Child Deaths in MICHIGAN 2006

Child Deaths IN MICHIGAN 2006

Michigan Child Death State Advisory Team S i x t h A n n u a l REPORT

A Report on Reviews conducted in 2004

A report on the causes and trends of child deaths in Michigan based on findings from community-based Child Death Review Teams. With recomendations for policy and practice to prevent child deaths.

The Michigan Department of Human Services Michigan Public Health Institute

ACKNOWLEDGEMENTS

We wish to acknowledge the dedication of the nearly twelve hundred volunteers from throughout Michigan who serve our state and the children of Michigan by serving on Child Death Review Teams. It is an act of courage to acknowledge that the death of a child is a community problem. Their willingness to step outside of their traditional professional roles, and examine all of the circumstances that lead to child deaths, and to seriously consider ways to prevent other deaths, has made this report possible.

Many thanks to the local Child Death Review Team Coordinators, for volunteering their time to organize, facilitate and report on the findings of their reviews. Because of their commitment to the child death review process, this annual report is published.

The Michigan Department of Community Health, Office of the State Registrar, Division for Vital Records and Health Statistics has been especially helpful in providing the child mortality data and in helping us to better understand and interpret the statistics on child deaths.

The Michigan Department of Human Services provides the funding and oversight for the Child Death Review program, which is managed by contract with the Michigan Public Health Institute.

Permission to quote or reproduce materials from this publication is granted when acknowledgement is made. Additional copies may be ordered from the Michigan Public Health Institute.

This report is also available at www.michigan.gov/dhs and www.keepingkidsalive.org.

Child Deaths IN MICHIGAN

Michigan Child Death State Advisory Team

SIXTH ANNUAL REPORT

A report on reviews conducted in 2004

To understand how and why children die in Michigan, in order to take action to prevent other child deaths.

Submitted to

The Honorable Jennifer Granholm, Governor, State of Michigan The Honorable Mike Bishop, Majority Leader, Michigan State Senate The Honorable Andy Dillon, Speaker of the House, Michigan House of Representatives MICHIGAN CHILD DEATH STATE ADVISORY TEAM 2004-2005

CHAIR TED FORREST Manager Children’s Protective Services Program Michigan Department of Human Services

MEMBERS

DAVID BLOCKER VINCENT J. PALUSCI, MD, FAAP Investigator Professor of Pediatrics, Office of the Children’s Ombudsman Wayne State University School of Medicine G. PAUL CLOUTIER Medical Director, Child Protection Center Native American Affairs Specialist Children’s Hospital of Michigan Office of Native American Affairs Michigan Department of Human Services DOUGLAS M. PATERSON Director SANDRA FRANK, JD Bureau of Family, Maternal Executive Director and Child Health Tomorrow’s Child Michigan Dept of Community Health

SHIRLEY MANN GRAY MARGARET PENNINGER, JD Manager of Social Work Services Assistant Prosecutor Children’s Hospital of Michigan Berrien County

VIRGINIA R. HARMON NANCY STIMSON Deputy Director, retired Detective Sergeant Michigan Department of Community Health Lapeer County Sheriff’s Department

BRIAN HUNTER, MD FRANK VANDERVORT, JD Forensic Pathologist Clinical Assistant Professor of Law Sparrow Health Systems University of Michigan Law School

SGT. GREGORY A. JONES JACQUELINE WOOD Prevention Services Section Early Childhood Education Consultant Michigan State Police Michigan Department of Education

JOSEPH MARSHALL, MD STEVE YAGER Professor, Department of OB/GYN Director Michigan State University Office of Family Advocate College of Human Medicine Michigan Department of Human Services CHILD DEATH REVIEW PROGRAM STAFF 2004-2005

Michigan Public Health Institute

LORI CORTEVILLE, MS JANE PATERSON, MSW Senior Data Analyst Project Coordinator

* ROSEMARY FOURNIER, BSN * PATRICIA TACKITT, RN, MA Fetal and Infant Mortality Review Coordinator Urban Case Coordinator

HEIDI HILLIARD, BS J. ROBIN BELL Community Health Consultant Community Health Consultant

LYNDA MEADE, MPA MICHELLE VOLKER Senior Project Coordinator Office Manager

Michigan Department of Human Services

TED FORREST Manager Children’s Protective Services

*Funding for these positions supported in part by the Michigan Department of Community Health, the Wayne County Health Department and/or the Detroit Department of Health and Wellness Promotions. Table of Contents

INTRODUCTION 9

SECTION ONE: THE MICHIGAN CHILD DEATH REVIEW PROCESS 11 Conducting a Local Review Taking Action State Support State Advisory Team National Center for Child Death Review

SECTION TWO: A TEN YEAR RETROSPECTIVE LOOK AT CHILD DEATH REVIEW 21

SECTION THREE: A SUMMARY OF MICHIGAN CHILD MORTALITY DATA AND CHILD DEATH REVIEW TEAM FINDINGS 31 A Note on the Data Used in this Report Michigan Child Mortality: 1990-2004 Data from Death Certificates Michigan Child Death Review: Summary of 2004 Findings

SECTION FOUR: NATURAL DEATHS 49 Overview Natural Infant Deaths Excluding SIDS, Ages 0-1 Sudden Infant Death Syndrome Natural Child Deaths, Ages 1-18

SECTION FIVE: ACCIDENTS (UNINTENTIONAL INJURIES) 67 Overview Motor Vehicle Suffocation and Strangulation Fire Drowning Other Causes

SECTION SIX: HOMICIDES 99 Overview Firearm and Weapon Child Abuse and Neglect Other Causes

SECTION SEVEN: SUICIDES 117 Overview Child Death Review Team Findings from CDR Case Reports SECTION EIGHT: UNDETERMINED DEATHS 127 Overview Child Death Review Team Findings from CDR Case Reports

SECTION NINE: FETAL AND INFANT MORTALITY REVIEW 133 Introduction FIMR Background FIMR Process FIMR Role in Public Health Community Involvement Michigan FIMR Network Findings Conclusions Next Steps

SECTION TEN: APPENDICES 153 Appendix A: Progress on Implementing the Recommendations of the Michigan State Advisory Team Appendix B: Local Child Death Review Team Coordinators, 2004 Appendix C: Number of Cases Reviewed and Reported by County Appendix D: Total Deaths, Michigan Residents, Ages 0-18, by County of Residence and Age Group, 2004 Appendix E: Total Deaths, Michigan Residents, Ages 0-18, by County of Residence and Age Group, 1994–2004

Introduction

Children are not supposed to die. The death of a child is a profound loss not only to the child’s parents and family, but also to the larger community. In order to reduce the numbers of these tragic losses, we must first understand how and why our children are dying.

The Child Death Review (CDR) process was implemented in Michigan in 1995 to do just that. CDR brings together a multidisciplinary group of people at the county level to conduct in-depth reviews of child deaths. These reviews identify the adverse factors that led to the death. The reviews motivate communities to take action to eliminate these factors in order to prevent similar tragedies in the future. The review process also aims at improving a community’s response to child deaths, including investigations and provision of services to those affected by the death.

The Michigan Child Death State Advisory Team studies county review team findings. The state team was authorized by Public Act 167 of 1997 to identify and make recommendations on policy and statutory changes pertaining to child fatalities and to guide statewide prevention, education and training efforts (Appendix B lists recommendations from past annual reports on which some type of action has been taken). It is required to publish these annual reports on child fatalities, based on the compilation of death data reported by the state registrar, as well as data received from the county level CDR teams across the state. This sixth annual report covers deaths reviewed in 2004. In that year, county teams reviewed 802 child deaths.

This report is written in memory of all of the children in Michigan who have died. The Michigan Child Death State Advisory Team issues this report with the hope that it will encourage additional efforts, both in local communities and among our state leaders, to keep every child in Michigan safe and healthy.

Child Deaths IN MICHIGAN section one

The Michigan Child Death Review PROCESS Conducting a Local Review

Purpose

Child Death Review (CDR) brings together multi-disciplinary groups of people to conduct comprehensive reviews of child deaths in order to identify the factors that may have contributed to the deaths. The reviews are designed to motivate communities and inform state agencies to take action in order to prevent other similar tragedies in the future.

Membership

There is no legislative mandate to participate on a review team, yet nearly 1,200 local professionals on 74 teams that cover all 83 counties demonstrate a tremendous volunteer commitment to the review process. Statute does require that where teams are established, they include at least the county medical examiner, the prosecuting attorney, a law enforcement officer and representatives from local public health and the county Department of Human Services. Most teams have even broader representation. The average team size is 15 members.

Representation on Local Child Death Review Teams, 2004

Agency Number Law enforcement. 298 Local public health. 132 Medical examiners’ offices. 117 County Department of Human Services. 113 County prosecutors’ offices. 110 Hospitals. 100 Community Mental Health. 58 Emergency medical services. 55 Schools. 46 Health clinics and physicians. 41 Courts. 31 Other social services. 25 Community collaboratives. 13 Tribal health/social services. 7 Other community providers. 6 Fire departments. 6 Funeral homes. 5 Churches. 1 Hospice. 1 Other. 23 Total 1,188

12 Child Death Review Team Coordination

In every county, a team member volunteers to coordinate the team’s activities. Duties often include selecting cases for team review, communicating with team members, coordinating and facilitating the meetings and completing case reports.

Coordinator Representation on Local Child Death Review Teams, 2004

Agency Number Local public health. 26 County Department of Human Services. 21 Medical examiners’ offices. 15 County prosecutors’ offices. 11 Law enforcement. 8 Community collaboratives. 4 Hospitals. 4 Courts. 3 Health clinics and physicians. 2 Community Mental Health. 2 Emergency medical services. 1 Other social services. 1 Total 98*

There are no CDR state program funds supporting the local coordinator activities. *In many cases, the role is shared. Some coordinators have served their teams since they were established. Annual meetings are held for team coordinators at regional locations throughout the state to provide training and networking opportunities.

Cases Reviewed by Teams

The teams attempt to review all deaths of children under the age of 19, with the exception of the largest counties in Michigan (Genesee, Ingham, Kent, Macomb, Muskegon, Oakland and Wayne). Because of their high numbers of child deaths, these teams review only cases that fall under the jurisdiction of the medical examiner. These cases include sudden and unexpected deaths, accidents, homicides and suicides.

Sixty-one counties submitted case report forms on the child death reviews that they conducted in 2004. Of the 22 counties not submitting reports in that year, 27 percent had no child deaths and 55 percent had five or fewer child deaths.

Since 2000, local CDR Teams have reviewed 40-50 percent of all child deaths occurring in the State of Michigan. A much higher percentage of unintentional injury and violent deaths have been reviewed compared to natural deaths. Since prevention efforts most often focus on injury and violence, it is important to capture details on as many of these types of deaths as possible. The Healthy People 2010 Report from the U.S. Department of Health and Human Services has an objective of extending all states’ child death reviews to include 100 percent of child deaths from external causes. Michigan is well poised to meet this objective.

Sixth Annual Report The CDR Process 13

Percent of Non-Natural Child Deaths in Michigan Reviewed by Local CDR Teams

100% 88% 93% 86% 79% 84% 80% 56% 60% 37% 40% 25% 14% 20% 4%

% of Child Deaths Reviewed 0%

1995 1996 1997 19981999 2000 200120022003 2004

Year

Teams often find it challenging to review natural infant deaths, because the maternal and perinatal health histories are often not available and the cases tend to be more medically complex. Fourteen Michigan communities conduct more intensive reviews of infant deaths through the Michigan Fetal and Infant Mortality Review (FIMR) program described in Section Nine of this report.

Access to Information for an Effective Review

The Office of the State Registrar, Division for Vital Records and Health Statistics at the Michigan Department of Community Health (MDCH) has facilitated a process that enables teams to more readily obtain notification of their child deaths, especially those occurring in counties other than the county of residence. Counties that border other states still find it difficult to obtain information from those states in a timely manner.

The 1997 CDR enabling legislation provides teams the authority to meet and requires that the meetings are confidential, but it does not address access to records. Many teams continue to report difficulty in gaining access to the information necessary for a complete review, especially health and medical information on the child or the mother regarding a perinatal or other natural death. Much of the information missing in this report is due to team members’ inability to gather and/or share information. Nineteen county teams also reported that confidentiality concerns prevented them from exchanging information.

When the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted, some CDR team members became wary of sharing information at review meetings. Fortunately, CDR qualifies as public health surveillance, so there is explicit language in the law that allows covered entities to disclose data for use in these activities. MPHI wrote an extensive review of the CDR process with respect to HIPAA that team members can share with their agencies if privacy concerns become an issue.

At the Review

An effective review begins with all participants sharing relevant information from their agencies regarding the circumstances surrounding the child’s death. Team members ask for clarification as needed. The team discusses each death, considering the following questions:

14 Child Death Review • Is the investigation comprehensive and complete? • Are there other children at imminent or serious risk of harm? • What were the risk factors involved in the death? • Are there services that should be provided? • Are there agency policies and practices that should be changed? • What action should be taken locally to prevent another death? • Who should take the lead to implement our recommendations? • What recommendations should be made to the state?

Taking Action

One of the functions of CDR is to help communities identify local issues that need to be addressed in order to prevent other children from dying. For every case reviewed, the team asks this question: could this death have been prevented? The definition of preventable is provided to teams as: “...if an individual or the community could reasonably have done something that would have changed the circumstances that led to the child’s death.”

Certain types of death are seen by teams as being more preventable than others. In 2004, deaths seen as most preventable were those due to unintentional injuries. They were viewed as probably or definitely preventable 96-100 percent of the time, depending on the type of injury. Those seen as least preventable were natural deaths to infants (10 percent) and natural deaths to children over age one (16 percent).

During the review, teams also ask if there is action that should be taken to reduce the risk of other children dying in a similar manner. Because of this, many local health and safety initiatives have come out of the CDR process. At the end of each cause of death section of this report, examples of these initiatives are highlighted.

At the annual CDR team member training in 2005, three counties were given the first-ever Keeping Kids Alive prevention awards. These commendations were in recognition of outstanding community-based initiatives that were catalyzed by findings of a local CDR team. Those honored were Mackinac and Muskegon counties, both for water safety projects, and Mecosta County for their teen driver task force activities.

State Support

The Michigan Department of Human Services provides funding to the Michigan Public Health Institute (MPHI) to manage the CDR program. This funding supports the following:

Technical Assistance, Consultation and Training for Local Teams

Staff regularly attend local review team meetings, assist teams in identifying deaths, facilitate access to information and organize and facilitate effective meetings. Staff provide follow-up materials and support to the teams as well as resources on death investigation, services, prevention and procurement of information on specific causes of death. CDR staff manage the reporting system and assist counties in utilizing the online database.

The 9th annual CDR Team Member Training was held in May 2005. Over 100 team members attended. Thirty- six percent of current team members have attended this annual two-day training event. All of the trainers are Michigan experts in areas related to child fatalities.

Sixth Annual Report The CDR Process 15 The Child Death Review Reporting System

As local teams conduct reviews, they also complete a confidential case report on each death. This information is entered into a secured Web-based system. Findings are then aggregated and shared with the Michigan Child Death State Advisory Team and form the basis for this report. When appropriate, and in accordance with state statute, general findings from the local teams are also shared with the public.

Starting in January 2005, Michigan’s CDR program became part of a multi-state pilot project utilizing a new reporting tool. It was developed by the National Center for Child Death Review, along with assistance from many professionals from around the country. Analysis with this in-depth tool will provide an even clearer picture of how and why children are dying.

Linking Local Programs, State and Other Resources

CDR has worked closely with MDCH in implementing the Fetal and Infant Mortality Review (FIMR) program. This has helped to ensure that all communities with FIMR and CDR work together to encourage and enhance prevention efforts in communities with high infant mortality rates and/or racial disparities.

The CDR program has served as the source for the printing and distribution of the State of Michigan Protocols to Determine Cause and Manner of Sudden and Unexplained Child Deaths since their development in 1995 by a collaboration of entities. They are a required standard for death investigations in some counties. CDR is involved in the revision process for these protocols, which is headed by MDCH, and involves multiple professionals from across Michigan representing several disciplines.

The program has collaborated with a number of other state programs to encourage and support local and state prevention initiatives. Collaborations have occurred with the SAFE KIDS Campaign, the Children’s Trust Fund, Michigan Suicide Prevention Coalition, the State Safe Sleep Coalition and the Michigan State Police Office of Highway Safety Planning. CDR reports regularly to the Governor’s Task Force on Children’s Justice.

Support for Local Prevention Efforts

CDR staff work closely with communities in identifying prevention strategies, designing programs, and locat- ing resources to implement these strategies. Communities are encouraged to share information on successful prevention efforts with other CDR teams at regional coordinator meetings, at the annual training, and on the program Web site. Examples of prevention strategies that have been implemented can be found in every section of this report and at www.keepingkidsalive.org.

Comments from Local Teams Regarding the CDR Process

Branch – Without the CDR process I don’t see anyone taking action themselves to advocate for the safety of children.

Cass – We have discovered some areas of weakness in our county that the team has been able to address.

Clare – It brings to light specific areas in a local community that are more likely to get the attention of local people versus ‘global’ initiatives or prevention activities that are easily dismissed due to the ‘that doesn’t happen in my area’ mentality.

Dickinson–Iron – The CDR process is effective in bringing together key system representatives that can initiate activities in prevention and victim services.

Eaton – Because of the diversity of our team composition, we have the potential to explore all of the variables that were involved in a child’s death. This comprehensive examination of facts allows the opportunity to look at prevention measures.

Gladwin – It brings the agencies together, forming a better bond and information sharing. It affords the opportunity to recognize trends and respond to them.

16 Child Death Review Huron – Although our county population is small and therefore our percentage of deaths is small, taken with the other counties and other states, these nationwide statistics can point to areas of improvement that all of us can benefit from.

Manistee – Team approach gets all involved at the same table. It seems more productive than working separately.

State Advisory Team

The Michigan Child Death State Advisory Team is a multi-disciplinary committee that was formed by Public Act 167 of 1997 to identify and make recommendations on policy and statutory changes pertaining to child fatalities and to guide statewide prevention, education and training efforts. It is required to publish annual reports on child fatalities, based on the compilation of death data reported by the state registrar, as well as data received from the county level child death review teams across the state.

The team is comprised of professionals around the state involved in the health, safety and protection of children. This team met four times during 2004. They utilized portions of these meetings to review past recommendations of the committee, in order to determine if any action had been taken on those issues. Appendix C contains a listing of these recommendation updates. Examples include:

• The prosecuting attorney, law enforcement agencies, medical examiner and the Department of Human Ser- vices in every county: Upon the promulgation of rules by the Michigan Department of Community Health per Public Act 179 of 2004, jointly adopt and implement the child death scene investigation protocols. Update: Public Act 179 of 2004 states, in part, “The department of community health shall promulgate rules and regulations under this act to promote consistency and accuracy among county medical examiners and deputy county medical examiners in determining the cause of death under this section. The department may adopt just one, by reference in its rules, all or any part of the ‘State of Michigan Protocols to Deter- mine Cause and Manner of Sudden and Unexplained Child Deaths’ published by the Michigan child death review program.” MDCH convened a multi-disciplinary group to advise them on this law. Plans are in place to revise the current protocols based in part on the new Centers for Disease Control and Prevention form. Multiple agencies have input into this. The next step will be developing a method by which all local jurisdictions will be able to obtain training on the soon to be revised and required protocols.

• The Michigan Legislature: Amend the current graduated licensing law to place limits on the number of teen passengers allowed in vehicles driven by teens with Level Two Intermediate Licenses. This limitation should apply at all times of day, and without an exception allowed for written parental permission. Update: House Bill 4756 was passed by the House on Dec 7, 2005, that would allow one unrelated passengers under the age of 18 to Level 2 licensees in the first 90 days of that licensure, to 2 passengers under age 18 in the second 90 days of that licensure, and to 3 passengers under the age of 18 for the third 90 days. If the licensee were to receive a moving violation or cause an accident during this time, they would revert back to 1 passenger, and have to go through the increments again. Also, this provision does not apply “...if the transportation is to or from a church, mosque, synagogue or other house of religious worship or to or from an activity or event sponsored by a church, mosque, synagogue or other house of religious worship.” The Senate did not take up the bill.

• The Michigan Department of Human Services Office of Children and Adult Licensing: Promulgate child care licensing rules for barriers to pools, hot tubs or open bodies of water at regulated child care facilities. Update: The new rules for day care homes state: “R 400.1814b. Water hazards and water activities. Rule 14b. (1) Each licensee/registrant must ensure that barriers exist to prevent children from gaining access to any swimming pool, drainage ditch, well, pond or other body of open water located on or adjacent to the property where the day care home is located. Such barriers must be of a minimum of 4 feet in height and appropriately secured to prevent children from gaining access to such areas. (2) The use of spa pools, hot tubs and fill-and-drain wading pools is prohibited. (3) Hot tubs and spas, whether indoors or outdoors, must be inaccessible to children and have a locked hard cover.”

Sixth Annual Report The CDR Process 17 • The Michigan Department of Community Health: Take the lead in collaborating with the Michigan Depart- ment of Education and Michigan Department of Human Services to support the development and implementation of a state suicide prevention plan. Update: The Michigan Suicide Prevention Coalition was convened, consisting of representatives of the CDR program, MDCH, the Department of Education and various other state and local organizations. The Michi- gan Surgeon General debuted the State Suicide Prevention Plan developed by this group on 9/12/05. The plan is based on the National Strategy for Suicide Prevention, adapted to Michigan’s needs.

The National Center for Child Death Review

The National Center for Child Death Review, funded by the U.S. Maternal and Child Health Bureau, Health Resources and Services Administraton, is also housed at MPHI. As a result, MPHI, including Michigan CDR program staff, are providing national leadership in promoting CDR to states and national organizations. The national center has provided technical assistance and training to all 50 states (32 on–site), developed a national CDR reporting system that was piloted by 18 states in 2005, developed national standards for the CDR process and is working with federal agencies and other national organizations to link CDR to national child health and safety initiatives.

Recommendations for Policymakers

1. Michigan Legislature: Ensure continued and enhanced resources to support the comprehensive review of Child Death Review (CDR) findings and trends, enhance local prevention efforts and training for CDR team members.

2. The Michigan Department of Community Health: Consider establishment of a state-based regional medical examiner system.

3. Michigan Department of Human Services: Create an ongoing system/mechanism to educate legislative policy staff on CDR process and findings, track legislative changes, and provide information at operative times.

18 Child Death Review

Child Deaths IN MICHIGAN section two

A T e n – Y e a r Retrospective Look at C hild Death Review

History

In January of 1995, the Governor’s Task Force on Children’s Justice spearheaded the planning of Child Death Review (CDR), in coordination with the Michigan Department of Social Services [now the Michigan Department of Human Services (MDHS)] and Michigan Department of Public Health [now the Department of Community Health (MDCH)]. Following a six-month study of initiatives in other states, process protocols and promotional materials were developed. With the help of a Children’s Justice Act two-year grant of $225,000 to the Michigan Public Health Institute (MPHI), the program was piloted in 17 counties.

The pilot counties were organized into multidisciplinary teams by December of 1995, and began conducting regular reviews of their child deaths in January of 1996. A broad representation of both population size and geographic area were involved. This helped bring to light process issues for rural vs urban areas, as well as identifying trends in the causes and circumstances of child deaths in different areas of the state.

CDR Pilot Counties by Population Estimate, 1995

CDR Pilot County Population Estimate, 1995 Wayne 2,125,818 Oakland 1,126,177 Kent 519,419 Genesee 431,755 Washtenaw 287,226 Kalamazoo 225,483 Berrien 161,329 St Clair 149,775 Calhoun 138,086 Eaton 95,354 Clinton 59,350 Tuscola 56,079 Sanilac 40,766 Chippewa 35,543 Mason 26,494 Mackinac 10,771 Luce 5,633

The results of the pilot led to revisions of the Michigan Child Protection Act, Section 7b (PA 220 of 1995 and PA 167 of 1997). These changes enabled CDR, encouraged expansion to all counties, mandated a Child Death State Advisory Committee and required these annual reports on child deaths. In 1999, state general funds were allocated through MDHS, who contracted with MPHI to manage the program.

In 1997, most other states’ CDR programs were only reviewing child abuse deaths. Michigan opted for a broader process that would encourage reviews of at least all preventable deaths to children under age 19, using a public health model. Michigan became a leader in developing this approach, that is now the national standard for CDR programs.

22 Child Death Review Reporting

Teams complete a case report on each death reviewed. These reports are confidential, per Public Act 167 of 1997. Three different versions of this Michigan-specific report have existed throughout the years. With each revision, more information was included, based on the latest research and the findings of the local teams. In 1999, Michigan CDR pioneered a Web-based reporting system, which was adopted by three other states. Starting in 2005, Michigan’s CDR became part of a multi-state pilot project utilizing a new reporting tool, developed by the National Center for Child Death Review, with assistance from many professionals around the country. Analysis with this in-depth tool will provide an even clearer picture of how and why children are dying.

Training

Since participating in CDR is a voluntary effort carried out by professionals at the county level, DHS realized that providing training to these individuals would be crucial. The CDR budget provides for an annual training for team members who have never been trained, or for whom it has been three years since they have last been trained. Audi- ences for these trainings have been as varied as the representation on the local teams.

CDR Team Member Trainings by Year and Number of Participants

Year Number of Participants 1995 183 1997 129 1998 171 1999 128 2000 84 2001 107 2002 161 2003 68 2004 129 2005 100 Total 1,260

These two-day trainings give participants the information they need to conduct comprehensive reviews of children’s deaths in their communities.

An Example of CDR’s Impact

One of the areas where CDR findings have had a major impact on the understanding of child death is in sudden unexpected infant deaths (SUIDs). When the program began, these types of deaths were most frequently attributed to Sudden Infant Death Syndrome (SIDS), as long as there were no signs of trauma. Since SIDS is categorized as natural in manner, information about the scene in which the death occurred was not often seen as crucial. Therefore, law enforcement agencies were not always conducting thorough investigations on these types of cases. A few questions might have been asked of the parents at the hospital, but efforts to closely inspect the scene where the infant was found were sporadic and in no way standardized among jurisdictions.

In 1991, an expert panel convened by the National Institute of Child Health and Human Development defined SIDS as “the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, review of the clinical history and examination of the death scene.” Because of this, when the Michigan CDR case report form was developed, it included specific questions about the scene, including how the infant was put down to sleep, how the infant was found, whether the infant was sleeping with others, etc. In the cases where the answers to these questions had not

Sixth Annual Report A Ten Year Retrospective on CDR 23 been obtained by investigators, discussion of the circumstances of the death at the review was difficult. Team members began to feel uncomfortable with the amount of information that was being gathered on these deaths.

With growing knowledge and the expansion of the CDR program across the state, medical examiners and law enforcement officers began to recognize the importance of conducting careful scene investigations in cases of SUID. One of the stated objectives of the CDR program was “The design and implementation of cooperative, standardized protocols for the investigation of certain categories of child deaths.” To this end, the CDR program office, in conjunction with a host of state-level medical and legal organizations, developed the State of Michigan Protocols to Determine Cause and Manner of Sudden and Unexplained Child Deaths. They included separate forms for documenting child autopsy, review of child medical history and complete death scene investigation. In 1997, these protocols were widely distributed and used by medical examiners and law enforcement agencies across the state.

Although completion of these protocols was not required by law, many jurisdictions welcomed them as a tool they could use to improve the quality and consistency of their investigation of infant deaths. Some county medical examiner offices made it known that the usage of these protocols was expected on every case. These improved investigations began to shed more light on the details regarding the exact positioning of the baby when found, as well as proximity of objects unsafe for infant sleeping environments (soft bedding, pillows, stuffed toys, other people, etc). Photos were now being taken of the scene, and bedding was being collected. In certain areas, especially southeast Michigan, the scene was often being recreated by investigators, with the assistance of the caretakers who found the infants, using dolls to show just how the baby was positioned at the time. As this information was shared with more and more pathologists and medical examiners, a diagnos- tic shift began to occur. Many deaths that would likely have been attributed to SIDS previously, began to be known as SUIDs and more and more were attributed to asphyxiation and other causes.

Rate of infant deaths from death certificates, 1995–2004

1.2

1.0 ths

0.8

0.6

0.4

0.2

0 Rate per 1,000 Live Bir 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year of Review Number 1995 3 SIDS Suffocation 1996 130 1997 201 1998 492 1999 601 Research findings have identified risk factors for SUIDs. Guidance from the Consumer Product Safety Commis- sion and the American Academy of Pediatrics recommend that to reduce the risk of SUIDs, infants should sleep 2000 806 alone, in a crib and on his or her back. Throughout the various versions of the CDR case report form over the 2001 885 years, these variables have been collected for cases in which the death was attributed to SIDS. 2002 899 2003 830 2004 802 Total 5,649

24 Child Death Review SIDS Cases Reviewed by Sleep Situation, 1995–2004

Year(s) of Review Number of SIDS Cases Number Reported to Reviewed have Been Alone, in a Crib, and on the Back 1995–1998 104 5 1999 63 8 2000 74 1 2001 77 2 2002–2003 105 8 2004 23 0 Total 446 24

As teams began to recognize the connection between unsafe sleep environments and SUIDs, many began grassroots efforts to educate professionals and the general public about these issues. Local public health departments and DHS offices are the most frequent leaders in these efforts. They distribute safe sleep information to their clients in a variety of ways. But other entities have also contributed. Community collaboratives have held “community baby showers,” where information is given out along with infant health and safety items, in fun, interactive events. Multiple county medical examiners have written articles in local newspapers about the dangers of sleeping with young infants, or featured the topic in their grand rounds. In one county, a law enforcement officer who sits on the CDR team addresses childbirth preparation classes about safe sleep. Schools have added safe sleep information to their domestic readiness and babysitter preparation classes. These efforts and others (such as the work of Tomorrow’s Child, formerly Michigan SIDS Alliance) are ongoing across the state, as these issues continue to gain recognition in communities.

Reviews

When the CDR program was implemented, it was recognized that it needed to be tailored to local needs, within the parameters of the team protocols that were developed in 1995-1996. Decisions that were left up to the teams included: Who would coordinate the team, additional membership beyond the core five members, which deaths would be reviewed and frequency and scheduling of review meetings. Because of this latitude, counties were able to develop their own ways of conducting the review process, that best fit their situation. More populous counties meet more often and may have to pick and choose which deaths to review. Less populous counties meet less frequently and are usually able to review all their child deaths. Mid-sized counties fall somewhere in between, and the decisions they reach on these questions may change over time. Therefore, the number of deaths reviewed in each year has varied.

Number of Child Death Reviews by Year

Year of Review Number 1995 3 1996 130 1997 201 1998 492 1999 601 2000 806 2001 885 2002 899 2003 830 2004 802 Total 5,649

Sixth Annual Report A Ten Year Retrospective on CDR 25 One of the pivotal questions that has been asked on all versions of the CDR report form is whether or not the team believed the death was preventable. As the program has evolved, teams appear to be seeing more and more of the deaths they are reviewing in this light.

Percent of Preventable Cases Reviewed by Year

Percent of Cases Deemed Year(s) of Review Preventable by Teams 1995–1998 44% 1999 47% 2000 48% 2001 55% 2002–2003 55% 2004 60 %

Important factors that impact how teams perceive preventability include cause and manner of death and age of the child. Teams have generally seen accidental and homicidal manners as being more preventable than natural deaths. Teams also view deaths to older children as being more preventable, likely because a larger number of these deaths are from accidents or homicides.

Positive Outcomes

From the beginning, Michigan’s CDR has focused on the prevention of child deaths, based on information learned at the reviews. Whether taken on as a team, or by outside entities, many efforts to prevent child deaths have been implemented as a result of team findings at the county level.

Number of Prevention Actions Proposed and Implemented by Teams

10–year data Type of Action (1995–2004)* Proposed Initiated Advocacy. 97 42 Legislation, law or ordinance. 103 38 Community safety project. 274 120 Product safety action. 51 27 Education in schools. 344 188 Education through the media. 575 379 Public forums. 97 62 New services. 48 22 Change in agency practice. 186 66 Other program or activity. 270 134 Total 2,045 1,078

* CDR teams began reporting advocacy actions in 1999.

26 Child Death Review The CDR program has also seen other types of positive outcomes from the review process. At the local level, these have included: Increased inter-agency communication, improved and more coordinated responses to child deaths, significant improvements in the way death scene investigations are conducted, better understanding of how and why children die, identification of risk factors in communities, increased effectiveness of community collaboratives and improvements in the delivery of services to families, in addition to the identification of concrete actions to prevent other children from dying.

Dedicated Child Death State Advisory Team members work to positively impact the lives of children across the state. Producing these annual reports, with recommendations made to state policymakers regarding the health, safety and protection of Michigan’s children, is a task that the state team takes very seriously. The wide range of expertise represented on this body makes it uniquely qualified to address these tough issues from a very broad perspective. They volunteer considerable time and energy to synthesize what is known from the latest research, what state mortality statistics are showing, and what the local teams are reporting, in order to be sure we are not missing opportunities to prevent child deaths.

Looking to the Future

As we move into the next decade of CDR, teams across the state will continue to conduct excellent, comprehensive reviews. The future focus of training, consultation and reporting will be to enhance local and state efforts to translate review findings into policies, programs and services to prevent child deaths and to keep Michigan’s children healthy, safe and protected.

Sixth Annual Report A Ten Year Retrospective on CDR 27

Child Deaths IN MICHIGAN section three

A S u m m a r y o f M i c h i g a n C h i l d Mortality Data and C h i l d D e a t h Review Team FINDINGS A Note on the Data Used in this Report

There are two types of data presented in this report: Michigan Mortality Data from Death Certificates and Child Death Review Team Findings. The purpose for presenting child death data in this manner is to provide an overview of the incidence of all child deaths using the Michigan Mortality Data from Death Certificates and then focusing on more specific issues surrounding types of death using the Child Death Review Team Findings data.

Michigan Mortality Data from Death Certificates are the official count of child deaths in Michigan from death certificates completed at the county level and submitted to the Division for Vital Records and Health Statistics, Office of the State Registrar at the Michigan Department of Community Health (MDCH). Included in this data are children ages 0 to 18, who died in the State of Michigan in a particular year. Vital Records continues to update the Michigan Resident Death File with changes and late additions after the year is completed; therefore, the numbers presented in this report may differ slightly from those published on the MDCH Web site or past annual CDR reports. Mortality rates were calculated using age- and race-specific population estimates from the U.S. Census Bureau. Child mortality rates were computed as the number of child deaths per 100,000 population in a specified age group. Infant mortality rates were computed as the number of infant deaths ages 0 through 12 months per 1,000 live births.

Child Death Review Team Findings are derived from CDR Case Reports. These reports were completed by local Child Death Review teams during the review of a child’s death, and compiled at the CDR state office. Deaths are not always reviewed in the same year they occurred, especially when the death occurs late in the year. Therefore, Child Death Review Team Findings from 2004 will include deaths from previous years, and some 2004 deaths will be included in the 2005 review findings.

Number and Percent of Child Deaths Reviewed in 2004 by Year of Death

Year of Death Number Percent 2000 2 0.2 2001 4 0.5 2002 17 2.1 2003 185 23.1 2004 594 74.1 Total 802 100.0

Since the two types of data track different cohorts, the reader is cautioned not to make direct one-to-one com- parisons between the Michigan Mortality Data from Death Certificates numbers and the Child Death Review Team Findings numbers.

32 Child Death Review Michigan Child Mortality: Summary of 1990–2004 Data from Death Certificates

Michigan Child Deaths, Ages 0-18, 1990-2004

3000 2693 2630 2484 2352 2500 2209 2062 1985 1973 1952 1863 1895 1831 1721 2000 1804 1823

1500

1000

Number of Deaths 500

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

The number of deaths in 2004 represents a 6 percent decrease from 2003 and 36 percent since 1990.

Michigan Child Death Rates, Ages 0-18, 1990-2004

120 103.5 100.4 100 94.4 88.6 82.9 80 76.6 73.3 72.5 71.5 69.2 68.1 66.4 67.5 68.1 64.2 60

40 20

0 Rate per 100,000 Population 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Sixth Annual Report Michigan Child Mortality Data and CDR Findings 33 Michigan Child Death Rates by Race, Ages 0-18, 2004

140 120 117.4 100 80 64.2 60 49.6 49.2 40 36.2 20 0

Rate per 100,000 Population White Black American IndianAsian / Pacific Total Islander

Race

Mortality rates for all race groups have decreased since last year, with the most significant decline (roughly 50 percent) occurring for American Indian children. Black children continue to die at a disproportionate rate compared to other children. In 2004, black children had a death rate 2.4 times that of white children, as compared to 2.1 times in 2003. However, the mortality for black children has declined 48 percent since 1990, which is more rapid than the decline in mortality for white children (37 percent).

In 2004, roughly four percent of Michigan’s child mortality was to children with Hispanic/Latino ethnicity, which is a death rate of 52.4 per 100,000 population, a significant decline compared to 88.9 in 2003. There has been a 27 percent decrease in mortality for Hispanic/Latino children since 1990.

Males continue to die at a higher rate than females; black males in particular have the highest rate of death. In 2004, males had a death rate 1.3 times that of females. Mortality for males has declined 42 percent since 1990 and declined 37 percent for females.

Michigan Child Death Rates by Sex and Race, Ages 0-18, 2004

160 140 120 100 80 60 40 20 0 Rate per 100,000 Population Male Female

White Black Other Total

34 Child Death Review Number and Percent of Michigan Child Deaths by Manner and Cause, 2004

Manner and Cause of Death Number Percent Natural: 1,213 70.5 Perinatal conditions. 567 32.9 Congenital anomalies. 230 13.4 Nervous system diseases. 77 4.5 Neoplasms. 75 4.3 Respiratory system diseases. 56 3.2 SIDS. 51 3.0 Circulatory system diseases. 39 2.3 All other natural causes. 118 6.9 Accident (Unintentional): 350 20.3 Motor vehicle. 208 12.1 Suffocation or strangulation. 66 3.8 Drowning. 20 1.2 Fire and burn. 19 1.1 Poisoning. 16 0.9 Firearm and weapon. 6 0.3 All other accidents. 15 0.9 Homicide: 80 4.6 Firearm and weapon. 51 2.9 Child abuse and neglect. 15 0.9 Suffocation or strangulation. 6 0.3 All other homicides. 8 0.5 Suicide: 58 3.4 Firearm and weapon. 26 1.5 Suffocation or strangulation. 26 1.5 Poisoning. 3 0.2 All other suicides. 3 0.2 Undetermined. 20 1.2 Total 1,721 100.0

Sixth Annual Report Michigan Child Mortality Data and CDR Findings 35 Michigan Child Deaths by Age Group, Ages 0-18, 2004

15–18 Years (21%) Under One Year 10–14 Years (57%) (8%)

5–9 Years (6%)

1–4 Years (8%)

Infant Deaths (Ages <1)

Michigan Infant Death Rates, Ages 0-1, 1990-2004

12 10.7

ths 10.4 10.1 9.5 10 8.6 8.3 8.0 8.1 8.2 8.0 8.2 8.0 8.1 8.5 7.6 8 6 4 2

Rate per 1,000 Live Bir 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

In 2004, Michigan saw a decline in infant mortality with 984 infant deaths, which was a rate of 7.6. Infant mortality rates are calculated by the number of infants that died in a year per 1,000 live births; rather than per 100,000 population for other age groups. This is a decrease of 11 percent from 2003 and 29 percent since 1990.

The Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) has published its Healthy People 2010 goals for major health indicators, which includes infant mortality. The 2010 target for infant mortality is a rate of 4.5 per 1,000 live births. When broken down by race-specific goals, Michigan has already met its target rate for white infants, but is still above the target rate for black infants.

36 Child Death Review While 2004 saw the lowest infant mortality in Michigan over the past 15 years, the gap for racial disparities is the highest, with black infants dying at a rate 3.3 times that of white infants. Mortality for black infants has declined 20 percent since 1990 and declined 34 percent for white infants.

Michigan Infant Deaths by Manner, Ages 0-1, 2004

Undetermined (0.2%) Natural (92%) Homicide (0.8%) Accident (7%)

Percent Causes of Michigan Infant Deaths, Ages 0-1, 2004

Perinatal Conditions (ex LBW) 36.2

Prematurity/LBW 21.1 Congenital Anomalies 18.8 Suffocation/Strangulation 6.2

SIDS 5.2 Respiratory Disease (ex Asthma) 2.0 Digestive Disease 1.7

Neurologic Disease 1.5 Circulatory Disease 1.2 All Other Natural Causes 1.2

Metabolic Disease 0.9 Renal/Urinary Disease 0.8

Infectious Disease 0.7 Motor Vehicle 0.5

All Other External Causes 0.5

Child Abuse or Neglect 0.4 Cancer/Neoplasms 0.4 Falls 0.2

Poisoning 0.2 Blood Disorder 0.2

Fire and Burn 0.1 Firearm and Weapon 0.1

Endocrine Disease (ex Diabetes) 0.1

Sixth Annual Report Michigan Child Mortality Data and CDR Findings 37 Child Deaths (Ages 1-18)

In 2004, there was a 15 percent increase in the death rate for teens between the ages of 15 and 18. This included a 23 percent increase in the suicide rate, a 21 percent increase in the rate of natural deaths, a 12 percent increase in the homicide rate and an 8 percent increase in the rate of accidental deaths. All other age groups saw a decline in the 2004 death rates.

Michigan Child Death Rates, Ages 1-18, 1990-2004

100

0 1990 1991 1992 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 1993 Rate per 100,000 Population

Year

1-4 5-9 10-14 15-18

Michigan Child Death Rate and Percent Decline, Ages 1–18

Rate in Percent Decline Healthy People Age Group 2004 Since 1990 2010 Target Rate 1-4 Years 26.1 41.0 18.6 5-9 Years 15.4 31.6 12.3 10-14 Years 18.3 27.9 16.8 15-18 Years 60.5 32.8 39.8*

* The Healthy People 2010 target rate is based on the age group 15-19 years.

Significant progress has been made in lowering the death rates for children in the past 15 years. Michigan seems to be on track for meeting Healthy People 2010 target rates for children ages 1-14.

There are some interesting trends in specific causes of death in 2004. Children ages 1-14 had an increase in the number of deaths due to congenital anomalies, which supplanted motor vehicle crashes to become the primary cause of death for children ages 1-4. There was an increase in the number of deaths due to firearms and weapons for children ages 1-9. Deaths attributed to child abuse or neglect showed an increase for children ages 1-4.

38 Child Death Review Michigan Child Deaths by Manner, Ages 1-4, 2004

Undetermined (2%) Natural (59%) Homicide (13%)

Accident (26%)

Percent Causes of Michigan Child Deaths, Ages 1-4, 2004

Congenital Anomalies 11.0

Motor Vehicle 10.3 Respiratory Disease (ex Asthma) 10.3

Drowning 8.1

Cancer/Neoplasms 8.1

Neurologic Disease 8.1

Child Abuse or Neglect 7.4

Fire and Burn 4.4

Suffocation/Strangulation 3.7

Firearm and Weapon 3.7

Metabolic Disease 3.7

Circulatory Disease 3.7 All Other Natural Causes 3.7

All Other External Causes 3.7

Infectious Disease 2.9

Digestive Disease 2.9 Blood Disorder 1.5

Perinatal Conditions (ex LBW) 1.5

Diabetes 0.7 Prematurity (LBW) 0.7

Sixth Annual Report Michigan Child Mortality Data and CDR Findings 39 Michigan Child Deaths by Manner, Ages 5-9, 2004

Undetermined (3%)

Natural Homicide (57%) (7%)

Accident (33%)

Percent Causes of Michigan Child Deaths, Ages 5-9, 2004

Motor Vehicle 23.8

Cancer/Neoplasms 20.0

Neurologic Disease 13.3

Congenital Anomalies 10.5

Firearm and Weapon 6.7

Fire and Burn 4.8

All Other External Causes 3.8

Drowning 2.9

All Other Natural Causes 2.9

Metabolic Disease 1.9

Asthma 1.9

Respiratory Disease (ex Asthma) 1.9

Digestive Disease 1.9

Infectious Disease 0.9

Circulatory Disease 0.9

Child Abuse or Neglect 0.9

Perinatal Conditions (ex LBW) 0.9

40 Child Death Review Michigan Child Deaths by Manner, Ages 10–14, 2004

Undetermined (1%)

Suicide Natural (8%) (49%)

Homicide (6%)

Accident (36%)

Percent Causes of Michigan Child Deaths, Ages 10–14, 2004

Motor Vehicle 21.6

Neurological Disease 10.8 Cancer/Neoplasms 8.6

Congenital Anomalities 7.9

Firearm and Weapon 7.2

Circulatory Disease 7.2

All Other External Causes 7.2

Suffocation/Strangulation 6.5

Fire and Burn 4.3 Asthma 4.3

Respiratory Disease (ex Asthma) 2.9

All Other Natural Causes 2.9 Drowning 2.2

Metabolic Disease 2.2

Poisoning 1.4

Falls 0.7

Infectious Disease 0.7

Blood Disorder 0.7

Perinatal Conditions (ex LBW) 0.7

Sixth Annual Report Michigan Child Mortality Data and CDR Findings 41 Michigan Child Deaths by Manner, Ages 15-18, 2004

Natural (28%) Undetermined (3%) Accident (44%) Suicide (13%)

Homicide (11%)

Percent Causes of Michigan Child Deaths, Ages 15-18, 2004

Motor Vehicle 37.4

Firearm and Weapon 16.7

Cancer/Neoplasms 7.6

Suffocation/Strangulation 6.7

Neurologic Disease 6.2

All Other External Causes 4.5

Poisoning 4.2

Circulatory Disease 3.1

Congenital Anomalies 2.5

All Other Natural Caiuses 2.0

Asthma 1.7

Drowning 1.1

Diabetes 1.1

Metabolic Disease 0.8

Digestive Disease 0.8

Fire and Burn 0.6

Infectious Disease 0.6

Respiratory Disease (ex Asthma) 0.6

Blood Disorder 0.6

Renal/Urinary Disease 0.6

Falls 0.3

Endocrine Disease (ex Diabetes) 0.3

42 Child Death Review Michigan Child Death Review: Summary of 2004 Findings

Since the inception of the Michigan CDR program, teams have reviewed more than 5,600 cases. This report covers 802 cases reviewed in 2004.

Number of Child Deaths Reviews by Year

Year of Review Number 1995 3 1996 130 1997 201 1998 492 1999 601 2000 806 2001 885 2002 899 2003 830 2004 802 Total 5,649

Number and Percent of Child Deaths Reviewed by Manner and Cause, 2004

Manner and Cause of Death Number Percent Natural: 322 40.1 Infant, excluding SIDS. 179 22.3 SIDS. 23 2.9 > 1 Year, excluding SIDS. 120 14.9 Accident (unintentional): 315 39.3 Motor vehicle. 165 20.7 Suffocation or strangulation. 83 10.3 Fire and burn. 28 3.5 Drowning. 21 2.6 All other accidents. 18 2.2 Homicide: 73 9.1 Firearm and weapon. 47 5.9 Child abuse and neglect. 20 2.5 All other homicides. 6 0.7 Suicide: 45 5.6 Firearm and weapon. 18 2.2 Suffocation or strangulation. 25 3.1 All other suicides. 2 0.3 Undetermined. 47 5.9 Total 802 100.0

Sixth Annual Report Michigan Child Mortality Data and CDR Findings 43 Number and Percent of Child Deaths Reviewed by Sex and Age, 2004

Sex and Age Group Number Percent Male 497 62.0 Under One Year 196 24.4 1 to 4 Years 42 5.2 5 to 9 Years 36 4.5 10 to 14 Years 40 5.0 15 to 18 Years 176 22.0 19 to 21 Years 7 0.9 Female 305 38.0 Under One Year 128 16.0 1 to 4 Years 41 5.1 5 to 9 Years 23 2.8 10 to 14 Years 48 6.0 15 to 18 Years 64 8.0 19 to 21 Years 1 0.1 Total 802 100.0

Number and Percent of Child Deaths Reviewed by Race, 2004

Race Number Percent White 511 63.7 Black 249 31.0 American Indian 6 0.8 Asian / Pacific Islander 5 0.6 Multi-racial 30 3.7 Unknown 1 0.1 Total 802 100.0

Number and Percent of Child Deaths Reviewed by Socio-Economic Status*, 2004

SES Number Percent High 10 1.2 Middle 239 29.8 Low 394 49.1 Unknown 159 19.8 Total 802 100.0

* A subjective item, determined by teams

44 Child Death Review Number and Percent of Child Deaths Reviewed by Factors that Contributed to Death*, 2004

Factors Number Percent Lack of supervision. 78 9.7 Alcohol. 51 6.4 Neglect (physical, medical, emotional). 47 5.9 Drugs. 44 5.5 Child abuse. 20 2.5 Domestic violence. 12 1.5

*A case can have more than one contributing factor, therefore these numbers do not sum to a total.

Prior Child Protective Services (CPS) involvement with the family is a variable that is discussed in review meetings. Teams found that in 26 percent of the cases reviewed, the family was involved in CPS either at the time of death or any time previous to the death. In 42 percent of these cases, the involvement was with the child. In 52 percent of these cases, there was prior contact with another family member. The point of contact was unknown in the remaining CPS cases.

Number and Percent of Preventable Deaths Reviewed by Manner and Cause, 2004

Number Number Percent Manner and Cause of Death Preventable Reviewed Preventable Natural: 43 322 13.4 Infant, excluding SIDS. 17 179 9.5 SIDS. 7 23 30.4 > 1 Year, excluding SIDS. 19 120 15.8 Accident (unintentional): 306 315 97.1 Motor vehicle. 160 165 97.0 Suffocation or strangulation. 81 83 97.6 Fire and burn. 28 28 100.0 Drowning. 21 21 100.0 All other accidents. 16 18 88.9 Homicide: 65 73 89.0 Firearm and weapon. 39 47 83.0 Child abuse and neglect. 20 20 100.0 All other homicides. 6 6 100.0 Suicide: 25 45 55.6 Firearm and weapon. 12 18 66.7 Suffocation or strangulation. 13 25 52.0 All other suicides. 0 2 0.0 Undetermined. 40 47 85.1 Total 479 802 59.7

Sixth Annual Report Michigan Child Mortality Data and CDR Findings 45 Number and Percent of Preventable Deaths Reviewed by Age of Child, 2004

Number Number Percent Age Group Preventable Reviewed Preventable Under One Year 147 324 45.4 1 to 4 Years 56 83 67.5 5 to 9 Years 36 59 61.0 10 to 14 Years 56 88 63.6 15 to 18 Years 178 240 74.2 19 to 21 Years 6 8 75.0 Total 479 802 59.7

Michigan’s CDR program operates on a model that is focused on obtaining information that will drive prevention efforts. A death is deemed preventable if an individual or group could reasonably have done something that would have changed the circumstances leading to the death. Local teams found that nearly 60 percent of all the deaths reviewed in 2004 were preventable. Teams more readily identify the deaths of older children and teens as being preventable.

Number of Prevention Actions Proposed and Initiated by Teams, 2004

Action Proposed Initiated Advocacy. 14 6 Legislation, law or ordinance. 15 3 Community safety project. 51 21 Product safety action. 9 4 Education in schools. 40 17 Education through the media. 94 66 Public forums. 11 6 New services. 4 1 Change in agency practice. 16 5 Other program or activity. 22 12 Total 276 141

A total of 276 prevention actions were proposed as a result of team reviews in 2004. At the time of this report, 141 of them were known to have been initiated (51 percent). These numbers should be interpreted as a minimum count. Teams can initiate prevention activities after the review meeting, which are not captured here because cases are not always updated. Also, some teams do not fill out this information on a case when they are aware that a prevention activity is already in place.

46 Child Death Review

Child Deaths IN MICHIGAN section four

Natural DEATHS Overview of Natural Child Deaths, Ages 0-18

Michigan Mortality Data from Death Certificates

Michigan Natural Child Death Rates, Ages 0-18, 1990-2004

76.1 72.2 80 68.8 63.2 56.6 52.4 50.4 50.5 60 49.6 48.3 49.1 48.4 47.8 49.2 45.3

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 45.3 in 2004 represents 1,213 deaths. This is a 40% decrease since 1990.

Number and Percent of Michigan Natural Child Deaths by Sex and Age, 2004

Sex Total Age Group Male Female Unknown Number Percent Number Percent Number Percent Number Percent Under One Year 510 42.0 392 32.4 2 0.2 904 74.6 1 to 4 Years 36 3.0 44 3.6 0 0.0 80 6.6 5 to 9 Years 39 3.2 21 1.7 0 0.0 60 4.9 10 to 14 Years 33 2.7 35 2.9 0 0.0 68 5.6 15 to 18 Years 63 5.2 38 3.1 0 0.0 101 8.3 Total 681 56.1 530 43.7 2 0.2 1,213 100.0

50 Child Death Review Michigan Natural Child Death Rates by Race, Ages 0-18, 2004

100 87.8 80

60 45.3 40 33.3 33.7

0 Rate per 100,000 Population White Black Other Total

Race

Note: “Other” race represents American Indian, Asian and Pacific Islanders.

Natural Infant Deaths Excluding SIDS, Ages 0-1

Background

Prematurity and low birth weight continue to be the greatest predictors of infant mortality. Preterm refers to births occurring before the 37th week of pregnancy, and low birth weight infants are those weighing less than 2,500 grams or 5 1/2 pounds at birth. While vast improvements have been made in treating these infants, preventing babies from being born too early and too small is still a great challenge.

In 2004, there were 12,892 preterm births in Michigan, representing 9.9 percent of all live births. This is an improvement over the 2003 preterm birth rate of 11.2 percent. More black infants were born preterm in Michigan (14.9 percent) than white infants (8.9 percent).

There are still many gaps in our understanding of why some women go into labor well ahead of schedule. Risk factors for preterm birth and low birth weight include: Previous preterm birth and/or low birth weight infant, multiple birth, smoking, unplanned pregnancy and poor nutrition. Certain pregnancy complications such as high blood pressure (hypertension) and diabetes increase the risk of prematurity. Other significant risks are reproductive tract infections (including sexually transmitted infections), stress, anxiety, depression and other psychological factors. Re- cent studies are looking at the long-term effects of stress over time and even inter-generational factors contributing to preterm delivery and low birth weight.

Preconception care helps to ensure that a woman is in optimal health before getting pregnant. Attention to nutrition, healthy weight and reducing or discontinuing use of tobacco, alcohol and drugs improves the chance for a healthy birth outcome. Early access to quality prenatal care, including health promotion, risk assessment and appropriate interventions can also have an impact on preventing preterm births and increasing the odds of an infant having normal birth weight.

If a pregnancy is unintended and unwanted, the mother is more likely to seek prenatal care late in pregnancy, or not at all. She is more likely to expose the fetus to harmful substances such as tobacco, alcohol or illegal drugs. Women who are not committed to the pregnancy are less likely to alter risky behavior or follow their provider’s advice, thus increasing the risk of a premature or low birth weight infant.

Sixth Annual Report Natural Deaths 51 Major Risk Factors

• Unintended or unwanted pregnancy. • Less than adequate prenatal care. • Smoking and substance use during pregnancy. • First birth as a teen and maternal age under 20 or over 40. • Physical abuse or other serious stress during pregnancy. • Poverty.

Michigan Mortality Data from Death Certificates

Michigan Natural Infant Death Rates Excluding SIDS, Ages 0-1, 1990-2004

ths 10 8.7 8.5 8.2 7.5 7.6 7.0 8 6.8 6.6 6.7 6.7 6.8 6.9 6.7 6.8 6.6 6

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 1,000 Live Bir

Year

Note: The rate of 6.6 in 2004 represents 853 deaths. This is a 24% decrease since 1990 and a 13% decrease from 2003.

Number and Percent of Michigan Natural Infant Deaths Excluding SIDS by Sex and Age, 2004

Sex Total Age Group Male Female Unknown Number Percent Number Percent Number Percent Number Percent 0 to 23 Hours after Birth 248 29.0 185 21.8 2 0.2 435 51.0 24 Hours thru 6 Days 69 8.1 54 6.3 0 0.0 123 14.4 7 Days thru 27 Days 61 7.2 59 6.9 0 0.0 120 14.1 28 Days thru 5 Months 74 8.7 54 6.3 0 0.0 128 15.0 6 Months thru 364 Days 27 3.2 20 2.3 0 0.0 47 5.5 Total 479 56.2 372 43.6 2 0.2 853 100.0

52 Child Death Review Michigan Natural Infant Death Rates Excluding SIDS by Race, Ages 0-1, 2004

16 15.0 ths 14 12 10 8 6.6 6 4.5 4 3.7 2

Rate per 1,000 Live Bir 0 White Black Other Total

Race

Note: “Other” race represents American Indian, Asian and Pacific Islanders.

Child Death Review Team Findings from CDR Case Reports

Teams reviewed a total of 179 cases of natural infant death excluding SIDS in 2004. Sixty-one percent of these were male and 39 percent were female. Roughly one-third of these reviews were missing large amounts of information due to the lack of some local teams’ access to medical records. Teams often find it challenging to review natural infant deaths, because the maternal and perinatal health histories are often not available and the cases tend to be more medically complex. Fourteen Michigan communities conduct more intensive reviews of infant deaths through the Michigan Fetal and Infant Mortality Review (FIMR) program, described in Section Nine of this report.

Number and Percent of Natural Infant Deaths Reviewed by Sex and Age

Sex Total Age Group Male Female Number Percent Number Percent Number Percent 0 to 23 Hours after Birth 46 25.7 31 17.3 77 43.0 24 Hours thru 6 Days 20 11.2 7 3.9 27 15.1 7 Days thru 27 Days 18 10.1 12 6.7 30 16.8 28 Days thru 5 Months 24 13.4 14 7.8 38 21.2 6 Months thru 364 Days 2 1.1 5 2.8 7 3.9 Total 110 61.5 69 38.5 179 100.0

At least two-thirds of the natural infant deaths reviewed were to infants who were born premature (< 38 weeks of gestation). Most of these infants also had low birth weight (<2,500 grams at birth), which is closely related to prematurity.

Sixth Annual Report Natural Deaths 53 Number and Percent of Natural Infant Deaths Reviewed by Age of Mother, 2004

Age of Mother Number Percent Under 15 Years 1 0.6 15 to 19 Years 16 8.9 20 to 24 Years 35 19.6 25 to 29 Years 21 11.7 30 to 34 Years 26 14.5 35 to 39 Years 15 8.4 40 Years and Older 4 2.2 Unknown 61 34.1 Total 179 100.0

At least one-third of all mothers had medical complications during the pregnancy. The most common complications reported included premature rupture of membranes (PROM), group B strep, diabetes, reproductive tract infection, pre-eclampsia and urinary tract infection.

At least 37 percent of these mothers were known to have entered prenatal care in the first trimester. It is known that at least 28 percent received adequate prenatal care, 15 percent received intermediate care and 1 percent received inadequate care.* Five percent of mothers in cases reviewed received no prenatal care.

At least 20 percent of mothers admitted to smoking during their pregnancy, 6 percent admitted to alcohol use and 6 percent admitted to using illicit drugs.

Prior Child Protective Services (CPS) involvement or past CPS complaints1 were reported in 24 (13 percent) of the cases. The prior CPS involvement was with the child who died in three cases, another family member in 19 cases and with a non-family caretaker in one case. In 18 cases, the Michigan Department of Human Services conducted an investigation as a result of the death. The referral was determined to be unsubstantiated in 17 cases and sub- stantiated in one case. None of the families had DHS family preservation services in place at the time of death.

Maternal Support Services or Infant Support Services (MSS/ISS) were known to have been utilized in 8 percent of these cases. Families were reported to be enrolled in the WIC program in 16 percent of the cases reviewed.

In 14 cases, teams were concerned that the infant was also in an unsafe sleeping environment, which included bed-sharing and heavy bedding.

* Scored using the Kessner Index, which takes into account gestational age, month of the first prenatal visit and the number of prenatal visits. 1 Past CPS complaints refers to any time prior to the death, including involvement with a parent when she or he was a child.

Local Initiatives to Prevent Child Deaths

Of the 179 natural infant deaths reviewed, teams believed the deaths were probably or definitely preventable in only 10 percent of the cases. Teams proposed 14 local prevention activities and implemented six of those. Examples include:

Grand Traverse – Identified need to improve community education regarding pre-pregnancy care.

Gratiot – Identified need to improve outreach to pregnant women and increase early enrollment in WIC.

54 Child Death Review Isabella – Identified need for increased WIC outreach promotion and need for increased smoking cessation information to pregnant women in WIC and Medicaid.

Van Buren – Sponsored a community baby shower where various topics concerning infant health were addressed.

Recommendations for Policymakers

1. The Michigan Department of Community Health: Expand and continue technical and financial support to Fetal and Infant Mortality Review programs in communities with high infant mortality rates and racial disparities.

2. The Michigan Department of Community Health: Promote the grief and bereavement services through the SIDS and Other Infant Death program to medical examiners, hospitals, funeral homes, local public health departments, Fetal and Infant Mortality Review teams and local Child Death Review teams.

3. The Michigan Legislature: Provide Medicaid coverage for family planning services to include all women up to 185 percent of the poverty level.

4. The Michigan Department of Community Health: Work with medical practitioners, medical organizations and insurance companies to ensure: a. An increase in the number of providers that discuss pregnancy intendedness at every visit with all patients of childbearing age. b. Providers offer preconception counseling to all patients of childbearing age. c. Adequate number of providers that accept Medicaid patients, in reasonable proximity to those patient populations. d. Early access to and continuity of care for all pregnant patients. e. Compliance with state laws that require physicians to offer pregnant patients client-centered counseling and voluntary HIV testing. f. Screening for all pregnant patients and new parents for domestic violence and substance abuse. g. Education of practitioners about the benefits of support programs that address maternal and infant health services, especially Maternal Infant Health Program, and other state and community-based primary and secondary prevention programs.

h. Providers offer referrals to smoking cessation services for pregnant and new parents.

5. The Michigan Department of Community Health: Continue the redesign of the Maternal Infant Health Program to: a. Improve identification and increase referrals of high-risk persons. b. Assure a quality assessment is performed. c. Assure services are designed to specifically improve risk.

6. Design reimbursement to reinforce the likelihood of improved birth outcomes.

Sixth Annual Report Natural Deaths 55 Recommendations for Parents and Caregivers

• If you think you are pregnant, see your health care provider early and often and follow their advice closely. • If you are pregnant, do not smoke anything, drink alcohol or take recreational drugs. • Learn about the warning signs for pre-term labor. If you experience any of them, call your doctor or health care provider right away.

Natural - Sudden Infant Death Syndrome

Background

Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant under one year of age that remains unexplained after a complete autopsy, examination of the death scene and review of the infant’s medical history. If any of these three steps are not conducted, a SIDS diagnosis should not be made. The SIDS diagnosis reflects that an infant’s death remains completely unexplained.

Historically, deaths from SIDS have been considered unpreventable. However, studies throughout the world have found that when infants are placed on their backs for sleep, they are much less likely to die unexpectedly. In 1994, the American Academy of Pediatrics (AAP) endorsed a nationwide Back to Sleep education campaign. In Michigan, Tomorrow’s Child (known then as the Michigan SIDS Alliance) served as the lead organization for this campaign. Since then, SIDS deaths in Michigan have been reduced by over 69 percent. It is the only cause of infant mortality that has seen a significant decrease over the last decade both in Michigan and across the nation.

In 2005, the AAP released a new policy statement regarding the reduction of risk in infant sleep environments. Recommendations include:

• Sleep infants on their back. • Remove soft bedding and soft objects from the sleep environment. • Do not share the same sleep surface with infants; infants may be brought into bed for nursing or comforting but should be returned to their own sleep surface when the parent is ready to return to sleep. • Avoid tobacco exposure in-utero and in the infant’s environment (second-hand smoke). • Avoid overheating by using lighter clothing for sleeping and a comfortable bedroom temperature.

These AAP recommendations are also a part of the State of Michigan’s infant safe sleep recommendations released in 2005 by the Michigan Department of Community Health (MDCH).

Better death scene investigations in the state are continuing to provide insights by helping to identify environmental risk factors. Since 2000, much of the reductions in SIDS numbers in Michigan are due to a shift in medical examiner diagnosis. As unsafe sleep environments are identified through investigation, many infant deaths that would have been called SIDS in past years are now classified as accidental asphyxia or undetermined cause.

These new insights have begun to move prevention strategies beyond the Back to Sleep campaign. MDCH, Michigan Department of Human Services, the Michigan Public Health Institute and Tomorrow’s Child are currently working together to develop targeted messages about safe infant sleep environments.

56 Child Death Review Major Risk Factors

• Infants sleeping on their stomachs or sides. • Soft infant sleep surfaces, loose bedding, stuffed toys, bumper pads. • Infants that share a sleeping surface with other children or adults. • Not recognizing the protective factors of a safe crib as defined by the Consumer Product Safety Commission. • Maternal smoking during pregnancy and second-hand smoke exposure to infants. • Overheating.

Michigan Mortality Data from Death Certificates

Michigan SIDS Death Rates, Ages 0-1, 1990-2004

ths 2.0 1.69 1.70 1.61 1.50 1.5 1.21 1.12 1.10 1.03 1.11 0.85 1.0 0.73 0.72 0.66 0.37 0.39 0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 1,000 Live Bir

Year

Note: The rate of 0.39 in 2004 represents 51 deaths. This is a 77% decrease since 1990.

Sixth Annual Report Natural Deaths 57 Number and Percent of Michigan SIDS Deaths by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under 2 Months 10 19.6 6 11.8 16 31.4 2 thru 3 Months 14 27.5 8 15.6 22 43.1 4 thru 5 Months 7 13.7 3 5.9 10 19.6 6 thru 7 Months 0 0.0 2 3.9 2 3.9 8 Months thru 364 Days 0 0.0 1 2.0 1 2.0 Total 31 60.8 20 39.2 51 100.0

Michigan SIDS Death Rates by Race*, Ages 0-1, 2004

1.0 0.85 ths 0.8

0.6

0.39 0.4 0.28

0.2 Rate per 1,000 Live Bir 0.0 White Black Total

Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

CDR teams reviewed 23 SIDS cases in 2004. Forty-eight percent were male and 52 percent were female. About 91 percent of these infants died before six months of age, with a majority of those deaths occurring between two and four months.

58 Child Death Review Number and Percent of SIDS Deaths Reviewed by Sex and Age

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under 2 Months 3 13.0 3 13.0 6 26.1 2 thru 3 Months 5 21.7 6 26.1 11 47.8 4 thru 5 Months 3 13.0 1 4.3 4 17.4 6 thru 7 Months 0 0.0 1 4.3 1 4.3 8 Months thru 364 Days 0 0.0 1 4.3 1 4.3 Total 11 47.8 12 52.2 23 100.0

All of the 23 SIDS deaths reviewed were designated as medical examiner cases, with autopsies completed. Teams reported that in 20 of the 23 cases, death scene investigations were conducted. In 78 percent of the cases, the infant’s medical records were reported to have been reviewed by the medical examiner.

Number and Percent of SIDS Deaths Reviewed by Infant’s Sleeping Location when Found, 2004

Sleeping Location Number Percent AAP Recommended 10 43.5 Crib 7 30.5 Bassinet 2 8.7 Playpen 1 4.3 Not AAP Recommended 13 56.5 Adult Bed 9 39.2 Couch 1 4.3 Other 2 8.7 Unknown 1 4.3 Total 23 100.0

Number and Percent of SIDS Deaths Reviewed by Sleeping Position when Found, 2004

Sleeping Position Number Percent Stomach 13 56.5 Back 7 30.5 Side 1 4.3 Unknown 2 8.7 Total 23 100.0

Sixth Annual Report Natural Deaths 59 While research has shown that the safest way for an infant to sleep involves three features - sleeping alone, in a crib and on his/her back - none of the SIDS cases reviewed in 2004 found the infant in all three of these conditions.

Over half of SIDS cases reviewed were on non-infant sleeping surfaces (adult beds, couches, etc). In a majority of these cases (75 percent), the teams noted bed-sharing was present. In two cases, the parent fell asleep during or soon after bottle or breastfeeding the infant.

The infants were found on their stomachs or sides in 61 percent of the cases. It was reported that this was their normal sleeping position in almost half of those cases. None of the infants sleeping in cribs, bassinets or play- pens were on their backs.

Teams noted that unsafe bedding was present in four cases. It is known that roughly a third of the infants were exposed to tobacco in-utero, second-hand, or both. Overheating was a risk factor in two of the cases. Most of the infants were reported to be healthy at the time of death. Two infants had slight illnesses at the time of death. One had been born premature.

Local Initiatives to Prevent Child Deaths

Of all 23 SIDS deaths reviewed, teams believed the deaths were probably or definitely preventable in 30 percent of the cases. Teams proposed nine local prevention activities related to SIDS and implemented four of those. Examples include:

Otsego – Published CDR Team findings and safe sleep recommendations in the local paper and sent reminders to local doctors regarding infant safe sleep.

Washtenaw - Added infant safe sleep brochures to parent packets distributed to all local hospitals for new parents; in conjunction with the county Human Services Collaborative Council, Zero to Five Action Group.

Recommendations for Policymakers

1. The prosecuting attorney, law enforcement agencies, medical examiner and Department of Human Services in every county: Upon the promulgation of rules by the Michigan Department of Community Health per Public Act 179 of 2004, jointly adopt and implement the child death scene investigation protocols.

2. The Children’s Cabinet: Continue and enhance resources among member agencies for infant safe sleep initiatives and, in partnership with the Michigan Department of Community Health SIDS and Other Infant Death program and Michigan professional associations, institutionalize a statewide infant safe sleep campaign consistent with the recommendations of the American Academy of Pediatrics.

3. The Michigan Department of Community Health: Strengthen the prenatal smoking cessation program, especially as it relates to Sudden Infant Death Syndrome.

60 Child Death Review Recommendations for Parents and Caregivers

• Always keep your baby in a smoke-free environment. • Practice the recommendations from the Consumer Product Safety Commission (CPSC) for infant safe sleep environments:

• Place your baby on his/her back on a firm, tight fitting mattress in a crib that meets current safety standards.

• Remove pillows, quilts, comforters, sheepskins, stuffed toys and other soft products from the crib.

• Use a sleep sack as an alternative to blankets, with no other covering.

• If using a blanket, put your baby with feet at the foot of the crib. Tuck a thin blanket around the crib mattress, reaching only as far as your baby’s chest.

• Make sure your baby’s head remains uncovered during sleep.

• Do not place your baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to sleep.

• Do not sleep in the same bed as your baby.

Natural Child Deaths, Ages 1-18

Background

Death from natural causes is the second leading cause of mortality to children ages 1-14, following unintentional injuries. Congenital anomalies, genetic disorders, cancers, heart and cerebral problems, serious infections and respiratory disorders such as asthma can all be fatal to children. Many of these conditions are not believed to be preventable in the same way in which accidents, homicides or suicides are preventable. But deaths due to certain illnesses do involve issues of preventability when there are prescribed care plans.

For example, deaths due to asthma are usually preventable. Asthma is a chronic respiratory disease that involves episodes of airway constriction due to inflammation. It is the most common chronic disorder in childhood, currently affecting an estimated 6.2 million children under age 18. Treatments for asthma are numerous and generally very effective. However, the asthma death rate for children ages 19 and younger has increased more steeply between 1980 and 2002 in Michigan (150 percent) than nationally (50 percent). The Michigan Asthma Coalition is working to improve the diagnosis and treatment of children with asthma by conducting in-depth case reviews of child asthma fatalities.

Sixth Annual Report Natural Deaths 61 Major Risk Factors

• Children with congenital anomalies and other genetic disorders. • Children who do not receive regular preventive medical care. • Children who live in poverty. • Lack of or non–compliance with prescribed care plans.

Michigan Mortality Data from Death Certificates

Michigan Natural Child Death Rates, Ages 1-18, 1990-2004

20 16.2 15.9 16.5 15.6 14.7 14.0 13.9 15 13.0 12.2 12.4 12.6 11.7 11.6 11.3 12.1

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 12.1 in 2004 represents 309 deaths. This is a 25% decrease since 1990.

Number and Percent of Michigan Natural Child Deaths by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent 1 to 4 Years 36 11.6 44 14.3 80 25.9 5 to 9 Years 39 12.6 21 6.8 60 19.4 10 to 14 Years 33 10.7 35 11.3 68 22.0 15 to 18 Years 63 20.4 38 12.3 101 32.7 Total 171 55.3 138 44.7 309 100.0

62 Child Death Review Michigan Natural Child Death Rates by Race*, Ages 1-18, 2004

20 18.1

15 12.1 10.6 10

0 Rate per 100,000 Population White Black Total

Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

CDR teams reviewed 120 cases of natural death to children over the age of one in 2004. Nearly one-third of these were children between one and four years of age.

Number and Percent of Natural Child Deaths Reviewed by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent 1 to 4 Years 15 12.5 17 14.2 32 26.7 5 to 9 Years 14 11.7 8 6.6 22 18.3 10 to 14 Years 15 12.5 14 11.7 29 24.2 15 to 18 Years 27 22.5 10 8.3 37 30.8 Total 71 59.2 49 40.8 120 100.0

Sixth Annual Report Natural Deaths 63 Number and Percent of Natural Child Deaths Reviewed by Underlying Cause*, 2004

Cause Number Percent Cerebral 31 25.8 Respiratory / Asthma 26 21.7 Congenital Anomalies 19 15.8 Cardiac 18 15.0 Cancer / Neoplasm 15 12.5 Infectious Illness 9 7.8 Other 21 17.5

*A case can have more than one underlying cause, therefore these numbers do not sum to a total.

A quarter of the cases reviewed in this category were due to cerebral causes, which includes cerebral palsy and seizure disorders. It should be understood that cerebral palsy is an “underlying” cause, which may lead to other complications that result in death. The most common fatal complications associated with cerebral palsy are respiratory and cardiovascular disease.

Nearly another quarter of natural deaths reviewed were due to respiratory disease or asthma. Eight of the 26 (31 percent) respiratory deaths reviewed were attributed to asthma. Three were to children ages 1-9, two were ages 10-14 and three were ages 15-18. The youngest child was the only one who was not previously diag- nosed. Teams noted that three children were only using short-term beta-agonists (such as Albuterol) to control their asthma. Despite the ability of beta-agonists to provide immediate relief of airway obstruction, there has been continuing concern in the medical community that regular use of these drugs may be associated with adverse outcomes. Chronic use of beta-agonists (once or more a day) may be an indicator that long-term prevention is needed. Only one child was known to be taking long-term control medication in addition to a beta- agonist.

An emerging concern in child death is sudden cardiac death. These are children who had no prior cardiac history and no acute symptoms 24 hours prior to the event. Nine of the 18 (50 percent) cardiac deaths reviewed fit this definition. Two of the children were ages 10-14 and seven were ages 15-18. Three of these children were engaged in a strenuous physical activity at the time of the cardiac event; the others were resting or engaged in light physical activity.

Prior CPS involvement was reported in 38 of the 120 cases reviewed in this category (32 percent). In 24 of those 38 cases, the involvement was with the child who died. In six of the 38 cases, teams felt that abuse or neglect on the part of the parent or caregiver contributed to the severity of the child’s medical condition and subsequent death. The causes in those six deaths include: pneumonia (2), asthma, cancer, cerebral palsy/sei- zures (with respiratory disease) and consequences of abusive head trauma.

Medicaid was the primary insurance in 44 percent of the cases reviewed in this category. Children were known to be receiving Children’s Special Health Care Services in 25 of the 120 cases (21 percent).

Local Initiatives to Prevent Child Deaths

Of the 120 natural deaths reviewed to children over one year of age, teams believed the deaths were probably or definitely preventable in only 16 percent of the cases. Teams proposed 12 local prevention activities and implemented six of those. They included:

Berrien – Contacted Southwest Michigan Asthma Coalition to work on establishing school policies for children with asthma to be able to carry inhalers on them at all times and have an emergency inhaler at the school nurse’s office.

Oakland – Identified a need for EKGs and chest x-rays as a standard part of school sports physicals.

Wayne – Provided information about asthma symptoms and treatments to an area newspaper.

64 Child Death Review Recommendation for Policymakers

Recommendations for Parents and Caregivers

• Ensure that your children receive regular preventive medical care. • Promptly seek medical care when you think your children need to see a doctor and make sure your children follow their treatment plans.

Sixth Annual Report Natural Deaths 65

Child Deaths IN MICHIGAN section five

ACCIDENTS (Unintentional Injuries)

Overview of Accidental Child Deaths, Ages 0-18

Michigan Accidental Child Death Rates, Ages 0-18, 1990-2004

18.9 17.6 17.0 17.2 20 16.6 15.9 16.1 14.9 14.8 15.3 13.7 14.2 14.0 12.9 13.1 15

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 13.1 in 2004 represents 350 deaths. This is a 23% decrease since 1990.

Number and Percent of Michigan Accidental Child Deaths by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 38 10.9 32 9.1 70 20.0 1 to 4 Years 23 6.6 13 3.7 36 10.3 5 to 9 Years 19 5.4 16 4.6 35 10.0 10 to 14 Years 24 6.9 26 7.4 50 14.3 15 to 18 Years 108 30.8 51 14.6 159 45.4 Total 212 60.6 138 39.4 350 100.0

68 Child Death Review Michigan Accidental Child Death Rates by Race, Ages 0-18, 2004

20 16.1 15 12.4 13.1

10 6.7 5

0 Rate per 100,000 Population White Black Other Total

Race

Note: “Other” race represents American Indian, Asian and Pacific Islanders.

Accidental – Motor Vehicle

Background

Children Under 16

Proper restraints are key to preventing deaths to children under 16 who ride in motor vehicles. Correctly installed child safety seats can reduce the risk of death by 71 percent for infants, and by 54 percent for children ages 1-4.

Belt-positioning booster seats are protective against death and serious injury to children ages 4-8 who are involved in motor vehicle crashes. Research has found that they reduce a child’s risk of injury by 59 percent in this age group. Yet, according to a recent observational study conducted by the University of Michigan Trans- portation Research Institute, only 8.6 percent of Michigan children ages 4-8 currently ride in booster seats.

Children less than 4’9” tall and less than 80 pounds generally do not fit safely in seat belts alone. Booster seats raise a child up so that the lap belt fits across the tops of the thighs instead of across the abdomen, and the shoul- der belt fits across the collarbone instead of the neck. This improved positioning of the child lowers the risk of injuries due to “seat belt syndrome,” in which the abdomen and spine are affected. With growing knowledge around the country of the importance of booster seat usage, currently 32 states and the District of Columbia have enacted provisions in their child restraint laws requiring the use of booster seats for children in the target age group.

Nationally, deaths to children on all-terrain vehicles (ATVs) increased every year from 1994-2002. In 2003, 111 children under age 16 died due to injuries they sustained while on ATVs, and an estimated 38,600 were treated in emergency departments across the country. Every year for the past 20, deaths to children under age 16 on ATVs have made up about one-third of the total annual deaths on these vehicles. Because of the alarming risk of injury and fatality, the American Academy of Pediatrics petitioned the Consumer Product Safety Commission in 2002 and again in the spring of 2005, to institute a ban on the sale of ATVs for use by children under 16 years of age.

Sixth Annual Report Accidents 69 Children Over 16

New teen drivers are at very high risk for causing motor vehicle crashes. According to the National Highway Traffic Safety Administration, teenagers are involved in three times as many fatal crashes as are all drivers, on the basis of miles driven. This difference is attributed in part to teens’ inexperience behind the wheel and increased likelihood of risk-taking behavior.

The risk of injury or death greatly increases for teens when they ride in a car with a new teen driver. Two out of three teens who die as passengers are in vehicles driven by other teens. The young drivers in these situations are also at increased risk. One study found that 16-year-olds driving with one teen passenger were 39 percent more likely to get killed than those driving alone. This percentage increased to 86 percent with two and 182 percent with three or more teen passengers. The rates increased even more with 17-year-old drivers: 48 percent with one teen passenger, 158 percent with two and a 207 percent increase with three or more teen passengers. The study theorized that “general foolishness and distractions” increased with each additional teen passenger, which, when coupled with their inexperience, was responsible for these findings.

Major Risk Factors

Children Under 16

• Non-use/misuse of appropriate child restraints. • Unskilled and/or unsupervised drivers of off-road vehicles, especially ATVs.

Children Over 16

• New driver inexperience and/or recklessness. • New drivers with other teens as passengers. • Exceeding safe speeds for road conditions. • Not using seat belts. • Hazardous road conditions, including loose gravel surfaces.

70 Child Death Review Michigan Mortality Data from Death Certificates

Michigan Accidental Child Death Rates Due to Motor Vehicles, Ages 0-18, 1990-2004

11.0 12 10.5 10.2 10.6 10.5 9.8 9.6 9.5 10 8.9 8.7 8.0 8.0 8.0 7.5 7.8 8 6 4

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 7.8 in 2004 represents 208 deaths. This is a 26% decrease since 1990.

Number and Percent of Michigan Accidental Child Deaths Due to Motor Vehicles by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 4 1.9 1 0.5 5 2.4 1 to 4 Years 8 3.8 6 2.9 14 6.7 5 to 9 Years 12 5.9 13 6.2 25 12.1 10 to 14 Years 15 7.2 15 7.2 30 14.4 15 to 18 Years 86 41.3 48 23.1 134 64.4 Total 125 60.1 83 39.9 208 100.0

Sixth Annual Report Accidents 71

Michigan Accidental Child Death Rates Due to Motor Vehicles by Race, Ages 0-18, 2004

10 8.1 7.8 8 6.1 6.7 6

Rate per 100,000 Population White Black Other Total Race

Note: “Other” race represents American Indian, Asian and Pacific Islanders.

Child Death Review Team Findings from CDR Case Reports

Local teams reviewed 165 motor vehicle related deaths to children in 2004. Thirty-nine percent of the cases reviewed were to males between the ages of 15 and 18.

Number and Percent of Accidental Motor Vehicle Deaths Reviewed by Sex and Age

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 2 1.2 2 1.2 4 2.4 1 to 4 Years 6 3.6 5 3.0 11 6.6 5 to 9 Years 14 8.5 8 4.8 22 13.3 10 to 14 Years 10 6.0 11 6.7 21 12.7 15 to 18 Years 65 39.4 38 23.0 103 62.4 19 to 21 Years 3 1.8 1 0.6 4 2.4 Total 100 60.6 65 39.4 165 100.0

Number and Percent of Accidental Motor Vehicle Deaths Reviewed by Cause of Crash*, 2004

Cause Number Percent Driving Error 89 53.9 Speeding 61 37.0 Recklessness 37 22.4 Poor Weather 15 9.1 Mechanical Failure 3 1.8 Other 50 30.3

*A case can have more than one cause, therefore these numbers do not sum to a total.

72 Child Death Review Number and Percent of Accidental Motor Vehicle Deaths Reviewed by Age of Driver at Fault, 2004

Age of Driver Number Percent at Fault <16 18 10.9 16-18 69 41.8 19-21 15 9.1 22-35 19 11.5 36-59 18 10.9 >59 3 1.8 Unknown 23 13.9 Total 165 100.0

Teams found that drivers 16-18 years of age were more than three times as likely to be at fault in the fatal crashes reviewed than the next most frequent at-fault age group (22-35).

Number and Percent of Accidental Motor Vehicle Deaths Reviewed for Drivers at Fault, Aged 18 and Under, by Number of Teen Passengers, 2004

Teen Passengers Number Percent One 26 29.9 Two 10 11.5 Three or More 14 16.1 None/Unknown 37 42.5 Total 87 100.0

One or more teen passengers were in the vehicle of over half (57 percent) of the fatalities reviewed in which the driver at fault was less than 18 years of age.

Number and Percent of Accidental Motor Vehicle Deaths Reviewed by Position of Child, 2004

Position of Child Number Percent Passenger 79 47.9 Driver 58 35.2 Pedestrian 17 10.3 Bicyclist 6 3.6 Other 5 3.0 Total 165 100.0

Sixth Annual Report Accidents 73 Number of Helmet-Related Crash Victims Reviewed by Helmet Use, 2004

Helmet Helmet Helmet Use Type of Vehicle Helmet On Total Not Worn Came Off Unknown Bicycle 0 5 0 1 6 Snowmobile 3 1 1 0 5 ATV 0 2 1 0 3 Motorcycle 2 0 0 0 2 Moped 0 1 0 0 1 Scooter 1 0 0 0 1 Total 6 9 2 1 18

All six of the bicycle-related incidents involved collision with a motor vehicle. Of the 12 cases involving other modes of transport for which a helmet would be used, only four involved collisions with motor vehicles. The rest involved the vehicles the children were on striking solid objects, rolling on top of them or some other type of mishap. Three reviews were conducted of children who died as a result of water craft crashes.

Number and Percent of Pedestrian Victims Reviewed by Age, 2004

Age of Child Number Percent 1-4 4 23.5 5-9 5 29.4 10-14 2 11.8 15-18 6 35.3 Total 17 100.0

It should be noted that very young children are not the only ones who are killed as pedestrians. Almost half of the victims reviewed in 2004 were at least 10 years of age. One of the teenage victims was under the influence of alcohol at the time. Three younger child pedestrians were the victims of “backovers”, or incidents in which children are killed in their own driveways, usually by a family member who does not see them.

Number and Percent of Accidental Motor Vehicle Deaths Reviewed by Road Condition, 2004

Condition of Number Percent Road Normal 103 62.4 Wet 22 13.3 Ice or Snow 14 8.5 Loose Gravel 10 6.1 Unknown 16 9.7 Total 165 100.0

74 Child Death Review Local teams have noted a lack of experience on gravel roads as a risk factor for new teen drivers. Teens often do not receive detailed instruction on how to drive on this road surface, and may not get any practice driving Helmet Helmet Helmet Use Type of Vehicle Helmet On Total (with a parent or driving instructor) on these roads, of which there are approximately 41,000 miles in Michi- Not Worn Came Off Unknown gan. For 2004 reviews, when age of driver at fault and road conditions were noted, drivers less than 18 were Bicycle 0 5 0 1 6 at fault in 70 percent of the crashes on gravel roads. Snowmobile 3 1 1 0 5 Number and Percent of Accidental Motor Vehicle Deaths Reviewed by ATV 0 2 1 0 3 Restraint Needed and Use of Restraint (Not Pedestrian or Bicycle), 2004 Motorcycle 2 0 0 0 2 Moped 0 1 0 0 1 Restraint Needed and Used Number Percent Scooter 1 0 0 0 1 Seatbelt needed: 108 80.0 Total 6 9 2 1 18 Used correctly. 61 45.2 Used incorrectly. 2 1.5 Present, but not used. 30 22.2 None in vehicle. 1 0.7 Unknown. 14 10.4 Child car seat needed: 12 8.9 Used correctly. 5 3.7 Used incorrectly. 2 1.5

Age of Child Number Percent Present, but not used. 1 0.7 1-4 4 23.5 None in vehicle. 2 1.5 5-9 5 29.4 Unknown. 2 1.5 10-14 2 11.8 Not needed*. 10 7.4 15-18 6 35.3 No answer. 5 3.7 Total 17 100.0 Total 135 100.0 * This answer may have been checked for cases involving ATVs, snowmobiles, etc.

Local Initiatives to Prevent Child Deaths

Motor vehicle related deaths were seen by teams as being highly preventable: they were judged to be either probably or definitely preventable in 96 percent of the cases reviewed. Teams proposed 72 prevention activities relating to motor vehicle crash deaths and 27 of those were initiated. Examples of these include:

Chippewa – Car Seat Safety Program developed to make sure all patients leaving the hospital after the birth of Condition of Number Percent a child are educated about car seats. Road Normal 103 62.4 Gogebic – Community safety project promoting alcohol-free graduation and drivers education presentation by Wet 22 13.3 law enforcement. Ice or Snow 14 8.5 Marquette – Local police chief provided a news release regarding bicycle safety. Loose Gravel 10 6.1 Unknown 16 9.7 Mecosta – Worked with AAA on improving Michigan’s child restraint laws and graduated licensing. Also began Total 165 100.0 working with the county road commission on traffic safety aimed at protecting the large number of Amish bug- gies using rural roadways.

Monroe – Information was sent to all drivers education programs to educate teens about driving too fast, citing the recent deaths in the county.

Washtenaw – Team advocated for legislation preventing minors from riding ATVs.

Sixth Annual Report Accidents 75 Recommendations for Policymakers

1. The Michigan Legislature: Amend the current graduated licensing law to place limits on the number of teen passengers allowed in vehicles driven by teens with Level Two Intermediate Licenses. This limitation should apply at all times of the day, and without exceptions.

2. The Michigan Department of State: Partner with the Office of Highway Safety Planning to conduct a comprehensive review and revision of driver education programs throughout the state to ensure that the instructors and curricula meet minimum requirements, including adequately addressing high-risk driving situations.

3. The Michigan Department of Education: Through the Great Parents, Great Start program, work with Michigan SAFE KIDS to develop a system for distributing child safety seat information to parents, coordinated through the local intermediate school districts.

4. The Michigan Legislature: Amend the Michigan Child Passenger law to: a. Require the use of booster seats to protect children ages 4-8 and under 4’9” tall; b. Increase fines and points for those not following the law; and c. Increase public awareness and education programs.

5. The Prosecuting Attorneys Association of Michigan: Educate all law enforcement agencies through the Police Law Bulletin, regarding: a. Public Act 451 of 1994 (MCL 324, sections 81129 and 81130); specifically, regarding the restrictions on children younger than 16 in the operation of all off-road vehicles, and encourage ticketing when this law is violated. b. The need for full enforcement of new teen driver speeding violations.

Recommendations for Parents and Caregivers

• Put limits on the number of teen passengers allowed in a car with your teen. • Ensure that you use the correct child restraint for your child’s age and weight. Children ages four to eight generally should be in booster seats. • Make sure all your children wear helmets when riding a bicycle or other recreational vehicle. • Do not allow your children ages 10-15 to drive an ATV out of your sight or without having completed the DNR’s Off-Road Vehicle (ORV) safety course. Do not let your children under age 10 drive ATVs.

76 Child Death Review Accidental – Suffocation and Strangulation

Background

Children can accidentally suffocate in a variety of ways. With each passing year, there are more reports of infant suffocations. According to the Centers for Disease Control and Prevention, unintentional suffocation was the number one cause of fatal injury for children less than one year of age in 2003 and has been the leading cause of fatal injury to infants for the last 20 years. In recent years, it has been recognized that many of these deaths occur when an infant is put to sleep in an unsafe sleep environment. Infants who suffocate often have no clinical findings at autopsy and a comprehensive scene investigation is usually the only way that unintentional suffocation can be determined.

Two common suffocation risks in an infant sleep environment include sharing a sleep surface with others and soft bedding. Overlays occur when an infant shares the same sleep surface with adults or siblings, and the other person inadvertently compromises the infant’s breathing ability with their body. Suffocation in bedding occurs when infants sleep with soft or too much bedding (pillows, quilts, comforters) or when they sleep in locations other than cribs that have a soft sleep surface (waterbeds, couches, adult beds). Their mouth and nose can become obstructed when covered or pressed into the soft bedding during sleep.

In 2005, the American Academy of Pediatrics (AAP) released a new policy statement regarding the reduction of risk in infant sleep environments. Recommendations made include: • Sleep infants on their backs. • Remove soft bedding and soft objects from the sleep environment. • Do not share the same sleep surface with infants; infants may be brought into bed for nursing or comforting but should be returned to their own sleep surface when the parent is ready to return to sleep. • Avoid tobacco exposure in-utero and in the infant’s environment (second-hand smoke). • Avoid overheating by using lighter clothing for sleeping and a comfortable bedroom temperature.

These AAP recommendations are also a part of the State of Michigan’s infant safe sleep recommendations released in 2005 by the Michigan Department of Community Health.

For choking and strangulation deaths, toddlers and preschoolers are at the highest risk. Because they are mobile and often active, they can become entangled in cords or choke on small objects. Foods (such as hot dogs, grapes or hard candy), coins and small toys are common causes of choking in young children. Window blind and drapery cords can cause strangulation. Product safety improvements including rigorous scrutiny and recalls by the Consumer Product Safety Commission on toys with choking hazards, removal of drawstrings from children’s clothing and safety cord hangers for window blinds have recently reduced the numbers of these types of suffocations and strangulations.

Major Risk Factors

• Infants sharing sleep surfaces with other persons. • Unsafe infant sleeping locations, such as adult beds, waterbeds, couches, futons. • Unsafe infant bedding, including poor-fitting or soft crib mattresses, pillows, stuffed toys, bumper pads, heavy or numerous blankets. • Easy access by infants and toddlers to small objects, cords and straps.

Sixth Annual Report Accidents 77 Michigan Mortality Data from Death Certificates

Michigan Accidental Child Death Rates Due to Suffocation or Strangulation, Ages 0-18, 1990-2004

3.0 2.5 2.3 2.5 2.2 1.9 2.0 2.0 1.6 1.4 1.4 1.5 1.4 1.3 1.1 1.1 1.1 1.0 0.9 1.0

0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 2.5 in 2004 represents 66 deaths. This is a 150% increase since 1990 and a 13% increase from 2003.

Number and Percent of Michigan Accidental Child Deaths Due to Suffocation or Strangulation by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 31 47.0 27 41.0 58 88.0 1 to 4 Years 0 0.0 3 4.5 3 4.5 5 to 9 Years 0 0.0 0 0.0 0 0.0 10 to 14 Years 1 1.5 2 3.0 3 4.5 15 to 18 Years 2 3.0 0 0.0 2 3.0 Total 34 51.5 32 48.5 66 100.0

78 Child Death Review Michigan Accidental Child Death Rates Due to Suffocation or Strangulation by Race, Ages 0-18, 2004

6 5.7

3 2.5

2 1.7

Rate per 100,000 Population 0 White Black Total

Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

Local teams reviewed the deaths of 83 children due to unintentional suffocation or strangulation in 2004. The vast majority of these deaths were to infants in a sleeping environment (93 percent). Although black children make up only 19 percent of Michigan’s child population, they were over-represented in the accidental suffocations reviewed (51 percent).

Number and Percent of Accidental Suffocation Deaths Reviewed by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 47 56.6 30 36.2 77 92.8 1 to 4 Years 0 0.0 1 1.2 1 1.2 5 to 9 Years 0 0.0 1 1.2 1 1.2 10 to 14 Years 1 1.2 1 1.2 2 2.4 15 to 18 Years 2 2.4 0 0.0 2 2.4 Total 50 60.2 33 39.8 83 100.0

Sixth Annual Report Accidents 79 Number and Percent of Accidental Suffocation Deaths Reviewed by Type, 2004

Suffocation Type Number Percent Sleep-related: 77 92.8 Overlay by person while sleeping. 45 54.3 Suffocation in bedding. 21 25.3 Wedged between objects. 6 7.2 Suffocation in object (non–bedding). 3 3.6 Unspecified suffocation. 2 2.4 Not Sleep–related: 6 7.2 Strangled by object. 2 2.4 Smothered by object. 2 2.4 Crushed by object. 2 2.4 Total 83 100.0

Sleep-related

Overlay - Teams reviewed 45 cases where an infant suffocated when another person rolled over onto them during sleep. Most of the deaths were to infants under four months of age (70 percent). Sleeping locations in these incidents were: 26 on adult mattresses, 13 on couches, two on the floor, one on a pull-out sofa and in three cases, the location was not given. In 15 cases, it is known that two or more other persons shared the sleeping surface. The adult sharing the sleep surface was impaired by drugs or alcohol in 11 cases (24 percent). Obe- sity was a factor in the overlay in six cases. In nine cases, the parent fell asleep during or soon after bottle or breastfeeding the infant. Teams also noted heavy or soft bedding was present in 15 of the overlay cases.

Suffocation in bedding - Infants suffocated in their bedding in 21 cases reviewed. Over half of the deaths were to infants under four months of age (57 percent). The type of bedding in these incidents were: blankets, pillows, soft mattress pads, comforter, stuffed toy, folded pillowcase, couch cushion and broken crib mattress. In 14 cases (67 percent), the infants were found on their stomachs. In the one case where the infant was sleeping on her back, she was found with her head covered by bedding. Sleeping locations in these incidents were: six bassinets, five cribs, three port-a-cribs, two adult mattresses, two couches, one playpen, one car seat and one in a type of bouncer that had a CPSC safety recall notice in 2000. Teams also noted that sleep surface sharing was present in six of the bedding suffocation cases.

Wedging - In six cases, infants were placed to sleep on an adult mattress or futon and subsequently rolled to the edge and became wedged between the mattress and wall, thereby restricting their ability to breathe. The infants were six months or older in four of these cases. Teams also noted bed-sharing in three of these cases.

Other object in sleep environment - Three infants suffocated on a non-bedding object in their sleep environment. All of these infants were between four and eight months of age. The non-bedding objects were plastic bags in two cases and clothing in the other case.

There was not enough information in two cases to categorize how the infant suffocated in their sleep environment. It is only known that the infants were found on their stomachs.

Not Sleep-related

Two children were accidentally strangled with ropes that they were playing with. In two cases, children were smothered by objects. Two teens were asphyxiated when cars that they were working under fell onto them.

80 Child Death Review Local Initiatives to Prevent Child Deaths

Suffocation Type Number Percent Of the 83 unintentional suffocation and strangulation deaths reviewed, teams believed the deaths were prob- Sleep-related: 77 92.8 ably or definitely preventable in 98 percent of the cases. Teams proposed 65 local prevention activities related to unintentional suffocation and strangulation and implemented 31 of those. Examples include: Overlay by person while sleeping. 45 54.3 Suffocation in bedding. 21 25.3 Barry – Pediatric discharge nurses now discuss infant safe sleep issues with parents and include a brochure in Wedged between objects. 6 7.2 the discharge packet. Suffocation in object (non–bedding). 3 3.6 Berrien – Distributed a press release about the dangers associated with working under cars. Unspecified suffocation. 2 2.4 Not Sleep–related: 6 7.2 Genesee – Educated the community about infant safe sleep issues through their REACH Team. Strangled by object. 2 2.4 Smothered by object. 2 2.4 Ingham – Convened a multi-disciplinary team to begin planning a multi-county safe sleep campaign. Crushed by object. 2 2.4 Jackson – Formed a safe sleep coalition and has made community presentations to both parents and providers. Total 83 100.0

Recommendations for Policymakers

1. The prosecuting attorney, law enforcement agencies, medical examiner and the Department of Human Services in every county: Upon the promulgation of rules by the Michigan Department of Community Health per Public Act 179 of 2004, jointly adopt and implement the child death scene investigation protocols.

2. The Children’s Cabinet: Continue and enhance resources among member agencies for infant safe sleep initiatives and, in partnership with the Michigan Department of Community Health’s SIDS and Other Infant Death program and Michigan professional associations, institutionalize a statewide infant safe sleep campaign consistent with the recommendations of the American Academy of Pediatrics.

3. The Michigan Chapter of the American Academy of Pediatrics: Identify a partner with whom to host a “Train the Trainer” event for pediatricians around the state in order to ensure the dissemination of consistent safe infant sleep messages to parents.

Recommendations for Parents and Caregivers

• Practice the recommendations from the Consumer Product Safety Commission (CPSC) for safe infant sleep environments. (See the Section on SIDS) • Keep all small objects, cords and ropes away from infants and toddlers, including foods like hot dogs, nuts and grapes. • Don’t leave babies in car seats out of your sight.

Sixth Annual Report Accidents 81 Accidental – Fire

Background

Young children, especially males ages 0-4, are at the greatest risk of dying in a house fire. Children of this age are less likely to recognize the dangers of playing with fire, more likely to hide once a fire breaks out and less likely to have been taught home fire escape. Poverty increases this risk. Lower income families are more likely to: live in older, wood frame housing or trailers; use alternative heating sources; have malfunctioning wiring or appliances; and have barriers to escape or rescue (i.e. having children’s bedrooms in basements with small or no access windows, security bars on first floor windows and back doors or windows nailed shut for security or warmth). They are less likely to have working smoke alarms, or have a family escape plan and practice it.

Nationally, about one-third of the fires that result in child fatalities are started by children in the home playing with incendiary devices such as matches and lighters. Since the Consumer Product Safety Commission took action in 1994 to require that cigarette lighters be child-resistant, deaths caused by children playing with lighters have decreased by 43 percent.

The single most important factor in reducing fire fatalities is the presence in the home of a working smoke detector. Although most American homes have at least one smoke detector, they may not contain good batteries or be in working order at the time of the fire. In addition, more than half of all fire fatalities nationwide occur in the small number of homes (6 percent) that lack detectors.

Learning the basics of home fire escape is another proven way to reduce fire fatality risk. Research shows that children, including preschoolers, are capable of learning life-saving means of home fire escape.

In June 2004, the United States Fire Administration announced a partnership with the National Fire Protection Association to examine what can be done to reduce the high death rate from fire in rural America. Communities with fewer than 2,500 residents have a per capita fire death rate almost twice the national rate.

Major Risk Factors

• Homes without working smoke detectors. • Young children’s easy access to lighters, matches and candles. • Black and American Indian males. • Preschool aged children. • Children in low income housing.

82 Child Death Review Michigan Mortality Data from Death Certificates

Michigan Accidental Child Death Rates Due to Fire and Burn, Ages 0-18, 1990-2004

2.8 3.0 2.7 2.8 2.4 2.5 1.9 1.9 1.9 2.0 1.7 1.6 1.5 1.3 1.5 1.2 1.3 1.0 1.0 0.7

0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 0.7 in 2004 represents 19 deaths. This is a 63% decrease since 1990 and a 53% decrease from 2003.

Number and Percent of Michigan Accidental Child Deaths Due to Fire and Burn by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 0 0.0 1 5.3 1 5.3 1 to 4 Years 6 31.6 0 0.0 6 31.6 5 to 9 Years 3 15.8 1 5.3 4 21.1 10 to 14 Years 3 15.8 3 15.8 6 31.6 15 to 18 Years 2 10.5 0 0.0 2 10.5 Total 14 73.6 5 26.4 19 100.0

Sixth Annual Report Accidents 83 Michigan Accidental Child Death Rates Due to Fire and Burn by Race*, Ages 0-18, 2004

1.5

1.0 1.0 0.7 0.7

0.5

0 White Black Total Rate per 100,000 Population Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

Teams reviewed the deaths of 28 children who were fire victims in 2004.

Number and Percent of Accidental Fire Deaths Reviewed by Sex and Age

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 1 3.6 1 3.6 2 7.2 1 to 4 Years 8 28.4 1 3.6 9 32.0 5 to 9 Years 2 7.2 1 3.6 3 10.8 10 to 14 Years 3 10.8 9 32.0 12 42.8 15 to 18 Years 2 7.2 0 0.0 2 7.2 Total 16 57.2 12 42.8 28 100.0

Due to the high proportion of fire incidents in 2004 involving multiple child fatalities, much of the following analysis refers primarily to the number of fatal fires reviewed, in addition to the number of actual deaths (15 fires killed 28 children).

84 Child Death Review Number and Percent of Child Deaths Reviewed per Accidental Fire Incident, 2004

Number Number Percent of Deaths of Fires One 8 53.4 Two 3 20.0 Three 2 13.3 Four 2 13.3 Total 15 100.0

Local teams determined the socio-economic status of the child victims’ families to be “low” in nine of the 15 fires reviewed, in which 19 children died.

Number and Percent of Accidental Fire Incidents Reviewed by Fire Source, 2004

Source of Fire Number Percent Gas explosion. 4 26.7 Kichen stove. 3 20.0 Wood stove / fireplace. 2 13.2 Lighter. 1 6.7 Candle. 1 6.7 Electrical cords. 1 6.7 Unknown. 3 20.0 Total 15 100.0

The child victims themselves or another minor present were involved in either playing with an incendiary device or lighting the source of the fire in seven incidents, killing a total of 15 children. Less than adequate supervision was indicated in nine fires, which killed a total of 19 children.

Number and Percent of Accidental Fires Reviewed by Smoke Detector Presence and Functionality, 2004

Smoke Detector Number Percent Present and Functioning Yes 4 26.7 No 5 33.3 Unknown 5 33.3 N/A 1 6.7 Total 15 100.0

Although not a specific item collected on the report form, it was noted in the narratives of two of the fire cases that security bars or similar device on windows prevented escape.

Sixth Annual Report Accidents 85 Local Initiatives to Prevent Child Deaths

Local teams indicated that all of the child fire deaths reviewed were either probably or definitely preventable. Teams proposed 16 local prevention activities related to child fire deaths, and action was initiated on nine of these. Examples include:

Genesee – Meeting with landlord association, to ask for the requirement of hard-wired smoke detectors in rental homes.

Wayne – Family fire safety activities spearheaded by the fire department.

Recommendations for Policymakers

1. The Michigan Department of Community Health and the Michigan Department of Labor and Economic Growth: Seek funding to support local efforts to increase the number of lithium-powered or hard-wired smoke detectors in residential dwellings.

2. The Michigan Department of Education and the Michigan Department of Human Services: Encourage the offering of fire safety education for young children in all early education and child care settings, including aides and relative care providers.

3. The Michigan Department of Education: Expand the current fire safety curriculum in the Michigan Model for Comprehensive School Health Education to include grades beyond 1st.

Recommendations for Parents and Caregivers

• Install smoke detectors inside or adjacent to every sleeping area and on every floor of your home; test them monthly and change their batteries when you change your clocks, if they are not equipped with 10-year lithium batteries.

• Keep matches, lighters and candles well out of the reach of children.

• Teach your family how to escape from your home in case of a fire, and practice it.

• Never leave your cooking unattended.

86 Child Death Review Accidental – Drowning

Background

According to the Centers for Disease Control and Prevention, drowning remains the second leading cause of injury-related death among children ages 1 to 14 in the U.S., despite a continuing decrease in the child drowning rate over the years.

Males are at a much higher risk of drowning than females. One study found that on average, nearly three-quar- ters of all drowning victims are male. Toddlers, especially boys under age four, are at highest risk of drowning. Very young children are curious near water but are not able to comprehend the potential danger.

Most child drownings occur when a supervising adult is distracted. Also, if there are multiple adults in the area, a diffusion of responsibility can occur for watching the children. Drowning experts now recommend that one adult at a time take responsibility for maintaining constant visual supervision of children in or near the water.

Age plays a large role in determining the most likely place for children to drown. Babies most often drown in bathtubs or other areas in the home (toilets, five-gallon buckets, washtubs) when left unattended. Toddler drownings most often occur in swimming pools or backyard ponds. Often, they are last seen inside the home or just outside of the home (not necessarily near the water), and are out of sight of the caretaker for less than five minutes when it is discovered that they are missing. Older children most often drown in open bodies of water (lakes, rivers, oceans, gravel pits) while swimming or boating.

A recent study by the National SAFE KIDS Campaign (now called Safe Kids USA) used data from 17 state child death review programs, as well as surveys of 564 parents of children 14 years old and younger. Among their conclusions were: Parents are overconfident about their children’s safety around water and their swimming abilities; multiple layers of protection must be installed around home pools and they must be used consistently; adults must increase the quality of their supervision of children around water (nearly 9 in 10 of the deaths reviewed occurred while the child was supposedly being supervised).

In Michigan, building codes require specifications for fencing around home pools. In recent years, the enforcement of these codes has fallen to localities, which rarely, if ever, pursue this enforcement. A lack of resources and personnel to enforce the codes are cited as reasons. And, with the recent advent and growing popularity of inflatable above-ground pools, the number of homes not in compliance with these codes has increased. Self- contained, ornamental landscaping ponds are another emerging factor that may increase child drowning risk.

Coast Guard-approved personal flotation devices (PFDs or life jackets) are very effective at preventing drowning for all ages, especially for children on boats or who are playing in or near open bodies of water, regardless of whether the child is thought to be a good swimmer.

Major Risk Factors

• Lapse in adult supervision, however brief. • Diffusion of supervisory responsibility by multiple adults. • Children under age four and males. • Unlocked gates and inadequate fencing of pools and ponds. • Children not wearing personal flotation devices.

Sixth Annual Report Accidents 87 Michigan Mortality Data from Death Certificates

Michigan Accidental Child Death Rates Due to Drowning, Ages 0-18, 1990-2004

2.0 1.72 1.69 1.67 1.58 1.59 1.61 1.44 1.46 1.37 1.5 1.29 1.28 1.34 1.24 1.25 1.0 0.75

0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 0.75 in 2004 represents 20 deaths. This is a 56% decrease since 1990 and a 44% decrease from 2003.

Number and Percent of Michigan Accidental Child Deaths Due to Drowning by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 0 0.0 0 0.0 0 0.0 1 to 4 Years 6 30.0 4 20.0 10 50.0 5 to 9 Years 2 10.0 1 5.0 3 15.0 10 to 14 Years 2 10.0 1 5.0 3 15.0 15 to 18 Years 4 20.0 0 0.0 4 20.0 Total 14 70.0 6 30.0 20 100.0

88 Child Death Review Michigan Accidental Child Death Rates Due to Drowning by Race*, Ages 0-18, 2004

1.5 1.39

1.0 0.75 0.62

0.5

Rate per 100,000 Population White Black Total Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

Local teams reviewed 21 child drownings in 2004. Over half of those were to children under the age of five (57 percent). Two-thirds were male.

Number and Percent of Accidental Drowning Deaths Reviewed by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 0 0.0 1 4.8 1 4.8 1 to 4 Years 5 23.7 5 23.7 10 47.4 5 to 9 Years 1 4.8 1 4.8 2 9.6 10 to 14 Years 3 14.4 0 0.0 3 14.4 15 to 18 Years 5 23.8 0 0.0 5 23.8 Total 14 66.7 7 33.3 21 100.0

Number and Percent of Accidental Drowning Deaths Reviewed by Location, 2004

Place of Drowning Number Percent Open water. 8 38.1 Swimming pool. 7 33.3 Bathtub. 2 9.5 Ornamental fish pond. 2 9.5 Bucket. 1 4.8 Gravel pit. 1 4.8 Total 21 100.0

Sixth Annual Report Accidents 89 One of the two bathtub drowning victims was an infant; the other was a toddler.

Four of the seven pool drowning victims were toddlers. One of the school-aged children who drowned in a pool was mentally and developmentally delayed. None of these five were swimming at the time. They all wandered away from a supervising adult who was at least momentarily distracted. Although the exact type of pool (other than above- vs in-ground) is not an item collected, it was noted in the narrative of one of the pool drowning cases that the toddler drowned in one of the newer-style inflatable above-ground pools.

Six of the eight children who died in open bodies of water were teenagers. The other two were toddlers who wandered off unattended and drowned in natural ponds.

Two other toddlers drowned in self-contained, ornamental ponds. Both had been in the house when last seen by supervisors; both exited the homes unseen through sliding glass doors.

Local Initiatives to Prevent Child Deaths

Local teams felt that 100 percent of the drowning deaths were either probably or definitely preventable. Teams proposed five initiatives to prevent child drownings in 2004, and took action to implement two of those:

Cass – Ran newspaper article and television spots on pool safety.

Washtenaw – Team advocated for local ordinance requiring fencing for homes that have ornamental ponds and consumer warnings at point of purchase.

Recommendations for Policymakers

1. The Michigan Municipal League, Michigan Association of Counties and Michigan Township Association: Work with communities to mandate enforcement of the Michigan Construction Codes that require local units of government to adopt and enforce pool fencing regulations.

2. The Michigan Department of Human Services Office of Children and Adult Licensing: In the orientation session for new child care providers, ensure distribution of the Consumer Product Safety Commission guidelines on pool fencing safety.

3. The Michigan Department of Natural Resources, Michigan Municipal League, Michigan Association of Counties, Michigan Township Association and Michigan Parks and Recreation Association: Work with local communities to: a. Provide adequate signage and appropriate rescue equipment in areas of waterfront and shorelines accessible to the public. b. Conduct public education campaigns regarding the dangers when children, teens and their parents overestimate swimming ability and level of safety in water.

90 Child Death Review Recommendations for Parents and Caregivers

• When you are near any pool or body of water, always designate one adult to keep sight of all the children, at all times. • Take the time to locate water sources in the areas surrounding your home (neighbors’ pools, landscape ponds, etc) and make sure there are barriers in place that will keep your children away from them. • Don’t leave standing liquid in five–gallon buckets, washtubs, wading pools or any other containers around your home. • Always ensure that your children are wearing PFDs when participating in recreational activities on open water (boating, jet-skiing, water-skiing, etc.), regardless of age or ability to swim.

Accidental – Other Causes

Background

This section addresses unintentional injury deaths not covered in previous sections, including incidents involving firearms, poisoning/overdose, electrocution and hyperthermia.

Unintentional injuries from firearms represent less than two percent of all firearm deaths in the U.S., but of this two percent, children and adolescents are involved 55 percent of the time. The majority of these deaths occur when children are playing with or showing the weapons to friends.

Michigan law requires that all guns sold have locking devices on them, be sold with a gun case or other locking storage container, and the dealer must provide free written information on the safe use and storage of firearms in the home environment. The dealer must also post a notice that states that a person “may be criminally and civilly liable for any harm caused by a person less than 18 years of age who lawfully gains unsupervised access to your firearm if unlawfully stored.”

Poisoning deaths can occur due to access by young children to toxic substances and the inattention of parents or other caregivers. Carbon monoxide poisonings often occur overnight, involving generators or other types of CO producing appliances. Teens can die from high levels of illegal drugs in their systems, or increasingly, by unintentionally overdosing on prescription medications in an attempt to get high.

Deaths due to hyperthermia (overheating) can occur when caregivers leave babies or young children alone in parked vehicles in warmer months, or when overdressing/using too many blankets in an overly warm home or other location.

Electrocution can occur inside or outside the home. Inside, sources of electrocution can include exposed outlets, faulty appliances or electrical cords. Outside, downed power lines and lightning strikes can cause electrocution.

Sixth Annual Report Accidents 91 Major Risk Factors

• Easy availability of and access to firearms by children. • Lack of adequate supervision from caregivers. • Homes that are not properly child-proofed. • Teens who can access strong prescription medications.

Michigan Mortality Data from Death Certificates

Michigan Accidental Child Death Rates Due to Other Causes, Ages 0-18, 1990-2004 2.5

2.06 2.0 1.96 1.95 1.86 1.73 1.66 1.69 1.68 1.5 1.37 1.38 1.34 1.10 1.02 1.03 1.00 1.0

0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 1.38 in 2004 represents 37 deaths. This is a 30% decrease since 1990 and a 38% increase from 2003.

Number and Percent of Michigan Accidental Child Deaths Due to Other Causes by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 3 8.1 3 8.1 6 16.2 1 to 4 Years 3 8.1 0 0.0 3 8.1 5 to 9 Years 2 5.4 1 2.7 3 8.1 10 to 14 Years 3 8.1 5 13.5 8 21.6 15 to 18 Years 14 37.9 3 8.1 17 46.0 Total 25 67.6 12 32.4 37 100.0

92 Child Death Review Michigan Accidental Child Death Rates Due to Other Causes by Race*, Ages 0-18, 2004

2.0 1.75

1.5 1.38 1.29

1.0

0.5

0 Rate per 100,000 Population White Black Total Race *There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

Teams reviewed the deaths of 18 children due to unintentional injuries other than motor vehicle-related, suffocations/strangulations, fires or drownings. Fifty-six percent were to children between the ages of 15 and 18. Ninety percent of those were male.

Number and Percent of Accidental Deaths Reviewed Due to Other Causes by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 1 5.6 1 5.6 2 11.1 1 to 4 Years 1 5.6 0 0.0 1 5.6 5 to 9 Years 1 5.6 1 5.6 2 11.1 10 to 14 Years 0 0.0 2 11.1 2 11.1 15 to 18 Years 9 50.0 1 5.6 10 55.6 19 to 21 Years 1 5.6 0 0.0 1 5.6 Total 13 72.2 5 27.8 18 100.0

Sixth Annual Report Accidents 93 Number and Percent of Accidental Deaths Reviewed by Other Causes, 2004

Cause Number Percent Poisoning / Overdose 11 61.1 Hyperthermia 3 16.7 Firearm 2 11.1 Electrocution 1 5.6 Other 1 5.6 Total 18 100.0

Number of Accidental Poisoning/Overdose Deaths Reviewed by Type of Substance, 2004

Type of Substance Number Percent Prescription Medication 5 45.4 Illegal Drug 3 27.3 Alcohol 1 9.1 Carbon Monoxide 1 9.1 Freon 1 9.1 Total 11 100.0

All of the victims of poisoning, overdose or acute illegal drug intoxication reviewed were 14 or over, and all of the prescription medication overdoses were to teens using recreationally pharmaceuticals not prescribed for them. In the case of the carbon monoxide poisoning, there was a CO detector in the home, but it had been unplugged. The victim of freon poisoning was a youth who was “huffing” the substance.

All three of the hyperthermia cases occurred in overly warm homes to two infants and a toddler. One case involved a fever and two cases involved overbundling, in addition to the warm environments.

The two firearm deaths were caused by a rifle that discharged when a family member attempted to move it, and an unregistered handgun that was found and played with by unsupervised children. Neither weapon had a trigger lock and neither was stored in a locked location.

The single case of electrocution involved the victim coming into contact with downed power lines.

Local Initiatives to Prevent Child Deaths

The teams believed that all of the deaths in this category were preventable. Local teams proposed 14 initiatives to prevent child deaths in this category, and action was taken on eight of these. They include:

Arenac – The local health department was asked to give WIC applicants information regarding available parenting classes.

Huron – Local schools and hardware store partnered to raise funds to be able to supply free and discounted carbon monoxide detectors to families who needed them.

Iron – Law enforcement did presentations in the schools regarding substance abuse.

Otsego – Team coordinator wrote an article for the local press regarding the fact that even recreational use of narcotics can kill, and that peers need to intervene if they know that friends are abusing prescription drugs.

94 Child Death Review Cause Number Percent Poisoning / Overdose 11 61.1 Recommendations for Policymakers Hyperthermia 3 16.7 Firearm 2 11.1 1. The Michigan Attorney General’s Office: Ensure statewide enforcement of the current laws that Electrocution 1 5.6 require: Other 1 5.6 a. Federally licensed firearm dealers to provide, at the point of sale, written materials on gun Total 18 100.0 safety and the proper storage of guns in homes with children; and b. Federally licensed firearm dealers are not to sell a firearm in Michigan without a commercially available trigger lock or other device, designed to disable the firearm and prevent it from discharging.

2. The Michigan Sheriff’s Association: Work collaboratively with county sheriffs’ offices to ensure that when handguns are presented for safety inspection and registration, the owner physically show an operable gun safety mechanism that can be used on the handgun presented for registration.

3. The Michigan Department of Education: Encourage school districts to include in middle and high school parent orientations, information regarding the potential for overdose when teens have access to prescription medications that do not belong to them.

Recommendations for Parents and Caregivers

• If you own guns, they should be properly stored. Keep them in locked cabinets with gun safety devices in place. Store ammunition in a separate locked cabinet. • Assess the safety of firearms storage of the homes that your children visit. • Be sure that all areas of the house are “child proofed,” including stairs, electrical outlets, storage cabinets and medication bottles. • If you suspect that your child might be abusing illegal or prescription drugs, intervene immediately. Even “experimenters” can accidentally overdose.

Sixth Annual Report Accidents 95

Child Deaths IN MICHIGAN section six

HOMICIDES

Overview of Child Homicides, Ages 0-18

Michigan Child Homicide Rates, Ages 0-18, 1990-2004

8 7.0 6.7 7 6.2 5.9 5.9 5.5 6 4.5 4.6 5 4.2 3.7 4 2.8 3.0 3.0 2.8 2.5 3 2 1

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 3.0 in 2004 represents 80 deaths. This is a 57% decrease since 1990 and a 20% increase from 2003.

Number and Percent of Michigan Child Homicide Deaths by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 4 5.0 4 5.0 8 10.0 1 to 4 Years 6 7.5 11 13.7 17 21.2 5 to 9 Years 4 5.0 3 3.8 7 8.8 10 to 14 Years 2 2.5 6 7.5 8 10.0 15 to 18 Years 33 41.3 7 8.8 40 50.0 Total 49 61.3 31 38.8 80 100.0

100 Child Death Review Michigan Child Homicide Rates by Race, Ages 0-18, 2004

12.0 10.9

10.0

8.0

6.0

4.0 3.4 3.0

2.0 0.9

Rate per 100,000 Population 0.0 White Black Other Total Race

Note: “Other” race represents American Indian, Asian and Pacific Islanders.

Homicide – Firearm and Weapon

Background

Most victims of firearm and other weapon homicides in the U.S. are adolescents. It is the leading cause of violence-related injury death (45 percent) for all youths ages 15–18. Ninety percent of males ages 15–18 who die as a result of firearm-related homicides are black. Over the last decade, an average of about nine Ameri- can youths were killed by weapons daily. A Centers for Disease Control and Prevention nationwide survey of high school students in 2004 reported that 17 percent of 9th through 12th grade students indicated that they had carried a firearm on one or more occasion within the previous 30 days. The prevalence of having carried a weapon was about four times higher for males than for females.

Youth homicide is a serious problem in large urban areas, especially among black males. Homicide is the second leading cause of death for black teens. Yet when socio-economic status is held constant, differences in homicide rates by race become insignificant. Major contributing factors in addition to poverty include easy access to handguns, involvement in drug and gang activity, low parental involvement, poor family functioning and school failure. These homicides usually occur in connection with an argument or dispute. They are almost always committed by acquaintances of the same gender, race and age group, using inexpensive, easily acquired handguns.

There are a myriad of prevention strategies available to communities to reduce gun violence among youths. Many of these are relatively easy to implement. However, research indicates that preventing youth violence requires complex, long-term solutions that should be focused on neighborhoods where the majority of these homicides occur. Violence prevention research has demonstrated that strategies are most effective when they identify high-risk children in their earliest years and intervene at multiple levels through collaborative community partnerships.

Sixth Annual Report Homicides 101 Major Risk Factors

• Easy availability of firearms. • Youths living in neighborhoods with high rates of poverty, social isolation and family violence. • Youths engaged in drug and gang activity, with prior histories of early school failure, delinquency and violence. • Youths with little or no connectedness to a supportive parent or adult mentor. • Prior witnessing of violence.

Michigan Mortality Data from Death Certificates

Michigan Child Homicide Rates Due to Firearms and Weapons, Ages 0-18, 1990-2004

6 5.4 5.2 4.7 5 4.5 4.1 4.1 4 3.1 3.0 3 2.5 2.1 1.9 1.9 2 1.6 1.7 1.5

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 1.9 in 2004 represents 51 deaths. This is a 65% decrease since 1990 and a 27% increase from 2003.

Number and Percent of Michigan Child Homicides Due to Firearms and Weapons by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 0 0.0 1 2.0 1 2.0 1 to 4 Years 0 0.0 4 7.8 4 7.8 5 to 9 Years 3 5.9 2 3.9 5 9.8 10 to 14 Years 2 3.9 3 5.9 5 9.8 15 to 18 Years 31 60.8 5 9.8 36 70.6 Total 36 70.6 15 29.4 51 100.0

102 Child Death Review Michigan Child Homicide Rates Due to Firearms and Weapons by Race*, Ages 0-18, 2004

10.0

8.0 7.7

6.0

4.0 1.9

2.0 0.4 0.0

Rate per 100,000 Population White Black Total Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

CDR teams reviewed a total of 47 child deaths in 2004 ruled to be homicides from firearms or other weapons. Thirty-seven of these deaths were to youths between the ages of 15-18, and 29 of those were to youths 17-18 years of age. Seventy-nine percent of the deaths were to black children and of those 37 deaths, 28 were males and nine were females. Males of all races accounted for 79 percent of all the firearms or other weapon homicides. Approximately 70 percent of the deaths reviewed in this category were to youths who were deemed to be of low socio-economic status.

Number and Percent of Child Homicides from Weapons Reviewed by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 0 0.0 0 0.0 0 0.0 1 to 4 Years 0 0.0 2 4.2 2 4.2 5 to 9 Years 2 4.2 1 2.2 3 6.4 10 to 14 Years 2 6.4 2 4.2 5 10.7 15 to 18 Years 32 68.1 5 10.7 37 78.7 Total 37 78.7 10 21.3 47 100.0

Sixth Annual Report Homicides 103 Number and Percent of Child Homicides from Weapons Reviewed by Type of Weapon, 2004

Type of Weapon Number Percent Handgun 36 76.6 Knife 4 8.5 Unknown Firearm 4 8.5 Shotgun 3 6.4 Total 47 100.0

Seventy-seven percent of the time, a handgun was the weapon used. When known, the injury was drug-related approximately half of the time. The person inflicting the injury had a history of violence in one-fifth of the cases. Sixty-eight percent of the firearm homicides reviewed occurred in Wayne County.

Number and Percent of Homicides from Firearms or Weapons Reviewed by Circumstance of Incident, 2004

Circumstance Number Percent Intent to harm. 41 87.1 Negligence. 5 10.7 Self–defense. 1 2.2 Total 47 100.0

Number and Percent of Child Homicides from Weapons Reviewed by Person Who Inflicted the Injury,2004

Relationship Number Percent Stranger. 9 19.1 Acquaintance. 5 10.7 Sibling. 3 6.4 Friend. 5 10.7 Parent. 2 4.2 Other family. 1 2.2 Unknown. 22 46.7 Total 47 100.0

The high number of unknown assailants could be because either the perpetrator remains unknown after complete investigation or the case was reviewed prior to suspects being charged.

104 Child Death Review Local Initiatives to Prevent Child Deaths

Type of Weapon Number Percent Teams indicated that there was prior CPS involvement with the child or family in 19 of the 47 deaths reviewed Handgun 36 76.6 in this category. Teams felt the homicides due to firearms and weapons were either probably or definitely Knife 4 8.5 preventable 83 percent of the time, but were hard-pressed to propose preventative activities: Unknown Firearm 4 8.5 Isabella – Team discussed with public school authorities their concern about how home-schooled children can Shotgun 3 6.4 fall through the cracks (primarily mental health and behavioral issues). Total 47 100.0 Jackson – Team addressed a change in agency practice regarding more placement options for children in the CPS system.

Mason – County initiated educational activities in the media regarding overnight supervision of children of all ages by parents via the local media.

Recommendations for Policymakers Circumstance Number Percent Intent to harm. 41 87.1 1. The Michigan State Police: Spearhead an initiative to partner with communities and local law Negligence. 5 10.7 enforcement experiencing high rates of teen homicides, to identify the neighborhoods most at-risk for gun homicides, and implement comprehensive violence-prevention initiatives. Self–defense. 1 2.2 Total 47 100.0 2. The Michigan Department of Education: Develop a comprehensive recommended plan for schools to prevent and reduce violence and bullying, including: a. Educating staff. b. Creating safe, supportive school environments. c. Identifying effective violence prevention and intervention curricula. Relationship Number Percent d. Working with community law enforcement and mental health professionals. Stranger. 9 19.1 e. Engaging parents in these issues. Acquaintance. 5 10.7 3. The Wayne County Sheriff’s Department: Work in collaboration with the Detroit Police Sibling. 3 6.4 Department and the Detroit area schools to identify and implement youth violence prevention Friend. 5 10.7 curriculum in the Middle and High Schools. Parent. 2 4.2 Other family. 1 2.2 4. The Michigan Sheriff’s Association: Work collaboratively with county sheriffs’ offices to ensure that when handguns are presented for safety inspection and registration, the owner physically Unknown. 22 46.7 shows an operable gun safety mechanism that can be used on the handgun presented for registration. Total 47 100.0 5. The Michigan Department of Community Health and the Michigan Department of Human Services: Ensure adequate resources are available to Community Mental Health to ensure accessible treatment for the mental health needs of families by:

a. Continuing to support the Family Resource Centers, evaluate the results and consider expanding into additional schools. b. Utilizing the services of DHS workers who are currently placed in schools to recognize violent tendencies and/or mental health concerns and secure appropriate services for youths.

6. The Michigan Department of Community Health: Partner with the Michigan Chapter of the American Academy of Pediatrics (AAP) to disseminate and implement the AAP’s Connected Kids: Safe, Strong, Secure program to all primary care offices around the state, not just the AAP members.

7. The Children’s Cabinet: Ensure adequate funding and accessibility to mental health services for youth.

Sixth Annual Report Homicides 105 Recommendations for Parents and Caregivers

• If you own guns, they should be properly stored. Keep them in locked cabinets with gun safety devices in place. Store ammunition in a separate locked cabinet. • Be knowledgeable about your child’s activities when they are with friends. • Recognize and seek professional help if your child displays violent behavior.

Homicide – Child Abuse and Neglect

Background

In the U.S. in 2004, National Child Abuse and Neglect Data System reported that an estimated 1,490 children died due to abuse or neglect. More than one-third of child maltreatment fatalities were attributed to neglect, followed by physical abuse (28 percent) and then combinations of maltreatment types (30 percent).

Many child maltreatment deaths from physical abuse involve children receiving injuries to their heads, known as Abusive Head Trauma (AHT). These injuries occur when a child’s head is slammed against a surface, is severely struck or when a child is violently shaken. Shaken Baby Syndrome (SBS) is a form of child abuse that affects between 1,200 and 1,600 children every year. About 25 percent to 30 percent of infant victims with SBS die from their injuries. There have been major improvements in the ability to diagnose AHT and in investigators’ abilities to recognize when a caregiver’s explanation does not match the severity/type of injuries. For example, it is now widely accepted that falls from short heights or a child being accidentally dropped do not cause serious head injuries.

The most common reported trigger for fatal abuse is that the caregiver lost patience when the child would not stop crying. Other common reasons given by abusers often include toilet training issues, fussy eating and disobedient behavior.

Children younger than five years old are at greatest risk of severe maltreatment injury or death in the U.S. In 2004, children four years old and younger accounted for 81 percent of child maltreatment fatalities. Infant boys had the highest rate of fatalities.

Nationally in 2004, 79 percent of the cases of fatal child maltreatment were caused by one or more parents (birth parents, adoptive parents and step-parents). Women acting alone accounted for 31 percent of the deaths. Fatal abuse is often interrelated with poverty, domestic violence and substance abuse. Other contributing factors include the immaturity of parents, lack of parenting skills, unrealistic expectations about children’s behavior or capabilities and social isolation.

National studies report that it is difficult to predict a fatal abuse event. In the U.S., the majority of child victims and their perpetrators had no prior contact with Child Protective Services (CPS) at the time of the death, yet many children had previous injuries that were not reported.

106 Child Death Review Major Risk Factors

• Younger children, especially under the age of five. • Parents or caregivers who are under the age of 30. • Low income, single-parent families experiencing major stresses. • Children left with male caregivers who lack emotional attachment to the child. • Children with emotional and/or health problems. • Lack of suitable child care. • Substance abuse among caregivers. • Parents and caregivers with unrealistic expectations of child development and behavior.

Michigan Mortality Data from Death Certificates

In Michigan, as well as nationally, the actual number of child abuse and neglect deaths is estimated to be much higher than what is reported by death certificate data. A study published in Pediatrics (2002) that reviewed nine years of children’s death certificates estimated that about half of child abuse and neglect deaths are not coded consistently on death certificates. This study reports that neglect is the most under-reported form of fatal maltreatment. There are a number of explanations for the under-reporting of child abuse and neglect, including:

• Physical abuse deaths may be coded as a homicide, but the cause is not coded specifically as child abuse because the perpetrator is not listed on the death certificate. • Neglect deaths may be coded as natural, for example due to malnutrition, hyperthermia or infectious disease. • Some deaths may be coded as accidents, even though grossly negligent acts (or failures to act) on the part of caregivers contributed to the death. • Deaths may have been poorly investigated and the child abuse or neglect went undetected.

In Child Deaths in Michigan: 5th Annual Report, published in 2005, a special section addressed Michigan’s response to the under-counting of child abuse and neglect deaths.

Sixth Annual Report Homicides 107 Michigan Child Homicide Rates Due to Abuse and Neglect, Ages 0-18, 1990-2004

1.0 0.85 0.8 0.72 0.73 0.64 0.59 0.62 0.57 0.56 0.6 0.49 0.48 0.51 0.52 0.44 0.40 0.4 0.22 0.2

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 0.56 in 2004 represents 15 deaths.

Number and Percent of Michigan Child Homicides Due to Child Abuse and Neglect by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 2 13.3 2 13.3 4 26.6 1 to 4 Years 5 33.3 5 33.3 10 66.6 5 to 9 Years 0 0.0 1 6.8 1 6.8 10 to 14 Years 0 0.0 0 0.0 0 0.0 15 to 18 Years 0 0.0 0 0.0 0 0.0 Total 7 46.6 8 53.4 15 100.0

108 Child Death Review Michigan Child Homicide Rates Due to Child Abuse and Neglect by Race*, Ages 0-18, 2004

1.78 2.0

1.5

1.0 0.56 0.5 0.19

0.0

Rate per 100,000 Population White Black Total Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

In 2004, CDR teams reviewed 20 cases of child abuse and neglect homicides. Children ages four and under accounted for 75 percent of these deaths. Sixty percent of the victims were black. Socio-economic status was indicated to be low in 80 percent of the deaths.

Number and Percent of Child Homicides Due to Child Abuse and Neglect Reviewed by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 1 5.0 3 15.0 4 20.0 1 to 4 Years 6 30.0 5 25.0 11 55.0 5 to 9 Years 0 0.0 1 5.0 1 5.0 10 to 14 Years 0 0.0 2 10.0 2 10.0 15 to 18 Years 1 5.0 1 5.0 2 10.0 Total 8 40.0 12 60.0 20 100.0

Sixth Annual Report Homicides 109 Number and Percent of Homicides from Child Abuse or Neglect Reviewed by Type of Abuse or Neglect, 2004

Type of Abuse/Neglect Number Percent Beating / battering. 15 75.0 Shaken Baby Syndrome.* 2 10.0 Strangulation. 1 5.0 Inadequate supervision. 1 5.0 Abandonment. 1 5.0 Total 20 100.0

*Although current head-related abuse is often called Abusive Head Trauma, in both of these cases, the birth certificate indicated the death to be the result of Shaken Baby Syndrome.

Number and Percent of Homicides from Child Abuse or Neglect Reviewed by Person Who Inflicted Injury,2004

Person Inflicting Number Percent the Injury Parent’s partner. 8 40.0 Parent. 7 35.0 Sibling. 2 10.0 Step-parent. 1 5.0 Unknown. 2 10.0 Total 20 100.0

Of the 20 cases of fatal child maltreatment reviewed, 40 percent were killed by their parent’s partner and 40 percent were killed by their parent or step-parent. Natural fathers or step-fathers were the perpetrator 15 percent of the time and natural mothers were the perpetrator 20 percent of the time.

Number and Percent of Homicides from Child Abuse or Neglect Reviewed by Suspected Trigger, 2004

Trigger Number Percent Crying. 5 25.0 Family violence. 4 20.0 Disobedience. 2 10.0 Trying to hide pregnancy/baby. 1 5.0 Toilet training. 1 5.0 Other. 4 20.0 Unknown. 3 15.0 Total 20 100.0

110 Child Death Review There had been known prior CPS involvement with the child who died in 16 of these deaths. Charges were filed in 14 of the 20 cases.

Type of Abuse/Neglect Number Percent There was evidence of prior injuries in 30 percent of the cases. The child or family was previously documented Beating / battering. 15 75.0 by the Department of Human Services as being high-risk for child abuse and neglect in about half of the cases. Shaken Baby Syndrome.* 2 10.0 Strangulation. 1 5.0 Inadequate supervision. 1 5.0 Local Initiatives to Prevent Child Deaths Abandonment. 1 5.0 Total 20 100.0 Teams believed that the child abuse and neglect deaths reviewed were definitely preventable 100 percent of the time. Four of the cases prompted teams to recommend preventative activities:

Kalamazoo – Team offered continued legal, education and media support of the Safe Delivery of Newborns Law.

Muskegon – Team recommended changes in hospital practice, specifically reminding them of their obligation to inform law enforcement in cases of child maltreatment.

Person Inflicting Number Percent the Injury Otsego – Team recommended that personnel at homeless shelters be added to the Child Protection Law as mandated reporters of suspected child abuse and neglect. Parent’s partner. 8 40.0 Parent. 7 35.0 Wayne – Team requested that the media focus on child abuse prevention messages. Sibling. 2 10.0 Step-parent. 1 5.0 Unknown. 2 10.0 Total 20 100.0 Recommendations for Policymakers

1. The Michigan Department of Human Services, Michigan Department of Community Health and Michigan Department of Education: Ensure that human service professionals working with high-risk families are knowledgeable about support programs and resources for new families, especially Maternal Infant Health Program and other state and community-based primary and secondary prevention programs.

2. The Michigan Department of Human Services, Michigan Department of Community Health Trigger Number Percent and Michigan Department of Education, in partnership with other disciplines: Continue the Crying. 5 25.0 collaboration with the Nurse Family Partnership, Inc. in targeting low-income, at-risk Family violence. 4 20.0 children/families and, if further funding can be identified (Michigan Legislature: allocate funds Disobedience. 2 10.0 for or encourage individual communities to fund at a local level), expand the home visitation Trying to hide pregnancy/baby. 1 5.0 programs into more jurisdictions. Toilet training. 1 5.0 3. The Michigan Department of Human Services and the Children’s Trust Fund: Update and continue Other. 4 20.0 funding the Shaken Baby Syndrome Prevention media campaign for the prevention of abusive Unknown. 3 15.0 head trauma. Total 20 100.0 4. Michigan Department of Community Health and Michigan Department of Human Services: In conjunction with the finalization of the new state protocols on child death scene investigation, develop support resources, such as a model of responder communication to be used by county/local agencies (including at least: law enforcement, hospitals, Medical Examiners, EMS, dispatch, local health department and CPS offices).

Sixth Annual Report Homicides 111

Recommendations for Parents and Caregivers

• Try to ensure that your choice of a caregiver or babysitter is a patient person, who is experienced in caring for children, has positive feelings for your child and is not prone to violent behavior, drug abuse or alcoholism.

• If you are feeling overwhelmed or frustrated by your child, call someone you trust and find a way to calm yourself. Never strike, shake or throw your child.

Homicide – Other Causes

Background

This section includes all other homicides reviewed by teams that were not the result of firearms or child abuse and neglect, as described in the previous sections. This includes homicides that resulted from poisoning, motor vehicle crashes, drowning, suffocation and strangulation and fire and burn.

Michigan Mortality Data from Death Certificates

Michigan Child Homicide Rates Due to Other Causes, Ages 0-18, 1990-2004

2.0 1.61

1.5 1.23

0.88 0.94 0.92 0.88 1.0 0.79 0.78 0.73 0.68 0.73 0.55 0.59 0.59 0.52 0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 0.52 in 2004 represents 14 deaths. This is a 29% decrease since 1990 and a 33% decrease from 2003.

112 Child Death Review Number and Percent of Michigan Child Homicides Due to Other Causes by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 2 14.2 1 7.2 3 21.4 1 to 4 Years 1 7.2 2 14.2 3 21.4 5 to 9 Years 1 7.2 0 0.0 1 7.2 10 to 14 Years 0 0.0 3 21.6 3 21.6 15 to 18 Years 2 14.2 2 14.2 4 28.4 Total 6 42.8 8 57.2 14 100.0

Michigan Child Homicide Rates Due to Other Causes by Race*, Ages 0-18, 2004

1.6 1.39 1.4 1.2 1.0 0.8 0.6 0.52 0.4 0.29 0.2 0.0

Rate per 100,000 Population White Black Total Race

*There were not enough deaths of “other” race to calculate a rate.

Sixth Annual Report Homicides 113 Child Death Review Team Findings from CDR Case Reports

CDR teams reviewed the homicides of six children in 2004 that were due to causes other than firearms/weapons or child abuse and neglect. Black children accounted for four of these deaths (67 percent).

Number and Percent of Homicides Reviewed Due to Other Causes by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 1 16.7 0 0.0 1 16.7 1 to 4 Years 1 16.7 1 16.7 2 33.3 5 to 9 Years 1 16.7 0 0.0 1 16.7 10 to 14 Years 1 16.7 0 0.0 1 16.7 15 to 18 Years 0 0.0 1 16.7 1 16.7 Total 4 66.7 2 33.3 6 100.0

Number and Percent of Homicides from Other Causes Reviewed by Cause, 2004

Cause Number Percent Suffocation / strangulation. 4 66.7 Burn. 1 16.7 Animal attack. 1 16.7 Total 6 100.0

These homicides were committed by mothers, a mother’s live-in partner, a teenage friend, an acquaintance and a grandmother. CDR teams deemed that supervision was inadequate in four of the six deaths and that all six were either probably or definitely preventable. There had been prior Child Protective Services involvement in only one of the cases. No prevention activities were proposed by teams in this category of death.

114 Child Death Review Cause Number Percent Suffocation / strangulation. 4 66.7 Burn. 1 16.7 Animal attack. 1 16.7 Total 6 100.0

Child Deaths IN MICHIGAN section seven

SUICIDES

Overview of Child Suicides, Ages 0-18

Background

Suicide is the third leading cause of death in the U.S. for ages 10-19, behind unintentional injury (mostly motor vehicle crashes) and firearm homicide. However, rates remain high. In 2003, more young people in the U.S. died of suicide than heart disease, AIDS, birth defects, stroke, pneumonia, influenza and chronic lung disease combined.

From 1992-2001, adolescent males of all races were four times more likely to commit suicide than females, completing 84 percent of suicides among youths aged 15-19 years. However, adolescent females are more than three times as likely as males to attempt suicide. In the 2003 Youth Risk Behavior Survey, it was reported that among Michigan high school students, 8 percent of boys and 13 percent of girls surveyed had made one or more suicide attempt(s) during the past 12 months. According to the Substance Abuse and Mental Health Administration’s Suicide Prevention Resource Center, one of the “imminent warning signs [of a potential suicide attempt is] exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn.”

The Centers for Disease Control and Prevention attributes the slight decrease in suicides in the U.S. from 1992- 2002 largely to the restriction of access to lethal means, mainly firearms. However, suffocation/strangulation as a means of suicide for persons ages 10-19 has increased over the last decade, with the most dramatic increase being during the time period of 1999-2002.

New research being conducted in the U.S. examines the protective factors that can prevent teen suicide. A strong, positive connection to parents, family and/or school may provide some immunity for teens when they are troubled and could therefore help prevent suicides.

In 2005, Michigan joined 39 other states in the development of a state suicide prevention plan to provide a roadmap to assist in coordinating prevention efforts.

Major Risk Factors

• Previous suicide attempt. • Mood disorders and mental illness. • Substance abuse. • Childhood maltreatment. • Parental separation or divorce. • Inappropriate access to firearms. • Interpersonal conflicts or losses without social support. • Previous suicide by a relative or close friend. • Other significant struggles such as bullying or issues of sexual identity.

118 Child Death Review Michigan Mortality Data from Death Certificates

Michigan Child Suicide Rates, Ages 0-18, 1990-2004

3.5 2.9 3.0 2.6 2.4 2.4 2.4 2.5 2.3 2.2 2.0 2.0 2.0 1.8 1.9 1.9 1.7 2.0 1.6 1.5 1.0 0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 2.2 in 2004 represents 58 deaths. This is a 24% decrease since 1990 and a 29% increase from 2003.

Number and Percent of Michigan Child Suicides by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent 10 to 14 Years 6 10.3 5 8.7 11 19.0 15 to 18 Years 37 63.8 10 17.2 47 81.0 Total 43 74.1 15 25.9 58 100.0

Sixth Annual Report Suicides 119 Michigan Child Suicide Rates by Race, Ages 0-18, 2004

3.0 2.4 2.5 2.2 2.2

2.0

1.5 1.2

1.0

0.5

Rate per 100,000 Population 0.0 White Black Other Total Race

Note: “Other” race represents American Indian, Asian and Pacific Islanders.

Michigan Child Suicide Rates Due to Firearms and Weapons, Ages 0-18, 1990-2004

2.0 1.69 1.63 1.66 1.65 1.57 1.52 1.5 1.15 1.18 1.10 1.06 1.04 0.99 0.97 0.84 1.0 0.71

0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 0.97 in 2004 represents 26 deaths. This is a 43% decrease since 1990 and a 37% increase from 2003.

120 Child Death Review Michigan Child Suicide Rates Due to Suffocation or Strangulation, Ages 0-18, 1990-2004

1.2 1.03 0.97 1.0 0.85 0.85 0.80 0.70 0.74 0.70 0.8 0.64 0.66 0.6 0.49 0.46 0.42 0.44 0.4 0.33

0.2

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 0.97 in 2004 represents 26 deaths. This is a 14% increase since 1990 and from 2003.

Michigan Child Suicide Rates Due to Other Causes, Ages 0-18, 1990-2004

0.38 0.37 0.4 0.35 0.31 0.3 0.26 0.26 0.19 0.18 0.18 0.19 0.22 0.2 0.15 0.11 0.08 0.07 0.1

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Rate per 100,000 Population

Year

Note: The rate of 0.22 in 2004 represents 6 deaths. This is a 37% decrease since 1990 and a 16% increase from 2003.

Sixth Annual Report Suicides 121 Child Death Review Team Findings from CDR Case Reports

Local teams conducted 45 reviews of deaths from suicide in 2004. One of the suicides was reviewed by both the county of residence and the county of incident. Because the findings of these teams differed slightly, both reviews are included in this analysis. There were 44 total suicides reviewed in 2004. Two-thirds of the deaths reviewed were to white males.

Number and Percent of Child Suicides Reviewed by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent 10 to 14 Years 3 6.7 5 11.1 8 17.8 15 to 18 Years 27 59.9 7 15.6 34 75.5 19 to 21 Years 3 6.7 0 0.0 3 6.7 Total 33 73.3 12 26.7 45 100.0

Teams considered most suicide victims (56 percent) to be of middle socio-economic status (SES). Of the remaining suicides, 18 percent were deemed to be of low SES and in 24 percent of the cases, status was unknown.

Number and Percent of Child Suicides Reviewed by Circumstances*, 2004

Circumstance Number Percent Cause Number Percent Followed a precipitating event. 28 62.2 Hanging. 25 55.6 Known mental health problems. 22 48.9 Firearm. 18 40.0 Completely unexpected. 19 42.2 Poisoning / overdose. 2 4.4 Receiving mental health treatment. 17 37.8 Total 45 100.0 Made prior verbal threats. 12 26.7 Made prior attempts. 9 20.0

*A case can have more than one circumstance, therefore these numbers do not sum to a total.

Although not an item collected on the form, teams reported in case narratives that in 11 percent of the suicides reviewed, the youth had been reported by parents, a friend or counselor as exhibiting a sudden or unexplained improvement in their mood after having been depressed or withdrawn.

A total of seven youths were known to be on prescription medications to treat depression and/or other mental health issues at the time that the suicide was completed.

Number and Percent of Child Suicides Reviewed by History of Violence*, 2004

History of Violence Number Percent Demonstrated behaviors predictable of violence. 9 20.0 Had a history of interpersonal violence. 3 6.7 Had a history of domestic violence exposure. 2 4.4

*A case can have more than one historical factor, therefore these numbers do not sum to a total.

122 Child Death Review Often, a precipitating event can be identified as a factor that contributed to the suicide. Other suicides occur with no indication as to why it happened. As they reviewed the deaths, teams found that 42 percent of the suicides appeared to be completely unexpected.

Twenty-four percent of the 45 cases reviewed found that the youths had drugs (illegal or an extremely high level of prescription), alcohol or both in their systems at the time that they completed suicide.

Number and Percent of Child Suicides Reviewed by Precipitating Event*, 2004

Precipitating Event Number Percent Death of friend or family member. 12 26.7 Recent family problems. 10 22.2 Problem with girlfriend/boyfriend. 10 22.2 Problems at school. 7 15.6 Criminal /legal problem. 6 13.3

*A case can have more than one precipitating event, therefore these numbers do not sum to a total.

Twenty percent of the suicide cases reviewed revealed a history of involvement with Child Protective Services. Of those, 44 percent had the suicide victim named as the victim in the abuse or neglect allegations that had been reported.

Number and Percent of Child Suicides Reviewed by Cause of Death, 2004

Type of Object Number Percent Rope or string. 10 40.0 Belt or tie. 6 24.0 Electrical cord. 5 20.0 Dog leash or chain. 2 8.0 Bed sheet. 1 4.0 Shoelace. 1 4.0 Total 25 100.0

History of Violence Number Percent Demonstrated behaviors predictable of violence. 9 20.0 Had a history of interpersonal violence. 3 6.7 Had a history of domestic violence exposure. 2 4.4

Sixth Annual Report Suicides 123 Number and Percent of Child Suicides Due to Firearms Reviewed by Type of Weapon Used, 2004

Weapon Number Percent Handgun. 7 38.9 Rifle. 6 33.3 Shotgun. 5 27.8 Total 18 100.0

Fifteen of the 18 firearms used in these suicides had not been stored in a locked cabinet. None of the firearms were reported to have a trigger lock in place at the time. Five of the youths had regular and easy access to firearms.

Local Initiatives to Prevent Child Deaths

Of the 45 suicides reviewed by all means, local teams decided that most (56 percent) were either probably or definitely preventable. Often, when teams indicate that a suicide was not preventable, they felt that it was either completely unexpected and, therefore, impossible to prevent, or that the teen was so determined to complete the act of suicide that even multiple interventions could not have prevented the death.

Charlevoix/Emmett, Monroe, St Clair – Began suicide prevention education in schools through the Yellow Ribbon Suicide Prevention Program.

Clinton – Suicide prevention subcommittee worked on an in-school education program that also educated the community. They applied for and received a grant from Blue Cross Blue Shield to administer the Columbia Teen Screen and Signs of Suicide (SOS) suicide prevention programs in two county schools.

Genesee – Team subcommittee began to work with teen suicide screening and prevention services that are already in place in area schools and the community. Also provided information on where teens could go/call for help.

Ionia – Community mental health stepped-up their mental health trainings for teens and parents.

Leelanau – Held public forums on suicide prevention and intervention education for parents regarding anti-depressant drugs and signs of depression.

Montcalm – Planned community-wide suicide prevention activities and educational activities in the schools, spearheaded by the intermediate school district.

Oakland - Reconvened the team’s suicide subcommittee, utilizing family service counselor from ME office, local chaplain, and forensic psychologist to look more closely for risk factor patterns in cases of teen suicide.

Saginaw – Coordinated a closer collaboration between the schools and mental health services.

124 Child Death Review Weapon Number Percent Recommendations for Policymakers Handgun. 7 38.9 Rifle. 6 33.3 1. The Michigan Department of Community Health: Encourage funding of a full-time position to Shotgun. 5 27.8 facilitate the implementation of the state suicide prevention plan in local communities. Total 18 100.0 2. The Office of the Governor: Support the State Mental Health Commission in addressing the access to services for youths at risk for suicide and other violence.

3. The Michigan Department of Community Health: Lead a collaborative effort between Community Mental Health, the Michigan Health and Hospital Association, the Department of Human Services and the Michigan Department of Education, to ensure that bereavement services are available to all children who have experienced the recent death of a family member or close friend. Utilize Family Resource Centers as mechanisms to provide referrals.

4. The Michigan Department of Education and the Michigan Department of Community Health: Ensure that parents and teachers are aware of the symptoms of suicidality and educated in the mental health referral process. Ensure that professionals in the fields of public health, mental health, substance abuse and juvenile justice screen for the risk factors of youth suicide and provide intervention services.

5. The Michigan Department of Human Services: Work with the Mental Health Association of Michigan to encourage more trained mental health professionals to work with teens and children.

Recommendations for Parents and Caregivers

• If you notice a change in your child’s behavior or habits, talk to them about it immediately and do not be afraid to seek professional help. • If your child seems depressed, highly anxious or has made suicide threats, seek help from a professional, make sure your child cannot gain access to weapons, and try to limit access to other means of suicide in your home.

Sixth Annual Report Suicides 125

Child Deaths IN MICHIGAN section eight

Undetermined DEATHS Overview of Undetermined Child Deaths, Ages 0-18

Background

“Undetermined” is assigned as the manner of death when the medical examiner believes that there is insufficient evidence or information, especially regarding intent, to assign the manner as Natural, Accident, Homicide or Suicide. That is why there may be deaths included in this section that have similar causes as deaths in other sections, but with an undetermined manner.

Since 2000, roughly half of the undetermined deaths reviewed have been to infants in sleeping environments. Improvement in the number and quality of death scene investigations for sudden unexplained infant deaths (SUID) is providing better information about the involvement of environmental factors in infant sleep-related deaths. Many infant deaths that would have been labeled SIDS a decade ago are now labeled accidental suffocation from unsafe sleeping conditions. However, in some infant sleep-related deaths, it may not be obvious whether an environmental mechanism (such as heavy or soft bedding, an adult sharing a sleep surface, etc.) contributed to the death, even though it is present. These deaths may be categorized as “undetermined” by the medical examiner.

Infant sleep-related deaths that are “undetermined” are not being counted accurately at the state and national levels. The death certificate electronic coding software provided to the state vital records department by the Centers for Dis- ease Control and Prevention (CDC) typically codes these deaths as SIDS rather than undetermined. This is one reason for the discrepancy in the number of “undetermined” deaths in mortality data vs. CDR findings.

Michigan Mortality Data from Death Certificates

Michigan Child Death Rates Due to Undetermined Manner, Ages 0-18, 1990-2004

0.8 0.75 0.7 0.62 0.59 0.56 0.6 0.44 0.44 0.44 0.5 0.40 0.41 0.38 0.38 0.38 0.37 0.34 0.4 0.29 0.3 0.2 0.1

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2003 Rate per 100,000 Population

Year

Note: The rate of 0.75 in 2004 represents 20 deaths. This is a 21% increase since 1990 and a 34% increase from 2003.

128 Child Death Review Number and Percent of Michigan Undetermined Child Deaths by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 2 10.0 0 0.0 2 10.0 1 to 4 Years 0 0.0 3 15.0 3 15.0 5 to 9 Years 1 5.0 2 10.0 3 15.0 10 to 14 Years 1 5.0 1 5.0 2 10.0 15 to 18 Years 8 40.0 2 10.0 10 50.0 Total 12 60.0 8 40.0 20 100.0

Michigan Undetermined Child Death Rates by Race*, Ages 0-18, 2004

1.5 1.39

1.0 0.75 0.62

0.5

Rate per 100,000 Population White Black Total Race

*There were not enough deaths of “other” race to calculate a rate.

Child Death Review Team Findings from CDR Case Reports

Well over half (66 percent) of the undetermined cases reviewed were to infants less than one year of age. Most of these infant deaths occurred in a sleep environment.

Sixth Annual Report Undetermined Deaths 129 Number and Percent of Undetermined Child Deaths Reviewed by Sex and Age, 2004

Sex Total Age Group Male Female Number Percent Number Percent Number Percent Under One Year 21 44.7 10 21.2 31 65.9 1 to 4 Years 0 0.0 3 6.4 3 6.4 5 to 9 Years 1 2.1 1 2.1 2 4.3 10 to 14 Years 1 2.1 2 4.3 3 6.4 15 to 18 Years 7 14.9 1 2.1 8 17.0 Total 30 63.8 17 36.2 47 100.0

Number and Percent of Undetermined Child Deaths Reviewed by Cause, 2004

Cause Number Percent Unknown Cause in a sleep environment. 28 59.6 Acute intoxication / overdose. 5 10.6 Fire. 3 6.4 Other undetermined. 11 23.4 Total 47 100.0

Unknown Cause/Possible Suffocation in a Sleep Environment

Fifteen infants were found in situations where bedding could have obstructed their mouth and nose. Six of these infants were placed to sleep on their stomachs on top of pillows, blankets or soft mattresses; five of these infants were placed to sleep on their backs or sides and subsequently rolled onto their stomachs on top of pillows, blankets or soft mattresses; and four of these infants were placed to sleep with blankets, quilts or comforters over their heads. Half of these infants (eight) were also reported to have had a cold or some other respiratory ailment that may have placed them at higher risk of suffocation in bedding.

Nine infants and a 19-month-old were likely victims of overlay while sharing a sleeping surface with adults or siblings. The bed-sharing adult was found to be impaired by drugs or alcohol in three of these deaths. Obesity was a factor in three cases. In three of the deaths, it was noted that the family had a crib or bassinet that could have been used. In one case, a mother fell asleep while breastfeeding the baby.

In one case, it was unclear whether the infant died from bedding over its head or by overlay. Two deaths were signed out as undetermined sleep-related, but the review team is suspicious of the stories given and believed that they may have actually been homicides.

Acute Intoxication / Overdose

Three underdetermined cases involved teenagers using drugs or alcohol. Illicit drugs were used in two cases and prescription drugs and alcohol were used in one case. Two children were given an overdose of over-the-counter medication. In all of these cases, intent was unclear.

130 Child Death Review Fire

Two children died in one fire where the older victim was a known fire starter. The older child was likely playing with matches or a lighter. One teenager died in a fire in an abandoned house. The fire may have been started by candles that were left burning. Again, the questions surrounding intent led to the “undetermined” manner determination.

Other Undetermined Deaths

Two children died from possible child neglect. One child died of malnutrition and failure to thrive and the other child died from not receiving needed medical services. Both families had prior contact with Child Protective Services and one family was receiving prevention services.

Two children died from strangulation. One involved a window blind cord and the other child had apparently hung himself. It was not clear in either case whether the children had meant to take their own lives.

Two teenagers possibly died from sudden cardiac death. One child was known to have been playing sports at the time.

One teen was hit by a car, but it is unclear whether it was accidental or intentional.

Cause Number Percent One infant died with a small amount of alcohol in his system, and it is believed that a family member put alco- Unknown Cause in a sleep environment. 28 59.6 hol in the bottle to “help the infant sleep.” Attempting to quiet a colicky infant with alcohol is generally consid- Acute intoxication / overdose. 5 10.6 ered dangerous by the medical community. Fire. 3 6.4 One toddler died suddenly and unexpectedly in her sleep with no evidence of illness. Another toddler also died Other undetermined. 11 23.4 suddenly and unexpectedly in his sleep after exhibiting flu-like symptoms. An older child died in his sleep after Total 47 100.0 apparently suffering a seizure.

Local Initiatives to Prevent Child Deaths

Of all 47 deaths reviewed that were given an undetermined manner, teams believed the deaths were probably or definitely preventable in 85 percent of the cases. Teams proposed 31 local prevention activities related to deaths of undetermined manner and implemented 24 of those. Examples include:

Branch – Created an office of cultural affairs to alleviate language barrier issues in prevention services.

Wayne – Wrote to a major store chain that sells baby products to request that they stop showing “demo rooms” with unsafe infant sleep environments and to ask them to stop selling “sleep packages” that include bumper pads.

Recommendations for Policymakers

2. The Michigan Department of Community Health and Michigan Association of Medical Examiners: Work together to resolve death certificate language to ensure that undetermined infant deaths in sleep environments are coded as undetermined in the state electronic death file rather than SIDS or other natural death.

Sixth Annual Report Undetermined Deaths 131 Authored by: Cheryl Lauber, MSN, DPA Child Deaths IN MICHIGAN section nine

Fetal and Infant Mortality REVIEW

Authored by: Cheryl Lauber, MSN, DPA Introduction

In the late 1980s, two local Fetal and Infant Mortality Review (FIMR) projects were begun in Michigan, modeled after the National FIMR project of the American College of Obstetricians and Gynecologists. The projects sought to identify factors associated with infant loss and develop recommendations to prevent future poor pregnancy outcomes. Today, there are 14 local FIMR projects operating under the leadership and technical assistance of the Michigan Department of Community Health (MDCH). This report summarizes the background, findings of the case reviews and recommendations of the teams for improving birth outcomes in Michigan.

Purpose of FIMR

Even though vital statistics data clearly identify disparities in infant outcomes, they may not necessarily suggest strategies at the local level to address the problem. The information from FIMR complements this quantitative population–based data and suggests meaningful local solutions to improve service systems and resources for those most at risk for poor outcomes.

As one FIMR team epidemiologist explained, “The Infant Mortality Review Program permits us to go well beyond the analysis of vital records data, to reveal the underlying experiences, attitudes and medical histories of pregnant and parenting women and the offspring they have lost. Held up for inspection and review by a multidisciplinary community review team committed to improving perinatal health outcomes in the community; this information provides a ‘window’ into the maternal and child health systems in the community.”

The overall goal of FIMR is to enhance the health and well-being of women, infants and families by improving the community resources and service delivery systems available to them. Through FIMR, key members of the community come together to review information from individual infant deaths. The purpose of these reviews is to identify the factors associated with these deaths, determine if they represent systems problems that require change, develop recommendations for change and assist in the implementation of change.

The overall FIMR objectives are:

• Identify both positive and negative social, economic, cultural, safety and health factors associated with the overall fetal and infant mortality as well as factors associated with neighborhoods and community groups with higher mortality through review of individual cases.

• Work with the community to plan a series of targeted and culturally competent interventions and policies that address the negative factors and improve the service systems and community resources.

• Participate in the implementation of these community-designed interventions and policies.

• Assess the progress of the interventions and work to maintain the positive aspects of the systems serving families.

Connection to Infant Mortality

Sadly, infants continue to die each year despite being born in one of the best health care systems in the world. In an effort to discover how the system fails these babies, case reviews have offered a way to gain in-depth information about individual cases. Furthermore, MDCH began a new infant mortality initiative in 2005 that targets racial disparity in infant deaths. Eleven communities were identified with high black infant mortality rates and have been given funding to, among other things, establish a FIMR team. African American infant deaths will be studied in-depth to find what’s missing in the overall strategy to improve pregnancy outcomes and reduce infant deaths.

134 Child Death Review Perinatal Periods of Risk Framework

The FIMR case study approach is providing information that further expands the PPOR model, suggesting specific interventions that may reduce deaths associated with particular periods of risk. The Michigan program is requesting that counties review cases that correspond to their highest periods of risk and make recommendations for systems change in those areas.

Maternal Health/ Prematurity 486 (3.7)

Maternal Newborn Infant Care Care Health 173 (1.3) 177 (1.4) 253 (2.0)

PPOR Map of Feto-infant Mortality Numbers and Rates, Michigan, 2002. Overall Rate = 8.4

The goals for improving maternal health/prematurity are:

• Improve the health status of women to maximize chances for having healthy babies. • Increase the proportion of pregnancies that are planned.

Best practice information suggests the objectives to reach these goals are:

• Provide access to family planning and effective contraception. • Assess women’s health and risks before conception/pregnancy. • Monitor and treat existing maternal medical problems. • Educate women on optimal spacing of pregnancies. • Assure early entry and adequate prenatal care. • Educate about symptoms of early labor. • Reduce smoking and alcohol consumption prior to pregnancy. • Improve percent of high-risk pregnancies delivered at appropriate hospitals.

The goal for improving maternal care is to increase the proportion of births born full term, at normal birth weight, and at low risk for infant morbidity and mortality.

Sixth Annual Report FIMR 135 Best practice information suggests the objectives to reach this goal are:

• Assure partners are healthy. • Identify and screen all women for pregnancy risk. • Provide in-home and/or in-community supports for at-risk women. • Assure early entry and adequate prenatal care. • Monitor and treat maternal medical problems. • Improve percent of high-risk pregnancies delivered at appropriate hospitals.

The goal for improving newborn care is to increase the proportion of newborns whose acute problems are immediately identified and effectively addressed.

Best practice information suggests the objectives to reach this goal are:

• Improve appropriate in-hospital preparation for parenting. • Provide newborn screening and follow-up. • Discharge plans to meet the newborn needs. • Assure link to pediatric provider. • Assure link with home visitation programs.

The goal for improving infant health is to improve infant health relative to known risk conditions.

Best practice information suggests the objectives to reach this goal are:

• Improve access to primary care. • Assure assessment of family social/environmental risks and intervention. • Assure teaching regarding infant safe sleep and breastfeeding. • Educate about the signs, symptoms and what to do for infection in infancy. • Assure access to developmental assessment and therapies.

Most communities continue to experience a higher percentage of deaths related to prematurity and low birth weight. The PPOR model suggests that interventions should be targeted at women before pregnancy in order to significantly lengthen gestation. FIMR teams are interested to learn where and how to reach women before conception.

The second period of concern is for deaths that occur to normal birth weight babies who die between one month and one year of age. Most of these deaths occur during sleep and are sudden and unexpected. Though safe sleep campaigns are active across the state, many infants continue to be sleeping in unsafe situations. FIMR reviews hope to determine how to overcome racial, economic and other barriers to accepting the safe sleep message.

136 Child Death Review FIMR Background

History of Michigan FIMR Network

The Michigan Department of Community Health (MDCH) supported these projects with technical assistance, and statistical and epidemiological information. The value of this surveillance and review was recognized, and provided the background for establishing statewide support for local FIMR teams. The three original FIMR projects also demonstrated the interaction needed between FIMR and other MCH programs designed to lower infant mortality.

MDCH received a grant in 1997 from the federal Maternal and Child Health Bureau to establish a state FIMR program that would provide technical assistance and support to new and established local FIMR teams. Using epidemiological data from MDCH, particular communities or counties were targeted for new teams based on their infant mortality rates. The FIMR program was established within the Division of Family and Community Health (DFCH) at MDCH, with program direction from an MCH program consultant. It is a good fit here with other infant death initiatives such as Healthy Start and Sudden Infant Death Services. Related programs, such as Adolescent Health, Family Planning, Maternal Infant Health Program, Medicaid Outreach, Prenatal Smoking Cessation, and PRAMS are also located in this division, allowing ease of coordination.

At the start of the support project, Michigan had two active FIMR sites. By the end of project year four, a total of 10 active FIMR sites existed in Michigan, establishing a FIMR presence in the communities that account for approximately 60 percent of the state’s infant mortality. The state FIMR Coordinator’s Network was established, with monthly meetings held for the purpose of keeping FIMR teams up-to-date with emerging state policies and programs, problem solving, and sharing program successes. Now there are 14 FIMR projects, 11 in the highest infant mortality counties in Michigan.

Annual statewide FIMR trainings are held to focus on new review team members and to explore relevant topics for experienced members. Training topics have now been added to the monthly FIMR Coordinator’s meetings to further develop the general wisdom about pregnancy outcomes. Contact is maintained between Michigan’s coordinators through email, both from National FIMR and from the state staff.

Sixth Annual Report FIMR 137 Figure 54 Fetal and Infant Mortality Review Teams, 2004

Intertribal Council of Michigan

* Teams in Formation

City of Pontiac

City of Southfield

City of Detroit

FIMR Process

Michigan FIMR projects use the national FIMR guidelines that advise the following process outlined by this sche- matic. Each local project determines the methods for each step that work best in that locale. Infant deaths are typically identified locally and the project coordinator determines which cases will be reviewed. Prenatal and delivery records from the birth hospital are the mainstream of information, while other records may be sought from other individual providers. An interview with the mother is requested and provides the most family- specific data. The coordinator produces a summary of the information gathered that is reviewed by the FIMR team and conclusions and recommendations are suggested. Most projects take these recommendations to a local board or committee that further analyze the information for making community changes. Finally, the summary data is provided to the state database for analysis.

The state coordinator works with local communities in developing a process for reviewing infant deaths in order to improve local systems of health care. The FIMR process identifies and examines factors associated with early deaths through the evaluation of individual cases. The family may receive an in-home interview, a unique opportunity to learn first-hand about the pregnancy and what led up to this baby’s demise. A community review team discusses the facts about each child’s situation from anonymous data collected from all providers. The team then makes recommendations from their findings to community leaders with the expectation of preventing future deaths.

138 Child Death Review FIMR Process

Case finding.

Records Home abstraction. interview.

Case summary.

Data report Case review. to state.

Recommendations to community board.

FIMR report to community.

FIMR Role in Public Health

Surveillance

Surveillance is the ongoing systematic collection and analysis of data about a health problem that can lead to action being taken to control or prevent the problem. An infant death is a sentinel event that triggers surveillance activities. Infant death is a measure of a community’s social and economic well being. It is also a measure of the organization and abilities of its health and human services resources. Infant mortality is associated with a variety of factors including quality of and access to prenatal and pediatric health care, socio-economic conditions, family stressors, strength of local service systems and the soundness of the community’s infrastructure.

FIMR is a surveillance methodology used in Michigan to monitor and understand infant death. Information gained from the FIMR team review, in conjunction with vital statistics data, Pregnancy Risk Assessment Monitor- ing System (PRAMS) data, Behavioral Risk Factor Survey System (BRFSS) data, Maternal Mortality Review data and other public health surveillance methods, can produce a complex system of information.

Sixth Annual Report FIMR 139 Functions of public health vs FIMR objectives

A national work group defined essential public health functions in the mid 1990s in an exercise to explain what public health is all about. As one compares these functions with the objectives of FIMR, it is clear that the process of local review of infant deaths contributes significantly to the essential role of public health.

1. Monitor health status to identify community health problems. 2. Diagnose and investigate health problems in the community. 3. Inform, educate and empower people about health issues. 4. Mobilize community partnerships to identify and solve health problems. 5. Develop policies and plans that support individual and community health. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure a competent public health and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems.

Community Involvement

This program provides an opportunity for members of the clinical, public health and social service communities to discuss poor reproductive and infant outcomes. The review process can establish new lines of communication among different arenas of health service delivery. The collaborative participation of these disciplines should be a central component of the review process.

Makeup of local FIMR review teams

Most teams have found that the community groups that should be part of the team include: 1) community service administrations, 2) public health, 3) social service agency, 4) physicians – obstetrician, pediatrician, 5) nurse and midwife, 6) child health organizations, 7) law enforcement and 8) health professional schools. The diversity of the team assures a broad perspective on the issues encountered and expert opinion about the circumstances of the death. Other experts on issues such as substance abuse may be added to the team for particular cases.

Focus of local recommendations

Local communities define the cases/issues that will be reviewed. Because time and resources are usually limited, most teams are unable to review all infant deaths. If a community has undertaken a community needs assessment related to infant mortality, the outcome will suggest the focus of team review and recommendations. Most projects want to provide information about gaps or problems in accessing prenatal and other care within the local health care delivery system.

To help identify the target population for review and thus to develop evidence-based local recommendations, MDCH is recommending that each of the local projects use the PPOR framework and its individual findings. The PPOR model proved to be a powerful community tool that also offers a scientific approach to solutions that can be used by the FIMR sites.

140 Child Death Review Michigan FIMR Network

Goals and objectives of state collaboration

Local FIMR teams have not always been successful in finding resources to operate. Collaboration with state Title V efforts offers credibility and a broader perspective that has enhanced the community will to offer this service. A state network of FIMR coordinators began meeting monthly in 1998 with the major goal of sharing experiences around developing a review team, identifying cases and gathering data. Since that time the network meetings continue to offer shared experience and motivation for new teams. The network now acts as a sounding board for MDCH infant mortality initiatives and a resource for local opinion and feedback about new projects and questions. In addition, network meetings are utilized for in-service and continuing education for FIMR coordinators.

A state coordinator provides training for new local coordinators, convenes the network meetings and facili- tates the objectives of the FIMR program. These meetings also serve to connect local coordinators to the other perinatal initiatives in the state, such as the Healthy Start Network, the State Infant Mortality Initiative, the Birth Defects Registry Project and Michigan’s Healthy Mothers/Healthy Babies Coalition.

Data collection and analysis process

Three instruments for data collection have been in use by local FIMR teams for several years and used for reporting to the common state database. Findings presented below come from the Maternal and Child Profile, the Issues Related to Infant Mortality Summary form and the Issues and Recommendations Form.

The Maternal and Child Profile is the first page of the large chart abstraction tool and summarizes demograph- ic information about the baby and mother, as well as the mother’s reproductive and prenatal history. The rest of the chart abstraction tool had not been adopted uniformly in all the local teams. A home interview tool is also used to collect that information, but has not been uniform to date and not reported to the state.

The Issues Related to Infant Mortality Summary is used at each case review to identify relevant issues to be discussed by the team. Though several modifications have occurred in the form over the last few years, the main categories are the same and continue to reflect the best wisdom about medical, family, psychosocial and environmental impacts associated with infant death.

The Issues and Recommendations are conclusions made by local reviews regarding the most significant factors. Teams discuss what local and/or state actions should be undertaken to make changes in the system. Local community action teams use these recommendations to plan strategically for local change. The state FIMR program uses these recommendations to evaluate where program change is needed.

The state FIMR network began developing a new data collection tool for chart abstraction and a new home interview tool in 2004. Both tools were piloted during 2005 and hold promise for producing more computerized information.

Findings

The state FIMR database is housed in and managed by the Michigan Public Health Institute, Child and Adolescent Health Program. The data presented below come from reports submitted by local FIMR coordinators reflecting team reviews of individual cases, basic information on mother and child from chart abstraction and summary case information from team consensus.

Sixth Annual Report FIMR 141 Cases Reviewed by Year, 2000–2004

Year of Review Cases Reviewed Gestational Age Number Percent 2000 75 Very preterm (<32 weeks). 113 49.1 2001 108 Moderate preterm (32-36 weeks). 28 12.2 2002 126 Term (37 weeks and over). 85 37.0 2003 222 Unknown. 4 1.7 2004 230 Total 230 100.0 Total 761

There were 761 cases reviewed between 2000 and 2004. The deaths reviewed in these cases occurred between 1998 and 2004.

Cases Reviewed by Year of Death, 2000–2004 Birth Weight Number Percent Infant deaths in Year of Death Number Percent Very LBW (<1,500 grams). 109 47.4 Michigan* Moderate LBW (1,500-2,499 grams). 31 13.5 2000 91 8.2 1,112 Normal BW (2,500 grams and over). 80 34.8 2001 123 11.5 1,066 Unknown. 10 4.3 2002 181 17.2 1,054 Total 230 100.0 2003 165 14.8 1,112 2004 51 5.2 984 Total 611 11.5 5,328

*Source: MDCH, Division for Vital Records and Health Statistics.

Typically, teams review cases about one year after the death. As the number of teams has increased since 1998, the percent of deaths reviewed annually has increased.

The rest of the findings refer just to cases reviewed in 2004.

Number and Percent of Cases Reviewed by Age at Death, 2004

Age at Death Number Percent Neonatal (Birth–28 days). 101 43.9 Postneonatal (28–364 days). 92 40.0 Unknown. 37 16.1 Total 230 100.0

The cases reviewed reflect an emphasis on postneonatal deaths (40 percent of cases reviewed) since only approximately 30 percent of infant deaths annually in the state are postneonatal. The missing information represents a significant portion of the cases reviewed.

142 Child Death Review Number and Percent of Cases Reviewed by Gestational Age, 2004

Gestational Age Number Percent Very preterm (<32 weeks). 113 49.1 Moderate preterm (32-36 weeks). 28 12.2 Term (37 weeks and over). 85 37.0 Unknown. 4 1.7 Total 230 100.0

There are 61 percent of cases reviewed that are born prematurely. This suggests that even though some babies survive after 30 days, prematurity may still impact the circumstances of death.

Number and Percent of Cases Reviewed by Birth Weight, 2004

Birth Weight Number Percent Infant deaths in Year of Death Number Percent Very LBW (<1,500 grams). 109 47.4 Michigan* Moderate LBW (1,500-2,499 grams). 31 13.5 2000 91 8.2 1,112 Normal BW (2,500 grams and over). 80 34.8 2001 123 11.5 1,066 Unknown. 10 4.3 2002 181 17.2 1,054 Total 230 100.0 2003 165 14.8 1,112 2004 51 5.2 984 Total 611 11.5 5,328 Since 75 percent of the cases reviewed were born under weight, the precursors of low birth weight need to be examined more to determine more effective strategies for improving the chances for survival.

Number and Percent of Cases Reviewed by Race/Ethnicity of Mother, 2004

Maternal Race / Ethnicity Number Percent White 96 41.7 Black 113 49.1 Hispanic / Latina 14 6.1 Native American 0 0.0 Age at Death Number Percent Asian / Pacific Islander 2 0.9 Neonatal (Birth–28 days). 101 43.9 Multi-racial 0 0.0 Postneonatal (28–364 days). 92 40.0 Unknown 5 2.2 Unknown. 37 16.1 Total 230 100.0 Total 230 100.0 African American infant deaths are over represented in these case reviews, but should provide more information on the basis of the racial disparity in infant mortality in Michigan.

Sixth Annual Report FIMR 143 Number and Percent of Cases Reviewed by Age of Mother, 2004

Maternal Age Group Number Percent Under 15 years 0 0.0 Factors Number Percent 15 to 19 years 36 15.7 Infection: 20 to 24 years 76 33.0 Chorioamnionitis. 31 25.4 25 to 29 years 63 27.4 Bacterial vaginitis. 7 5.7 30 to 34 years 36 15.7 Sexually transmitted infection. 21 17.2 35 to 39 years 13 5.7 Terminations/loss: 40 years and older 5 2.2 Previous voluntary interruption. 16 13.1 Unknown 1 0.4 Previous spontaneous abortion. 32 26.2 Total 230 100.0 Previous fetal loss. 11 9.0 Previous infant loss. 5 4.1 Although the cases reviewed somewhat over–represent the number of teen births in Michigan, the numbers Obesity and nutrition: do reflect the fact that most infant deaths happen to older women. Obesity. 38 31.1 Overweight. 7 5.7 Number and Percent of Cases Reviewed by Risk Factors, 2004* Insufficient weight gain. 11 9.0 Poor nutrition. 6 4.9 Factors Number Percent Substance used: Maternal Risk Factors: Smoked during pregnancy. 43 35.2 First Pregnancy <18 Years Old. 77 33.5 Drank alcohol. 15 12.3 < 12th Grade Education. 60 26.1 Used illicit drugs. 20 16.4 Unintended Pregnancy. 91 39.6 Method of payment: Entry to Prenatal Care: Self pay; medically indigent. 4 3.3 12 weeks gestation and earlier. 134 60.9 Medicaid; managed care. 70 57.4 Greater than 12 weeks gestation. 52 22.6 Maternal stress: Unknown. 44 19.1 Lack of family support. 17 13.9

*A single case can include more than one factor, therefore these numbers do not sum to a total. Lack of father of baby support. 21 17.2 History of mental illness. 14 11.5 Current depression/mental illness. 21 17.2 The high percentage of reviewed deaths with the risk factor “unintended pregnancy” continues to raise Multiple stresses / social chaos. 45 36.9 questions for MDCH about the importance of this factor in predicting infant death and how to reduce this factor among at-risk women. The information about beginning the reproductive life as a teenager suggests History of abuse / harassment. 21 17.2 that it is often the second, third or higher pregnancy that has a poor outcome. There should be points of Current abuse / harassment. 7 5.7 intervention with these at-risk women during the childbearing years as needed.

It is also interesting to note that most cases reviewed had entered prenatal care in the first trimester. More information is needed to determine if any changes could be made in the care provided to improve pregnancy outcomes.

144 Child Death Review Number and Percent of Neonatal Deaths (N=122) Reviewed by Factors Associated with Infant Death, 2004 Maternal Age Group Number Percent Under 15 years 0 0.0 Factors Number Percent 15 to 19 years 36 15.7 Infection: 20 to 24 years 76 33.0 Chorioamnionitis. 31 25.4 25 to 29 years 63 27.4 Bacterial vaginitis. 7 5.7 30 to 34 years 36 15.7 Sexually transmitted infection. 21 17.2 35 to 39 years 13 5.7 Terminations/loss: 40 years and older 5 2.2 Previous voluntary interruption. 16 13.1 Unknown 1 0.4 Previous spontaneous abortion. 32 26.2 Total 230 100.0 Previous fetal loss. 11 9.0 Previous infant loss. 5 4.1 Obesity and nutrition: Obesity. 38 31.1 Overweight. 7 5.7 Insufficient weight gain. 11 9.0 Poor nutrition. 6 4.9 Substance used: Smoked during pregnancy. 43 35.2 Drank alcohol. 15 12.3 Used illicit drugs. 20 16.4 Method of payment: Self pay; medically indigent. 4 3.3 Medicaid; managed care. 70 57.4 Maternal stress: Lack of family support. 17 13.9 Lack of father of baby support. 21 17.2 History of mental illness. 14 11.5 Current depression/mental illness. 21 17.2 Multiple stresses / social chaos. 45 36.9 History of abuse / harassment. 21 17.2 Current abuse / harassment. 7 5.7

FIMR teams have discovered many factors that may impact a family that has an infant death. Each of these factors deserves more attention and study to understand its significance. Screening and treatment of infections should command more attention. The fact that these families seem to be familiar with fetal and infant loss is important in identifying at-risk women. Obesity has become a national epidemic and seems to play some role in infant death as well. A higher percentage of these cases was covered by Medicaid than the overall births. Stress in many areas seems to be a common factor as well.

Sixth Annual Report FIMR 145 Number and Percent of Cases Reviewed by Cause of Death*, 2004

Cause of Death Number Percent Perinatal condition: 104 45.2 Complications of pregnancy / labor / delivery. 4 1.7 Prematurity (28-37 weeks). 10 4.3 Extreme prematurity (<28 weeks). 88 38.3 Birth trauma. 1 0.4 Respiratory distress. 1 0.4 Congenital anomaly: 36 15.7 Nervous system. 7 3.0 Cardiovascular. 9 3.9 Respiratory. 1 0.4 Gastrointestinal. 1 0.4 Genitourinary. 3 1.3 Musculoskeletal. 1 0.4 Chromosomal. 8 3.5 Other. 5 2.2 Unknown. 1 0.4 Infection: 13 5.7 Nervous system. 2 0.9 Respiratory. 8 3.5 Septicemia. 2 0.9 Other. 1 0.4 Injury: 38 16.5 Motor vehicle. 2 0.9 Poisoning. 1 0.4 Fire / burn. 1 0.4 Drowning. 3 1.3 Post Suffocation. 31 13.5 Birth Weight Fetal Neonatal neonatal SIDS. 14 6.1 Other. 10 4.3 < 500 grams 0 137 6 Undetermined. 5 2.2 500–1,499 grams 0 154 46 Unknown. 10 4.3 1,500–2,499 grams 0 44 48 Total 230 100.0 2,500+ grams 0 44 161 UNK 0 15 8 *Cause of death is based on team findings. Total 0 394 269 Even though some FIMR teams have targeted certain types of deaths, the distribution by cause is diverse, suggesting that infant death is complicated. Targeted study of specific causes may be important to finding prevention strategies.

146 Child Death Review The following table reflects the number of cases reviewed by each of the FIMR teams in 2004.

Cause of Death Number Percent Cases Reviewed by Each FIMR Team, 2004 Perinatal condition: 104 45.2 County Number Percent Complications of pregnancy / labor / delivery. 4 1.7 Berrien 33 14.3 Prematurity (28-37 weeks). 10 4.3 Branch 0 — Extreme prematurity (<28 weeks). 88 38.3 Calhoun 13 5.7 Birth trauma. 1 0.4 Genesee 13 5.7 Respiratory distress. 1 0.4 Ingham 0 — Congenital anomaly: 36 15.7 Jackson 20 8.7 Nervous system. 7 3.0 Kalamazoo 11 4.8 Cardiovascular. 9 3.9 Kent 29 12.6 Respiratory. 1 0.4 Oakland 24 10.4 Gastrointestinal. 1 0.4 Saginaw 21 9.1 Genitourinary. 3 1.3 Tuscola 0 — Musculoskeletal. 1 0.4 Washtenaw 19 8.3 Chromosomal. 8 3.5 Detroit 36 15.7 Other. 5 2.2 Other 5 2.2 Unknown. 1 0.4 UNK 6 2.6 Infection: 13 5.7 Total 230 100.0 Nervous system. 2 0.9 Respiratory. 8 3.5 Septicemia. 2 0.9 Other. 1 0.4 Having the FIMR cases reviewed between 2000-2004 into the PPOR framework would help understanding the association between the two dimensions, birthweight and age at death, that leads to focused recom- 38 16.5 Injury: mendations as mentioned above in this report. Motor vehicle. 2 0.9 Poisoning. 1 0.4 Age at Death vs. Birthweight of Cases Reviewed (PPOR framework), 2000-2004 Fire / burn. 1 0.4 Drowning. 3 1.3 Post Suffocation. 31 13.5 Birth Weight Fetal Neonatal neonatal SIDS. 14 6.1 Other. 10 4.3 < 500 grams 0 137 6 Undetermined. 5 2.2 500–1,499 grams 0 154 46 Unknown. 10 4.3 1,500–2,499 grams 0 44 48 Total 230 100.0 2,500+ grams 0 44 161 UNK 0 15 8 Total 0 394 269

The framework for the perinatal periods of risk map needs enough numbers in each cell to be valid, therefore requiring using multiple years of data. There were 98 cases with unknown age at death that could not be included in this map and no fetal deaths were reviewed.

Sixth Annual Report FIMR 147 Cases Reviewed by Period of Risk, 2000-2004

343 Maternal Health/ Prematurity

0 88 209 Maternal Neonatal Infant Care Care Health

This map of the periods of risk shows that 54 percent of the cases reviewed were very low birthweight (maternal health/prematurity). Interventions to prevent many of these deaths must be directed at women prior to pregnancy. Another 33 percent of the cases reviewed were normal birthweight and died during the postpartum period infant health). Interventions to prevent many of these deaths must be directed at improving infant health. About 14 percent of the cases reviewed were normal birthweight but died of complications of pregnancy, usually without going home from the neonatal intensive care unit (NICU). Interven- tions to prevent these deaths require investigation of the medical conditions involved and the access to expert NICU care. No fetal deaths were reviewed so there is no information about maternal care.

An important part of the FIMR process is the information provided about cause of death and the environment or circumstances at the time of death. Because this information is unique to each case, it is often hard to aggregate the data. Environmental conditions contributed to seven infant deaths in Jackson County. Five infants died co-sleeping. Two infants died sleeping prone with blankets nearby. In four of the cases, lack of adequate adult supervision was identified.

FIMR team reviews also attempt to find factors that may be associated with the death, such as events prior to pregnancy. The Kent County FIMR team found that most of the 57 cases reviewed in 2004 were associated with substance abuse, Medicaid eligibility, first pregnancy before age 18 and previous pregnancy termination among the African American infant deaths.

Psychosocial factors have also been implicated in infant death. Kent County FIMR also found that most of the African American mothers experienced multiple stresses, unintended pregnancy, less than 12th grade education and domestic violence.

148 Child Death Review Recommendations

The state Infant Mortality Initiative and local FIMR teams endorse the following recommendations to improve the excess (preventable) deaths related to maternal health (see PPOR model). Though there are some preventable deaths related to the maternal care and newborn care periods, the numbers are small. MDCH has determined that resources should be devoted to maternal health and infant health to have the best results.

1. Study the characteristics of all deaths in the maternal health category, particularly characteristics of the mother. 2. Improve the ability to interview mothers to gain information on this period of risk. 3. Determine how to identify and review fetal deaths. 4. Determine available points of contact with mothers prior to pregnancy to enable risk assessment, intervention and planning of pregnancy. 5. Identify the tested strategies that have worked to prolong pregnancies to term and promote normal birth weight. 6. Explore how existing programs might monitor preconception or other maternal health promotion strategies, i.e. PRAMS questions re: pregnancy intention, block grant objectives, etc. 7. Decrease substance use prior to pregnancy by educating young women about the effects of exposure during pregnancy. 8. Assure proper dietary education to reduce the risk of obesity by partnering with schools and other providers about physical activity and acceptable dietary alternatives.

The Washtenaw County FIMR team concluded that they have a great need for preconception counseling and infant safe sleep promotion. In response they planned a community baby shower to provide information on pre-term labor to pregnant moms. Pre-term labor signs and symptoms stickers were made available to area pharmacies to apply to all prenatal vitamin containers. This FIMR team will also study the zip codes that have the highest rate of infant mortality to determine any gaps in services in those areas.

The following recommendations are endorsed by MDCH to improve infant health related outcomes.

1. Review the characteristics of deaths in this category, particularly characteristics of home environment and safety. 2. Implement safe sleep campaigns in at-risk counties. 3. Determine the efficacy of strategies utilized so far, such as post delivery handouts and education for parents of NICU graduates. 4. Assure the consistent assessment of mental health for pregnant and parenting women. 5. Ensure cultural competency, especially for African American families. 6. Assure access to a medical home for all infants.

Sixth Annual Report FIMR 149 Recommendations Continued

Funding from the Heart of Cook foundation was used for the initiation of the Baby’s Own Bed (BOB) program in Berrien County. Portable cribs or Fun Sport Play Yards are provided to parents who otherwise could not afford one for their baby. Various agencies throughout the county provide safe sleep education and distribution of the cribs. 800 “onesies” with a safe sleep message were distributed to three birthing facilities in the county for distribution to every new mom. A grant from the March of Dimes helped to purchase the newborn outfits.

Emerging data from FIMR reviews contributed to a multi-strategic approach with Tomorrow’s Child to institutionalize safe sleep.

The Skillman Center for Children obtained a grant to fund a project titled: “Sudden Infant Death Syndrome (SIDS) in Detroit: Talking Directly to Families At-Risk”. Information from FIMR and other community organizations informed and contributed to the project.

Conclusions

The FIMR process is an important source of qualitative data about the families who have lost an infant and the local health care systems. How MDCH uses this information to inform programs and policy is still under development. This report attempts to link the FIMR data with the perinatal periods of risk conceptual model in order to help target information and strategies for improving pregnancy outcomes. The task of finding answers to preventing infant deaths is not an easy one, but the passionate efforts of local and state providers are dedicated to this end.

Funds to support the program continue to be a concern. The local teams who have been the most consistent in their operation have been supported by local funds. Without local funds, teams are often unable to implement the guidelines set by MDCH for universal abstracting tools, home interviewing, data reporting and action team activity. The findings above demonstrated that there is missing data that, if available, might improve the overall analysis. Increased resources in personnel time and consistent use of reporting tools may help correct the problem.

It is very time–consuming to review an infant death, resulting in a small number of cases reviewed annually. Small numbers make it difficult to analyze the data and almost impossible to generalize the results across the state. Targeting of cases for review is important to maximize the information gained.

150 Child Death Review Next Steps

The FIMR process is unique to MDCH and is designed to inform health related programs and the Infant Mortal- ity Reduction Initiative in particular. In order to improve the dissemination of the information to key stakeholders, the department plans to initiate, fund and support an annual independent FIMR report in 2006. MDCH is grate- ful to the Department of Human Services for allowing the program to be included in the Keeping Kids Alive Report for the last two years, and will continue to utilize the information shared from the Child Death Review process in setting forth guidelines for the FIMR program.

MDCH will continue to consult and meet monthly with local FIMR coordinators to assure dissemination of policy and guidelines for the program. An annual training will help bring abstractors, home interviewers and coordinators together to improve consistent data collection, sharing of recent research findings, and sharing of stakeholder perspectives. The data from the revised abstraction and home interview tools are being entered into the database at MPHI as this report is being written, and has the potential to improve the information for state level data analysis.

Sixth Annual Report FIMR 151

Child Deaths IN MICHIGAN section ten

APPENDICES Appendix A Progress on Implementing the Recommendations of the Michigan Child Death State Advisory Team

The Child Death Review Process 2nd Annual Report (1999 reviews)

1. Consider a state-level mechanism to assist and support local teams in developing protocols to ensure that they have timely and complete access to all information necessary for an effective review. Update: Michigan Public Health Institute now has an agreement with the Michigan Department of Community Health, Division for Vital Records and Health Statistics, on obtaining death certificates for local CDR Teams. Still, teams often lack needed information, especially medical records, or if the child died in another county.

2. Provide training on the child death review process and on child death prevention to other organizations and systems. Update: MPHI presents information on child death review to many state organizations; CWI staff have attended the annual CDR training.

4th Annual Report (2001 reviews)

3. The Michigan Legislature should amend the Child Protection Law, the Mental Health Code and the Public Health Code so that CDR teams have timely and complete access to all information necessary for an effective review. (similar in 1999)

4. The Children’s Action Network should encourage collaborative efforts between local and state CDR teams and Human Service Coordinating Bodies to make prevention funding a priority based on review team findings. (similar in 1999)

5. The Michigan Legislature should amend the Child Protection Law so that the CDR Case Report may be used for research purposes, in accordance with current Child Protection Law research provisions.

5th Annual Report (2002/2003 reviews)

6. The Michigan Legislature: Ensure continued and enhanced resources to support the comprehensive review of Child Death Review (CDR) findings and trends, enhance local prevention efforts and training for CDR team members. (similar in 2001)

7. The Michigan Department of Community Health: Consider establishment of a state-based regional medical examiner system. (similar in 2001)

Natural Deaths All Causes of Natural Infant Deaths Ages 0–1, Excluding SIDS 2nd Annual Report (1999 reviews)

1. Encourage support of educational, case management and grief services to families who experience an infant death. Update: Tomorrow’s Child, under contract with MDCH, provides grief support services for families who experience an infant death.

2. Ensure that all women on Medicaid have access to the entire array of Medicaid services, including family planning services.

3. Encourage the distribution of family planning information to new parents in prenatal care, at delivery, in pediatrician offices and at other sites utilized by persons of childbearing age.

154 Child Death Review Appendix A

4th Annual Report (2001 reviews)

4. The Children’s Action Network should lead an effort to develop a single comprehensive system of care and service that crosses agency boundaries and responsibilities and provides coordinated, culturally competent, community based services to families with children under age five. Update: The Michigan Early Childhood Investment Corporation (ECIC) was formed in February 2005. The ECIC is designed to allow the state to more effectively focus early childhood efforts and leverage public and private dollars to expand the availability of high-quality early education and child care, including parenting education.

5th Annual Report (2002/2003 reviews)

5. The Michigan Department of Community Health: Expand and continue technical and financial support to Fetal and Infant Mortality Review Programs in communities with high infant mortality rates and racial disparities. (similar in 1998, 1999, 2001) Update: Funding has continued through FY ’06, with some expansion for the state FIMR coordinator to go full-time.

6. The Michigan Department of Community Health: Promote the Grief and Bereavement services through the SIDS and Other Infant Death Program to medical examiners, hospitals, local public health departments, Fetal and Infant Mortality Review teams and local Child Death Review teams. (similar in 1998, 2001)

7. The Michigan Legislature: Continue to provide Medicaid coverage for family planning services to include all women up to 185 percent of the poverty level. (similar in 2001) Update: This is continuing through FY ‘06

8. The Michigan Surgeon General: Work with medical practitioners, medical organizations and insurance companies to ensure: a. An increase in the number of providers that discuss pregnancy intendedness at every visit with all females of childbearing age. Update: In early 2006, MDCH’s Gary Kirk spoke at a Michigan Association of Health Plans meeting, and stressed the importance of this with them. b. Providers offer preconception counseling to all females of childbearing age. c. Adequate number of providers that accept Medicaid patients, in reasonable proximity to those patient populations. Update: In 2005, Medicaid agreed to increase the reimbursement rate for OB/GYNs, which, it is thought, could help in this area. d. Early access to and continuity of care for all pregnant females. e. Compliance with state laws that require physicians to offer pregnant females client-centered counseling and voluntary HIV testing. f. Screening for all pregnant females and new parents for domestic violence and substance abuse. g. Redesign of the Maternal Support Services and Infant Support Services programs to: i. Improve identification and increase referrals of high risk persons; ii. Assure a quality assessment is performed iii. Assure services are designed to specifically reduce risk; and iv. Design reimbursement to reinforce the likelihood of improved birth outcomes. Update: The MCH section at MDCH is currently working on revamping these programs. They will be joined into one, called the Maternal and Infant Health Program. The issues mentioned here are among the priorities that their group is focusing on in this retooling.

Sixth Annual Report Appendix A 155 Appendix A

h. Providers offer referrals to smoking cessation services for pregnant and new parents. Update: this point would be included in with g. (similar in 1998, 1999, 2000, 2001)

Sudden Infant Death Syndrome/Accidental Suffocation 1st Annual Report (1995–1998 reviews)

1. Ensure that adequate training is available for medical examiners, medical examiner investigators and law enforcement personnel in the thorough investigation of child deaths. Update: In late 2002/early 2003, MPHI hosted three child death investigation trainings around the state. Attendees included medical examiner investigators and law enforcement personnel.

2. Continue to fund SIDS professional bereavement counseling through MDCH beyond the 1998 supplemental funding, in order to better help families. Update: Tomorrow’s Child, under contract with MDCH, provides grief support services for families who experience an infant death.

2nd Annual Report (1999 reviews)

3. Study the merits of mandating autopsies for all sudden an unexplained child deaths. (similar in 1998) Update: MDCH indicates all known SUID cases are now being autopsied.

4. Institute a practice in the Division for Vital Records and Health Statistics (DVRHS) of notifying the appropriate local medical examiner whenever a death certificate is received which shows SIDS as the cause of death, but for which no autopsy was done, and/or the medical examiner had not been involved with the case. DVRHS should encourage a comparable practice with offices of county and city registrars.

5. Encourage all health care professionals to reinforce the “Back to Sleep” message with parents and caregivers at every opportunity for contact.

3rd Annual Report (2000 reviews)

6. Encourage local jurisdictions to require that those medical examiners and law enforcement officers assigned to investigate child deaths be trained on protocols for investigating child deaths modeled after the State of Michigan Protocols to Determine Cause and Manner of Sudden and Unexplained Child Deaths. (similar in 1998, 1999) Update: In late 2002/early 2003, MPHI hosted three child death investigation trainings around the state. Attendees included medical examiner investigators and law enforcement personnel. These trainings encouraged the use of the State of Michigan Protocols to Determine Cause and Manner of Sudden and Unexplained Child Deaths. A coordinated approach to investigations was recommended.

5th Annual Report (2002/2003 reviews)

7. The prosecuting attorney, law enforcement agencies, medical examiner and the Department of Human Services in every county: Upon the promulgation of rules by the Michigan Department of Community Health per Public Act 179 of 2004, jointly adopt and implement the child death scene investigation protocols. (similar to 1998, 1999, 2000 2001) Update: Public Act 179 of 2004 states, in part, “The department of community health shall promulgate rules and regulations under this act to promote consistency and accuracy among county medical examiners and deputy county medical examiners in determining the cause of death under this section. The department may

156 Child Death Review Appendix A

adopt, by reference in its rules, all or any part of the “State of Michigan Protocols to Determine Cause and Manner of Sudden and Unexplained Child Deaths” published by the Michigan child death review program.” MDCH convened a multi-disciplinary group to advise them on this law. Plans are in place to revise the current protocols based in part on the new CDC version. Multiple agencies will have input into this. The next step will be developing a method by which all local jurisdictions will be able to obtain training on the soon to be revised and required protocols.

8. The Children’s Cabinet: Collaborate among member agencies and partner with the Michigan Department of Community Health’s SIDS and Other Infant Death Program and Michigan professional associations to implement a statewide campaign promoting safe infant sleep environments consistent with the recommendations of the American Academy of Pediatrics. (similar in 1998, 1999, 2000, 2001) Update: MDCH is currently in collaboration with DHS, Tomorrow’s Child, CDR and local community representatives to promote a statewide campaign on safe infant sleep.

9. The Michigan Department of Community Health: Strengthen the prenatal smoking cessation program, especially as it relates to Sudden Infant Death Syndrome. (similar in 1999, 2001) Update: Current state prenatal smoking cessation programs now include safe sleep materials.

10. The Michigan Chapter of the American Academy of Pediatrics: Identify a partner with whom to host a “Train the Trainer” event for pediatricians around the state in order to ensure the dissemination of consistent safe infant sleep messages to parents. Update: The Michigan Chapter of the American Academy of Pediatrics applied unsuccessfully for such funding from the Governor’s Task Force on Children’s Justice in November 2004.

All Causes of Natural Child Deaths Ages 1-18 5th Annual Report (2002/2003 reviews)

1. The Michigan Department of Community Health and the Michigan Department of Human Services: Support a partnership and the sharing of information between the Michigan Child Death Review Program and the Michigan Asthma Coalition to improve the diagnosis, treatment and prevention of childhood asthma. (similar in 2000, 2001) Update: MPHI currently is involved with the Michigan Asthma Coalition. MDCH is committed to ensuring that CDR findings are shared with the Michigan Asthma Advisory Committee in order to incorporate prevention recommendations into the activities of the Asthma Initiative of Michigan. The Department will share its experience and findings from the MDCH Asthma Mortality Review with the Michigan Child Death Review Program staff and local team members.

Accidental

Motor Vehicle 1st Annual Report (1995–1998 reviews)

1. Consider the merits of legislation and provide public education on: a. Primary seat belt enforcement. Update: PA 29 of 1999 enacted this into law. b. Prohibition on children riding in the back of pickup trucks. Update: PA 434 of 2000 puts limits on how/when children may ride this way. c. Bicycle helmet use.

2. Encourage partnerships among state level highway and traffic safety agencies and local communities to improve dangerous roads, traffic and pedestrian areas.

Sixth Annual Report Appendix A 157 Appendix A

3. Encourage communities to support and fund local Students Against Driving Drunk (SADD) chapters and other similar interventions to encourage responsible teen driving.

4. Improve and increase enforcement and public education of watercraft and snowmobile regulations with an emphasis on prevention of alcohol use.

2nd Annual Report (1999 reviews)

5. Ensure the enforcement of new legislation that makes it illegal under certain conditions to ride in the back of a pickup truck.

3rd Annual Report (2000 reviews)

6. Encourage auto dealerships to provide point-of-sale information and resources about proper installation and usage of child safety seats and booster seats when selling new or used vehicles. (similar in 1998, 1999)

4th Annual Report (2001 reviews)

7. The Michigan Department of Community Health should enhance resources to encourage health care providers to provide anticipatory guidance to expectant and new parents on the proper installation and usage of child safety seats and booster seats.

5th Annual Report (2002/2003 reviews)

8. The Michigan Legislature: Amend the current graduated licensing law to place limits on the number of teen passengers allowed in vehicles driven by teens with Level Two Intermediate Licenses. This limitation should apply at all times of the day, and without an exception allowed for written parental permission. (similar in 1999, 2000, 2001) Update: House Bill 4756 was passed by the House on Dec 7, 2005, that would limit unrelated passengers under the age of 18 to Level 2 licensees in the first 90 days of that licensure, to 2 passengers under age 18 in the second 90 days of that licensure, and to 3 passengers under the age of 18 for the third 90 days. If the licensee were to receive a moving violation or cause an accident during this time, they would revert back to 1 passenger, and have to go through the increments again. Also, this provision does not apply “if the transportation is to or from a church, mosque, synagogue or other house of religious worship or to or from an activity or event sponsored by a church, mosque, synagogue or other house of religious worship.” The Senate did not take up the bill.

9. The Michigan Department of State: Partner with the Office of Highway Safety Planning and the Michigan Department of Community Health to conduct a comprehensive review and revision of driver education programs throughout the state to ensure that the curricula adequately addresses all high-risk driving situations. (similar in 2001)

10. The Michigan Department of Education: Through the Great Parents, Great Start program, work with Michigan SAFE KIDS to develop a system for distributing child safety seat information to parents, coordinated through the local intermediate school districts. Update: The Dept of Ed approached Safe Kids Michigan about this, and several ISDs are beginning to work with Safe Kids on this issue.

158 Child Death Review Appendix A

11. The Michigan Legislature: Amend the Michigan Child Passenger law to:

a. Require the use of booster seats to protect children ages four to eight and under 4’9” tall; b. Increase fines and points for those not following the law; and c. Increase public awareness and education programs. (similar in 2001) Update: The package of bills regarding child passenger safety (Senate Bills 183, 262, 314, 491 and 1041) was approved by the Senate transportation committee on 2/23/06 and referred to the Senate as a whole for consideration. They did not take action on the bill package. These bills would have required: a. Children less than 8 years or less than 4’9” ride in booster seats; b. Drivers in violation could have the citation waived if they acquire a booster seat; c. Removal of the current nursing exemption for restraining infants; d. A fine of $10 for the 1st and $100 for subsequent violations of the booster rule; and e. Children age 12 and under ride in the back seat.

12. The Prosecuting Attorneys Association of Michigan: Educate all law enforcement agencies through their Police Law Bulletin, regarding Public Act 451 of 1994 (MCL 324, sections 81129 and 81130); specifically, regarding the restrictions on children younger than 16 in the operation of all off-road vehicles, and encourage the prosecution of cases wherein this law was violated.

Fire and Burn 1st Annual Report (1995–1998 reviews)

1. Examine ways to fund and support public education campaigns on proper storage and use of space heaters.

2nd Annual Report (1999 reviews)

2. Encourage tobacco companies to only produce and market cigarettes that are self-extinguishing. Update: The Coalition for Fire-Safe Cigarettes, a national coalition of fire service members, consumer and disability rights advocates, medical and public health practitioners and others, coordinated by the National Fire Protection Association, are petitioning cigarette manufacturers to immediately produce and market only cigarettes that adhere to an established cigarette fire safety performance standard. Fire-safe cigarettes are already the law in California, New York and Vermont.

3. Encourage the Consumer Product Safety Commission to require the furniture manufacturing industry to expand the current fire retardant standards for upholstered furniture beyond commercial aircraft and prisons, to include furniture made for residential use. Update: The CPSC issued a “Working Draft” Standard for Upholstered Furniture Flammability in May 2005, increasing the requirements for smoldering and open flame resistance on upholstered furniture sold for residential use. It is prominently noted on the draft, however, that it is “not a proposed regulation; the information is released by the staff of the CPSC solely for discussion purposes” and “any formal action…would be taken by the Commission at a later date.” In May 2006, CPSC staff and fire safety representatives met with furniture industry representatives to discuss the issue. No further action has occurred.

4. Encourage local building inspection programs to put high priority on home inspections when children are believed to be at risk of environmental hazards.

5. Support local fire departments in maintaining and expanding further development of “Smokehouse” or similar programs in Michigan.

Sixth Annual Report Appendix A 159 Appendix A

3rd Annual Report (2000 reviews)

6. Encourage public education on the increasing number of candle-related fire deaths and develop campaigns to promote safe candle use in homes.

4th Annual Report (2001 reviews)

7. The Michigan Department of Community Health and the Michigan State Police should collaborate to develop an awareness campaign on the increased risks of fatal house fires when children play with incendiary devices. Update: In February 2001, the Michigan State Police’s Teaching, Educating And Mentoring (T.E.A.M.) school liaison program incorporated an additional training module on fire safety. The curriculum, taught in four graduated segments across K-12, specifically addresses the risks and consequences of playing with fire.

5th Annual Report (2002/2003 reviews)

8. The Michigan Department of Community Health, the Michigan State Police and the Michigan Department of Labor and Economic Growth: Campaign to promote local efforts to increase the number of lithium-powered or hard-wired smoke detectors and sprinkler systems in residential dwellings. (similar in 1998, 1999, 2000, 2001) Update: Although it does not require lithium power or hard-wiring specifically, the Michigan Construction Code R 408.30566 was amended such that as of 3/14/06, homes built before November 6, 1974 must have smoke detectors inside or adjacent to all sleeping rooms and on each level, including the basement. The law applies to building owners and homeowners, and a one-year deadline was set for compliance.

9. The Michigan Department of Education and the Michigan Department of Human Services: Ensure that all school districts and child care organizations offer fire safety education for young children, especially in preschool and child care settings. (similar in 1998, 1999, 2000, 2001) Update: The Michigan Model for Comprehensive School Health Education, currently in use in about 90 percent of Michigan’s public schools, contains fire safety curriculum for kindergarten and first grade students.

Drowning 1st Annual Report (1995–1998 reviews)

1. Publicize the need to reduce children’s access to gravel pits, uncapped wells and other water hazards.

2nd Annual Report (1999 reviews)

2. Support public education and awareness campaigns on water safety with a special emphasis on the need for constant adult supervision and a focus on pools and bathtubs. (similar in 1998)

3. Encourage schools to seek ways to include swimming lessons and water safety classes for all students through curricula or linkages with other community groups.

5th Annual Report (2002/2003 reviews)

4. The Michigan Municipal League, Michigan Association of Counties and Michigan Township Association: Work with communities to enforce the Michigan Construction Codes that require local units of government to adopt and enforce pool-fencing regulations. (similar in 1999, 2000, 2001)

5. The Michigan Department of Human Services Office of Children and Adult Licensing: Promulgate child care licensing rules for barriers to pools, hot tubs or open bodies of water at regulated child care facilities. Update: The new rules for day care homes state:“R 400.1814b. Water hazards and water activities. Rule 14b. (1) Each licensee/registrant must ensure that barriers exist to prevent children from gaining access to any swimming pool, drainage ditch, well, pond or other body of open water located on or adjacent to

160 Child Death Review Appendix A

the property where the day care home is located. Such barriers must be of a minimum of 4 feet in height and appropriately secured to prevent children from gaining access to such areas. (2) The use of spa pools, hot tubs and fill-and-drain wading pools is prohibited. (3) Hot tubs and spas, whether indoors or outdoors, must be inaccessible to children and have a locked hard cover.”

6. The Department of Natural Resources, Michigan Municipal League, Michigan Association of Counties, Michi- gan Township Association and Michigan Parks and Recreation Association: Work with local communities to provide adequate signage and appropriate rescue equipment in areas of waterfront and shorelines accessible to the public. Signage should include warnings and appropriate safety precautions. (similar in 1999)

Firearms and Weapons 1st Annual Report (1995–1998 reviews)

1. Consider ways to provide trigger locks with all firearms sold in Michigan. Update: PA 265 of 2000 requires provision of trigger locks or similar device at point of sale for federally licensed dealers.

2. Explore ways to require gun dealers to provide material at the point of sale or resale, on gun safety and the proper storage and usage of guns, especially as they relate to children. Update: PA 265 of 2000 also contains this provision, for federally licensed dealers.

2nd Annual Report (1999 reviews)

3. Support youth and parent gun safety education. (similar in 1998)

4. Evaluate current licensing procedures that enable a child to legally use a firearm without attending a gun safety class.

5th Annual Report (2002/2003 reviews)

5. The Michigan Attorney General’s Office: Ensure statewide enforcement of the current laws that require: a. Federally licensed firearm dealers to provide, at the point of sale, written materials on gun safety and the proper storage of guns in homes with children; and b. Federally licensed firearm dealers not to sell a firearm in Michigan without a commercially available trigger lock or other device, designed to disable the firearm and prevent it from discharging. (similar in 1999, 2000, 2001)

6. The Michigan Legislature: Enact legislation that provides specific criminal penalties to adults who are negligent in the safekeeping of guns that are used to injure or kill children. (similar in 1999, 2001)

7. The Michigan Department of Education: Take the lead in developing an education plan for family gun safety.

Other Accidents 1st Annual Report (1995–1998 reviews)

1. Study state policies and strategies to improve the safe and responsible distribution of methadone to reduce accidental poisoning to children.

2nd Annual Report (1999 reviews)

2. Encourage compliance through strict enforcement of laws pertaining to excessive alcohol consumption among teens, especially binge drinking.

Sixth Annual Report Appendix A 161 Appendix A 3rd Annual Report (2000 reviews)

3. Promote educational programs for parents, child care providers and children on the issues surrounding safe environments for children, especially the safe storage and dispensing of medications. (similar in 1999)

Homicides

Firearms and Weapons 2nd Annual Report (1999 reviews)

1. Support consequences against adults who furnish guns to minors for non-hunting purposes.

2. Support after-school and evening education and recreation programs for high-risk youth. (similar in 1998)

3. Support crisis team and victim advocacy to children who witness violence. (similar in 1998)

4. Encourage Human Service Collaborating Bodies to work with other local groups to strengthen or enhance innovative, intensive, community based violence prevention initiatives and programs that promote youth suc cesses. (similar in 1998)

5. Encourage local educational alternatives and social support for students expelled from schools. (similar in 1998)

5th Annual Report (2002/2003 reviews)

6. The Michigan State Police: Spearhead an initiative to partner with communities and local law enforcement experiencing high rates of teen homicides, to identify the neighborhoods most at risk for gun homicides, and implement comprehensive violence-prevention initiatives. (similar in 2000, 2001) Update: The Michigan Youth Leadership Academy (MYLA) is a program developed by the Michigan State Po- lice that provides youths ages 14-16 with practical skills to become productive, achievement-oriented youths and community leaders. Areas of instruction for the program include: conflict resolution, anger management, community leadership responsibility, team building activities, military courtesy, health awareness and physical fitness. The MYLA builds trust through partnership with local and state law enforcement agencies. The MYLA graduated 82 student cadets during the summer of 2006. The communities that participated were Benton Harbor, Kalamazoo and Saginaw.

7. Michigan Courts: Support enforcement of laws that require gun safety mechanisms on all firearms at the point of sale. (similar in 1999, 2000)

8. The Michigan Department of Community Health and the Michigan Department of Human Services: Work with local community mental health to recognize and ensure treatment for the mental health needs of families.

9. The Michigan Department of Community Health: Partner with the Michigan Chapter of the American Academy of Pediatrics to disseminate and implement the AAP’s Violent Injury Prevention Program (VIPP) in primary care offices around the state.

Child Abuse and Neglect 1st Annual Report (1995–1998 reviews)

1. Support efforts to strengthen enforcement of the current mandatory child abuse and neglect reporting laws.

2. Enhance training opportunities on the Child Maltreatment Investigation Coordinated Protocol and Forensic Interviewing Protocol. Update: Currently, the 8-week Child Welfare Institute training for all new workers includes a section on the Forensic Interviewing Protocol. Also, the Prosecuting Attorneys Association of Michigan offers training on this protocol 6-8 times per year.

162 Child Death Review Appendix A

2nd Annual Report (1999 reviews)

3. Ensure that the Family Independence Agency’s Children’s Protective Services worker training emphasizes assessment for medical neglect. Update: A training session in medical issues in child abuse cases was developed and provided in March of 2004. In addition, Medical Resource Services offers case specific support through consultation with field staff, and reviews of medical records in order to provide in-depth explanations of medical findings relevant to abuse and neglect cases.

4. Encourage Human Service Collaborative Bodies to examine communication and coordination among public and private agencies, including those across county lines, when serious risk factors are known or identified. (similar in 1998)

3rd Annual Report (2000 reviews)

5. Enhance the Family Independence Agency’s Child Protective Services caseworkers’ ability to recognize potential indicators of abuse and neglect in high-risk environments.

4th Annual Report (2001 reviews)

6. The Family Independence Agency should increase and improve the resources available to educate and support the medical community and other mandated reporters to understand, identify and report suspected child abuse and/or neglect. (similar in 1998, 1999, 2000) Update: A guide for mandated reporters was developed at DHS and released in 5/05. It is a tool to identify, educate and encourage reporting by mandated reporters, as well as outline the civil duty and process for reporting. Specialized training on the reporting process is currently available through the Medical Services Advisory and Prosecuting Attorneys Association of Michigan.

5th Annual Report (2002/2003 reviews)

7. The Michigan Department of Human Services, Michigan Department of Community Health and Michigan Department of Education: Ensure that human service professionals working with high-risk families are knowledgeable about support programs and resources for new families, especially Maternal Support Services, Infant Support Services and other state and community-based primary and secondary prevention programs. (similar in 1999)

8. The Michigan Department of Human Services, Michigan Department of Community Health and Michigan Department of Education, in partnership with other disciplines: Develop (and Michigan Legislature: allocate funds for) home visitation programs using best practices, with home nursing as a component, targeting low- income, at-risk children/families. (similar in 1999, 2000, 2001) Update: The agencies listed worked with the National Nurse Family Partnership, Inc. to implement a project to help first time parents succeed in Michigan. Based on the positive outcomes in Benton Harbor, three additional cities were funded in 2004: Detroit, Grand Rapids and Pontiac. More than 700 families have received services. Each team consists of four specially trained nurses, a supervisor and a part-time clerk.

9. The Michigan Department of Human Services and the Children’s Trust Fund: Continue the Shaken Baby Syndrome Prevention campaign. (similar in 2001)

10. The Michigan Health and Hospital Association: Implement, statewide, of the Children’s Trust Fund Shaken Baby Syndrome prevention information/programs.

11. The Children’s Cabinet: Commission research identifying the risk and protective factors for fatal child maltreatment.

Sixth Annual Report Appendix A 163 Appendix A Suicide 1st Annual Report (1995–1998 reviews)

1. Develop protocols to help families, case workers and law enforcement officers identify and respond to suicide risks for teens awaiting sentencing or detention as juvenile offenders.

2nd Annual Report (1999 reviews)

2. Encourage the development and evaluation of new prevention technologies, especially firearm safety measures, to reduce easy access to lethal means of suicide. Update: MSP transitioned from distribution of trigger-only locks to cable locks, once studies showed that they were a safer way to disable a firearm.

3. Develop model bereavement, grief support and prevention programs for friends and families of suicide victims. Update: Jean Larch from the Macomb Crisis Center and Beverly Cobain, who works on issues of suicide prevention, have written a book entitled “Dying to be Free: A Healing Guide for Families after a Suicide.” Published in 2006, it could be explored as a possible resource. 4th Annual Report (2001 reviews)

4. The Michigan Department of Community Health should conduct a statewide assessment of the capacity of children’s mental health services to adequately assess and provide treatment to adolescents who exhibit signs of depression.

5th Annual Report (2002/2003 reviews)

5. The Michigan Department of Community Health: Take the lead in collaborating with the Michigan Department of Education and Michigan Department of Human Services to support the development and implementation of a state suicide prevention plan. (similar in 1998, 1999, 2000, 2001) Update: The Michigan Suicide Prevention Coalition was convened, consisting of representatives of the CDR program, MDCH, the Dept of Education and various other state and local organizations. The Michigan Sur- geon General debuted the State Suicide Prevention Plan developed by this group on 9/12/05. The plan is based on the National Strategy for Suicide Prevention, adapted to better address needs specific to Michigan.

6. The Office of the Governor: Support the State Mental Health Commission in addressing the access to services for youths at risk for suicide.

7. The Michigan Department of Community Health: Lead a collaboration between community mental health, the Michigan Health and Hospital Association and the Michigan Department of Education, to ensure that bereavement services are available to all children who have experienced the recent death of a family member or close friend.

8. The Michigan Department of Community Health: Ensure that parents, teachers and professionals in the fields of public and mental health, substance abuse and juvenile justice have an awareness of the risk factors of youth suicide and how to access intervention services by providing educational training and materials. (similar in 1998, 1999, 2000) Update: Public Act 324 of 2006 amends the Revised School Code (MCL 380.1171) to encourage school boards to provide age-appropriate instruction for students, and professional development for school personnel, about the warning signs and risk factors for suicide and depression. The instruction and professional development must be designed to: a) prevent both fatal and nonfatal suicide behaviors among youth; b) increase students’ awareness of the warning signs and risks factor for suicide and depression; and, c) improve access to appropriate prevention services for vulnerable youth groups. Under the Act, a school board is encouraged to work with school personnel and local or state organizations and resources specializing in suicide prevention and awareness. Further, the Dept of Ed is required to develop or select model programs and materials on suicide prevention and awareness that are appropriate, and make those available to school districts and charter schools.

164 Child Death Review Appendix B Local Child Death Review Team Coordinators, 2004

County Coordinator(s) Agency Alcona Doug Ellinger, Sheriff Alcona County Sheriff’s Department Alger Dr. James Terrian LMAS District Health Department Allegan Cathy L. Weirick, Executive Director Allegan County CA/N Council Alpena Cindy Shackleton Alpena County DHS Antrim Bob Lewis, Services Supervisor Antrim County DHS Arenac Brian Millikin Arenac County DHS Dr. Gail Shebuski, Health Officer/ Baraga-Houghton-Keweenaw Western UP Health Department Medical Director Dr. Jeff Chapman, Medical Examiner Barry County Medical Examiner Barry Ann Wilson Barry County Medical Examiner’s Office Bay Dominic Wright, Victim’s Advocate Bay County Prosecutor’s Office Benzie Jenifer Murray, Personal Health Director Benzie-Leelanau District Health Dept Berrien Margaret Penninger, Assistant Prosecutor Berrien County Prosecutor’s Office Branch Kim McFellin Branch County DHS Calhoun Renay Montgomery Calhoun County Health Department Cass Ruth Andrews, Director Woodlands Behavioral HC Network Rhonda Buchanan Charlevoix Emmett DHS Charlevoix-Emmet Jenny Deegan Charlevoix Prosecutor’s Office Cheboygan Det. Tim Cook Cheboygan County Sheriff’s Dept Vicki Schuurhuis, Clinical Director, OB/ Chippewa War Memorial Hospital Nursery Clare Kathy Kent, Nursing Supervisor Central Michigan District Health Dept Clinton Mary Pino, Chief Assistant Prosecutor Clinton County Prosecutor’s Office Crawford — — Delta Renee Barron Delta-Menominee District Health Dept Dickinson-Iron Carol Thornton Dickinson-Iron County DHS Eaton Sue Thurma Barry-Eaton District Health Department Dr. Gary Johnson, Medical Director Genesee County Health Department Genesee Pamala Watkins, Medical Examiner Genesee County Health Department Investigator Gladwin Robert Adams, Director Gladwin County DHS Dr. Charles Iknayan, Medical Examiner Grandview Hospital Gogebic Dan Borth Gogebic County DHS Grand Traverse Deanna Kelly Grand Traverse County Health Dept Hillsdale Valerie White, Assistant Prosecutor Hillsdale County Prosecutor’s Office Mark Gaertner, Prosecuting Attorney Huron County Prosecutor’s Office Huron Elizabeth Weisenbach, Assistant Prosecutor Huron County Prosecutor’s Office Ingham Dr. Dean Sienko, Medical Examiner Ingham County Health Department Ionia JoAnne Eakins, Director of Personal Health Ionia County Health Department Carla Grezeszak, Family Division Iosco Iosco County Family Court Administrator Mari Pat Terpening, Personal Health Isabella Central Michigan District Health Dept Svcs Supervisor

Sixth Annual Report Appendix B 165 Appendix B Local Child Death Review Team Coordinators, 2004

Jackson Jill Glair Jackson County Health Department Joni Idzkowski, Personal Health Services Kalamazoo Kalamazoo Human Services Department Supervisor Kalkaska Ranae McCauley, Program Specialist MSU Extension Tracy Cyrus, Child Protection Team DeVos Children’s Hospital Kent Carmen Perez Kent County Health Department Lake Undersheriff Mike Dermyer Lake County Sheriff’s Department D/Sgt. Nancy Stimson Lapeer County Sheriff’s Department Lapeer Gerald Redman, Acting Program Manager Lapeer County DHS Sara Brubaker, Prosecuting Attorney Leelanau County Prosecutor’s Office Leelanau Laurie laCross, Victims Advocate Leelanau County Prosecutor’s Office Lenawee Mary Vallad, Nursing Director Lenawee County Health Department Dr. Stan Reedy, Medical Director Livingston County Health Department Livingston Elaine Brown, Personal and Prevention Livingston County Health Department Health Services Dr. James Terrian, Medical Examiner/ Luce LMAS District Health Department Director Mackinac Sgt. Mark Wilk St. Ignace Police Department Dr. Kevin Lokar, Medical Director Macomb County Health Department Macomb Angelo Nicholas, Director; Macomb County DHS Brenda Piekarski Manistee Ford Stone, Chief Prosecutor Manistee County Prosecutor’s Office Marquette M. Cookie Aho, Health Educator Marquette County Health Department Richard Trier, Service Manager Mason County DHS Mason Sheriff Laude Hartrum Mason County Sheriff’s Department Mecosta Kevin Courtney, Director Big Rapids Dept of Public Safety

Menominee Renee Barron Delta-Menominee District Health Dept Dr. Dennis Wagner, Deputy Medical Mid-Michigan Regional Medical Center Midland Examiner Andrea Muladore, ACSW Mid-Michigan Regional Medical Center

Missaukee-Wexford Cheryl Szagesh, Program Manager Missaukee-Wexford DHS

Monroe Sandie Pierce Monroe CMH Authority

Bonnie Ayers Mid-Michigan District Health Dept Montcalm-Gratiot Jamie Lovelace, Children’s Services Ionia Montcalm District DHS Supervisor Montmorency John Eurich, Services Supervisor Montmorency County DHS

Joyce L. deJong, DO, Chief ME Muskegon County Health Department Muskegon Roberta Skinner, Records Office Muskegon County Health Department

Richard W. Peters, MD Mercy General Health Partners Newaygo Sue Ordiway, Administrator Newaygo County Administration

166 Child Death Review Appendix B Local Child Death Review Team Coordinators, 2004

Oceana Rachel Sollner, CPS Supervisor Oceana County DHS

Ogemaw Dr. James Hall, Pathologist/ME HistoDiagnostic

Ontonagon Janet Holmstrom Ontonagon County DHS

Osceola Becky Johnson-Himes Central Michigan District Health Dept

Oscoda Joan Fox, Services Supervisor Oscoda County DHS

Otsego Kevin Hessselink, Prosecuting Attorney Otsego County Prosecutor’s Office

Ottawa Tom Perna, CPS Supervisor Ottawa County DHS

Presque Isle John Keller Alpena County DHS

Roscommon Cynde Kochensparger, Nursing Supervisor Central Michigan District Health Dept

Kristan Outwater, MD Partners in Pediatrics Saginaw Debbie Tubb, ME Investigator Saginaw County Health Department

St. Clair Amy Smith, Planning Officer Community Mental Health Elizabeth O’Dell, Collaborative St. Joseph St. Joseph Co Human Svcs Commission Coordinator Dennis Smallwood, DO, Medical Sanilac Sanilac County Health Department Examiner/Director Schoolcraft Dr. James Terrian LMAS Dist Health Department

Cindy Eberhard, CPS Supervisor Shiawassee County DHS Shiawassee Rose Mary Asman, Pers Health Services Shiawassee County Health Dept Director Dennis Smallwood, DO, Medical Tuscola Tuscola County Health Department Examiner/Director Trooper Paula Doan Michigan State Police Van Buren Sandy Nicholas Van Buren/Cass District Health Dept

Washtenaw Susan Gialanella Washtenaw County Human Services

Dr. Charles Barone Henry Ford Hospital Wayne Teresa Marshall, Child and Family Services Wayne County DHS

Sixth Annual Report Appendix B 167 Appendix C Number of Cases Reviewed by CDR Teams by County Number of Reviews Number of Reviews County in 2004 1995–2004 Alcona 0 4 Alger 0 5 Allegan 7 64 Alpena 0 10 Antrim 0 0 Arenac 4 10 Baraga 0 0 Barry 12 66 Bay 4 24 Benzie 0 1 Berrien 17 295 Branch 9 44 Calhoun 0 142 Cass 6 53 Charlevoix 5 13 Cheboygan 6 10 Chippewa 0 24 Clare 4 12 Clinton 10 63 Crawford 0 18 Delta 0 11 Dickinson 2 11 Eaton 4 72 Emmet 4 11 Genesee 50 146 Gladwin 5 28 Gogebic 4 6 Grand Traverse 4 10 Gratiot 5 36 Hillsdale 0 25 Houghton 0 0 Huron 2 20 Ingham 16 80 Ionia 7 45 Iosco 3 21 Iron 1 3 Isabella 12 59 Jackson 24 86 Kalamazoo 16 148 Kalkaska 0 4 Kent 73 513

168 Child Death Review Appendix C Number of Cases Reviewed by CDR Teams by County

Keweenaw 0 0 Lake 4 15 Lapeer 10 83 Leelanau 4 11 Lenawee 4 54 Livingston 8 112 Luce 1 14 Mackinac 0 16 Macomb 15 172 Manistee 0 5 Marquette 2 12 Mason 5 21 Mecosta 9 70 Menominee 0 11 Midland 5 38 Missaukee 4 18 Monroe 23 91 Montcalm 15 102 Montmorency 1 4 Muskegon 11 99 Newaygo 4 43 Oakland 36 295 Oceana 8 48 Ogemaw 0 0 Ontonagon 2 4 Osceola 5 24 Oscoda 0 0 Ostego 7 21 Ottawa 12 115 Presque Isle 0 2 Roscommon 6 19 Saginaw 19 181 St. Clair 24 227 St. Joseph 8 84 Sanilac 0 11 Schoolcraft 0 2 Shiawassee 14 91 Tuscola 3 42 Van Buren 11 82 Washtenaw 9 84 Wayne 188 1,090 Wexford 9 43 Michigan 802 5,649

Data Source: Michigan Child Death Review, Michigan Public Health Institute

Sixth Annual Report Appendix C 169 Appendix D Total Number of Deaths Among Michigan Residents, Ages 0-18, by County of Residence and Age Group, 2004

Age Group by Years County of Residence Total Under 1 1-4 5-9 10-14 15-18 Alcona 0 0 0 0 0 0 Alger 0 0 0 0 0 0 Allegan 8 1 1 1 5 16 Alpena 1 0 1 2 0 4 Antrim 3 0 1 0 0 4 Arenac 1 0 1 0 2 4 Baraga 0 0 0 0 0 0 Barry 4 1 0 3 4 12 Bay 2 0 1 1 6 10 Benzie 0 1 0 0 2 3 Berrien 8 0 0 1 6 15 Branch 8 0 1 1 1 11 Calhoun 18 3 4 2 7 34 Cass 3 2 0 2 3 10 Charlevoix 0 0 0 0 5 5 Cheboygan 1 0 1 0 0 2 Chippewa 0 0 0 0 0 0 Clare 5 0 0 1 3 9 Clinton 3 0 0 1 3 7 Crawford 0 0 0 1 0 1 Delta 4 0 0 0 0 4 Dickinson 1 0 1 1 0 3 Eaton 5 1 0 0 3 9 Emmet 1 0 0 0 1 2 Genesee 77 12 6 5 16 116 Gladwin 3 1 1 0 0 5 Gogebic 0 1 0 1 2 4 Grand Traverse 6 0 1 2 4 13 Gratiot 5 0 1 1 0 7 Hillsdale 0 2 0 1 5 8 Houghton 3 0 1 1 5 10 Huron 0 0 0 2 2 4 Ingham 29 5 6 3 6 49 Ionia 3 1 1 0 2 7 Iosco 1 0 0 1 1 3 Iron 1 0 0 0 0 1 Isabella 3 1 0 1 0 5 Jackson 14 1 0 2 4 21 Kalamazoo 21 1 2 2 11 37 Kalkaska 1 0 0 0 0 1 Kent 75 10 8 14 18 125 Keweenaw 0 0 0 0 0 0

170 Child Death Review Appendix D Total Number of Deaths Among Michigan Residents, Ages 0-18, by County of Residence and Age Group, 2004

Lake 1 0 1 1 2 5 Lapeer 1 1 0 1 5 8 Leelanau 2 0 0 1 2 5 Lenawee 5 1 2 1 1 10 Livingston 6 2 2 1 4 15 Luce 0 0 0 1 0 1 Mackinac 1 0 0 0 1 2 Macomb 58 12 8 9 14 101 Manistee 2 0 0 0 0 2 Marquette 0 1 2 1 2 6 Mason 0 0 2 1 1 4 Mecosta 5 1 0 1 1 8 Menominee 0 0 0 0 1 1 Midland 8 1 1 1 2 13 Missaukee 0 0 0 0 2 2 Monroe 13 2 2 1 14 32 Montcalm 4 1 1 2 4 12 Montmorency 0 0 0 0 0 0 Muskegon 21 1 2 3 5 32 Newaygo 3 0 0 0 3 6 Oakland 95 10 7 11 28 151 Oceana 4 1 0 0 4 9 Ogemaw 2 1 0 0 1 4 Ontonagon 1 0 0 1 1 3 Osceola 2 2 0 0 2 6 Oscoda 0 0 0 0 0 0 Ostego 3 0 0 0 1 4 Ottawa 18 2 3 5 5 33 Presque Isle 1 0 0 0 0 1 Roscommon 4 0 0 0 1 5 Saginaw 21 2 3 5 10 41 St. Clair 20 1 1 4 6 32 St. Joseph 8 0 0 0 3 11 Sanilac 3 2 1 0 1 7 Schoolcraft 1 0 0 0 0 1 Shiawassee 8 1 0 0 5 14 Tuscola 5 0 0 0 4 9 Van Buren 9 0 1 2 4 16 Washtenaw 29 6 4 4 7 50 Wayne 301 41 23 28 82 475 Wexford 1 0 0 1 1 3 Michigan 984 136 105 139 357 1,721

Data Source: Michigan Residents Death File, Division for Vital Records and Health Statistics, Office of the Registrar, Michigan Department of Community Health

Sixth Annual Report Appendix D 171 Appendix E Total Number of Deaths Among Michigan Residents, Ages 0-18, by County of Residence and Year of Death, 1995-2004

Year of Death 2004 2004 Rate County of Population, per 100,000 1996 1997 1998 1999 2000 2001 2002 2003 2004 Residence 1995 Ages 0-18 Population

Alcona 1 0 2 0 0 2 0 3 5 0 2,130 ** Alger 1 2 2 2 1 1 2 2 2 0 1,955 ** Allegan 19 23 16 29 19 17 21 22 19 16 31,531 50.7 Alpena 3 7 4 5 14 4 4 2 0 4 7,024 ** Antrim 4 6 7 0 2 3 3 1 1 4 5,775 ** Arenac 2 2 1 5 0 3 2 4 4 4 3,865 ** Baraga 2 1 3 1 1 1 0 1 2 0 1,935 **

Barry 9 6 15 14 14 11 13 6 10 12 15,634 76.8

Bay 23 21 14 14 13 15 21 12 13 10 26,837 37.3 Benzie 5 2 3 0 2 1 1 0 6 3 4,083 ** Berrien 47 40 46 32 43 37 37 30 33 15 43,126 34.8 Branch 6 9 6 9 9 6 12 8 13 11 11,711 93.9

Calhoun 25 25 47 22 25 29 40 29 23 34 37,102 91.6

Cass 11 9 11 11 5 11 4 12 7 10 12,928 77.4 Charlevoix 7 8 6 6 5 4 3 5 2 5 6,743 ** Cheboygan 6 3 6 6 2 5 4 6 3 2 6,315 **

Chippewa 9 5 6 4 3 7 7 4 4 0 8,096 **

Clare 5 7 6 5 7 6 1 3 11 9 7,614 ** Clinton 11 4 11 8 8 10 8 14 12 7 18,520 ** Crawford 4 4 1 1 3 5 3 5 2 1 3,442 ** Delta 6 3 7 3 2 9 8 3 9 4 8,843 ** Dickinson 3 3 3 5 3 2 4 1 2 3 6,683 **

Eaton 14 21 5 14 13 15 7 17 16 9 27,230 **

Emmet 4 2 6 2 6 6 2 5 4 2 8,219 ** Genesee 122 139 138 122 119 117 105 113 113 116 123,982 93.6 Gladwin 10 6 4 6 7 2 5 5 3 5 6,197 ** Gogebic 3 1 8 3 3 2 1 0 1 4 3,297 ** Grand 8 13 11 12 11 11 13 8 6 13 20,189 64.4 Traverse Gratiot 11 9 7 6 7 6 6 3 5 7 10,149 ** Hillsdale 9 7 14 8 13 12 9 5 8 8 12,533 ** Houghton 6 3 7 5 7 2 1 7 5 10 8,034 124.5 Huron 6 7 4 8 5 10 6 3 2 4 8,175 ** Ingham 50 50 42 46 41 50 43 36 41 49 70,338 69.7 Ionia 9 12 13 4 7 18 16 7 12 7 17,059 ** Iosco 5 2 1 3 1 2 6 8 1 3 5,831 ** Iron 3 0 0 4 2 3 0 1 2 1 2,494 ** Isabella 11 8 7 13 6 7 10 11 12 5 14,187 ** Jackson 25 30 32 41 36 31 32 22 39 21 42,345 49.6 Kalamazoo 41 40 44 58 28 44 50 57 43 37 61,265 60.4

Kalkaska 2 5 4 3 3 3 1 4 2 1 4,339 **

Kent 120 129 98 106 119 125 119 122 131 125 172,489 72.5

172 Child Death Review Appendix E Total Number of Deaths Among Michigan Residents, Ages 0-18, by County of Residence and Year of Death, 1995-2004 Keweenaw 0 1 0 0 0 0 0 1 0 0 475 ** Lake 3 3 4 2 1 3 0 0 3 5 2,698 ** Lapeer 9 13 24 19 18 14 12 22 13 8 24,595 ** Leelanau 1 3 1 1 1 4 0 3 4 5 5,075 ** Lenawee 18 12 18 20 23 15 16 5 12 10 26,206 38.2 Livingston 13 25 15 23 27 18 16 17 24 15 48,018 31.2 Luce 0 2 3 0 1 2 0 2 1 1 1,374 ** Mackinac 1 5 3 0 1 3 0 3 1 2 2,461 ** Macomb 113 109 103 101 94 104 104 95 105 101 203,521 49.6 Manistee 5 5 2 5 4 0 3 7 6 2 5,588 ** Marquette 12 10 12 9 7 3 9 9 4 6 13,640 ** Mason 4 6 8 6 6 7 9 3 4 4 6,801 ** Mecosta 4 5 6 14 4 8 7 11 6 8 10,078 ** Menominee 5 4 2 4 2 6 5 4 2 1 5,884 ** Midland 10 15 15 16 20 8 11 12 13 13 22,461 57.9 Missaukee 2 3 3 2 2 3 1 4 6 2 3,946 ** Monroe 22 29 25 18 10 16 27 29 10 32 40,377 79.3 Montcalm 13 11 12 18 24 12 13 8 19 12 16,874 71.1 Montmorency 1 1 1 0 1 0 1 1 0 0 2,038 ** Muskegon 37 37 39 39 46 23 43 26 39 32 48,126 66.5 Newaygo 9 9 12 8 6 6 7 10 5 6 14,152 ** Oakland 180 148 175 168 147 180 153 153 168 151 312,066 48.4 Oceana 5 5 4 7 2 7 6 8 4 9 7,712 ** Ogemaw 6 7 3 9 2 5 2 2 0 4 4,955 ** Ontonagon 1 1 0 1 0 0 0 0 1 3 1,413 ** Osceola 2 4 5 9 6 7 6 4 7 6 6,338 ** Oscoda 4 1 1 4 1 5 1 4 1 0 2,084 ** Ostego 2 6 5 3 4 5 3 4 2 4 6,330 ** Ottawa 40 39 31 44 39 45 48 45 35 33 72,407 45.6 Presque Isle 7 0 0 2 4 5 4 1 1 1 2,871 ** Roscommon 4 4 4 5 7 2 3 2 2 5 5,161 ** Saginaw 48 49 51 47 43 43 38 43 40 41 56,214 72.9 St. Clair 20 32 32 15 29 26 27 22 34 32 44,900 71.3 St. Joseph 18 11 10 13 8 11 20 13 16 11 17,570 62.6 Sanilac 13 7 3 7 10 11 8 3 5 7 11,689 ** Schoolcraft 2 3 0 4 0 1 1 2 1 1 1,954 ** Shiawassee 11 10 14 13 6 8 15 18 11 14 19,295 72.6 Tuscola 18 17 17 13 12 15 13 15 11 9 15,123 ** Van Buren 19 15 17 25 21 13 17 13 14 16 21,891 73.1 Washtenaw 50 34 39 36 42 51 52 46 40 50 81,195 61.6 Wayne 654 603 581 570 554 536 468 543 531 475 585,363 81.1

Wexford 8 5 4 5 12 8 5 3 1 3 8,158 **

Michigan 2,062 1,985 1,973 1,952 1,863 1,895 1,804 1,823 1,831 1,721 2,679,321 64.2

** Rates are too small to calculate (<10 cases). Note: Rates based on 20 or fewer deaths may be unstable. Use with caution.

Data Sources: Michigan Residents Death File, Division for Vital Records and Health Statistics, Office of the Registrar, Michigan Department of Community Health

Bridged Vintage 2003 Postcensal File, National Center for Health Statistics

Sixth Annual Report Appendix E 173 Appendix F Michigan FIMR Team Coordinators, 2004

County Coordinator(s) Agency Berrien Carol Klukas Berrien County Health Department Family Services Network/ Branch Diane Blaske Branch-Hillsdale- St Joseph Community Health Agency Calhoun Genessa Doolittle Calhoun County Health Department Genesse Leslie Lathrop Genesee County Health Department Ingham Jeanne Sullivan Ingham County Health Department Jackson Louise Bernstein Jackson County Health Department Kalamazoo Oemeeka Marcilous Kalamazoo Human Services Department Kent Sarah MacDonald Spectrum Health Oakland (Pontiac Mary White Oakland County Health Division and Southfield) Saginaw Dawn Shanafelt Saginaw County Department of Public Health Washtenaw Sue Gialanella Washtenaw County Health Department Wayne (Detroit) Lynn Kleiman Detroit Department of Health and Wellness Promotion Native American Darlene VanOveren Intertribal Council of Michigan Macomb Elaine Habib Macomb County Department of Public Health Muskegon Laurel Sproul Muskegon County Department of Public Health Out Wayne Cathy Oliver Wayne County Health Department

174 Child Death Review

This report is written in memory of all of the children in Michigan who have died. The Michigan Child Death State Advisory Team issues this report with the hope that it will encourage additional efforts, both in local communities and among our state leaders, to keep every child in Michigan safe and healthy.

The Michigan Department of Human Services Grand Tower Building 235 South Grand Avenue Lansing, MI 48909 www.michigan.gov/dhs

Michigan Public Health Institute Child and Adolescent Health Program 2438 Woodlake Circle, Suite 240 Okemos, MI 48664 (517) 324–7330 www.keepingkidsalive.org