know of was the Rockefeller Commission.  That was almost 20 years ago.  We have had no national White House conferences in this country since 1970.

     This is an issue that has ‑‑ receives very scant attention by the public.  And it needs to be opened up.  And that is why I would recommend this national commission and, at the same time, lift the confidentiality requirements.

     *Chairman Davis.  I appreciate your passion, Mr. Petit.  That is one of the reasons we are having this hearing today, is to move forward ‑‑

     *Mr. Petit.  Thank you, sir.

     *Chairman Davis.  ‑‑ on this.  And, with that, we will recognize the gentleman from Georgia, Mr. Lewis, for five minutes.

     *Mr. Lewis.  Thank you, Mr. Chairman.  Thank you, Mr. Chairman and Ranking Member Doggett, for holding this hearing.

     I have been here for almost 25 years, and attended many hearings.  But this has been one of the most painful.  What some of you have said is almost unreal, unbelievable.  But I know it is real.  I know it is believable.  In my own district, in my own state of Georgia, just watching the news, reading the newspaper, seem like something happened to some little child, somebody child, somebody baby, almost every other day.

     And, Mr. Petit, I would really like to know from you.  You mentioned race and poverty.  It is not something that we should sweep under the rug or in some dark corner.  We should face it, and face it head on.  Could you tell me ‑‑ maybe some of you have data, information on the state of Georgia ‑‑ but could you tell me or speak to the whole issue of young families where there is a father, a mother, a boyfriend, a girlfriend with a child?  Reading that something happened to this child.  The child was beaten or left alone and died.  What is happening there?

     Ms. Tunie, I love what you said about putting a face on it.  How do you dramatize that?  How do you make it real?  How do you sensitize and educate the American people that this is a major problem and we have to face it?

     I think there is a great undercount, Ms. Brown.  I think there is a great undercount.

     *Mr. Petit.  May I say very directly?  The legacy of slavery endures.  The behavior that we are talking about is manufactured.  It is not innate to any particular culture or any DNA.  And in the black community what you have is a very high out‑of‑wedlock birth rate.  You have a very high poverty rate.  You have a very high imprisonment rate of young males.

     The family formation in the black community has been extremely challenged in the last few decades, and the research that does exist shows that children in a home with an unrelated male are almost 100 times more at risk of dying than when there is a biological‑related father in the household.

     So, I have just made some broad‑sweeping statements on this.  I believe it requires a much closer look.  But there are realities, in the black community in particular, which shows in this report that there is a three times higher fatality rate in the black community.  But it is manufactured behavior that contributes to it.

     *Mr. Lewis.  Could you speak about poverty?  Ms. Covington, you wanted to say something?

     *Ms. Covington.  I was going to add on to that.  There was a headline in the Washington Post yesterday.  Keith Jackson wrote a story, and the headline was, “Would Anybody Have Cared if Caylee Anthony was of a Different Color?”  And I think that is really important, because when we look at these deaths across the country, there is no question that the white, you know, middle‑income kids who die at the hands of their caregivers get a lot of attention.  But African American kids are really over‑representative in the numbers, and poverty is a huge correlation in these deaths.

     In fact, in a lot of the neglect cases, that is one of the reasons they don’t get counted, because, you know, people give a little room there when there is poverty issues tied in to some of the parental responsibility problems, in terms of ‑‑ they are living in poor families, and so there is ‑‑ that is one of the reasons they don’t get counted as well.

     But then it leaves us with numbers that don’t make a whole lot of sense, and it doesn’t give us the ability to actually be able to respond to those cases.

     *Mr. Lewis.  Any other member of the panel?

     *Mr. Petit.  On the poverty question, if I may say, in 1960 the poorest cohort were seniors, the ‑‑ children were the second poorest cohort.  In 2010, children are the most poor cohort and seniors are the least poor cohort.  The Federal Government is spending 7 times more per senior over 65 than per child under the age of 18.

     And if you look at the federal benefits that go to seniors, they are the same from one end of the country to the next.  They are the same in Maine as they are in Texas as they are in Hawaii.  That is true with Medicare, that is true with Social Security.

     When you look at the income security programs for children, and the health care programs for children, they are largely left up to the states to shape, which, in fact, is attributable to some of the poverty that we are talking about, is that there is wide variation among the states in dealing with this issue.

     *Chairman Davis.  All right, thank you.  The gentleman’s time has expired.  I would like all the Members to know that in the back of your packets or binders is state‑specific information for your home states on this data from the Congressional Research Service.

     And with that, I would like to recognize Mr. Berg from North Dakota for five minutes.

     *Mr. Berg.  Thank you, Mr. Chairman.  This is ‑‑ you know, has to be one of the worst crimes that can be committed, a crime against a child.  I ‑‑ you know, these stories you talk about, putting a face on it, I mean it is just horrific.

     My wife is a family practice doctor.  And one of her most difficult days is when she recognizes abuse in a child.  And in our state of North Dakota, the support for her has been outstanding, to get that child in a good environment, a safe as possible environment.

     But, you know, in the discussion ‑‑ I guess, Ms. Brown, the discussion really relates around this coordination.  And I guess I am confused that, you know, almost half the states that are reporting this data are just kind of regurgitating data that you already have.  And it seems to me that these states really should be accessing other information that they have in their states, whether that is a death certificate, medical examination after death, or the child death review team structure, which, to me, seems like an outstanding ‑‑ somewhat volunteer, but again, you can bring some real experts into that.

     So, I guess I’m just asking, how do we get more accurate information?  Not necessarily recreating the wheel, but how can we get more of a response?

     *Ms. Brown.  Well, it seems to me that we have two places in the count where the response breaks down.  And the first one is related to identifying whether a death is caused by maltreatment.  And we have heard about how challenging that can be.

     And then, the second one is, as you referred to, collecting the data from the community in a way that can give a more complete picture.  And I agree that the child death review teams that are on the local level can be very, very useful, because that is a vehicle for bringing different organizations together.

     And part of the issue there is trust, and having personal relationships.  So, if you have a vehicle that regularly brings them together, that could make a difference, and it doesn’t cost much.

     *Mr. Berg.  Well, and it ‑‑ again, our overall objective here is really to prevent this from happening.  And, you know, we are gathering this data, and as I look at this data it is ‑‑ I mean it is as accurate and current as you can get it, but we are years and years behind.

     And so, again, it seems to me that what you are talking about there on the local area ‑‑ and again, you have a large state, very populous, or a small state ‑‑ if you could create a system where you have local experts that are getting that accurate information, but also thinking what steps can be done on the local level and on the state level to, you know, again, catch these children.

     So that brings up the other question, and I just am always frustrated by the lack of communications between different agencies.  And it seems to me, if you took this further in a local, you have the child death review committee and they are identifying certain trends, or certain things that really stand out ‑‑ let’s take drugs, for example, drug abuse.  If they are saying that this is something that is a real ‑‑ it is in almost every one of these cases, how can they access the other agencies within that local community that could identify and share that information, so rather than reactively waiting, become more proactive and encouraging these people to get treatment or having a higher level of watchfulness over that child?  Please.

     *Dr. Jenny.  One thing that I think is very helpful is hospital‑based child protection teams.  Because that is a place ‑‑ in children’s hospitals they have teams that meet weekly and go over every case that has been in that jurisdiction ‑‑ not of deaths, but of kids that have been abused or neglected.  And it is a proactive process.

     And having more support in the children’s hospitals for child protection teams is going to, I think, make a big difference because we all talk to each other and we do a lot of preventative work up front to avoid those deaths at the back end.

     *Mr. Berg.  Sure.

     *Ms. Covington.  I think, too, there is a trend in states for more improved coordination of just general child protection investigations.  Some states actually require it, even though they don’t necessarily follow through on making sure that those investigations are done in a coordinated way.

     But in places where they are done in a coordinated way, I think there is profound improvements in the way kids are identified, because you have got ‑‑ you have law enforcement, the prosecutor, mental health, education, social services, they are all at the table ‑‑ public health, they are all at the table, looking at this child from a more comprehensive ‑‑

     *Mr. Berg.  It seems that those are best practices we could share with other states, if we had a little more ‑‑

     *Mr. Petit.  May I say that, actually, there is a lot of this going on right now through the Department of Justice?  And one of our coalition members is the National Children’s Alliance.  And there are some 800 local jurisdictions that have district attorneys, child protection, law enforcement, medical, that come together, typically around child sexual abuse cases.

     And may I just say in your own state of North Dakota, where I had the privilege of spending the better part of a year doing a project on child well‑being for the North Dakota legislature, that year North Dakota ranked first or second in the national Kids Count survey.  But if you had taken the seven percent of children who are Native American and put them in a new state of East Dakota, they would have ranked 51st.

     And so, the data kind of misrepresented what the overall well‑being was.  It took us a year to get data from the Native community.  It was this question of trust.  And they finally put their numbers on the table.  It created a new North Dakota Commission on Indian Affairs and Child Welfare.  And I have been curious ‑‑ this was 15 or 20 years ago ‑‑ to see what impact finally putting that data on the table had, which is what the legislature was looking for.  They didn’t know how to help the community ‑‑

     *Mr. Berg.  Right.

     *Mr. Petit.  ‑‑ without the numbers, and they didn’t want to start spending money without the numbers.

     *Chairman Davis.  Thank you very much.  The gentleman’s time has expired.  And Mr. Crowley from New York, you are recognized for five minutes.

     *Mr. Crowley.  Thank you, Mr. Chairman.  Let me sincerely thank you for holding this hearing today, and my colleague, Mr. Doggett, for bringing this issue that really, in light of the Caylee Anthony case, didn’t necessarily need to be highlighted, but I think in terms of what we, as a nation, are doing to combat the abuse of children is certainly needed.

     And I wonder whether or not the attention we have here today would be as strong if it were not for this particular case.  I ‑‑ and, Ms. Tunie, I appreciate your lending your voice and your face to this issue, and all the panelists here today.  But this is a disturbing yet necessary subject matter that needs to be addressed.  And I wonder, though, whether or not we would have the same attention we have today ‑‑ I think you would be, and I think all of you and the panelists would be, but I am not so sure the media would be as strong as it is today.

     Whether or not the death of Caylee Anthony was by means or ‑‑ of ‑‑ caused by accidental neglect or first degree murder, at the end of the day that young child was killed, and may very well have been preventable if signs were ‑‑ and steps were taken ‑‑ if signs were seen, and proper steps were taken to prevent that.  And I think the death of any young child, if it can be prevented, we should be doing everything we can to do that.

     I have been involved in this area for some time, going back to my days in the state legislature.  I chaired a subcommittee on child product safety.  I was concerned by maybe not even accidental neglect, just the aspiration of small parts in toys, and children dying from what appeared to be the cause of pneumonia, when, in fact, it was they had aspirated a small plastic piece into their lungs, and therefore, only through autopsy later on was this found, to more high‑profile today of baby cribs.

     I would like to ask the witnesses ‑‑ you know, because I know the GAO report has been focusing on the proper gathering of statistics, and questioning whether or not we actually are getting all the reportable statistics and compiling them correctly to really get an understanding of the breadth and the extent of neglect that is taking place.  But whether or not ‑‑ it doesn’t really address the issues of what to do once we have that information.

     And I know my colleagues have asked this in some ways, but what else can we be doing to raise awareness?  I know in a state like mine, in New York, we have ‑‑ we have seen success in public awareness campaigns, especially as it pertains to the issue of shaken baby syndrome, as well as safe sleeping for children.  What else can we be doing?  What can we be doing to help parents that may not be mindfully neglectful?

     If you just ‑‑ they have tough lives right now.  The economy being where it is, and the stress that that brings to bear on people’s lives, they would never put themselves in the category of being accidentally neglectful, you know.  What can we be doing to help those folks, as well?

     And other caregivers that just may be unaware of the dangers in everyday situations ‑‑ for instance, like bath tub safety and crib safety and choking hazard safeties?  What could we be doing to help those folks?

     *Dr. Jenny.  One thing that your state has done, has been ‑‑ nurse home visitation to young families, particularly at‑risk young families.  And they have done a randomized control trial where they have found actually that over the years it decreases welfare dependency, it increases the educational level of the child in 15, 20‑year follow‑ups, and also, it decreases the abuse rate and also the illness rate.

     So, David Olds model nurse home visitation would be an excellent model for prevention.

     *Ms. Covington.  And that was funded in the Health Care Reform Act, and all states are now going to start doing that.  And I think that that is really, really important, that that stay there and be a large part for every state to be able to have those dollars to be able to do those family home visits, because it is one of the very few demonstrated evidence‑based practices that we know could actually reduce child maltreatment.

     That is part of the things I think we can do, is try to figure out what really does work, because the research is limited.  Funds to figure out what really works for families is limited.  So there is little research looking at evidence‑based practices, but I think we need to keep doing that work.  And then, when we find something that works, make sure it gets out to the general public and to communities, so they can start implementing these practices.

     *Chairman Davis.  Thank you very much.  The gentleman’s time has expired.  I would like to thank all of our witnesses for your time and preparation, for your staffs, the investment of research, and also helping us understand this very critical issue further.

     If Members have additional questions, they will submit them directly to you in writing.  And what we, on the committee, would ask is that you also send a copy of your response back to us at the subcommittee, so that we can insert it into the record, as well.

     Thank you again for highlighting this very critical subject.  And, with that, the committee stands adjourned.

     [Whereupon, at 11:26 a.m., the subcommittee was adjourned.]

Chairman Davis, Questions
Kay E. Brown
Tamara Tunie
Theresa Covington
Michael Petit
Carole Jenny, M.D.
Jane McClure Burstain, Ph.D.

American Public Human Services Association
Andrea Kivolowitz and Ayla Annac
Childrens Hospital of Pittsburgh of UPMC
National Association of Social Workers
National Coalition for Child Protection Reform
Skipper Initiative
Tiffany Conway Perrin Organization