Twenty-Second Annual Report November 15, 2015 Mission: To reduce preventable child fatalities through systematic, multidisciplinary, multi-agency and multi-modality review of child fatalities in Arizona through interdisciplinary training, community-based prevention education, and data-driven recommendations for legislation and public policy. Twenty-Second Annual Report November 15, 2015 Dear Friends of Arizona’s Children: For over 20 years, the Arizona Child Fatality Review (CFR) Program has explored the causes and contributing factors associated with child deaths in order to identify recommendations that could reduce the number of preventable deaths. In 2014, 834 children under 18 years of age died in Arizona which is a four percent increase in our Arizona child mortality rate from 2013 when 811 children died. The Arizona CFR Teams reviewed 100 percent of these deaths and determined that Preventability ••• In 2014, 834 children under the age of 18 years died in Arizona. Arizona CFR Teams reviewed 100 percent of 36 percent of these deaths could have been prevented. these deaths and In 2014, 547 of the child deaths were due to natural causes (medical could have been conditions). This is an increase from the 513 deaths due to medical conditions in 2013. The most common medical condition was prematurity which accounted for 27 percent of all child deaths in Arizona in 2014, a six percent increase since 2013. Our review found that 85 percent of these deaths due to prematurity were associated with medical complications during pregnancy and that 18 percent of the pregnant mothers who lost their child due to prematurity had received no prenatal care. Deaths caused by unsafe sleep environments, suicide and drowning also increased. One hundred percent of the drowning deaths, 94 percent of the sleep related infant deaths and 87 percent of the suicides were determined to be preventable. However, motor vehicle crash deaths decreased 29 percent from 2013 to 2014. Although there has been a 24 percent increase in maltreatment deaths since 2009, determined 36 percent prevented. Teams determined that 100 percent of the following deaths were preventable:     Homicides Firearm-related deaths Drowning deaths Maltreatment deaths the mortality rate dropped 18 percent in 2014. The Arizona CFR Program reviews each child death in order to identify future actions that can reduce the number of preventable deaths. Some of our recommendations this year include taking action to reduce the number of uninsured, decrease medical complications of pregnancy, increase safe sleep practices for infants and support suicide prevention programs and access to mental health services. We have included specific recommendations in this report to prevent child deaths for individuals, communities, first responders, elected officials and the public. Mary Ellen Rimsza, MD Chair, Arizona CFR Program 2|Page Submitted to: The Honorable Douglas A. Ducey, Governor, State of Arizona The Honorable Andy Biggs, President, Arizona State Senate The Honorable David Gowan, Speaker, Arizona State House of Representatives This report is provided as required by A.R.S. §36-3501.C.3 Prepared by: Arizona Department of Health Services – Office of Injury Prevention Jennifer Dudek, MPH, Injury Epidemiologist Shannon Rupp, MPP, MSc Program Manager, Child Fatality and Maternal Mortality Review This publication can be made available in alternative formats. Contact the CFR Program at (602) 364-1400 (voice) or call 1-800-367-8939 (TDD). Permission to quote from or reproduce materials from this publication is granted when acknowledgment is made. Resources for the development of this report were provided in part through funding to the Arizona Department of Health Services from the Centers for Disease Control and Prevention, Cooperative Agreement 5U17CE002023, Core Violence and Injury Prevention Program. 3|Page Acknowledgments We would like to kindly acknowledge the following individuals, organizations and agencies for their tireless efforts to help reduce child deaths and make Arizona communities safer for all Arizona residents and visitors. • • • • • Susan Newberry, Maricopa County CFR Coordinator, who is responsible for coordinating the reviews of more than 60 percent of all child deaths occurring annually in Arizona. Susan has spent more than 30 years as a dedicated champion for children. She tirelessly devotes her time and energy to creating and maintaining effective collaboration, cooperation and communication among team members. Margaret Strength, Fatality/Near Fatality Information Release Officer, Arizona Department of Child Safety, who acts as liaison between both state and local CFR teams. Ms. Strength has been instrumental in improving communication and records sharing for all CFR teams. She is a strong advocate for improving the health and safety of all children and their families in Arizona. Dr. Jeffrey Johnston, Chief Medical Examiner, Maricopa County Office of the Medical Examiner, who is responsible for overseeing the examination of two-thirds of all deaths occurring in Arizona. Dr. Johnston is a strong partner with county and state CFR teams helping to improve training efforts and collaboration among agencies, review teams, and the community. All agencies (e.g. hospitals, doctors, medical examiner’s, child protective service agencies, and law enforcement) that promptly provided the CFR program with the records teams have requested. Informed child fatality reviews are only possible when the teams have accurate, current detailed information to review. Local team members that have served for several years who are retiring this year: Dr. Herbert Winograd, Maricopa County; Zannie Weaver, Maricopa County; Cindy Porterfield, D.O., Pima County; Lt. David McBride, Yuma County; Detective Debbie Machin, Yuma County; Wendy Holt, Yuma County (posthumously). 4|Page Table of Contents Preventability.............................................................................................................................................. 2 Acknowledgments ..................................................................................................................................... 4 Executive Summary ................................................................................................................................... 7 Report Highlights ........................................................................................................................................................ 8 Future Actions for Prevention ............................................................................................................................. 11 Glossary ..................................................................................................................................................... 12 Introduction .............................................................................................................................................. 15 Methods ..................................................................................................................................................... 15 Demographics........................................................................................................................................... 16 Preventable Deaths .................................................................................................................................. 20 Natural Deaths ......................................................................................................................................... 23 Prematurity ................................................................................................................................................................. 24 Unintentional Injury Deaths ................................................................................................................... 27 Home-Safety Related Deaths ................................................................................................................................ 28 Sudden Unexplained Infant Death (SUID) and Sleep Related Deaths ............................................. 31 Maltreatment Deaths (Deaths due to Child Abuse and Neglect) ..................................................... 34 Motor Vehicle Crash and Other Transport Deaths ............................................................................. 39 Suicides ...................................................................................................................................................... 45 Homicides ................................................................................................................................................. 48 Drowning Deaths ..................................................................................................................................... 51 Firearm Deaths ......................................................................................................................................... 54 Accomplishments of the CFR Program ................................................................................................ 57 Technical Appendix ................................................................................................................................. 58 Classifications ............................................................................................................................................................. 58 Review Process .......................................................................................................................................................... 62 Appendix of Summary Tables: Age Group, Cause and Manner of Death ..................................... 65 Appendix of Child Deaths by Age Group ............................................................................................ 76 The Neonatal Period, Birth through 27 Days................................................................................................. 76 The Post-Neonatal Period, 28 Days through 365 Days.............................................................................. 77 Children, One through Four Years of Age........................................................................................................ 79 Children, Five through Nine Years of Age ....................................................................................................... 80 Children, 10 through 14 Years of Age ............................................................................................................... 82 Children, 15 through 17 Years of Age ............................................................................................................... 83 5|Page Appendix of Population Denominators for Arizona Children ......................................................... 85 Appendix: Arizona Local CFR Teams................................................................................................... 87 State CFR Team .......................................................................................................................................................... 87 Apache County CFR Team...................................................................................................................................... 88 Coconino County CFR Team.................................................................................................................................. 89 Gila County CFR Team ............................................................................................................................................. 90 Graham County and Greenlee County CFR Team......................................................................................... 91 Maricopa County CFR Team.................................................................................................................................. 92 Mohave County and La Paz County CFR Team .............................................................................................. 94 Navajo County CFR Team....................................................................................................................................... 95 Pima County, Cochise County and Santa Cruz County CFR Team ......................................................... 96 Pinal County CFR Team .......................................................................................................................................... 98 Yavapai County CFR Team..................................................................................................................................... 99 Yuma County CFR Team ...................................................................................................................................... 100 6|Page Executive Summary The Arizona Child Fatality (CFR) Program has spent more than 20 years reviewing child fatalities occurring in the state. This year there is hopeful news to share as well as areas for improvement. The number of deaths identified in four critical categories of preventable fatalities has decreased since the previous year. These categories are unintentional injuries including motor vehicle crashes, child abuse and neglect, homicides and firearm-related deaths. While the overall number of deaths has greatly decreased over the past five years, the number of deemed preventable child deaths have gone up in the following categories: natural deaths (e.g. prematurity), sudden unexplained infant deaths, suicide and drowning. Local teams found that in 2014, 36 percent of all deaths could have been prevented. This conclusion is drawn from in depth reviews conducted by local CFR teams. These teams examined the factors surrounding the deaths of all children less than 18 years old who died in their community in 2014. In order to determine the causes and preventability of each child's death, teams spend many hours each year reviewing records, providing their expertise and coming up with recommendations for prevention. Their hard work results in the information within this report based upon a total of 834 deaths that were reviewed in 2014. By identifying preventable child deaths, the CFR program serves as a resource to help communities reduce the risk factors that are associated with child deaths, promote the protective steps that may prevent a death and improve outcomes for Arizona’s children. Each child’s death is a tragedy not only for their family but also for all of us who care about children. Everyone regardless of age, race or position can help prevent a child death. While much work has been done to prevent child deaths over the past twenty years, more work is needed and the hope is the findings will assist those who are working to prevent child deaths Many people might not consider themselves prevention agents, but they contribute a great deal to prevention strategies and programming. Some examples of these contributions include law enforcement officers who serve as car seat safety technicians, social workers who provide valuable insight into the signs and symptoms of abuse and neglect, and a parent who takes the time to speak with their child daily about their lives and daily stresses. The combined contributions of these individuals can positively affect the community, parents and caregivers to help prevent future fatalities. This annual report provides recommendations that can help prevent further child deaths. The State CFR Team recommendations are supported by the findings from the review of the data. Found in the body of the report are recommendations for individuals, communities, first responders, elected officials and the public. 7|Page Report Highlights Natural Deaths (Deaths due to Medical Conditions) • Natural deaths increased from 513 in 2013 to 547 in 2014 and accounted for 66 percent of all child deaths in Arizona. • The average mortality rate due to natural causes between 2009 and 2014 was 33.8 deaths per 100,000 children. • Prematurity accounted for 41 percent (n=222) of all natural deaths. • Congenital anomalies, neurological disorders, cancer, cardiovascular diseases and infections were the other leading causes of natural death. • The majority of children who died from natural causes were less than 1 year old (n=421, 77 percent). • Hispanic and African American deaths were disproportionately higher than the percentages of the population they comprise. • Only five percent of the natural deaths were determined by the team to be preventable. Prematurity • • • • • • • Prematurity accounted for 222 (27 percent) of all child deaths in 2014, a six percent increase from 2013 (n=210). The average prematurity mortality rate between 2009 and 2014 was 2.4 deaths per 1,000 live births. Eighty-five percent of the deaths due to prematurity (n=188) were associated with medical complications during pregnancy. Eighteen percent of the pregnant mothers had received no prenatal care (n=41), an increase from ten percent in 2013. Sixteen percent of the prematurity deaths were infants born at less than 20 weeks of gestation (n=35); 68 percent were between 20 and 25 weeks of gestation (n=152); the remaining 14 percent were between 26 and 37 weeks of gestation (n=31). Hispanic and African American deaths were disproportionately higher. Six percent of the prematurity deaths were determined to be preventable. Unintentional Injury Deaths (Deaths due to Accidents) • • • • • • Unintentional injury deaths decreased from 186 in 2013 to 180 in 2014 and composed 22 percent of all child deaths. The average mortality rate between 2009 and 2014 was 10.6 deaths per 100,000 children. Thirty-eight percent of these children were less than one year old (n=68). African American and American Indian deaths were disproportionately higher. Boys accounted for 62 percent of the 186 deaths (n=115). Ninety-seven percent of unintentional injury deaths were determined by the team to be preventable. 8|Page Sudden Unexplained Infant Deaths (SUID) and Sleep Related Deaths • • • • • • • • In 2014, 85 infant deaths were categorized as SUID and accounted for 10 percent of all child deaths in Arizona; this is a 15 percent increase from 74 in 2013. The average SUID mortality rate between 2009 and 2014 was 0.96 deaths per 1,000 live births. Eighty-two of the 85 infants died in unsafe sleep environments, an increase from 65 in 2013. Forty-one (50 percent) of those infants died while co-sleeping (bed sharing with adults and/or other children). Deaths due to suffocation remained high, and it was determined to be the cause of death for 60 infants compared to 45 in 2013. Hispanic, African American and American Indian deaths were disproportionately higher. 92 percent of SUID deaths were preventable. 94 percent of sleep related deaths were determined by the team to be preventable. Maltreatment Deaths (Deaths due to Child Abuse and Neglect) • • • • • • • • Child fatalities due to maltreatment decreased from 92 in 2013 to 75 in 2014 and accounted for nine percent of all child deaths in Arizona. Blunt force traumas, suffocation, drowning and motor vehicle crashes accounted for 65 percent of maltreatment deaths (n=49). The average mortality rate due to maltreatment between 2009 and 2014 was 4.5 deaths per 100,000 children. Seventy-nine percent of children who died due to maltreatment were less than 5 years old. In 43 percent of maltreatment deaths, the perpetrator was the child’s mother or father. Substance use was associated with 55 maltreatment deaths (73 percent). African American and American Indian deaths were disproportionately higher. 100 percent of maltreatment deaths were determined by the team to be preventable. Motor Vehicle Crash and Other Transport Deaths • • • • • Fifty-seven children died in motor vehicle crashes and other transportation related accidents accounting for seven percent of all child deaths. The average mortality rate due to motor vehicle crashes and other transport between 2009 and 2014 was 3.7 deaths per 100,000 children. There has been a 29 percent decrease in motor vehicle crash deaths since 2013 (n=80). American Indian deaths were disproportionately higher. 96 percent of motor vehicle and other transport deaths were determined by the team to be preventable and lack of proper vehicle restraint remained the leading preventable factor accounting for 28 motor vehicle crash fatalities (49 percent). 9|Page Suicides • • • • • • Child suicides increased from 25 in 2013 to 38 in 2014 and accounted for five percent of all child deaths. The average mortality rate due to suicide between 2009 and 2014 was 1.8 deaths per 100,000 children. Drug use was the most commonly identified preventable factor in suicides followed closely by family discord and bullying. The majority of suicide deaths occurred in children 15 through 17 years old (n=27). White, non-Hispanic deaths were disproportionately higher. 87 percent of suicides were determined by the team to be preventable. Homicides • • • • • • • • Homicides decreased from 51 in 2013 to 36 in 2014 and accounted for four percent of all child deaths. The average mortality rate due to homicide between 2009 and 2014 was 2.6 deaths per 100,000 children. Twenty-seven of the homicide deaths (73 percent) were due to child abuse. The biological parents were the perpetrator in 41 percent of the deaths (n=15). Nineteen of the deaths were from blunt force trauma and ten were due to firearms. Children aged one through four years were the most affected (n=14, 38 percent). Hispanic and African American deaths were disproportionately higher. 100 percent of homicides were determined by the team to be preventable. Drowning Deaths • • • • • • • Drowning deaths increased from 23 children in 2013 to 31 in 2014 and accounted for less than four percent of all child deaths. The average mortality rate due to drowning between 2009 and 2014 was 1.9 deaths per 100,000 children. The majority of drowning deaths (58 percent) occurred in children one through four years of age (n=18). Sixty-one percent of the deaths occurred in a pool or hot tub (n=19) and six deaths took place in open water (19 percent). Lack of supervision was the contributing factor in 83 percent of the deaths (n=26). White, non-Hispanic and African American deaths were disproportionately higher. 100 percent of drowning deaths were determined by the teams to be preventable. Firearm Deaths • • • Firearm deaths decreased from 29 in 2013 to 25 in 2014 and accounted for three percent of all child deaths. The average mortality rate due to firearms between 2009 and 2014 was 1.7 deaths per 100,000 children. Substance abuse was identified as a preventable factor in nine deaths (36 percent). 10 | P a g e The majority of firearm deaths (56 percent) occurred in children 15 through 17 years of age (n=14). The majority (56 percent) of firearm deaths occurred in White, non-Hispanic children (n=14). One hundred percent of firearm deaths were determined by the teams to be preventable. • • • Disparities Deaths continued to be disproportionately higher among some race/ethnicities in Arizona during 2014 and varied by cause and/or manner of death. Hispanic children represented higher percentages of deaths compared to their population make-up in deaths due to natural causes, the sub-category prematurity, SUID and homicides. African American child deaths are overrepresented in deaths due to natural causes, the subcategory prematurity, unintentional injuries, SUID, maltreatment, homicide and drowning deaths. American Indian child deaths were higher in unintentional injuries, SUID and motor vehicle crash deaths. White, non-Hispanic children comprised higher percentages of suicides, drowning and firearm deaths. • • • • • Future Actions for Prevention The following are a summary of the overarching prevention recommendations found in the report: • • • • • Promote public awareness of the importance of healthy behaviors and women’s overall health prior to pregnancy in order to prevent pregnancy complications and improve the health of women and their future children. Promote safe sleep practices and provide services and education to new parents. This may include public service announcements for Safe Sleep education, safe breastfeeding/sleep practices and co- sleeping education. Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid, that train community members, teachers, families and students how to identify and address depression, bullying, and related behaviors that can lead to suicide. Promote community and family awareness about drowning risks through public awareness campaigns that address the need for age-appropriate supervision of infants and children near water and barriers to young children's access to pools. Support sufficient funding for behavioral health and substance abuse assessment and treatment services for children, youth and their families and drug prevention education and awareness programs in Arizona. 11 | P a g e Glossary ADES - Arizona Department of Economic Security ADCS - Arizona Department of Child Safety (formerly child protective services under Arizona Department of Economic Security (ADES)) ADHS - Arizona Department of Health Services Cause of death – The illness, disease or injury responsible for the death. Examples of natural causes include heart defects, asthma and cancer. Examples of injury-related causes include blunt impact, burns and drowning. CFR Data Form - A standardized form, approved by the State CFR Team, required for collecting data on all child fatality reviews. CFR State Program - Established in the ADHS, provides administrative and clerical support to the State Team; provides training and technical assistance to Local Teams; and develops and maintains the CFR data program. Confidentiality Statement - A form, which must be signed by all review process participants, that includes statute information regarding confidentiality of data reviewed by local child fatality teams. Firearm-related death – Death caused by an injury resulting from the penetrating force of a bullet or other projectile shot from a powder-charged gun. Fire/flame death – Death caused by injury from severe exposure to flames or heat that leads to tissue damage or from smoke inhalation to the upper airway, lower airway or lungs. Home-safety related death – Home safety-related deaths are unintentional or undetermined deaths that occur in or around the home environment (e.g. bedroom, driveway, yard). Homicide – Death resulting from injuries inflicted by another person with the intent to cause fear, harm or death. Infant – A child younger than one year of age. Intentional injury – Injury resulting from the intentional use of force or purposeful action against oneself or others. Intentional injuries include interpersonal acts of violence intended to cause harm, criminal negligence or neglect (e.g., homicide) and self-directed behavior with an intent to kill oneself (e.g., suicide). 12 | P a g e Local CFR Team - A multi-disciplinary team authorized by the State CFR Team to conduct reviews of child deaths within a specific area, i.e. county, reservation or other geographic area. Manner of death – The circumstances of the death as determined by postmortem examination, death scene investigation, police reports, medical records, or other reports. Manner of death categories include: natural, accident (e.g., unintentional), homicide (e.g., intentional), suicide (e.g., intentional), therapeutic complication and undetermined. In this report, manner is used interchangeably with “intent” or “type.” Motor vehicle crash-related death – Death caused by injuries from a motor-vehicle incident, including injuries to motor vehicle occupant(s), pedestrian(s), pedal cyclist(s) or other person. Prematurity death - A death that was due to a premature birth (less than 37 week gestation). Preventable death - A child’s death is considered to be preventable if the community or an individual could have done something that would have changed the circumstances leading to the child’s death. A death is preventable if reasonable medical, educational, social, legal or psychological intervention could have prevented the death from occurring. The community, family and individual’s actions (or inactions) should be considered in making this determination. Record Request Forms - A form required to request records for the purpose of conducting a team review. Sleep-related death – A unique grouping of infant injury deaths inclusive of select injury causes (unintentional suffocation in bed, unspecified threat to breathing, and undetermined causes) in which the infant was last known to be asleep when last seen alive (see Technical Appendix). Substance use – The CFR program defines substance use as associated with a child’s death if the child, the child’s parent, caretaker and/or if the person responsible for the death, during or about the time of the incident leading to the death, used or abused substances, including illegal drugs, prescription drugs and/or alcohol. Suffocation death – Death resulting from inhalation, aspiration or ingestion of food or other object that blocks the airway or causes suffocation; intentional or accidental mechanical suffocation, including hanging, strangulation or lack of air in a closed place. State CFR Team - Established by A.R.S. 36-3501 et seq., the State CFR Team provides oversight to Local CFR Teams, prepares an annual report of review findings and develops recommendations to reduce preventable child deaths. 13 | P a g e Suicide – Death from self-directed intentional behavior where the intent is to die as a consequence of that behavior. Sudden Unexplained Infant Death (SUID) – SUID is defined as the death of a healthy infant who is not initially found to have any underlying medical condition that could have caused their death. It includes the deaths that might have previously been categorized as "crib deaths" if the death occurred during sleep, however not all of these deaths are sleep-related. Many of these SUIDs are due to suffocation and unsafe sleep environments. 1 Undetermined – Deaths that the medical examiner is unable to decide whether the manner of death was natural, accident, homicide or suicide. A death may be listed as undetermined because information is lacking, incomplete or conflicting. In some cases, a death is listed as undetermined because it is not clear if it was an intentional injury or an unintentional injury. For example, it may not be clear when a firearm death is due to an accident, suicide or homicide. Unintentional injury – This is when an injury occurred where there was no intent to cause harm or death; an injury that was not intended to take place. This is also often referred to as an “accident.” 1 See the Technical Appendix for further explanation of SUIDs and its subcategories. 14 | P a g e Introduction Injuries and preventable medical conditions are the leading causes of death among children in Arizona and the United States. Injuries in particular are often seen as being the result of unavoidable incidents. This is problematic as many injuries follow patterns of behavior and circumstances that can be tracked based upon factors such as age and gender. Such risk and protective factors can then be anticipated and prevented. The Arizona CFR (CFR) Program was established in order to review factors in a child’s death and determine ways to reduce or eliminate Conducting a Case Review any identified preventable fatalities. Legislation passed in 1993 (A.R.S. § 36-342, 36- 3501-4) authorizing the creation of the CFR Program. Data collection and case reviews began in 1994. Since 2005, the ••• According to the National program has reviewed the death of every child in the state. Center for Child Death This report provides comprehensive review of fatalities among quality review of a child’s children and youth 0-17 years of age occurring in Arizona. Descriptive death: statistics and trend analysis are used to present summary information about cases as well as the leading causes under each manner of death by factors such as age, gender and race/ethnicity. Demographic and prevention information represented in the report are used to help Review, there are six steps to a   broadly inform public health initiatives and the community. Recommendations for prevention are decided upon by both State and  local review teams based upon the information collected and reviewed on each child death. Methods   Arizona has 11 Local County CFR Teams who complete reviews at the county level (Second level reviews of SUID and Maltreatment Deaths are done at the State level). The review process begins when a child under 18 years-old dies and the State CFR program sends a copy of their death certificate to the local CFR team in the deceased child’s county of residence. If the child is not a resident of Arizona, the local  Share, question, and clarify all case information. Discuss the investigation that occurred. Discuss the delivery of services (to family, friends, schoolmates, community). Identify risk factors (preventable factors or contributing factors). Recommend systems improvements (based on any identified gaps in policy or procedure). Identify and take action to implement prevention recommendations. team in the county where the death occurs will conduct the review. These teams are located throughout the state and must include local representatives from the ADCS, a county medical examiner’s office, a county health department, law enforcement and a 15 | P a g e county prosecuting attorney’s office. Membership also includes a pediatrician or family physician, a psychiatrist or psychologist, a domestic violence specialist and a parent. 2 Information collected during the review is then entered into the National Child Death Review Database. The resulting dataset is used to produce the statistics found in this annual report. Descriptive statistics are used in the report to present summary information about cases as well as the leading causes under each manner of death by age, gender and race/ethnicity. Frequencies and cross-tabulations are used, if the sample size is small, tests for statistical significance are not always completed as they would not provide accurate statements about statistical significance. Rather the demographic and prevention information represented in the report is primarily used to help broadly inform public health initiatives and the community. In Arizona, the cause of death refers to the injury or medical condition that resulted in death (e.g. firearm-related injury, pneumonia, cancer). Manners of death include natural (e.g., cancer), accident (e.g., unintentional car crash), homicide (e.g., assault), suicide (e.g., self-inflicted intentional firearm injury) and undetermined. Manner of death is not the same as cause of death, but specifically refers to the intentionality of the cause. For example, if the cause of death was a firearm-related injury, then the manner of death may have been intentional or unintentional. If it was intentional, then the manner of death was suicide or homicide. If it was unintentional, then the manner of death was an accident. In some cases, there was insufficient information to determine the manner of death, even though the cause was known. It may not have been clear that a firearm death was due to an accident, suicide or homicide; and in these cases the manner of death was listed as undetermined. Demographics During 2014, there were 834 fatalities among children younger than 18 years of age in Arizona an increase from the 811 deaths in 2013. Males accounted for 56 percent of deaths (n=467) and females composed the remaining 44 percent (n=367) (Figure 1). 2 For a full list of participants see the Technical Appendix. 16 | P a g e Figure 1. Number of Deaths among Children by Age Group and Sex, Arizona, 2014 (n=834) 190 200 180 151 160 140 120 103 100 80 80 63 50 45 60 40 28 28 33 37 5-9 Years (n=56) 10-14 Years (n=70) 26 20 0 Birth-27 Days (n=341) 28-365 Days (n=183) 1-4 Years (n=95) Male (n=467) 15-17 Years (n=89) Female (n=367) Arizona’s child mortality rate showed a four percent increase from 2013 to 2014 (from 49.5 in 2013 to 51.3 in 2014) (Figure 2). The rate has decreased seven percent overall during the past five years, from 55.1 deaths per 100,000 children in 2009 to 51.3 deaths per 100,000 children in 2014. Figure 2. Mortality Rates per 100,000 Population among Children 0 through 17 year olds, Arizona, 2009-2014 3 60 55 50 55.1 52.9 45 51 52.4 49.5 51.3 40 35 30 2009 2010 2011 2012 2013 2014 From 2009 to 2014 mortality rates decreased in every age group except for those less than one year old which increased from 5.9 deaths per 1,000 live births in 2009 to 6.0 in 2014 (Figure 3). 3 Note that for all rate charts throughout the report that there was a change in the calculation for population denominators in 2014. See the Appendix of Population Denominators for Arizona Children for further information. 17 | P a g e The infant mortality rate in Arizona in 2014 was the same as the U.S. rate for 2013 as reported from the CDC (6.0 infant deaths per 1,000 live births). Figure 3. Infant Mortality Rates per 1,000 Live Births, Arizona & U.S., 2009-2014 7 6.5 6.4 6.2 6.1 6 6 5.9 5.8 6 6 5.5 5.9 5 6 5.3 4.5 4 2009 2010 2011 2012 AZ Rate U.S. Rate 2013 2014 Children aged 15-17 years saw the most significant decrease in mortality rates (27 percent) from 45 deaths per 100,000 population in 2009 to 32.8 deaths per 100,000 population in 2014 (Figure 4). Figure 4. Mortality Rates per 100,000 Population among Children by Age Group, 1 through 17 year olds, Arizona, 2009-2014 4 50 40 30 20 10 0 2009 4 2010 2011 1-4 Years 5-9 Years 2012 10-14 Years 2013 2014 15-17 Years Mortality rates for children less than one are calculated differently and can be seen in Figure 3. 18 | P a g e Figure 5. Mortality Rates among Children by Race/Ethnicity, per 100,000 Population, Arizona, 20092014 120 100 80 60 40 20 0 2009 African American 2010 2011 American Indian 2012 Asian 2013 Hispanic 2014 White, non-Hispanic Figure 5 shows the child mortality rates for the last five years by race and ethnicity. While there is some yearly fluctuation of the rates within each of the five categories, the graph illustrates that African American and American Indian children consistently maintain higher rates of death compared to other races/ethnicities. Though the graph above indicates the rates for African American and American Indian children have decreased significantly from 2013 to 2014, the population estimate methodology changed in 2014 and therefore changed the denominators used to calculate the mortality rates. The change in the race/ethnicity population denominators may have contributed to the increases in White, non-Hispanic and Hispanic mortality rates between 2013 and 2014 as well (see table 70 in the appendix for population denominators by race/ethnicity). African American children comprised six percent of the Arizona child population in 2014 but make up nine percent of all child fatalities. Hispanic children comprised 39 percent of the population and 44 percent of the fatalities (Figure 6). Though White, non-Hispanic children made up a significantly lower percentage of deaths than the percentage of the population they represent, there are some categories in which they were overrepresented compared to other race/ethnicities. Each section heading includes disparities information by race/ethnicity and gender. 19 | P a g e Figure 6. Percentage of Deaths among Children by Race/Ethnicity Compared to Population, Arizona, 2014 (n=806) 5 50% Fatalities Population 45% 40% 44% 43% 39% 34% 35% 30% 25% 20% 15% 10% 9% 6% 8% 8% 5% 2% 4% 0% African American American Indian Asian Hispanic White, nonHispanic Preventable Deaths The main purpose of the CFR program is to identify preventable factors in a child’s death. Throughout the report the term “preventable death” will be used. Each multi-disciplinary team is made up of professionals who review the circumstances of a child’s death using records ranging from autopsies to law enforcement reports. The team then determines if there were any preventable factors present prior to the death. They used one of the following three labels to determine preventability; 1) Yes, probably 2) No, probably not 3) Team could not determine. A determination is based on the program’s operational definition of preventability in a child’s death. A child’s death is considered to be preventable if the community (education, legislation, etc.) or an individual could reasonably have done something that would have changed the circumstances that led to the child’s death. “Yes, probably,” means that some circumstance or factor related to the death could probably have been prevented. “No, probably not” indicates that everything reasonable was most likely done to prevent the death, but the child would still have died. A designation of “Team could not determine” means that there was insufficient information for the team to decide upon preventability. 5 Does not include the 28 from the category for 2 or more races. 20 | P a g e When discussing all deaths, the report is referring to the total 834 child deaths that took place in 2014. When the text refers to preventable deaths these are the fatalities that the review teams deemed to be preventable. The majority of the data discussed in this report are based on those fatalities seen as preventable by the teams. This is important so that efforts are targeted to the areas where prevention initiatives will be most effective. In 2014, CFR Teams determined 297 child deaths were probably preventable (36 percent), 481 child deaths were probably not preventable (58 percent), and could not determine in 56 deaths (7 percent) (Figure 7). Figure 7. Number and Percentage of Deaths among Children by Preventability, Arizona, 2014 (n=834) Could Not Determine, 7% (n=56) Probably Preventable, 36% (n=297) Probably Not Preventable, 58% (n=481) CFR Teams determined 97 percent of the unintentional injury deaths were preventable (n=174), 100 percent of homicides were preventable (n=36), and 87 percent of suicides were preventable (n=33). Only five percent of natural deaths were determined to have been preventable (n=30) (Figure 8). 21 | P a g e Figure 8. Number and Percentage of Preventable Deaths among Children by Manner, Arizona, 2014 (n=297) 120% 100% 97% 100% 87% 80% 71% 60% 40% 20% 5% 0% Natural (n=30) Unintentional (n=174) Suicide (n=33) Homicide (n=36) Undetermined (n=24) Preventability also varied by age group. Neonatal infants (birth to 27 days) had the lowest percentage of preventable deaths (7 percent, n=25). The highest percentage of preventable deaths was among youth between the ages of 15-17 years (72 percent, n=64) (Figure 9). Figure 9. Percentage of Preventable Deaths among Children by Age Group, Arizona, 2014 (n=297) 80% 72% 70% 58% 60% 49% 50% 52% 49% 40% 30% 20% 10% 7% 0% Birth-27 Days 28-365 Days (n=25) (n=90) 1-4 Years (n=55) 5-9 Years (n=29) 10-14 Years (n=34) 15-17 Years (n=64) Table 1 shows the leading causes of death by age group in Arizona. Those boxes highlighted in blue are some of the leading causes of preventable injury deaths. Two of the top causes were suffocation which was the most common cause of preventable death in infants and motor 22 | P a g e vehicle crashes which was the most common cause of preventable deaths among children 15-17 years old. Drowning was the most common cause of preventable death for children aged 1-4 years and Other Injuries was the most common cause of preventable deaths among children aged 5-14 years old. Table 1. Leading Causes of Death by Age Group, Arizona, 2014 6 Rank 0-27 Days 41% (n=341) 28-365 Days 22% (n=183) 1-4 Years 11% (n=95) 5-9 Years 7% (n=56) 10-14 Years 8% (n=70) 15-17 Years 11% (n=89) 1 Prematurity (n=195) Suffocation (n=59) Other medical condition (n=30) Other medical condition (n=16) Other medical condition (n=21) MVC (n=25) 2 Congenital Anomaly (n=74) Other Medical Condition (n=36) Drowning (n=18) Other Injury (n=14) Other Injury (n=16) Firearm Injury (n=14) Other medical condition (n=217) Congenital Anomaly (n=28) Blunt Force Trauma (n=10) MVC (n=12) Cancer (n=15) Hanging (n=9) Congenital Anomaly (n=109) Prematurity (n=25) MVC (n=10) Cancer (n=8) MVC (n=9) Poisoning Cancer (n=10) Neurological & Seizure Disorders (n=6) Firearm Injury (n=6) 3 4 5 Other Medical Condition (n=40) Other Perinatal Condition (n=24) Unintentional Injury (n=9) Undetermined (n=23) All Deaths 100% (n=834) Prematurity (n=222) (n=7) Suffocation (n=72) Cancer (n=7) MVC (n=57) Natural Deaths In Arizona, as well as nationally, deaths classified as natural deaths due to a medical condition account for the largest percentage of child deaths every year. Natural deaths increased seven percent from 513 in 2013 to 547 in 2014. Prematurity accounted for 41 percent (n=222) and other medical conditions accounted for the remaining 59 percent of the deaths (n=324). Children less 6 Note that causes highlighted in blue are the most common causes of preventable death in each age group. 23 | P a g e than 1 year were the most affected, comprising 77 percent of total natural deaths (n=421). Hispanic children accounted for 46 percent (n=251) of natural deaths and were overrepresented compared to the 39 percent of the population they compose. White, non-Hispanic children made up 33 percent (n=178) of the deaths. Congenital anomalies, neurological disorders, cancer, cardiovascular diseases and infections were the leading causes of natural death. Figure 10. Mortality Rates Due to Natural Causes per 100,000 Children, Arizona, 2009-2014 40 37.3 34.7 35 32.7 33.3 2011 2012 33.6 31.3 30 25 20 2009 2010 2013 2014 Prematurity For the purposes of this report, a death is due to prematurity if the infant was born before 37 weeks gestation and with no underlying medical condition besides being premature. Approximately, a quarter of all child deaths in Arizona are due to prematurity, and in 2014, accounted for 27 percent (n=222) of those fatalities, a slight rise from 26 percent in 2013 (n=210). The rate of prematurity deaths has been increasing since 2012 from 2.2 deaths per 1,000 live births in 2012 to 2.6 deaths per 1,000 live births in 2014 (Figure 11). 24 | P a g e Figure 11. Mortality Rate due to Prematurity (per 1,000 live births), Arizona, 2009-2014 2.7 2.6 2.6 2.6 2.5 2.4 2.4 2.3 2.3 2.3 2.2 2.2 2.1 2 2009 2010 2011 2012 2013 2014 Hispanic children remain at the highest risk in Arizona for prematurity related death. Forty-six percent of the prematurity related deaths were Hispanic infants (n=103) compared to making up 39 percent of the total birth population in 2014 (Figure 12). Figure 12. Percentage of Child Deaths due to Prematurity Compared to Percentage of Births by Race/Ethnicity, Arizona, 2012-2014 60 50 40 2012 (n=192) 53 45 46 2013 (n=210) 46 2014 (n=222) 39 30 30 24 % of births in 2014 28 20 11 10 15 13 5 5 6 5 6 4 2 2 4 0 Hispanic White, nonHispanic African American American Indian Asian Prevention It can be difficult to determine the exact cause of premature birth. The report instead identifies the preventable risk factors that are known to be associated with premature birth for each of these infants. The steady increase in the prematurity rate indicates a need for continued and 25 | P a g e expanded surveillance into the variety of risk and protective factors associated with prematurity. Some of the most common risk factors are medical complications, late prenatal care or the absence of prenatal care, the overall health of the mother, socioeconomic status, gestational age, substance use or abuse by the mother or partner, mother’s age and education level and domestic violence. The top three risk factors for 2014 included medical complications during pregnancy (85 percent, n=188), preterm labor (51 percent, n=114) and bacterial infection (15 percent, n=34). Sixteen percent of the prematurity deaths were less than 20 weeks of gestation (n=35); 68 percent were between 20 and 25 weeks of gestation (n=152); the remaining 14 percent were between 26 and 37 weeks of gestation (n=31) (Table 2). Lack of prenatal care is a risk factor for premature birth. In eighteen percent of the prematurity deaths the mother reported that she did not receive any prenatal care (n=41). Only forty-seven percent of the mothers whose infants died due to prematurity started prenatal care within the first trimester of pregnancy (n=105), a 20 percent decrease from 67 percent in 2013. In eight percent of the prematurity deaths, the mother was 16 through 19 years of age at the time of the birth (n=18). Fifty-one percent of the mothers were 20 through 29 years of age (n=113); 32 percent were 30 through 39 years of age (n=71), and three percent of mothers were 40 through 45 years of age (n=7). In six percent of the cases the age of the mother was unknown (n=13). Fifty-nine percent of mothers whose infants died from prematurity were insured by the Arizona’s Medicaid System called the Arizona Health Care Cost Containment System (AHCCCS) (n=124). Ten percent of mothers had less than a high school education (n=22); 49 percent completed high school (n=103); and 24 percent attended at least some college (n=51); six percent were post-graduates (n=12); and for another six percent the mother’s educational status was unknown (n=12). Table 2. Risk Factors for Prematurity Deaths, Arizona, 2014 Factor* Medical complications during pregnancy Preterm labor No prenatal care Chorioamnionitis (bacterial infection) Cervical insufficiency Drugs and/or alcohol use 7 *More than one factor may have been identified for each death Number 188 114 41 34 16 15 Percent 85 51 18 15 7 7 7 Note: For further information on the change to the reporting of substance use and abuse in this report see the Technical Appendix. 26 | P a g e It is not always possible to determine if any one of these prematurity deaths was specifically preventable. However, studies have shown that the post neonatal period mortality rate is high for children in the U.S., and babies born to lower income mothers are at highest risk of death. 8 There are several protective factors that can help including good preconception health, early access to prenatal care, and community awareness about good health practices. Strengthening these can help reduce incidence and target prevention efforts to improve birth outcomes for groups at higher risk. 9 Recommendations For the Arizona public • • • In order to have a healthy baby, take care of your health before pregnancy by maintaining a healthy weight, adopting healthy eating habits, and avoiding alcohol and other drugs. Seek prenatal care as soon as you become pregnant. Assure that all Arizona women of child bearing age have access to medical care by providing educational resources regarding their health insurance options in both English and Spanish for their families. Support public awareness campaigns and distribution of resources regarding the importance of healthy behaviors and women’s overall health prior to pregnancy in preventing pregnancy complications and improving the health of women and their future children. Unintentional Injury Deaths Unintentional injury deaths, decreased from 186 in 2013 to 174 in 2014. The mortality rate for unintentional injury deaths decreased by four percent from 2013 to 2014, overall the rate has increased by 14 percent from 2009 to 2014 (Figure 13). Thirty eight percent of unintentional injury deaths occurred in children less than one year of age (n=68). American Indian children composed 14 percent of the unintentional injury deaths but represent eight percent of the total 0-17 population in Arizona (n=25). African American children were also disproportionately represented, totaling ten percent of the deaths but comprising six percent of the child population. Boys were almost twice as likely as girls to die from an unintentional injury. There were 115 boys who died from an unintentional injury compared to 63 girls. The leading causes of unintentional injury deaths are shown in Figure 14. 8 9 http://economics.mit.edu/files/9922. http://www.amchp.org/Transformation-Station/Documents/AMCHP%20Preconception%20Issue%20Brief.pdf. 27 | P a g e Figure 13. Unintentional Injury-Related Mortality Rates per 100,000 Children, Arizona, 2009-2014 12 11.7 11 10 9 9.6 9.8 2009 2010 11.4 11 10.2 8 7 6 2011 2012 2013 2014 Figure 14. Leading Causes of Unintentional injury deaths for Children 0-17 Years, Arizona, 2014 14% (n=25) 16% (n=29) 39% (n=69) 31% (n=55) Suffocation MVC Drowning Other Injury Home-Safety Related Deaths Home safety-related deaths are unintentional or undetermined deaths that occur in or around the home environment (e.g. bedroom, driveway, and yard). Although other deaths due to suicide, natural causes or homicide may also occur in the home environment, these categories are not included in the home-safety related deaths. Sixteen percent (n=130) of all Arizona child fatalities in 2014 were classified as home-safety related. Although the numbers of deaths have gone down since 2010, the rate has increased by 14 percent since 2009 (Figure 15). 28 | P a g e Figure 15. Mortality Rate due to Home Safety-Related Deaths per 100,000 Children, Ages 0-17 Years, Arizona, 2009-2014 10 9.5 9 8 8.2 7 7.1 8 7.4 7.3 2012 2013 6 5 4 2009 2010 2011 2014 Prevention In 2014, a child’s gender, race, ethnicity and age were the main risk factors associated with an increased risk for a Home-Safety Related death. Ninety three percent of children who died in this category were less than five years old (n=121) and more than half of the deaths were infants less than one year (71 percent, n=92) (Figure 16). Sixty percent (n=78) were boys and forty percent were girls (n=52). Thirty-six percent were White, non-Hispanic (n=47) and 40 percent were Hispanic (n=52). American Indian (n=14) and African American (n=14) children each accounted for 11 percent. Twenty-two percent of these deaths were also classified as maltreatment deaths due to neglect by the child's caretaker (n=29). 29 | P a g e Figure 16. Number of Home Safety Related Deaths among Children by Age Group, Arizona, 2014 100 92 90 80 70 60 50 40 27 30 20 11 10 0 < One Year 1-9 Years 10-17 Years The most common cause of death in or around the home was suffocation accounting for 52 percent of fatalities (n=68), followed by 28 undetermined deaths (22 percent) and 12 drowning incidents at home (9 percent) (Table 3). Table 3. Number and Percentage of Child Deaths In or Around the Home by Cause, Arizona, 2014 (n=130) Cause Number Percent Suffocation 68 52 Undetermined 28 22 Drowning 12 9 The most commonly identified preventable factors were lack of supervision (48 percent, n=62), unsafe sleep environments for infants (62 percent, n=80) and substance use (50 percent, n=65) (Table 4). Table 4. Preventable Factors for Child Deaths In or Around the Home, Arizona, 2014 Factor* Number Lack of supervision 62 Unsafe sleep environment 80 Substance use 65 Access to water 7 *More than one factor may have been identified for each death Percent 48 62 50 5 There are a variety of protective factors that can be employed to reduce these types of deaths. This might include educating families about the dangers of unsafe sleep environments, how to 30 | P a g e store medications safely, learning the warning signs of substance use by children, having proper pool fencing and providing adequate supervision to young children. Recommendations For the Arizona public • • • Conduct community awareness campaigns regarding the risks and hazards to children of prescription drugs and over-the-counter medications. Physicians and behavioral health providers should limit their prescriptions of potentially addicting medications for their patients, especially if there is a history of substance abuse. Law enforcement agencies, community leaders and parents should collaborate to promote awareness of drug take-back programs. For parents and caregivers • • Educate children about the risks associated with prescription and over-the-counter drug use and other dangerous substances present in the home. Follow directions for the use of medications carefully and properly discard old or unused medications. Sudden Unexplained Infant Death (SUID) and Sleep Related Deaths SUID is defined as the death of a healthy infant who is not initially found to have any underlying medical condition that could have caused their death. It includes deaths that might have previously been categorized as "crib deaths" if the death occurred during sleep but not all of these deaths are sleep-related. Many SUIDs are due to suffocation and unsafe sleep environments. 10 Although SUID mortality rates have declined by 26 percent since 2009, the number of SUIDs increased from 74 in 2013 to 85 in 2014 (Figure 17). Hispanic children accounted for 42 percent of the deaths (n=36), White, non-Hispanic children for 33 percent (n=28), American Indians for 11 percent (n=9) and African Americans for nine percent (n=8). 10 Please see the Methodological Appendix for an expanded definition of SUID and its subcategories. 31 | P a g e Figure 17. Mortality Rates due to Sudden Unexplained Infant Death, Unsafe Sleep Environments, and Suffocation per 1,000 Live Births, Arizona, 2009-2014* 1.4 1.33 1.33 1.31 1.2 1 0.98 0.87 0.89 0.8 0.95 0.77 0.75 0.6 0.6 0.4 0.45 0.2 0 0.98 0.95 0.18 2009 0.54 0.53 Unsafe Sleep Environment Suffocation 0.26 2010 2011 0.69 SUID 2012 2013 2014 *These mortality rates are number of deaths per 1,000 live births. Prevention Local CFR teams determined 78 of these 85 SUIDs were preventable (92 percent). The most commonly identified cause of SUID was suffocation (71 percent, n=60) (Table 5). The major risk factors in many SUIDs are situations where a young infant (less than 14 weeks old) is placed to sleep on his/her stomach; on an unsafe sleeping surface, such as an adult mattress, couch, or chair; excessive soft coverings; in an overheated environment; has been exposed to cigarette smoke either prenatally or postnatally; with adults, other children or pets, especially in an adult bed or on other surfaces (e.g. couch, chair) and/or they are co-sleeping with an adult who smokes or is impaired due to alcohol or drugs. Table 5. Number and Percentage of Sudden Unexpected Infant Deaths by Cause, Arizona, 2014 (n=85) Cause Number Percent Suffocation 60 71 Undetermined 23 27 An unsafe sleep environment was associated with the majority of SUID deaths in Arizona; 82 of the 85 SUID fatalities in 2014 (96 percent) (Table 6). Forty-one infants died while co-sleeping (bed sharing with adults and/or other children) and in seven of these deaths there was no crib in 32 | P a g e the home. Thirty infants died while sleeping in an adult bed, four died sleeping on a couch/futon and 21 died while sleeping on their side or stomach. Table 6. Preventable Factors for Sudden Unexpected Infant Deaths, Arizona, 2014 Factor* Number Percent Unsafe sleep environment 82 96 Drugs and/or alcohol 48 56 *More than one factor may have been identified for each death These deaths could have potentially been prevented by using safe sleep practices. These include being alone on their back in a crib, always using a firm sleep surface, keeping soft objects and loose bedding out of the crib, and placing young infants to sleep on their back instead of on their side or stomach. Other measures that are known to be associated with a decreased risk for SUID include breast-feeding, and placing an infant to sleep in a crib in the same room with the caretaker. Since exposure to cigarette smoke has been associated with SUID, reducing smoking exposure can also help reduce the risk of SUID. Education and safety information that addresses these factors in a culturally appropriate way should be provided to all new parents in order to minimize the risk of SUID. Recommendations For the Arizona public • • • • • • • Parents and other caregivers should always place babies to sleep alone on their backs, in a crib that does not have toys or extra bedding. Parents should make sure all those who care for their infant understand safe sleep practices (use of a crib, avoidance of co-sleeping, and positioning infants on their back to sleep). Early childhood home visitors should educate families about and reinforce safe sleep practices. Encourage all health care providers and Arizona hospitals caring for infants to model safe-sleep practices including placing infants on their back to sleep and having cribs free of soft objects and loose bedding. Encourage all health care providers working with parents to discuss unsafe sleep practices and risk factors at every visit. Arizona Perinatal Trust should continue to promote safe sleep guidelines in birthing hospitals. Child care centers promote and enforce safe sleep practices. For elected officials and public administrators • Support public awareness campaigns and distribution of resources regarding the risk factors associated with sudden unexplained and sleep related infant deaths. 33 | P a g e • • Support and expand the use of the Arizona Unexpected Infant Death Investigation Checklist by Law enforcement, first responders, and medical investigators through regular training. ADHS continue to reinforce safe sleep practices. Maltreatment Deaths (Deaths due to Child Abuse and Neglect) Nine percent (n= 75) of Arizona child fatalities in 2014 were due to maltreatment. There has been a 24 percent increase in mortality rates due to maltreatment from 2009 to 2014. From 2012 to 2013 the mortality rate increased 30 percent from 4.3 deaths per 100,000 children to 5.6 deaths per 100,000 children but decreased by 18 percent from 2013 to 2014 as noted in Figure 19. In 2013, 92 children died due to maltreatment compared to 75 in 2014. In 59 percent of the 2014 maltreatment deaths (n=44) physical abuse such as intentional trauma, suffocation and drowning was the cause of death. Child neglect was the cause of 36 percent of the deaths (n=30). However, it is important to note that while the number of maltreatment deaths has gone down in the last year this does not necessarily indicate that overall incidences of child abuse and neglect have been reduced. 11 Males represented 49 percent of the maltreatment deaths, (n=37) versus 51 percent among females (n=38). Thirty-nine percent of children who died due to maltreatment were Hispanic (n=29); 39 percent were White, non-Hispanic (n=29); 11 percent were American Indian (n=8) and 11 percent were African American (n=8). Seventy-nine percent of the children who died from maltreatment were less than five years old. 11 Please see the Technical Appendix for a full explanation and definition on maltreatment. 34 | P a g e Figure 18. Number of Maltreatment Deaths among Children by Age Group, Arizona, 2014 (n=75) 40 36 35 32 30 25 20 15 10 7 5 0 < One Year 1-9 Years 10-17 Years Figure 19. Mortality Rates due to Maltreatment per 100,000 Children, Arizona, 2009-2014 6 5.5 5.6 5 4.5 4 3.5 3 4.3 4.3 4.3 2010 2011 2012 4.6 3.7 2.5 2 2009 2013 2014 Neglect that resulted in unintentional injuries (accidents) was the leading manner of death for maltreatment fatalities in Arizona (43 percent, n=32). This was followed by homicides which made up 36 percent of the deaths (n=27). Thirteen percent of maltreatment deaths were due to a natural manner (n=10) (Figure 20). Examples of maltreatment deaths due to a natural manner of death include prenatal substance use resulting in premature birth or failure to obtain medical care. 35 | P a g e Figure 20. Number and Percentage of Maltreatment Deaths among Children by Manner, Arizona, 2014 (n=75) Undetermined, 8% (n=6) Natural, 13% (n=10) Homicide, 36% (n=27) Accident, 43% (n=32) Table 7. Maltreatment Deaths Among Children by Top Three Causes of Death, Arizona, 2014 (n=75) Cause Number Percent Blunt/sharp Force Trauma 19 25 Suffocation 15 20 Drowning 10 13 Blunt/sharp force trauma, suffocation and drowning were the leading causes of maltreatmentrelated deaths among children in Arizona (59 percent, n=44) (Table 7). The primary perpetrator in 49 percent of maltreatment deaths was the child’s mother (n=37). This was followed by 19 percent where the perpetrator was the child’s father (n=14) and the mother’s partner accounted for nine percent of the deaths (n=7) (Table 8). Table 8. Number and Percentage of Maltreatment Deaths Among Children by Primary Perpetrator, Arizona, 2014 (n=75) Perpetrator Number Percent Mother 37 49 Father 14 19 Mother’s partner 7 9 Other relative <6 7 Other non-relative 12 16 36 | P a g e Any Child Protective Services Involvement with Families of Children Who Died Due to Maltreatment Local CFR Teams attempt to obtain records from child protective services (cps) agencies, including ADCS and cps agencies in other jurisdictions, such as tribal authorities and other states. Review teams consider a family as having previous involvement with a cps agency if a cps agency investigated a report of maltreatment for any child in the family prior to the incident leading to the child’s death. Unsubstantiated reports of maltreatment are also included in this definition. In 2014, 36 of the 75 children who died from maltreatment were from families with prior involvement with any cps agency (48 percent). Among the families who had prior involvement with a cps agency, 11 of the 36 families had an open case with a cps agency at the time of the child’s death (31 percent); 25 of the 36 families had a history of cps agency involvement but the case was closed at the time the child died (69 percent). The number of children from families with prior cps agency involvement decreased from 49 in 2013 to 36 in 2014. The number of families with an open cps case at the time of the child's death decreased from 21 in 2013 to 11 in 2014 (Figure 21). Less than six of the 75 maltreatment cases involved a Tribal cps agency or involved out-of-state cps agencies. Figure 21. Maltreatment deaths: involvement with any child protective services agency, Arizona, 20122014 100 92 90 80 75 71 70 60 50 40 30 20 10 cases unknown to cps closed cps cases 43 37 39 24 21 22 11 open cps cases 25 11 total maltreatment cases for that year 0 2012 2013 2014 Prevention Child maltreatment is any act or series of acts of commission or omission by a parent or other caregiver (e.g., clergy, coach, teacher) that results in harm, potential for harm, or threat of harm to a child. There are several modifiable risk factors that exist when a child is at risk for 37 | P a g e maltreatment. These factors, usually in combination, may involve the parent or caregiver, the family, the child or the environment. 12 • • • • Parent or caregiver factors: personality characteristics and psychological well-being, having a history of maltreatment as a victim and/or perpetrator, history or patterns of substance use/abuse, incorrect attitudes and/or knowledge about caring for a child i.e. adequate nutrition, safe sleep practices and age Family factors: marital discord, domestic violence, single parenthood, unemployment, financial problems and stress Child factors: child’s age and level of development, disabilities, and problem behavior Environmental factors: poverty and unemployment, social isolation and lack of social support and community violence One hundred percent of child maltreatment deaths were determined to have been preventable (n=75). The CFR teams identified preventable factors in each of these deaths. The most common preventable factor was substance use or abuse which was associated with 73 percent (n=55) of the deaths. Lack of supervision contributed to 47 percent of maltreatment deaths (n=35) and 20 percent were determined to be in an unsafe sleep environment (n=15) (Table 9). Twenty-two maltreatment deaths were also considered to be associated with a poor caregiver choice. More than one factor may have been identified for each death. Table 9. Preventable Factors for Maltreatment Deaths Among Children, Arizona, 2014 Factor* Number Percent Substance use 55 73 Lack of supervision 35 47 Unsafe sleep environment 15 20 *More than one factor may have been identified for each death When a child is at risk for maltreatment there are a number of protective factors that can be strengthened to reduce the risk. These include mentally healthy caregivers, a healthy relationship with a parent or caregiver, parental resilience and strong social connections. Recommendations For the Arizona public • • 12 The Arizona legislature should increase funding for childcare assistance programs so that all low-income working families can have access to safe child care for their children and are not forced to use caregivers who may harm or neglect their child. The Arizona Legislature should ensure there is sufficient funding for the Arizona Department of Child Safety, Juvenile Court System, Attorney General’s Office and https://www.childwelfare.gov/pubpdfs/2011guide.pdf. 38 | P a g e • • • • • • community based services to effectively prevent and respond to child abuse and neglect. Public and community leaders should expand public awareness campaigns and provide free community trainings to promote knowledge and understanding about child abuse and neglect reporting laws, and effective prevention programs such as Safe Sleep, the Protective Factors, Adverse Childhood Experiences, Who Do You Trust with Your Child, Don’t Shake a Baby and Prevent Child Abuse America initiatives. Communities should support evidenced based programs focused on prevention such as Healthy Families Arizona, Nurse Family Partnership, Triple P-Positive Parent Program, Family Resource Centers, Strengthening Families and Nurturing Parenting. Report any suspected abuse or neglect to the Department of Child Safety at 1-888-SOSCHILD (1-888-767-2445). For professional mandated reporters an online reporting system is available for non-emergency situations. Concerns submitted online will be reviewed within 72 hours of submission. Register for online reporting at: https://www.azdes.gov/dcyf/cps/mandated_reporters/ Home visiting programs should collaborate with law enforcement and child protective services agencies to increase awareness and support for home-visitation programs and child abuse prevention initiatives that assist parents and caregivers. Law enforcement agencies and the Arizona Department of Public Safety should collaborate with the Arizona Department of Child Safety and receive training on the recognition of signs and symptoms of maltreatment. Support sufficient funding for timely behavioral health and substance abuse assessment and treatment services for parents and their children. For parents and caregivers • • Report any suspected abuse or neglect by parents or caregivers to the Department of Child Safety at 1-888-SOS-CHILD (1-888-767-2445) and to law enforcement agencies. If in need of safe childcare, parents and caregivers can contact Arizona Childcare Resource & Referral or the Association for Supportive Child Care (ASCC) for assistance. They match parents seeking childcare with appropriate community resources. Motor Vehicle Crash and Other Transport Deaths Deaths due to motor vehicle crashes have decreased since 2009, yet remain one of the leading causes of death for children aged 10 years and older in the United States and accounted for seven percent (n=57) of all child deaths in Arizona. There are a number of risk factors that contribute to these deaths. • • Age and gender: males aged 15–19 are at greatest risk, children under 11 are less able to make safe decisions and teens and young adults have the lowest seatbelt use ratings Improperly or unrestrained children, especially children under five, are at increased risk of severe injury or death in the event of a motor vehicle crash 39 | P a g e • • • • Cyclists, motorcyclists or motorcycle passengers not wearing helmets are at greater risk of severe head injury or death Substance use/abuse by both children and adults Poor supervision Excessive speed, distracted and reckless driving including using mobile devices and texting Effective prevention efforts have reduced the overall number of fatalities. Since 2009, the rate of motor vehicle crash (MVC) fatalities alone has been reduced by 36 percent (Figure 22), and the rate of MVC fatalities combined with other transport deaths saw a 29 percent decrease between 2013 and 2014 (Figure 23). 13 Figure 22. Mortality Rate Due to Motor Vehicle Crashes per 100,000 Children, Arizona, 2009-2014 5.0 4.5 4.7 4.0 3.5 3.6 3.7 3.9 3.5 3.0 3.0 2.5 2.0 2009 2010 2011 2012 2013 2014 13 Other transport accident is defined as any accident involving a device designed primarily for, or used at the time primarily for, conveying persons or good from one place to another. Examples include all-terrain vehicles (ATV) and pedacyclist collisions with motor vehicles. 40 | P a g e Figure 23. Mortality Rate Due to Motor Vehicle Crashes and Other Transport per 100,000 Children, Arizona, 2009-2014 6.0 5.5 5.0 5.4 4.5 4.9 4.8 4.0 4.3 3.5 3.7 3.0 3.5 2.5 2.0 2009 2010 2011 2012 2013 2014 Prevention Local CFR teams determined that 96 percent of the 80 MVC and transport fatalities were preventable (n=55). Among these fatalities, certain groups still carry a larger part of the mortality burden and are in need of targeted prevention initiatives. Two of these groups continue to be American Indian and African American children, as they represent a higher percentage of deaths when compared to their percentage of the Arizona child population (Figure 24). Figure 24. Percentage of Motor Vehicle and Other Transport Deaths by Race/Ethnicity, Compared to Populations, Arizona, 2014 50% 45% 40% 40% 39% 35% MVC fatalities 43% Population 30% 30% 25% 18% 20% 15% 8% 10% 7% 6% 5% 4% 4% 0% Hispanic White, nonHispanic American Indian African American Asian/Pacific Islander 41 | P a g e Teenagers 15 to 17 years old made up more than 44 percent of all MVC and transport fatalities in 2014 (Figure 25). Although the total number of motor vehicle and transport deaths decreased by 29 percent from 2013 to 2014, the number of deaths to those 15 to 17 years old remained relatively the same with 24 deaths in 2013 and 25 deaths in 2014. The second highest age group were those five to nine years old accounting for 21 percent of all transport fatalities (n=12), followed by those one through four year of age with 18 percent of the deaths (n=10). Figure 25. Number of Motor Vehicle and Other Transport Deaths by Age Group, Arizona, 2014 (n=80) 30 25 25 20 15 10 10 12 9 5 0 1-4 Years 5-9 Years 10-14 Years 15-17 Years Of the 57 children who died in motor vehicle crashes and other types of transportation, 40 children were vehicle occupants, 13 children were pedestrians and three children were riding bicycles. Among the 40 motor vehicle occupant fatalities, 38 children were passengers. Among the passenger deaths, ten children were seated in the vehicle’s front seat and 19 children were seated in the back seat. In eight child fatalities, the seating position within the vehicle was unknown. 42 | P a g e Figure 26. Number and Percentage of Motor Vehicle Crash Deaths by Occupant Position, Arizona, 2014 (n=57) 4% 24% 72% Driver Passenger Pedestrian In addition, 29 children were known to have been improperly restrained or unrestrained in vehicles (51 percent) (Figure 27). The highest number of transport related deaths were due to lack of vehicle restraint (Table 10). This indicates although child safety restraint laws have reduced the number of motor vehicle crash fatalities further prevention efforts are needed. Figure 27. Number of Motor Vehicle and Other Transport Deaths with Improper or Unknown Restraint Use by Age Group, Arizona, 2014 (n=29) 16 14 14 12 10 8 6 5 5 5 0-4 Years 5-9 Years 10-14 Years 4 2 0 15-17 Years 43 | P a g e Additional preventable risk factors associated with transport related deaths in Arizona include speeding, reckless driving, driver inexperience, driver distraction, and substance use (Table 10). Table 10. Preventable Factors for Transportation-Related Deaths Among Children, Arizona, 2014 Factor* Number Percent Lack of vehicle restraint 29 51 Excessive driving speed 25 44 Reckless driving 20 35 Drugs and/or alcohol 13 23 Driver inexperience 11 19 Driver distraction/ Driver fatigue 8 14 *More than one factor may have been identified for each death Each of these factors was determined to be 100 percent avoidable. They can be best addressed by strengthening protective factors such as using proper child restraints every time a vehicle is in operation, wearing helmets, following passenger safety and established motor vehicle laws. The continuation of targeted awareness and education efforts to the most at risk populations is essential. Recommendations For parents and caregivers • • Place children in the appropriate child safety restraints when operating a motor vehicle. Model good behavior by always wearing a seatbelt and never operate a vehicle while distracted. For the elected officials and other public administrators • • • • • Enact stricter distracted driving laws to include the prohibition of texting while driving. Enact a primary seat belt law to allow law enforcement officers to cite a driver and occupants for not wearing a seat belt in the absence of other traffic violations. Strengthen the graduated driver licensing system to build driving skills and experience among new drivers. Law enforcement officers should continue rigorous DUI enforcement and educate the community regarding the consequences of driving under the influence of alcohol and/or drugs. Promote awareness about child passenger and motorized vehicle safety and encourage participation in events such as car-seat checkups, safety workshops, and sports clinics. 44 | P a g e Suicides In 2014, there were 38 suicides among children in Arizona, which accounted for five percent of all child deaths. This was a 53 percent increase from 2013. There are number of identifiable risk factors associated with suicide deaths. • • • • • • • • • • Behavioral health issues and disorders, particularly mood disorders, depressant and anxiety disorders Substance use and abuse Impulsive and/or aggressive tendencies History of trauma or abuse Major physical illnesses Family history of suicide and previous suicide attempts Easy access to lethal means Lack of social support and a sense of isolation Stigma associated with asking for help Lack of health care, especially mental health and substance abuse treatment Figure 28. Mortality Rates due to Suicide per 100,000 Children, Arizona, 2009-2014 2.6 2.4 2.3 2.4 2.2 2 1.8 1.6 1.6 1.7 1.5 1.5 1.4 1.2 1 2009 2010 2011 2012 2013 2014 The majority of suicide deaths occurred in boys. Seventy-four percent of all suicide deaths occurred in boys (n=28) compared to 26 percent (n= 10) in girls. The distribution of suicide by race/ethnicity varies year by year. In 2014, White, non-Hispanic children made up 55 percent of the suicide deaths (n=21) and Hispanic children accounted for 34 percent (n=13) (Figure 29). White, non-Hispanic children were overrepresented compared to the population accounting for more than half the suicides. 45 | P a g e Figure 29. Percentage of Suicide Deaths by Race/Ethnicity, Compared to Populations, Arizona, 2014 60% Population 50% 40% Suicides 55% 39% 43% 34% 30% 20% 8% 8% 10% 6% 4% 0% Hispanic White, NonHispanic American Indian African American Asian/Pacific Islander Youth ages 15 through 17 years remained at highest risk for suicide death with 71 percent (n=27) of suicides followed by children 10 through 14 years of age (29 percent, n=11). This distribution of suicides by age group has remained consistent since 2009. Causes of death from suicides included firearm injuries (37 percent) followed by hanging (34 percent). Objects used for hanging suicides included belts, rope, strings and electrical cords. Prevention As with other categories of death, understanding the circumstances, risk factors, and events leading up to the suicide aids in developing appropriate interventions for future prevention efforts. Several risk factors were identified by local CFR teams that may have contributed to the child’s despondency prior to the suicide. The most common factors noted were that children were known to have a history of family discord (34 percent); a history of drug/alcohol use by the child (26 percent) and history of a recent break-up with a girlfriend or boyfriend (26 percent) (Table 11). 46 | P a g e Table 11. Factors That May Have Contributed to the Child’s Despondency Prior to Suicide, Arizona, 2014 Factor* Percent History of drug/alcohol use 26 History of family discord 34 Victim of bullying 11 History/recent break-up 26 Argument with parent 21 History of suicide within the family 0 History of parent divorce 13 Argument with boyfriend or girlfriend 11 Failure in school 18 Death in the family 8 History of issues related to sexual orientation 0 History of physical abuse 0 History of sexual abuse 0 History of problems with the law 11 *More than one factor may have been identified for each death For many of the child suicides, important information regarding risk factors was unknown or unavailable to review teams, even after law enforcement records were available. Local review teams determined 33 child suicides were preventable (87 percent). Of the top preventable factors for child suicides, the use of drugs was the most commonly identified (39 percent, n=15) followed by alcohol use (18 percent, n=7) (Table 12). Table 12. Preventable Factors for Child Suicides, Arizona, 2014 Factor* Number Drug use 15 Alcohol use 7 *More than one factor may have been identified for each death. Percent 39 18 There are ways to help children, youth, and their families strengthen protective factors and prevent suicide. Some of these factors include seeking early treatment of effective clinical care for mental, physical and substance abuse issues; restricting access to lethal means of suicide; building strong family and support connections; gaining and retaining skills in problem solving, conflict resolution and stress management; having family, friends, and acquaintances taking any discussion of suicide seriously and seeking help. 47 | P a g e Recommendations For the Arizona public • • Arizona schools should collaborate with the Arizona Suicide Prevention Coalition to support and implement school and community prevention programs, such as Mental Health First Aid, that train teachers and students how to address suicide, bullying, and related behaviors. Increase awareness about suicide prevention and reporting resources by connecting communities and families with these resources. For parents and caregivers • • • • Monitor children with known behavioral problems (substance abuse and delinquency) or possible mental disorders (depression or impulse control problems) for signs and symptoms of suicide and immediately seek treatment and care. Talk with children about firearm safety if there is any evidence of mental health issues and limit youth access to any lethal means. Completely remove firearms from homes where children or adolescents are showing signs of mental health issues, substance abuse, or suicide. Monitor your child’s social media for any talk about suicide and take immediate action. For the elected officials and other public administrators • • Schools should work closely with suicide prevention groups to expand and implement bullying awareness and prevention programs. Support funding for behavioral health and substance use assessment and treatment services for youth and their families. Homicides In 2014, thirty-six children were victims of homicide in Arizona accounting for four percent of all child deaths. The child homicide rate decreased between 2013 and 2014 by 29 percent (Figure 30). 48 | P a g e Figure 30. Mortality Rate due to Homicides per 100,000 Children, Arizona, 2009-2014 3.2 3.1 3.0 3.0 2.8 2.6 2.6 2.6 2.4 2.2 2.2 2.2 2.0 2009 2010 2011 2012 2013 2014 Unlike previous years, females accounted for the majority of homicides in 2014 (female, 58 percent n=21 vs. male, 42 percent, n=15). Hispanic children experienced the highest number of child homicides accounting for 50 percent of deaths (n=18) followed by 27 percent among White, non-Hispanics (n=10). The remaining 23 percent were African American, American Indian, Asian/Pacific Islander/Hawaiian and children of two or more races. Figure 31. Number of Homicides among Children by Age Group, Arizona, 2014 (n=36) 19 20 15 10 10 7 5 0 < One Year 1-9 Years 10-17 Years The number of homicides in some age groups has remained consistent since 2009 with an overall downward trend except in those one to nine years of age. Children aged 10-17 years experienced a decrease in the number of deaths from 25 homicides in 2013 to ten in 2014 (Figure 31). 49 | P a g e Prevention Local teams review the unique circumstances surrounding each child homicide in order to determine any patterns in the causes of death and identity of the perpetrator. In 2014, blunt force trauma remained the leading cause of death among child homicides (53 percent, n=19), decreasing only two percent from 2013, followed by firearm injuries (28 percent, n=10) (Figure 32). Figure 32. Number of Homicides among Children by Cause of Death, Arizona, 2014 (n=36) 19 20 18 16 14 12 10 10 7 8 6 4 2 0 Firearm Injury Blunt Force Trauma Other In 42 percent of child homicides, the biological parent of the child was the perpetrator. The mother’s partner was responsible for 17 percent. Teams were unable to identify the nature of the relationship between the perpetrator and the child in 13 percent of the deaths (Table 13). Table 13. Homicides Among Children by Perpetrator, Arizona, 2014 (n=36) Perpetrator* Number Biological Parent 15 Mother’s Partner 6 *Perpetrator may fall into more than one category for each death Percent 42 17 One hundred percent of child homicides were determined to have been preventable (n=36). The most common preventable factor was drugs, followed by lack of supervision and alcohol. These remained the top three preventable risk factors in child homicides from 2013 to 2014 (Table 14). 50 | P a g e Table 14. Preventable Factors for Child Homicides, Arizona, 2014 Factors* Number Drugs 24 Lack of supervision 12 Alcohol 9 *More than one factor may have been identified for each death Percent 67 33 25 Recommendations For parents and caregivers • If feeling stressed or overwhelmed, parents and caregivers can seek assistance through the National Parent Helpline at 1-855-427-2736, the Birth to Five Helpline at 1-877-705KIDS (Available Monday-Friday 8:00 am to 8:00 pm), the Fussy Baby Helpline at 1-877705-KIDS ext. 5437 (Available Monday-Friday 8:00 am to 8:00 pm or Childhelp National Child Abuse Hotline at 1-800-4-A-CHILD (24 hours, 7 days per week). These resources offer crisis intervention, information, literature, and referrals to thousands of emergency, social service, and support resources. All calls are confidential. For the elected officials and other public administrators • Support sufficient funding for behavioral health and substance use assessment and treatment services for children, youth and their families. Drowning Deaths Drowning accounted for 31 child deaths and four percent of all child deaths in Arizona. While the drowning rate increased by 36 percent from 1.4 deaths in 2013 to 1.9 deaths in 2014, the rate has decreased by five percent since 2009 (Figure 33). It is important to note with some of these rates that while they appear to fluctuate quite drastically from year to year are just a result of small numbers. Therefore, a slight increase or decrease in the total number of deaths can impact the rates from year to year. It is more important to look at the five-year average rate when determining whether a change is significant or not. 51 | P a g e Figure 33. Mortality Rate due to Drowning per 100,000 Children, Ages 0-17, Arizona, 20092014 2.4 2.2 2.2 2 2 2 1.9 1.9 1.8 1.6 1.4 1.4 1.2 1 2009 2010 2011 2012 2013 2014 Prevention Drowning is a highly preventable cause of death with identifiable risk factors that can be recognized and addressed. • • • • Sex: males are twice as likely to drown as girls Age: children under the age of five are at highest risk for drowning Substance use or abuse: either by the caregiver or child Access to water: residential pools not adequately fenced In 2014, review teams determined 100 percent of the 31 child-drowning fatalities were preventable. There are three main preventable factors associated with child drowning in Arizona (Table 15). Lack of supervision was the most commonly identified factor in 84 percent of drowning deaths (n=26), followed by access to water at 68 percent (n=21) and substance use at 33 percent. Table 15. Preventable Factors for Child Drowning, Arizona, 2014 Factor* Lack of supervision Access to water Drugs and/or alcohol Number 26 21 10 Percent 84 68 33 *More than one factor may have been identified for each death 52 | P a g e The group at highest risk of drowning are children aged one to four accounting for 58 percent of drowning deaths in 2014 (n=18), the remaining 13 deaths are relatively evenly distributed among the other age groups. White, non-Hispanic children made up 55 percent of the deaths (n=17); Hispanic children composed an additional 23 percent of the drowning deaths (n=7) followed by African American children at 19 percent (n=6). Sixty-one percent (n=19) of children drowned in a pool, hot tub or spa. The second most prevalent place was in open bodies of water (Table 16). Table 16. Location of Child Drowning Fatalities, Arizona, 2014 (n=31) Location Number Pool/hot tub/spa 19 Open water 6 Percent 61 19 Drowning fatalities in Arizona have been reduced overall in the past several years, but vigilance in promoting protective factors must continue. It is especially important because drowning deaths have increased over the last year, although, the number of fatalities to children aged 1-4 remained fairly stable. Prevention strategies include removing the hazard by draining unnecessary accumulations of water i.e. pools and bathtubs; creating barriers by building and maintaining fencing around pools and other bodies of water when possible; and protecting children at risk: promote learning to swim, train lifeguards and practice proper supervision of children near water. Lack of supervision is the leading risk factor in drowning deaths, so prevention efforts need to continue to promote proper supervision of young children around water and “touch supervision” of young non-swimmers. Touch supervision is defined as the adult who is responsible for supervising the non-swimmer remain within an arm’s length of the child they are supervising. Recommendations For the Arizona public • • • • Teach children to swim and about water safety at an appropriate age. Never leave a young child alone and without "touch" supervision around all bodies of water. Seek training on child and infant CPR. Secure public and private pools by installing fencing and self-latching gates that are kept in good repair. 53 | P a g e Support public drowning prevention education including public service announcements and legislation regarding proper pool fencing. • For parents and caregivers To prevent drowning, parents and other caregivers should designate at least one responsible adult to monitor the pool area when children are present. They should also not rely solely on flotation devices to protect the child from drowning. Continue to use “touch supervision,” where the adult can reach out and touch the child at all times. • Firearm Deaths There were 25 firearm-related fatalities in 2014, compared to 29 in 2013 and 32 in 2012. The percentage of firearm-related deaths for the year was three percent. The overall rate for firearm-related deaths has remained on a downward trend since 2009 with only a slight increase in 2012 and decreasing again in 2013 (Figure 34). The number of males dying from firearm-related fatalities continually remains higher than the number of females; 76 percent of firearm-related deaths in 2014 were among males and the remaining 24 percent were among females. White, non-Hispanic children were most affected representing 56 percent of firearm fatalities, followed by Hispanic children at 40 percent. Figure 34. Mortality Rate due to Firearms per 100,000 Children, Ages 0-17, Arizona, 2009-2014 2.5 2 1.5 2 1.9 1 1.8 1.4 1.4 2010 2011 1.5 0.5 0 2009 2012 2013 2014 In 2014, children aged 15-17 years accounted for fourteen firearm-related deaths (56 percent) and those 0-14 composed an additional 44 percent (n=6) (Figure 35). 54 | P a g e Figure 35. Number of Firearm-related Deaths Among Children by Age Group, Arizona, 2014 (n=25) 16 14 12 14 11 10 8 6 4 2 0 0-14 Years 15-17 Years Suicides and homicides accounted for 96 percent of firearm-related deaths in 2014. Fourteen firearm-related deaths were a result of suicide (56 percent) and ten firearm-related deaths were homicides (40 percent). Handguns accounted for 68 percent of the firearm-related fatalities in 2014 (n=17) (Table 17). Table 17. Types of Firearms Involved in Child Deaths, Arizona, 2014 (n=25) Type Number Handgun 17 Other 8 Percent 68 32 When reviewing cases to see who owned the firearm used in the fatality incident the category showing the greatest percentage was a biological parent (44 percent). The other category includes a variety of other individuals including acquaintances, mother’s partner, friend, etc (Table 18). Table 18. Owners of Firearms Involved in Child Deaths, Arizona, 2014 (n=25) Owner Biological Parent Other (e.g. acquaintance, mother’s partner) *other category the numbers are too small to separate Percent 44 56 In several firearm-related deaths, the storage location of the firearm was unknown to the review teams (56 percent, n=14). Eleven of the firearms were not stored in secured locations (44 percent) (Table 19). 55 | P a g e Table 19. Locations of Firearms Involved in Child Deaths, Arizona, 2014 (n=25) Location Number Unknown 14 Other (e.g. unsecure location) 11 Percent 56 44 Prevention Local teams determined 100 percent of the firearm-related child deaths were preventable (n=25). Of the preventable risk factors for firearm-related deaths, drug and alcohol use were associated with 56 percent of deaths. Drug use was involved in 9 deaths (36 percent); alcohol use factored into 5 deaths (20 percent) and lack of supervision contributed to 6 deaths (24 percent) (Table 20). Table 20. Preventable Factors for Firearm-Related Deaths Among Children, Arizona, 2014 Factor* Number Percent Drug use 9 36 Alcohol use 5 20 Lack of supervision 6 24 *More than one factor may have been identified for each death Recommendations For the Arizona public • Collaborate with the firearm injury prevention programs to hold community events promoting gun safety education. For parents and caregivers • Families with children should store all firearms unloaded, in a secure locked location. 56 | P a g e Accomplishments of the CFR Program The following are accomplishments achieved by the CFR Program in the past year: • • • Establishment of an informed partnership with Arizona’s Vital Records Office to increase the timely collection and distribution of death and birth certificates to local teams for completing on time reviews of all child deaths. Completion of three infant death scene re-enactment trainings for law enforcement and other first responders increasing awareness and use of the statutorily required Arizona Infant Death Checklist. Implementing a new Safe Sleep Awareness campaign and the creation of crib cards for new parents. 57 | P a g e Technical Appendix Classifications Injury deaths. Death certificates of all persons who died in Arizona are collected and maintained by the ADHS Bureau of Population Health and Vital Statistics. For the years 2009 through 2014, all deaths of Arizona residents and out-of-state residents aged 0 to 17 were identified by underlying cause of death with International Classification of Disease codes, Version 10 (ICD-10; http://www.who.int/classifications/icd/en/). CFR local teams take the demographic and incident information from death certificates of children and youth aged 0 to 17 for the purpose of completing comprehensive reviews and subsequent aggregate data analysis. To categorize injury intent and mechanism, teams followed a guideline similar to the National Center for Health Statistics ICD-10 external cause of injury matrix available at: (http://www.cdc.gov/nchs/injury/injury_matrices.htm). Deaths caused by injuries where the intent is known are identified using the definitions below and related ICD-10 codes: Unintentional injury. An injury or poisoning fatality that took place without any intent to cause harm or death to the victim, also referred to as an accident. These are identified using ICD-10 codes V01-X59. Homicide. An intentional injury resulting in death from the injuries inflicted by an act of violence carried out by another individual whose action was intended to cause harm, fear, and/or death. Homicide deaths are identified using ICD-10 codes X85-Y09. Suicide. An injury death caused by an individual’s purposeful intent to die as a result of their actions. Suicides are identified using ICD-10 codes X60-X84. Undetermined injury death. These can be injury death in which investigators and medical examiners have insufficient information available to fully determine a cause and/or manner of death. Undetermined injury deaths are identified using ICD-10 codes Y10–Y34. Maltreatment. Maltreatment is a form of child abuse and neglect, an act or failure to act on the part of the parent or caregiver of a child resulting in the serious physical or emotional harm of the child. Some of the most common injuries CFR teams will encounter in maltreatment cases involve physical abuse which includes internal abdominal and blunt head injuries leading to fatalities. When looking at neglect cases, CFR teams determine if parents or caregivers failed to arrange for the child’s daily necessities including clothing, food, safe shelter, medical care and appropriate supervision. Deaths attributed to neglect are typically failure to thrive, accidents 58 | P a g e resulting from unsafe environments and prenatal substance exposure. The circumstances around these maltreatment deaths vary greatly, some fatalities are the result of long-term abuse and neglect, unintentional and intentional, but some are the result of a single incident. To gain greater understanding of the contribution of abuse and neglect to child mortality, the Arizona CFR Teams answers several questions regarding maltreatment during a review. Classification of a death due to maltreatment must meet the following four conditions: 1. Was there “An act or failure to act by a parent, caregiver, or other person as defined under State law which results in physical abuse, neglect, medical neglect, sexual abuse, emotional abuse, or an act or failure to act which presents an imminent risk of serious harm to a child” as it applied to the circumstances surrounding the death? (From the U.S. Department of Health and Human Services definition of maltreatment). 2. The relationship of the individual accused of committing the maltreatment to the child must be the child’s parent, guardian, or caretaker. 3. A team member, who is a mandated reporter, would be obligated to report a similar incident to the appropriate child protective services agency. 4. Was there an act or failure to act during critical moments that caused or contributed to the child’s death? The program also reports deaths classified as maltreatment in other categories by manner and cause of death. For example, one classifies a death from abusive head trauma caused by the use of blunt force as a homicide and a maltreatment death. Teams may also classify an accidental or natural death as a maltreatment death if the team concludes a caretaker’s negligence or actions contributed to or caused the fatality. For example, the death of child in a motor vehicle crash due to the actions of a parent who drove while intoxicated would be considered a maltreatment fatality. Reporting. The number of child maltreatment deaths presented in this report is not comparable to child maltreatment deaths reported by the Arizona Department of Child Safety (DCS) (Formerly Arizona Department of Economic Security Child Protective Services) for the National Child Abuse and Neglect Data System (NCANDS). NCANDS includes maltreatment deaths identified through child protective services investigations, and because some maltreatment deaths identified by Local CFR Teams may not have been reported to child protective services agencies or were within the jurisdiction of Tribal Nations or other states, these deaths would not be included in DCS’ annual report to NCANDS. However, when a Local CFR team identifies a death due to maltreatment not previously reported to a child protective services agency, the Local CFR Program notifies child protective services of the team’s assessment so they can initiate an investigation. It is also important to note the differences in reporting of maltreatment numbers in this report compared to the number of maltreatment fatalities reported by DCS. DCS reports only those 59 | P a g e deaths that have been investigated by DCS and substantiated as maltreatment. The CFR team reports all deaths related to maltreatment to DCS, if a report has not been previously generated. Per A.R.S. § 8-807, DCS is required to post information on child fatalities due to abuse or neglect by the child’s parent, custodian or caregiver. This information is posted after a final determination of the fatality due to abuse or neglect has been made by DCS. The determination is made by either a substantiated finding or specific criminal charges filed against a parent, guardian or caregiver for causing the fatality or near fatality. Sudden unexplained infant deaths and sleep-related deaths. In Arizona, all sudden unexpected infant deaths (SUID) are determined using a protocol based on the CDC’s SUID guidelines. Based upon these guidelines, review teams will follow the protocol to determine if unsafe factors were in place at the time of the child’s death. If any such factors are identified then the death will be classified as one of the following: (1) With sufficient evidence, including death scene reenactment photos, death checklist information, and autopsy results, it will be deemed as asphyxia or suffocation with an accidental manner; (2) If there is not enough evidence to determine intent, but the cause of death of suffocation is clear then it will be labeled with an undetermined manner of death. (3) If all evidence is reviewed and cause of death is suspected, but there is not enough information to fully determine the cause or manner then the death will be labeled as undetermined for both cause and manner. Sleep-related injury deaths in this report are identified by reviewing all potential cases of children less than one year with causes and manners of death using the ICD-10 codes of W75, W84 (suffocation injuries) and Y33, Y34 (injuries of undetermined cause and intent). A death is considered to be sleep related if the child was found in a sleep environment or the last time they were seen alive was while they were asleep. Limitations. Data is based upon vital records information and information from local jurisdictions. Arizona has a medical examiner system with each county having its own jurisdiction. Law enforcement also varies around the state. Arizona is also home to 22 different Native American tribes each of whom has their own sovereign laws and protocols. Jurisdiction and records sharing for each tribal government varies. These intricate relationships and individual jurisdictions mean that sources and information may vary. 60 | P a g e Factors impacting protocols to certify SUID and sleep related deaths include death scene investigation by trained investigators and law enforcement, completion of the death scene investigation form, and the final determination of death by a certified forensic pathologist. The Arizona CFR program works to mitigate these limitations by providing statewide training to law enforcement on the statutorily required AZ Infant Death Checklist, and completing both local and state level reviews of all identified SUID cases. In 2014, out of 270 deaths where a death scene investigation was completed, authorities filled out a death checklist in 63 of the cases. The cases in this report use the final cause and manner of death that are determined by the state SUID Review Team. This expert panel reviews all available information to determine the certification. However, this methodology accounts for the differences between the numbers in the report and the numbers reported by vital records and medical examiners. Limitations of the overall data. It is significant to note that the report has certain limitations. While every child death is important the small numbers in some areas of preventable deaths reduce the ability to examine some trends in detail. The numbers are used to inform public health efforts in a broader sense, but the sample size reduces the ability to make true statements about statistical significance in any differences or causal relationships. It is also of note that much of the collected data is done through qualitative methods such as the collection of witness reports on child injury deaths. This means that there is always the potential for bias when the information is taken. Other variables that may not be captured on the death certificate or other typical records may include family dynamics, mental health issues, or other hazards. CFR team meetings. Meetings are closed to the public. All team members must sign a confidentiality statement before participating in the review process. The confidentiality statement specifically defines the conditions of participation and assures that members will not divulge information discussed in team meetings. To further maintain confidentiality, identifying information in data and research reports has been omitted. All cases reviewed by the CFR Team are kept completely confidential. Information shared in the meetings is protected under ARS 36-3502 and cannot be shared with anyone outside the meeting. Every effort is made in this report to keep information private, and is intended only to provide summary statistics of all child deaths in Arizona. Substance Use. In Arizona, substance use and abuse are a contributing factor in some preventable child deaths. In previous annual reports this was a separate section, but to be clearer about when substance use and abuse are a contributing factor in a child death this information has been moved and is now noted in the prevention portion of each section of the report. 61 | P a g e Review Process Case reviews take place throughout the year. Once the local team coordinator or chairperson receives the death certificate they send out requests for relevant documents, which may include the child’s autopsy report, hospital records, DCS records, law enforcement reports, and any other information that may provide insight into the death. Additionally, the birth certificate is reviewed when the child is younger than one year of age at the time of death. Legislation requires that hospitals and state agencies release this information to the Arizona CFR Program’s local teams. Note: Team members are required to maintain confidentiality and prohibited from contacting the child’s family. During the review, team members from representing agencies provide information on each case. If an agency representative is unable to attend a meeting the pertinent information is collected by the local team coordinator and presented at the review meeting. Information collected during the review is then entered into the National Child Death Review Database. The data is entered by the local team staff using a collection tool developed by the National Center for Child Death Review. The form is formatted using a wide variety of variables so all possible detailed information is collected using specific questions about the demographics of the child, the supervisor of the child at the time of the fatality incident, caregiver, the family, and the circumstances surrounding the fatality. There are several variables present on the form, but not all such specific information will be available to teams. The form is regularly reviewed and updated by the National Center and the State CFR Program Office to ensure it is as effective as possible in capturing the most relevant information for preventing future fatalities. This county level data is then put through a system of quality assurance checks by the State CFR Program Office. The resulting dataset is used to produce the statistics found in this report. An independent state level team meets annually to review the analysis of these findings, and is required to include statutorily mandated representatives from a variety of community and governmental agencies including: • • • • • • Attorney’s General Office Bureau of Women’s and Children’s Health in the Arizona Department of Health Services Division of Behavioral Health in the Arizona Department of Health Services Division of Developmental Disabilities in the Arizona Department of Economic Security Division of Children, Youth and Families in the Arizona Department of Economic Security Governor’s Office of Youth, Faith, and Family 62 | P a g e • • • • • • • • • • • • Administrative Office of the Courts Arizona Chapter of the American Academy of Pediatrics Medical Examiner’s Office Maternal Child Health Specialist who works with members of Tribal Nations Private nonprofit organization of Tribal Governments The Navajo Nation United States Military Family Advocacy Program Prosecuting Attorney’s Advisory Council Law Enforcement Officer’s Advisory Council with experience in child homicide Association of County Health Officers Child Advocates not employed by the state or a political subdivision of the state A member of the public The statute authorizes the state team to study the adequacy of existing statutes, ordinances, rules, training and services in order to determine the need for changes. Second, the state team is responsible for raising awareness and educating the public on the causes and number of fatalities and by providing recommendations for prevention strategies. Adoption of the recommendations has often occurred as a result of the experience and expertise of the team. Reviewing 100 percent of the deaths allows for multi-year outcome comparisons and trend identification. In Arizona, the cause of death refers to the injury or medical condition that resulted in death (e.g. firearm-related injury, pneumonia, cancer). Manner of death is not the same as cause of death, but specifically refers to the intentionality of the cause. For example, if the cause of death was a firearm-related injury, then the manner of death may have been intentional or unintentional. If it was intentional, then the manner of death was suicide or homicide. If it was unintentional, then the manner of death was an accident. In some cases, there was insufficient information to determine the manner of death, even though the cause was known. It may not have been clear that a firearm death was due to an accident, suicide, or homicide, and in these cases, the manner of death was listed as undetermined. After a person dies, the county medical examiner or other appointed medical authority will determine both a cause and manner of death and write it on the deceased’s death certificate. However, it is important to note since CFR Teams review all records related to a fatality, because of this comprehensive, multidisciplinary approach, the teams’ determinations of cause and manner of death may differ from those recorded on the death certificate. Their determination of cause and manner are what is used in this report. In the report, deaths are counted once in each applicable section based upon team consensus of the cause and manner of death. For example, a homicide involving a firearm injury perpetrated 63 | P a g e by an intoxicated caregiver would be counted in the sections addressing firearm injuries, homicides and maltreatment fatalities. Frequencies and cross-tabulations are used, but due to the small sample size, tests for statistical significance are not always done. In several instances the subset of cases discussed in the report are too small to make accurate statements about statistical significance. All cases reviewed by the Child Death Review Team are kept completely confidential. Information shared in the meetings is protected under ARS 36-3502 and cannot be shared with anyone outside the meeting. Every effort is made in this report to keep information private, and is intended only to provide summary statistics and trends of all child deaths taking place in Arizona. 64 | P a g e Appendix of Summary Tables: Age Group, Cause and Manner of Death The following section of this report provides data on the cause and manner of child deaths by age group. Individuals and agencies can use the information provided for each age group to guide prevention efforts within each stage of child development. For the past nine years, teams’ completed review of 100 percent of Arizona child fatalities and data from 2008 through 2013 are included in the following tables in order to provide comparison data. 14 Table 21. Number and Percentage of Deaths Among Children by Age Group, Arizona, 20092014 Age Group 2009 2010 2011 2012 2013 2014 0-27 Days 366 39% 334 38% 334 40% 325 38% 298 37% 341 41% 28-365 Days 183 19% 192 22% 175 21% 171 20% 156 19% 183 22% 1-4 Years 130 14% 119 14% 106 13% 120 14% 130 16% 95 11% 5-9 Years 67 7% 58 7% 54 6% 63 7% 47 6% 56 7% 10-14 Years 73 8% 66 8% 72 9% 75 9% 77 9% 70 8% 15-17 Years 128 14% 93 11% 96 11% 100 12% 103 13% 89 11% Total 947 862 837 854 811 834 Table 22. Mortality Rates per 100,000 Population Among Children by Age Group, Arizona, 2009-2014 Age Group 2009 2010 2011 2012 2013 2014 <1 Year* 5.9 6.0 5.9 5.8 5.3 6.0 1-4 Years 32.0 32.3 28.6 33.6 37.0 27.1 5-9 Years 14.3 12.8 11.8 13.7 10.1 12.1 10-14 Years 15.6 14.7 15.9 16.5 16.9 15.3 15-17 Years 45.0 34.3 35.2 37.0 37.7 32.5 Total 55.1 52.9 51.0 52.4 49.5 51.3 *deaths in the neonatal and post-natal periods have been combined and are rates per 1,000 births 14 For all tables in Appendix A, 2013 and 2014 data with a count less than six are denoted as <6 and are suppressed due to concern with individual identification. 65 | P a g e Table 23. Number and Percentage of Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014* 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # African 93 10 68 8 65 8 73 American American 85 9 74 9 80 10 91 Indian Asian 22 2 32 4 19 2 30 Hispanic 420 44 393 45 374 45 376 White, non327 35 289 33 293 35 268 Hispanic Total 947 856 831 838 *Does not include the 28 from the category for 2 or more races. % 9 78 10 75 9 11 76 9 66 8 4 44 31 16 343 280 2 42 35 14 366 285 2 44 34 793 806* Table 24. Mortality Rates per 100,000 Children by Race/Ethnicity, Arizona, 2009-2014* Race/Ethnicity 2009 2010 2011 2012 2013 African American 109.0 89.1 77.3 96.9 103.3 American Indian 71.5 75.1 64.7 92.5 76.7 Asian 48.6 72.8 39.6 69.0 35.7 Hispanic 62.4 58.1 55.5 55.0 49.6 White, non-Hispanic 41.0 42.6 41.2 36.8 38.5 *Does not include 28 cases for the category for 2 or more races 2014 67.3 53.4 22.3 57.7 41.0 66 | P a g e Table 25. Number and Percentage of Deaths Among Children by County of Residence, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 County # % # % # % # % # % # % Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Outside AZ Total 26 21 18 9 5 0 5 542 21 22 130 60 7 20 28 33 947 3 2 2 1 <1 -<1 57 2 2 14 6 1 2 3 3 12 20 26 12 6 2 2 486 22 23 130 40 9 20 31 21 862 1 2 3 1 <1 <1 <1 56 3 3 15 5 1 2 4 2 15 15 19 9 4 5 3 478 23 26 109 51 4 14 33 29 837 2 2 2 1 <1 <1 <1 57 3 3 13 6 <1 2 4 3 9 17 20 14 6 1 8 500 21 28 91 48 9 24 26 32 854 1 2 2 2 1 <1 1 59 2 3 11 6 1 3 3 4 17 14 17 9 7 <6 <6 477 15 23 102 46 <6 20 27 25 810* 2 2 2 1 <1 <1 <1 59 2 3 13 6 <1 2 3 3 15 12 14 12 6 <6 <6 501 24 20 112 46 <6 21 26 19 834 2 1 2 1 1 <1 <1 60 3 2 13 6 <1 3 3 2 Table 26. Mortality Rates per 100,000 Children by Cause of Death, Arizona 0-17 Year Olds, 2009-2014 Cause 2009 2010 2011 2012 2013 2014 SUID* 1.33 1.31 1.33 0.95 .87 .98 Motor Vehicle Crashes 4.7 3.6 3.7 3.9 3.5 3.0 Drowning 2.0 2.0 1.9 2.2 1.4 1.9 Suicide 1.6 1.5 2.0 1.7 1.5 2.3 Homicide 3.0 2.2 2.6 2.6 3.1 2.2 Maltreatment 3.7 4.3 4.3 4.3 5.6 4.6 Firearms 1.9 1.4 1.4 2.0 1.8 1.5 Home Safety-Related 7.1 9.5 8.2 7.4 7.3 8.0 *SUID rates are per 1,000 births 67 | P a g e Table 27. Percentage of Child Deaths by Age Group and Manner, Arizona, 2014 (n=834) Manner Birth-27 28-365 1-4 5-9 Years 10-14 15-17 Years Days Days Years Years Natural 97 49 42 52 53 21 Accident 2 34 38 37 24 42 Homicide 0 4 15 9 6 7 Suicide 0 0 0 0 16 30 Undetermined 1 13 5 2 1 0 Total 341 183 95 56 70 89 Table 28. Number and Percentage of Deaths Among Children Birth Through 17 Years by Manner, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Manner # % # % # % # % # % # Natural 641 68 565 66 537 64 542 63 513 63 546 Accident 165 17 160 19 167 20 190 22 186 23 180 Undetermined 63 7 74 9 Homicide 51 5 36 4 Suicide 27 3 24 3 Total 947 859* *Does not include deaths of pending manner 52 42 38 836* 6 5 5 45 43 33 853* 5 5 4 36 51 25 811 5 6 3 34 36 38 834 % 66 22 4 4 5 Table 29. Number of Deaths Among Children Birth to 17 Years by Cause and Manner, Arizona, 2014 Cause Natural Medical* 324 Prematurity 221 Transport 0 Firearm 0 Suffocation 0 Drowning 0 Blunt Force Trauma 0 Hanging 0 Undetermined 1 Other Non-Medical 0 Poisoning 0 Fire/Burn 0 Exposure 0 Fall/Crush 0 Other Injury 0 Total 546 *Excluding SIDS and prematurity Accident 0 0 55 1 70 30 0 0 0 0 5 5 4 7 3 180 Suicide 0 0 2 14 1 0 0 13 0 0 4 0 0 0 4 38 Homicide 0 0 0 10 0 1 19 1 1 1 0 1 0 0 1 36 Undetermined 2 1 0 0 1 0 0 0 29 0 0 0 1 0 0 34 Total 326 222 57 25 72 31 19 14 31 1 9 6 5 7 8 834 68 | P a g e Table 30. Number and Percentage of Deaths Among Children Birth Through 17 Years by Cause, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Cause # % # % # % # % # % # Medical* 372 39 359 42 342 41 353 41 303 37 326 Prematurity 241 25 197 23 199 24 192 22 210 26 222 Transport 82 9 61 7 70 8 88 10 80 10 57 Firearm 32 3 22 3 23 3 32 4 29 4 25 Suffocation 17 2 25 3 50 6 53 6 48 6 72 Drowning 35 4 33 4 32 4 36 4 23 3 31 Blunt Force 13 1 11 1 26 3 19 2 28 3 19 Trauma Hanging 20 2 19 2 27 3 20 2 18 2 14 Undetermined 57 6 74 9 46 6 40 5 35 4 31 Other Non1 <1 <6 <1 <6 Medical Poisoning 17 2 18 2 10 1 7 1 14 2 9 Fire/burn 3 <1 6 <1 6 1 5 1 <6 <1 6 Exposure 7 1 11 1 0 0 1 <1 7 <1 <6 Fall/crush 7 1 4 <1 4 <1 5 1 6 <1 7 Other Injury 16 2 21 2 0 0 1 <1 6 <1 8 SIDS 28 3 1 <1 2 <1 0 0 <6 <1 0 Total 947 862 837 853 811 834 *Excluding SIDS and prematurity % 39 27 7 3 9 4 2 2 4 <1 1 <1 <1 <1 1 0 Table 31. Number and Percentage of Natural Deaths Among Children by Age Group, Arizona, 2009- 2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # % 0-27 Days 349 55 324 57 318 59 315 58 289 56 332 61 28-365 Days 116 18 109 19 91 17 84 16 79 15 89 16 1-4 Years 54 8 52 9 40 8 57 11 62 12 40 7 5-9 Years 43 7 32 6 26 5 37 7 25 5 29 5 10-14 Years 47 7 30 5 34 6 36 6 36 7 37 7 15-17 Years 32 5 18 3 27 5 13 2 22 4 19 4 Total 641 565 536 542 513 546 69 | P a g e Table 32. Number and Percentage of Natural Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # African American 62 10 50 9 43 8 48 9 52 10 48 American Indian 57 9 40 7 42 8 45 8 38 7 34 Asian/Pacific 15 2 24 4 13 2 20 4 10 2 12 Islander Hispanic 297 46 280 50 256 48 266 49 234 46 252 White, non-Hispanic 210 33 170 30 179 33 152 28 169 33 178 Total 641 565 536 542 513 546 Table 33. Number and Percentage of Unintentional injury deaths Among Children by Age Group, Arizona, 2009- 2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # 0-27 Days 7 4 <6 <2 7 4 <6 2 6 3 6 28-365 Days 18 11 25 16 38 23 48 25 44 23 63 1-4 Years 56 34 52 33 47 28 39 21 46 25 36 5-9 Years 19 12 20 13 22 13 22 12 20 11 21 10-14 Years 17 10 18 11 22 13 27 14 24 13 17 15-17 Years 48 29 43 27 31 19 50 26 46 25 37 Total 165 160 167 190 186 180 Table 34. Number and Percentage of Unintentional injury deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # African American 8 5 <6 <3 12 7 13 7 15 8 18 American Indian 17 10 20 13 20 12 24 13 21 11 25 Asian <6 3 6 4 <6 <3 7 4 <6 <3 <6 Hispanic 65 39 57 36 62 37 69 36 70 38 71 White, non-Hispanic 70 42 70 44 69 41 75 39 70 38 62 Total 165 160 167 190 186 180 % 9 6 2 46 33 % 3 35 20 12 9 21 % 10 14 <2 39 34 70 | P a g e Table 35. Number and Percentage of Home Safety Related Deaths Among Children by Age Group, Arizona, 2009- 2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # % 0-27 Days 11 9 6 4 11 8 6 5 6 5 8 6 28-365 Days 51 44 70 45 67 49 70 58 67 56 84 65 1-4 Years 39 33 45 29 36 27 7 22 33 28 21 16 5-9 Years <6 <2 8 5 7 5 7 6 <6 <1 6 5 10-14 Years <6 <1 9 6 5 4 <6 2 <6 <2 6 5 15-17 Years 13 11 17 11 10 7 8 7 11 9 <6 4 Total 117 155 136 121 120 130 Table 36. Number and Percentage of Home-Safety Related Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # African American 21 18 11 7 10 7 11 9 13 11 14 American Indian 8 7 10 7 12 9 11 9 12 10 14 Asian <6 <4 <6 <2 <6 <3 <6 <3 <6 <2 0 Hispanic 37 32 54 35 57 42 44 36 40 33 52 White, non-Hispanic 47 40 75 48 53 39 50 41 50 42 47 Total 117 155 136 121 120 130 % 11 11 0 40 36 Table 37. Number of Sudden Unexplained Infant Deaths Among Children by Age Group, Arizona, 2009- 2014 Age Group 2009 2010 2011 2012 2013 2014 < 1 year 123 114 114 81 74 85 Table 38. Number and Percentage of Sudden Unexplained Infant Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # % African American 22 18 13 11 13 11 8 10 11 15 8 9 American Indian 17 14 16 14 13 11 7 9 6 8 9 11 Asian <6 <1 <6 <1 0 0 <6 <4 0 0 0 0 Hispanic 45 37 45 39 50 44 31 38 22 30 36 42 White, non-Hispanic 38 31 36 32 38 35 31 38 34 46 29 34 Total 123 114 114 81 74 85 71 | P a g e Table 39. Number and Percentage of Maltreatment Deaths Among Children by Age Group, Arizona, 2009- 2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # % 0-27 Days 9 14 17 24 7 10 9 13 13 14 10 13 28-365 Days 18 28 20 29 29 40 23 33 29 32 26 35 1-4 Years 20 31 18 26 22 30 23 33 31 34 23 31 5-9 Years 5 8 10 14 7 10 7 10 <6 <6 9 12 10-14 Years 6 9 <6 <5 <6 5 <6 <3 11 12 7 9 15-17 Years 6 9 <6 <3 <6 5 <6 <8 <6 <4 0 0 Total 64 70 73 69 92 75 Table 40. Number and Percentage of Maltreatment Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 Race/Ethnicity # % # % # % # % # % African American 9 14 8 11 6 8 <6 <6 11 12 American Indian 7 11 7 10 1 15 13 19 15 16 Asian <6 <2 <6 <3 <6 <2 0 0 <6 <2 Hispanic 20 31 27 39 34 47 29 42 34 37 White, non-Hispanic 27 42 25 36 21 29 21 30 27 29 Total 64 70 73 69 92 2014 # % 8 11 8 11 0 0 29 39 29 39 75 Table 41. Number and Percentage of Motor Vehicle Deaths Among Children by Age Group, Arizona, 2009- 2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # % 0-27 Days <6 <3 <6 <2 0 0 <6 <4 0 0 0 0 28-365 Days <6 <3 <6 <2 <6 <6 <6 <4 <6 <2 <6 <2 1-4 Years 20 24 19 31 15 21 11 13 18 23 10 18 5-9 Years 15 18 10 16 13 19 12 14 17 21 12 21 10-14 Years 13 16 12 20 17 24 21 24 20 25 9 16 15-17 Years 30 37 18 30 21 30 38 43 24 30 25 44 Total 82 61 70 88 80 57 72 | P a g e Table 42. Number and Percentage of Motor Vehicle and Other Transport Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # % American Indian 10 12 11 18 13 19 18 21 12 15 10 18 Hispanic 37 45 26 43 28 40 32 36 28 35 23 40 White, non-Hispanic 31 38 20 33 24 34 29 33 29 36 17 30 Other 4 5 4 6 5 7 9 10 11 14 7 12 Total 82 61 70 88 80 57 Table 43. Number and Percentage of Suicides Among Children by Age Group, Arizona, 20092014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # % <10 Years 0 0 0 0 1 3 0 0 <6 <1 0 0 10-14 Years 3 11 9 37 13 33 9 27 8 32 11 29 15-17 Years 24 89 15 63 25 64 24 73 17 68 27 71 Total 27 24 39 33 25 38 Table 44. Number and Percentage of Suicides Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # % American Indian 5 19 6 25 7 18 9 27 <6 20 <6 8 Hispanic 12 44 8 33 10 26 5 15 8 32 13 34 White, non-Hispanic 9 33 9 38 19 49 17 52 9 36 21 55 Other 1 4 1 4 3 7 <6 8 <6 3 African American 2 6 <6 4 0 0 Total 27 24 39 33 25 38 Table 45. Number and Percentage of Homicides Among Children by Age Group, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # % 0-27 Days 3 6 1 3 1 2 2 5 <6 4 0 0 28-365 Days 7 14 8 22 12 29 10 23 7 14 7 19 1-4 Years 12 24 6 16 12 29 17 40 16 31 14 39 5-9 Years 5 10 6 16 4 9 3 7 <6 2 <6 14 10-14 Years 4 8 4 11 2 5 2 5 9 18 <6 1# 15-17 Years 20 39 11 31 11 26 9 21 16 31 6 17 Total 51 36 42 43 51 36 73 | P a g e Table 46. Number and Percentage of Homicides Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # % African American 7 14 <6 <3 <6 <10 <6 <12 <6 <6 <6 <12 American Indian <6 <6 <6 <3 <6 <15 <6 <12 9 18 <6 <9 Asian 0 0 <6 <3 <6 <3 <6 <3 0 0 0 0 Hispanic 24 47 21 58 23 55 19 44 23 45 18 50 White, non-Hispanic 17 33 7 19 8 19 11 26 14 27 10 28 Total 51 36 42 43 51 36 Table 47. Number and Percentage of Drowning Deaths Among Children by Age Group, Arizona, 2009- 2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # 0-27 Days 0 0 0 0 0 0 0 0 <6 <1 0 28-365 Days 3 9 2 6 3 9 4 11 <6 <1 <6 1-4 Years 24 68 22 67 18 56 18 50 19 83 18 5-9 Years 3 9 4 12 7 22 5 14 <6 4 <6 10-14 Years 1 3 2 6 2 6 4 11 <6 <1 <6 15-17 Years 4 11 3 9 2 6 5 14 <6 13 <6 Total 35 33 32 36 23 31 % 0 6 58 13 13 10 Table 48. Number and Percentage of Drowning Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Race/Ethnicity # % # % # % # % # % # % African American <6 <6 0 0 <6 <4 <6 <9 <6 <5 6 19 American Indian 0 0 <6 <7 <6 <7 <6 <12 0 0 <6 <4 Asian <6 <6 <6 <7 <6 <10 <6 <9 <6 13 0 0 Hispanic 15 43 10 30 11 9 9 25 14 61 7 23 White, non-Hispanic 16 46 19 58 15 17 17 47 <6 22 17 55 Total 35 33 32 36 23 31 Table 49. Number and Percentage of Firearm-Related Deaths Among Children by Age Group, Arizona 2009-2014 2009 2010 2011 2012 2013 2014 Age Group # % # % # % # % # % # % <10 Years 8 25 7 32 5 22 6 19 <6 10 <6 20 10-14 Years 1 3 8 36 3 13 4 13 <6 17 6 24 15-17 Years 23 72 7 32 15 65 22 69 21 73 14 56 Total 32 22 23 32 29 25 74 | P a g e Table 50. Number and Percentage of Firearm-Related Deaths Among Children by Race/Ethnicity, Arizona, 2009-2014 2009 2010 2011 2012 2013 Race/Ethnicity # % # % # % # % # % African American <6 <10 0 0 <6 <5 <6 <10 <6 <7 American Indian <6 <7 0 0 <6 <5 <6 <7 <6 <4 Asian 0 0 0 0 0 0 0 0 <6 <4 Hispanic 14 44 9 41 14 61 9 28 15 52 White, non-Hispanic 13 41 13 59 7 30 18 56 9 31 Total 32 22 23 32 29 2014 # % 0 0 <6 4 0 0 10 40 14 56 25 75 | P a g e Appendix of Child Deaths by Age Group The following section of this report provides data on the cause and manner of child deaths by age group. Individuals and agencies can use the information provided for each age group to guide prevention efforts within each stage of child development. For the past nine years, teams’ completed review of 100 percent of Arizona child fatalities and data from 2008 through 2013 are included in the following tables in order to provide comparison data. 15 The Neonatal Period, Birth through 27 Days Table 51. Number of Deaths Among Children Ages Birth Through 27 Days by Cause and Manner, Arizona, 2014 Cause Natural Accident Suicide Homicide Undetermined Total Medical* 138 0 0 0 0 138 Prematurity 194 0 0 0 <6 195 Suffocation 0 <6 0 0 0 <6 Blunt Force Trauma 0 0 0 0 0 0 Undetermined 0 0 0 0 <6 <6 Other Injury 0 <6 0 0 0 <6 Total 332 6 0 0 <6 341 *Excluding SIDS and prematurity Table 52. Number and Percentage of Deaths Among Children Ages Birth Through 27 Days by Cause, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Cause # % # Prematurity 221 60 180 Medical* 128 35 145 Undetermined 5 1 6 SIDS 1 <1 0 MVC/Transport 2 <1 1 Other 5 1 0 Suffocation 4 1 1 Exposure 0 0 1 Drowning 0 0 0 Total 366 334 *Excluding SIDS and Prematurity 15 % 54 43 2 0 <1 0 <1 <1 0 # 181 143 5 0 0 1 5 0 0 334 % 54 43 2 0 0 <1 1 0 0 # 172 143 5 0 3 0 2 0 0 325 % 53 44 2 0 1 0 1 0 0 # 188 102 <6 <6 <6 <6 <6 <6 <6 298 % 63 34 <1 <1 <1 <1 <1 <1 <1 # 195 138 <6 0 0 <6 <6 0 0 341 % 57 40 <1 0 0 <1 <2 0 0 For all tables in Appendix A, 2013 data with a count less than six are denoted as <6 and are suppressed due to concern with individual identification. 76 | P a g e Table 53. Number and Percentage of Deaths Among Children Ages Birth Through 27 Days by Manner, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Manner # % # % # % # % # % # % Natural 349 95 324 97 318 95 315 58 289 97 332 97 Undetermined Accident Homicide Suicide Total 7 7 3 0 366 2 2 1 0 7 2 1 0 334 2 1 <1 0 8 7 1 0 334 2 2 <1 0 4 4 2 0 325 9 2 5 0 <6 6 <6 <6 298 <6 2 <6 <1 <6 6 0 0 341 <1 2 0 0 The Post-Neonatal Period, 28 Days through 365 Days Table 54. Number of Deaths Among Children Ages 28 Days Through 365 Days by Cause and Manner, Arizona, 2014 Cause Natural Accident Suicide Homicide Undetermined Total Medical 64 0 0 0 0 64 Prematurity 25 0 0 0 0 25 MVC/Transport 0 <6 0 0 0 <6 Firearm 0 0 0 <6 0 <6 Suffocation 0 58 0 0 <6 59 Drowning 0 <6 0 0 0 <6 Blunt Force Trauma 0 0 0 <6 0 6 Undetermined 0 0 0 0 23 23 Fire/Burn 0 <6 0 0 0 <6 Exposure 0 <6 0 0 0 <6 Total 89 63 0 7 24 183 77 | P a g e Table 55. Number and Percentage of Deaths Among Children Ages 28 Days Through 365 Days by Cause, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Cause Medical Prematurity MVC/Transport Firearm Suffocation Drowning SIDS Blunt Force Trauma Hanging Undetermined Poisoning Fire/Burn Exposure Fall/Crush Other Injury Total # 77 18 <6 0 13 <6 27 <6 % 42 10 <2 0 7 <2 15 <2 # 82 17 <6 0 22 <6 <6 6 % 43 9 <1 0 11 1 <1 3 # 75 17 <6 <6 34 <6 <6 9 % 43 10 2 <1 19 <2 1 5 # 68 17 <6 <6 44 <6 0 6 % 40 10 <2 <1 26 2 0 4 # 60 18 <6 <6 41 0 0 6 % 38 12 <1 <1 26 0 0 4 # 64 25 <6 <6 59 <6 0 6 % 35 14 <1 <1 32 1 0 3 0 35 <6 0 0 <6 <6 183 0 19 <1 0 0 <2 <1 0 56 <6 0 <6 0 <6 192 0 29 <1 0 <1 0 <2 0 29 0 0 0 0 6 175 0 17 0 0 0 0 <1 <6 26 0 0 <6 0 0 171 <1 15 0 0 <1 0 0 <6 26 0 0 <6 0 0 156 <1 17 0 0 1 0 0 0 23 0 <6 <6 0 0 183 0 13 0 <1 <1 0 0 Table 56. Number and Percentage of Deaths Among Children Ages 28 Days Through 365 Days by Manner, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Manner # % # % # % # % # % # % Natural 116 63 109 57 92 53 84 49 79 51 89 49 Undetermined 42 23 50 26 32 18 29 17 26 17 24 13 Accident 18 10 25 13 38 22 48 28 44 28 63 34 Homicide 7 4 8 4 12 7 10 6 7 4 7 4 Suicide 0 0 0 0 0 0 0 0 <6 <1 0 0 Unknown 0 0 0 0 1 <1 0 0 <6 <1 0 0 Total 183 192 17 171 156 156 5 78 | P a g e Children, One through Four Years of Age Table 57. Number of Deaths Among Children Ages One Through Four Years by Cause and Manner, Arizona, 2014 Cause Natural Accident Suicide Homicide Undetermined Total Medical* 39 0 0 0 <6 40 Prematurity <6 0 0 0 0 <6 MVC/Transport 0 10 0 0 0 10 Firearm 0 0 0 <6 0 <6 Suffocation 0 <6 0 0 0 <6 Drowning 0 17 0 <6 0 18 Blunt Force 0 0 0 10 0 10 Trauma Undetermined 0 0 0 <6 <6 <6 Poisoning 0 0 0 0 0 0 Exposure 0 <6 0 0 <6 <6 Fall/Crush 0 <6 0 0 0 <6 Other Injury 0 0 0 <6 0 <6 Total 40 36 0 14 <6 95 * Excluding SIDS and Prematurity Table 58. Number and Percentage of Deaths Among Children Ages One Through Four Years by Cause, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Cause # % # % # % # % # % # % Medical* 50 38 52 44 40 38 57 48 62 48 40 42 Drowning 24 18 22 18 18 17 18 15 19 15 18 19 MVC/Transport 20 15 19 16 15 14 11 9 18 14 10 11 Other non11 8 7 6 0 0 1 1 <6 <1 <6 1 Medical Undetermined 10 8 6 5 5 5 4 3 6 5 26 4 Blunt Force 7 5 4 3 10 9 9 8 14 11 10 11 Trauma Firearm 4 2 2 2 1 1 4 3 <6 <1 <6 1 Poisoning 0 0 0 0 1 1 1 1 <6 <1 0 0 Exposure 0 0 2 2 0 0 0 0 <6 <1 <6 2 Fire/burn 3 2 2 2 2 2 1 1 <6 <1 0 0 Fall/crush 2 2 2 2 2 2 <6 <1 <6 2 Hanging 1 <1 3 3 3 3 <6 <1 0 0 Prematurity 1 1 0 0 1 1 3 3 <6 <1 <6 1 Suffocation 0 0 0 0 8 8 5 4 <6 <1 <6 5 Other Injury 1 1 <6 <1 <6 1 Total 130 119 106 120 130 95 *Excluding SIDS and Prematurity 79 | P a g e Table 59. Number and Percentage of Deaths Among Children Ages One Through Four Years by Manner, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Manner # % # % # % # % # % # % Natural 54 42 52 44 40 38 57 48 62 48 40 42 Accident 56 43 52 44 47 44 39 33 46 35 36 38 Undetermined 8 6 8 7 7 7 7 6 6 5 <6 5 Homicide 12 9 6 5 12 11 17 14 16 12 14 15 Suicide 0 0 0 0 0 0 0 0 <6 <1 0 0 Unknown 1 <1 0 0 0 0 <6 <1 0 0 Total 130 119 106 120 130 95 Children, Five through Nine Years of Age Table 60. Number of Deaths Among Children Ages Five Through Nine Years by Cause and Manner, Arizona, 2014 Cause Natural Accident Suicide Homicide Undetermined Total Medical* 29 0 0 0 <6 30 MVC/Transport 0 12 0 0 0 12 Firearm 0 <6 0 <6 0 <6 Suffocation 0 <6 0 0 0 <6 Drowning 0 <6 0 0 0 <6 Blunt Force Trauma 0 0 0 <6 0 <6 Hanging 0 0 0 <6 0 <6 Fall/Crush 0 <6 0 0 0 <6 Other Injury 0 <6 0 0 0 <6 Total 29 21 0 <6 <6 56 *Excluding SIDS and prematurity 80 | P a g e Table 61. Number and Percentage of Deaths Among Children Ages Five Through Nine Years by Cause, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Cause # % # % # % # % # % # % Medical 42 63 31 53 26 48 37 59 24 51 30 54 Prematurity 1 1 0 0 0 0 0 0 <6 <1 0 0 MVC/Transport 15 22 10 17 13 34 12 19 17 36 12 21 Other 6 9 2 3 0 0 0 0 <6 <1 <6 <2 Drowning 3 4 4 7 7 13 5 8 <6 <1 4 7 Fire/Burn 0 0 2 3 1 2 3 5 <6 <1 0 0 Hanging 0 0 0 0 1 2 0 0 <6 <1 <6 2 Firearm 5 9 3 6 1 2 <6 <1 <6 5 Undetermined 1 2 1 2 1 2 <6 <1 0 0 Fall/Crush 2 3 0 0 2 2 <6 <1 <6 4 Blunt Force 0 0 0 0 1 2 2 2 <6 <1 <6 4 Trauma Suffocation 0 0 1 2 1 2 0 0 <6 <1 <6 2 Poisoning 0 0 0 0 0 0 0 0 <6 <1 0 0 Total 67 58 54 63 47 56 *Excluding SIDS and Prematurity Table 62. Number and Percentage of Deaths Among Children Ages Five Through Nine Years by Manner, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Manner # % # % # % # % # % # % Natural 43 64 32 55 26 48 37 59 25 53 29 52 Accident 19 28 20 34 22 41 22 35 20 43 21 38 Undetermined 0 0 0 0 1 2 1 2 <6 <6 <6 2 Homicide 5 7 6 10 4 7 3 5 <6 <6 <6 9 Suicide 0 0 0 0 1 2 0 0 0 0 0 0 Total 67 58 54 63 47 56 81 | P a g e Children, 10 through 14 Years of Age Table 63. Number of Deaths Among Children Ages 10 Through 14 Years by Cause and Manner, Arizona, 2014 Cause Natural Accident Suicide Homicide Undetermined Medical* 36 0 0 0 0 MVC/Transport 0 9 0 0 0 Firearm Injury 0 0 <6 0 0 Suffocation 0 <6 0 0 0 Drowning 0 <6 0 0 0 Blunt Force Trauma 0 0 0 <6 0 Hanging 0 0 <6 0 0 Undetermined <6 0 0 0 <6 Poisoning 0 <6 <6 0 0 Fire/Burn 0 <6 0 <6 0 Fall/Crush 0 <6 0 0 0 Other Injury 0 0 0 <6 0 Total 37 17 11 <6 <6 Total 36 9 6 <6 <6 <6 <6 <6 <6 <6 <6 <6 70 Table 64. Number and Percentage of Deaths Among Children Ages 10 Through 14 Years by Cause, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Cause # % # % # % # % # % # % Medical* 43 59 29 44 34 47 35 47 34 44 36 51 MVC/Transport 13 18 12 18 17 24 21 28 20 26 9 13 Firearm 1 1 8 12 3 4 4 5 <6 6 6 9 Hanging 3 4 7 11 10 14 7 9 7 9 <6 6 Other Injury 8 11 1 2 0 0 0 0 <6 <6 <6 1 Fall/Crush 2 3 0 0 0 0 0 00 <6 <6 <6 1 Poisoning 0 0 1 2 0 0 0 0 <6 <6 <6 3 Blunt Force 0 0 0 0 2 3 0 0 <6 <6 <6 1 Trauma Exposure 2 3 1 2 0 0 0 0 <6 <1 0 0 Suffocation 0 0 0 0 1 1 1 1 <6 <1 <6 1 Drowning 1 1 2 2 2 3 4 5 <6 <1 <6 6 Undetermined 3 5 1 1 2 3 <6 <6 <6 3 Fire/burn 2 2 2 3 1 1 <6 <6 <6 3 Total 73 66 72 75 77 70 *Excluding SIDS and Prematurity 82 | P a g e Table 65. Number and Percentage of Deaths Among Children Ages 10 Through 14 Years by Manner, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Manner # % # % # % # % # % # % Natural 47 64 30 45 34 47 36 48 36 47 37 53 Accident 17 23 18 27 22 31 27 36 24 31 17 24 Suicide 3 4 9 14 13 18 9 12 8 20 11 16 Homicide 4 5 4 6 2 3 2 3 9 23 <6 <6 Undetermined 25 3 5 8 1 1 1 1 <6 <1 <6 1 Total 73 66 72 75 77 70 Children, 15 through 17 Years of Age Table 66. Number of Deaths Among Children Ages 15 Through 17 Years by Cause and Manner, Arizona, 2014 Cause Natural Accident Medical* 18 0 Prematurity <6 0 MVC/Transport 0 23 Firearm 0 0 Suffocation 0 0 Drowning 0 <6 Hanging 0 0 Poisoning 0 <6 Fire/Burn 0 <6 Exposure 0 <6 Fall/Crush 0 <6 Other Injury 0 0 Total 19 37 *Excluding SIDS and prematurity Suicide 0 0 <6 8 <6 0 9 <6 0 0 0 <6 27 Homicide 0 0 0 0 6 0 0 0 0 0 0 0 6 Undetermined 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 18 <6 25 14 <6 <6 9 7 <6 <6 <6 <6 89 83 | P a g e Table 67. Number and Percentage of Deaths Among Children Ages 15 Through 17 Years by Cause, Arizona, 2009-2014 2009 2010 2011 2012 2013 Cause # % # % # % # % # % Firearm 23 18 7 8 15 16 22 22 21 20 MVC/Transport 30 23 18 19 21 22 38 38 24 23 Medical* 32 25 20 22 25 26 13 13 21 20 Hanging 12 9 11 12 13 14 9 9 10 10 Poisoning 15 12 16 17 9 9 6 6 12 12 Other 4 3 8 9 0 0 1 1 <6 <1 Exposure 5 4 6 6 0 0 0 0 <6 <1 Drowning 4 3 3 3 2 2 5 5 <6 <1 Undetermined 1 1 2 2 4 4 2 2 <6 <1 Fall/Crush 0 0 0 0 2 2 1 1 <6 <1 Blunt Force 2 2 1 1 3 3 2 2 <6 <1 Trauma Fire/Burn 0 0 0 0 1 1 0 0 <6 <1 Suffocation 1 1 1 1 1 1 <6 <1 Total 128 93 96 100 103 *Excluding SIDS and Prematurity # 14 25 18 9 7 <6 <6 <6 0 <6 0 <6 <6 89 2014 % 16 28 20 10 8 6 2 <3 0 2 0 3 1 Table 68. Number and Percentage of Deaths Among Children Ages 15 Through 17 Years by Manner, Arizona, 2009-2014 2009 2010 2011 2012 2013 2014 Manner # % # % # % # % # % # % Accident 48 37 43 46 31 32 50 50 46 45 37 42 Natural 32 25 18 19 27 28 13 13 22 21 19 21 Homicide 20 16 11 12 11 11 9 9 16 16 6 7 Suicide 24 19 15 16 25 26 24 24 17 17 27 30 Undetermined 4 3 4 4 2 2 3 3 <6 <1 0 0 Unknown 2 2 0 0 <6 <1 0 0 Pending 1 1 <6 <1 0 0 Total 128 93 96 100 103 89 84 | P a g e Appendix of Population Denominators for Arizona Children The population denominators shown below were used in computing the rates presented in this report. Denominators for 2009 through 2014 were provided by the Arizona Department of Health Services Bureau of Public Health Statistics. Population denominators for 2010 were tabulated from the 2010 Decennial Census, Summary File 1, available online from: www.census.gov. Population estimates for 2014 were modified from previous years by applying county level demographic proportions in the census estimates for 2013 to the 2014 county population totals published by ADOA Department of Demography. This was done in order to determine the county-level proportions by race/ethnicity, gender, and age. Table 69. Population of Children Ages Birth Through 17 Years by County of Residence, Arizona, 2009-2014 County 2009 2010 2011 2012 2013 2014 Apache 25,888 22,660 22,808 21,843 21,493 21,271 Cochise 35,356 30,250 30,099 30,434 30,621 29,190 Coconino 36,439 31,788 31,716 31,310 31,463 31,097 Gila 14,002 11,471 11,451 11,317 11,351 11,062 Graham 10,819 10,575 10,718 10,623 10,818 10,871 Greenlee 2,496 2,463 2,463 2,408 3,016 2,952 La Paz 4,074 3,678 3,682 3,685 3,708 3,682 Maricopa 1,064,572 1,007,861 1,014,790 1,008,347 1,015,472 1,016,044 Mohave 45,296 41,265 41,301 40,338 39,786 39,076 Navajo 35,814 31,973 31,901 31,551 31,463 30,868 Pima 244,390 225,316 226,652 223,677 223,639 222,413 Pinal 81,414 99,700 101,929 102,591 103,403 99,111 Santa Cruz 14,898 14,560 14,752 14,396 14,369 14,304 Yavapai 44,969 40,269 40,305 39,602 39,417 38,243 Yuma 59,089 55,185 56,547 56,415 57,367 56,542 Total 1,719,515 1,629,014 1,641,114 1,628,537 1,637,386 1,626,726 Table 70. Population of Children Ages 0 though 17 by Race/Ethnicity, Arizona, 2009-2014 Race/Ethnicity African American American Indian Asian Hispanic White, nonHispanic Total 2009 85,301 118,917 45,230 672,777 797,290 2010 73,298 98,555 43,969 75,146 677,752 2011 84,112 123,712 47,936 673,462 711,892 2012 75,371 98,426 43,452 683,843 727,446 2013 75,491 99,014 44,838 691,459 726,558 2014 111,448 123,657 62,673 634,110 694,838 1,719,515 1,629,014 1,641,108 1,628,539 1,637,386 1,626,726 85 | P a g e Table 71. Population of Children Ages 0 Through 17 Years by Age Group, Arizona, 2009-2014 <1 Year 1-4 Years 5-9 Years 10-14 Years 15-17 Years Total 2009 92,263 406,201 469,372 467,149 284,530 1,719,515 2010 87,557 368,158 453,680 448,664 270,955 1,629,014 2011 88,211 370,926 457,080 451,989 272,914 1,641,108 2012 87,184 356,828 459,232 454,826 270,469 1,628,539 2013 89,196 351,077 464,622 459,528 272,963 1,637,386 2014 84,342 350,065 462,931 458,488 270,900 1,626,726 Table 72. Number of Resident Births, Arizona, 2009-2014 2009 92,454 2010 86,945 2011 85,142 2012 85,675 2013 84,963 2014 86,648 Table 73. Number of Births by Race/Ethnicity, Arizona, 2009-2014 Race/Ethnicity African American American Indian Asian Hispanic White, nonHispanic Total 2009 4,263 6,090 3,388 37,985 40,428 2010 4,230 5,746 3,284 34,059 39,626 2011 4,290 5,787 3,493 32,217 39,355 2012 4,674 5,547 4,674 33,030 38,800 2013 4,726 5,476 3,466 33,075 38,220 2014 4,522 5,145 3,169 33,715 40,097 92,454 86,945 85,142 85,675 84,963 86,648 86 | P a g e Appendix: Arizona Local CFR Teams State CFR Team Chair Mary Ellen Rimsza, MD, FAAP University of Arizona College of Medicine American Academy of Pediatrics Members David K. Byers Nancy Molever (proxy) Administrative Office of the Courts Mary Ellen Cunningham Tomi St. Mars (proxy) Arizona Department of Health Services Bureau of Women’s and Children’s Health Cdr. Stacey Dawson Phoenix Indian Medical Center Tim Flood, MD Nick Bishop (Proxy) Arizona Department of Health Services Diana Gomez, MPH Yuma County Department of Public Health Services Gaylene Morgan Office of the Attorney General Susan Newberry, LBSW, MEd. Maricopa County CFR Team Sheila Polk Kim MacEachern (proxy) Arizona Prosecuting Attorney’s Advisory Council John Raeder Ashley Miles Governor’s Office for Children, Youth and Families Beth Rosenberg Representative of a child advocacy organization Director of Child Welfare & Juvenile Justice Children's Action Alliance Christi Shelton AZ Department of Child Safety Nicola Winkel, MPA Arizona Coalition for Military Families David Winston, MD, PhD Forensic Pathologist Pima County Forensic Science Center Twenty-Second Annual Report ••• Apache County CFR Team Chair/Coordinator Matrese Avila, Coordinator and Team Chair Apache County Youth Council Apache County Drug Free Alliance Jim Staffnik, PhD St. Johns Middle School Michael B. Whiting Apache County Attorney’s Office Members CB Misbach, Apache County Attorney’s Office Chief Mike Hogan Eagar Police Department Abbey Walker, DCS Chief Mike Nuttall Springerville Police Department Christie Orona Arizona Department of Economic Security Division of Children, Youth and Families Debbie Padilla Apache County Public Health Department Dino Walker, Medical Investigator Jim Staffnik, SJHS Dr. Kartchner, Physician W. Johnson, SJPD Siona Willie, Navajo Reservation Scott Poche Little Colorado Behavior Health Center Kelli Sine-Shields Apache County Public Health Department 88 | P a g e Twenty-Second Annual Report ••• Coconino County CFR Team Chair/Coordinator Heather Taylor Injury Prevention Program Manager Coconino County Public Health Services District Co-Chair Larry Czarnecki, MD Coconino County Medical Examiner Members Kristen Curtis, Admin Specialist Coconino County Public Health Services District Mayte Giubardo, Psychiatrist Northern Arizona Regional Behavioral Health Authority Diana Hu, MD Tuba City Regional Health Care Corporation Glen Austin, Pediatrician Flagstaff Pediatric Care Shannon Johnson, Tuba City Regional Medical Center Trauma Bruce Applin, Supervisor Federal Bureau of Investigations Michael Lessler, Prosecutor Coconino County Attorney Ryan Beckman, Detective Sgt. Flagstaff Police Department John Philpot, Major Arizona Department of Public Safety Michael Begay Navajo Nation Criminal Investigator Bill Pribil, Sheriff Coconino County Sheriff’s Office Shawn Bowker, RN Flagstaff Medical Center Trauma Casey Rucker, Detective Flagstaff Police Department Corey Cooper, Health Educator Coconino County Public Health Services District Siona Willie Indian Health Services Cindy Sanders, BSN Flagstaff Medical Center NICU Jared Wotasik, Detective Flagstaff Police Department 89 | P a g e Twenty-Second Annual Report ••• Gila County CFR Team Chair Edna Welsheimer Time Out, Inc. Coordinator Kathleen Kelly Emergency Room Nurse Members Lucinda Campbell, RN, BSN Gila County Health Department Yvonne Harris Arizona Department of Economic Security Division of Children, Youth and Families Deana Monk Time Out, Inc. Detective Matt VanCamp Payson Police Department 90 | P a g e Twenty-Second Annual Report ••• Graham County and Greenlee County CFR Team Chair/Coordinator Brandie Lee CASA of Graham County Members Jeanette Aston Domestic Violence Specialist Mt. Graham Safe House Scott Bennett County Attorney Graham County Attorney’s Office Brian Douglas Health Director Graham County Health Department Richard Keith, MD Pediatrician Gila Valley Clinic Diane Thomas Detective Safford Police Department Victoria Torres Department of Economic Security Division of Children, Youth and Families 91 | P a g e Twenty-Second Annual Report ••• Maricopa County CFR Team Chair Mary Ellen Rimsza, MD, FAAP American Academy of Pediatrics University of Arizona College of Medicine Coordinator Susan Newberry, LBSW, MEd. Assistant Coordinator Arielle Unger, BS Members Sergeant Kevin Baggs Mesa Police Department Angelica M Baker Phoenix Children’s Hospital Sergeant Adam Barrett Phoenix Police Department Wendy Bernatavicius, MD Phoenix Children’s Hospital Sara Bode, MD Phoenix Children’s Hospital Sergeant Jesse Boggs Chandler Police Department Detective Jennifer Borquez Arizona Department of Public Safety Kevin Casey, NREMTP, FP-C Native Air Amira El-Ahmadiyyah, LCSW Phoenix Children’s Hospital Kimberly Choppi, MSN-Ed, RN, CPEN Maricopa Integrated Health System Michelle Fingerman, MS Childhelp Hotline and School Based Programs Kathryn Coffman, MD Phoenix Children’s Hospital Elisha Franklin, MC, LASAC Chicanos Por La Causa Dianna Contreras Arizona Birth Defects Monitoring Program Arizona Department of Health Services Dyanne Greer Deputy County Attorney Family Violence Bureau Maricopa County Attorney’s Office Detective Dan Coons Chandler Police Department Tiffaney Isaacson Water Safety Coordinator Phoenix Children’s Hospital Shawn Cox, LCSW Victim Services Division Chief Maricopa County Attorney’s Office Frances Baker Dickman, PhD, JD Paul S. Dickman, MD Phoenix Children’s Hospital University of Arizona College of Medicine Ilene Dode, PhD, LPD CEO Emeritus Jeffrey Johnston, MD Maricopa County Chief Medical Examiner Maura Kelly, MEd Department of Child Safety Karin Kline, MSW Arizona State University Center for Child Well-Being Detective Chris Loeffler Phoenix Police Department Sergeant Eric Lumley Phoenix Police Department Christen Eggers Investigator Maricopa County Medical Examiner’s Office 92 | P a g e Twenty-Second Annual Report ••• Zora Manjencich Assistant Division Chief Counsel Child and Family Protection Division Arizona Attorney General’s Office Terence Mason, RN Mesa Fire and Medical Department Sandra McNally, MA, LISAC La Frontera Arizona, EMPACT Suicide Prevention Center Louise Roskelley Fred Santesteban Michele F. Scott, MD Phoenix Children’s Hospital James Simpson Section Chief Counsel Child and Family Protection Division Arizona Attorney General’s Office Margaret Strength Department of Child Safety Kindra Nelson, BA Department of Child Safety William Stuebe Office of Child Welfare Investigations Department of Child Safety Sergeant David Otanez Phoenix Police Department Sergeant Jennifer Pinnow Arizona Department of Public Safety Sergeant Mike Polombo Phoenix Police Department Leslie Quinn, MD Banner Health System Cardon Children’s Medical Center Herbert Winograd, MD Pediatrician Joseph T. Zerella, MD Pediatric Surgeon Stephanie Zimmerman, MD Phoenix Children’s Hospital Sergeant Randy Stewart El Mirage Police Department Casey Melsek, MSW Department of Child Safety Ayrn O’Connor, MD Banner Health, University Medical Center of Phoenixl Family Violence Bureau Chief Maricopa County Attorney’s Office Melissa Sutton SWIMkids USA Denis Thirion, MA La Frontera Arizona, Empact Suicide Prevention Center Marcella Valenzuela Confirmation Supervisor TASC Solutions Zannie Weaver US Consumer Product Safety Commission Hilary Weinberg Deputy County Attorney 93 | P a g e Twenty-Second Annual Report ••• Mohave County and La Paz County CFR Team Chair Vic Oyas, MD Havasu Rainbow Pediatrics Coordinator Anna Scherzer Mohave County Department of Public Health Patty Mead, RN, MS Mohave County Health Department Rexene Worrell, MD Mohave County Medical Examiner Detective Mike Munding Lake Havasu City Police Department Members Angelica Pichardo Mohave County Health Department Dawn Abbott Mohave Mental Health Clinic, Inc. Melissa Register Mohave County Probation Department Detective Earl Chalfont Lake Havasu City Police Department Lieutenant Steve Smith Bullhead City Police Department Suzanne Clark Domestic Violence Specialist Kingman Aid to Abused People Loria Gattis Mohave County Medical Examiner Craig Diehl, MD Lake Havasu Pediatrics Lieutenant Larry Kubacki La Paz County Sheriff’s Department Lt. Jerry Duke Bullhead City Police Department Charles Solano Colorado River Indian Tribal Police Department Steven Draper La Paz County Sheriff’s Department Detective Todd Foster Kingman Police Department Debra Walgren Arizona Department of Economic Security Division of Children, Youth and Families 94 | P a g e Twenty-Second Annual Report ••• Navajo County CFR Team Chair/Coordinator Janelle Linn, RN Navajo County Public Health Services Co-chair Susie Sandahl, RN Navajo County Public Health Services Members Tammy Borego, RN Summit Regional Medical Center Injury Prevention Kenneth Brown Whiteriver Indian Health Services Social Worker Trent Clatterbuck Navajo County Public Health Medical Examiner Investigator Kirk Grugel Navajo County Court Appointed Special Advocate Program Wade Kartchner, MD Navajo County Public Health Services Medical Director Kateri Piecuch Arizona Department of Economic Security Division of Children, Youth and Families Assistant Medical Examiner Investigator Scott Self Navajo County Medical Examiner’s Office Amy Stradling Navajo County Public Health Injury Prevention & Safe Kids Detective Sergeant Roger Conaster Winslow Police Department Detective Sergeant Tim Dixon Holbrook Police Department 95 | P a g e Twenty-Second Annual Report ••• Pima County, Cochise County and Santa Cruz County CFR Team Chair Dale Woolridge, MD Department of Emergency Medicine University of Arizona Michelle Chamblee Pima County Attorney’s Office Sharon Hitchcock, RN College of Nursing University of Arizona Rosanna Cortez Victim Services Pima County Attorney’s Office Karen Ives Pima County Juvenile Detention Center Lisa Jacobs, RN Rachel Cramton, MD Department of Pediatrics University of Arizona Trahern Jones, MD University of Arizona Detective Marty Fuentes Tohono O’odham Police Department Lynn Kallis Pilot Parents Program of Southern Arizona Nicole Abdy, MD Department of Pediatrics University of Arizona Amy Gomez Emerge Kathleen Kelley Office of Child Welfare Albert Adler, MD Indian Health Services Alan Goodwin Pima County Attorney’s Office Tracy Koslowski Public Education/Information Manager Drexel Heights Fire Department Coordinator Becky Lowry University of Arizona Members Carol Baker, RN Pima County Health Department Kathy Benson, RN Retired School Nurse Kathy Bowen, MD Pediatrician Hans Bradshaw, MD Department of Pediatrics University of Arizona Keven Burkhart Rural Metro Fire Department Christine Chacon Casa de los Ninos Lori Groenewold, MSW Children’s Clinics for Rehabilitation Sandy Guizzetti Foster Care Specialist Joseph Livingston, MD Department of Pediatrics University of Arizona Karen Harper Southern Arizona Child Advocacy Center Chan Lowe, MD Department of Pediatrics University of Arizona Captain Ryder Hartley Northwest Fire Department Mary McDonald Tucson Fire Department Greg Hess, MD Chief Medical Examiner Pima County Medical Examiner’s Office Kathleen Malkin, RN Public Health Department 96 | P a g e Twenty-Second Annual Report ••• Mary Molina Pima County Attorney’s Office Brenda Neufeld, MD Indian Health Services Michelle Nimmo Attorney General’s Office Marie Olson, MD Pediatric Hospitalist University of Arizona Karen Owen, BSN, RNC Sgt. Jennifer Pegnato-Hill Tucson Police Department Sgt. Sonia Pesqueria Pima County Sheriff’s Office Cindy Porterfield, DO Pima County Medical Examiner’s Office Leah Robeck, MSW Division of Children, Youth and Families Arizona Department of Economic Security Adam Rossi Pima County Attorney’s Office Pepper Sprague Retired Teacher Margaret Strength Deborah Weber, RN Public Health Department Commander Donald Williams US Public Health Services Indian Health Services Brian Wilson, MD Emergency Medicine Department University of Arizona David Winston, MD, PhD Pima County Medical Examiner’s Office Dr. Melissa Zukowski Department of Pediatrics Tucson Medical Center Melissa Richey Tucson Medical Center Sue Rizzi Pima Community College Audrey Rogers Pima County Vital Records Melissa Rosinski Pantano Behavioral Health 97 | P a g e Twenty-Second Annual Report ••• Pinal County CFR Team Chair/Coordinator Lorena Velasquez Against Abuse, Inc. Members Jason Agresta Pinal County Sherriff’s Department Mark Bonsall Casa Grande Police Department Graham Briggs Pinal County Health Department Linda Devore Teacher, retired Christina Holt Children’s Justice Coordinator Pinal County Advocacy Center JD Sanchez Rocky Jimenez Crimes Against Children Unit Eloy Police Department Gerald Smith Pinal County Attorney’s Office Andrea Kipp Records Supervisor Pinal County Sheriff’s Department Detective Stephen Knauber Coolidge Police Department Thomas Kohler Deputy County Attorney Pinal County Attorney’s Office Mark Dyrdahl Arizona Department of Economic Security Division of Children, Youth and Families Stephen Knauber Shelly Fuentes Research Coordinator Maricopa Medical Center Leann Mclean Patrick Gard Deputy County Attorney Pinal County Attorney’s Office Leslie Montijo Detective Troy Schmitz Pinal County Attorney’s Office Sergeant Rodney Smith Investigations Division Coolidge Police Department John Stevens Brian Walsh Detective Ashley Walker Criminal Investigations Division Coolidge Police Department Robert Kull, MD Director of the Free Pediatric Clinic of Casa Grande Jesus Noriega-Lopez Paul Parker Chief Investigator Pinal County Medical Examiner’s Office 98 | P a g e Twenty-Second Annual Report ••• Yavapai County CFR Team Chair/Coordinator Barbara Jorgensen, MSN, RN Yavapai County Community Health Services Administrative Specialist Carol Espinosa Yavapai County Community Health Services Erin Wright Arizona Department of Economic Security Division of Children, Youth and Families Members Jerry Bruien Law Enforcement, Yavapai County Attorney’s Office Sue Carlson Mental Health/ Counselor Kathryn Chapman Family Advocacy Center Karen Dansby, MD Pediatrician, retired Consultant Joseph Lopez Yavapai County Medical Examiner’s Office Kathy McLaughlin Community at large – Family advocacy Kathy Swope, RN School Nurse 99 | P a g e Twenty-Second Annual Report ••• Yuma County CFR Team Chair Patti Perry, MD Yuma Regional Medical Center/Cactus Kids Coordinator Ryan Butcher Yuma County Health District Members Jay Carlson Yuma County Sheriff’s Office Chip Schneider Amberly’s Place Jennifer Stanton Yuma Regional Medical Center Robert Vigil Medical Examiner’s Office Yuma County Sheriff’s Office Maria Estrada Division of Children, Youth and Families Arizona Department of Economic Security Wendy Holt Yuma Regional Medical Center Melvin Lawson Accident Investigations Yuma Police Department Detective Debbie Machin Yuma Police Department Lt. David McBride Yuma County Sheriff’s Office 100 | P a g e