Twenty-Fourth Annual Report November 15, 2017 Mission: To reduce preventable child fatalities in Arizona through a systematic, multi-disciplinary, multi-agency, and multi-modality review process. Prevention strategies, interdisciplinary training, community-based education, and data-driven recommendations are derived from this report to aid legislation and public policy. 1|Page Twenty-Fourth Annual Report November 15, 2017 For 24 years, the Arizona Child Fatality Review Program (ACFRP) has prepared an annual report on child deaths Preventability ••• that occurred in Arizona. By reviewing these deaths, the In 2016, 783 children ACFRP is able to identify the causes, contributing factors, under the age of 18 preventability and trends which can help reduce child years died in Arizona. deaths in Arizona. In 2016, 783 children under 18 years of Arizona Child Fatality age died in Arizona. CFR teams reviewed 100% of these Review Teams deaths and determined that 330 of these deaths (42%) reviewed 100% of were preventable including 100% of the maltreatment, suicide, and accidental deaths. these deaths and determined 42% Key findings in this year's report were a 12% increase in could have been accidental deaths from 2015 to 2016, including increases prevented (n=330). in motor vehicle crash deaths and infant deaths due to unsafe sleep environments. Motor vehicle crash deaths increased 42% from 50 deaths in 2015 to 71 deaths in 2016. Unsafe sleep deaths increased 7% from 74 deaths in 2015 to 79 in 2016. Forty-one of these infants died of sleep suffocation due to bed-sharing with adults or other children. Teams determined that 100% of the following deaths were preventable:  Homicides  Suicides  Accidental deaths Maltreatment (child abuse and/or neglect) directly caused or contributed to 10% of all deaths in 2016. The total number of maltreatment deaths decreased 6% from 2015 (87deaths) to 2016 (82 deaths). Substance abuse of drugs or alcohol was a contributing factor in 58 of the 82 deaths. In 2016, substance use was a contributing factor in 107 child deaths including 20 deaths due to motor vehicle crashes and 21 firearm deaths. In 56 of these substance use related deaths the child's parent use or misuse of alcohol, marijuana, methamphetamine, opiates, 2|Page cocaine or other drugs alone or in combination either directly caused or contributed to a child's death. The Arizona CFR Program reviews each child death that occurs in Arizona in order to identify future actions that can reduce the number of preventable deaths1. 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 State Team 3|Page Submitted to: The Honorable Douglas A. Ducey, Governor, State of Arizona The Honorable Steve Yarbrough, President, Arizona State Senate The Honorable J.D. Mesnard, 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 Kyle Gardner, MSPH, CHES, Injury Epidemiologist Teresa Garlington, Administrative Secretary II 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. This publication was supported by a Cooperative Agreement Number: 5 NU58DP006122-02-00 funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. 4|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% 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, Arizona Department of Child Safety, whose tireless commitment, provided an invaluable amount of information to the review teams as well as the program office. Her contributions are an asset to the review process which is a testament to her care of all Arizona’s children. • 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 needed for teams to conduct effective reviews. Informed child fatality reviews are only possible when the teams have accurate and detailed information to review. 5|Page Table of Contents Preventability ................................................................................................................................................................ 2 Acknowledgments ........................................................................................................................................................ 5 Executive Summary...................................................................................................................................................... 8 Report Highlights ................................................................................................................................................ 10 Future Action for Prevention .............................................................................................................................. 14 Glossary ....................................................................................................................................................................... 15 Introduction ................................................................................................................................................................. 18 Methods ....................................................................................................................................................................... 19 Demographics ............................................................................................................................................................. 20 Preventable Deaths ..................................................................................................................................................... 23 Natural Deaths ............................................................................................................................................................ 27 Prematurity .......................................................................................................................................................... 27 Unintentional Injury (Deaths Due to Accidents) .................................................................................................... 31 Injury Deaths In-or-Around the Home ................................................................................................................ 32 Sudden Unexpected Infant Death (SUID) and Sleep Related Suffocation Deaths ............................................ 36 Maltreatment Deaths (Deaths due to Child Abuse and Neglect) ........................................................................ 39 Motor Vehicle Crash and Other Transport Deaths ................................................................................................ 44 Suicides ........................................................................................................................................................................ 50 Homicides .................................................................................................................................................................... 54 Drowning Deaths........................................................................................................................................................ 57 Firearm Related Deaths ............................................................................................................................................. 60 Substance Use Related Deaths .................................................................................................................................. 63 Classifications.............................................................................................................................................................. 67 Appendix of Summary Tables Age Group, Cause, and Manner of Death.....………………………………………75 Appendix of Child Deaths by Age Group............................................................................................................... 85 The Neonatal Period, Birth through 27 Days........................................................................................................ 85 The Post-Neonatal Period, 28 Days through 365 Days ........................................................................................ 86 Children, One through Four Years of Age ............................................................................................................ 88 Children, Five through Nine Years of Age ............................................................................................................ 89 Children, 10 through 14 Years of Age ................................................................................................................... 91 6|Page Children, 15 through 17 Years of Age ................................................................................................................... 92 Appendix of Population Denominators for Arizona Children ............................................................................ 94 Appendix of State and Local Child Fatality Review (CFR) Teams ...................................................................... 96 State CFR Team..................................................................................................................................................... 96 Apache County CFR Team .................................................................................................................................... 98 Coconino County CFR Team ................................................................................................................................ 99 Gila County CFR Team ....................................................................................................................................... 100 Graham County and Greenlee County CFR Team.............................................................................................. 101 Maricopa Countty CFR Team ............................................................................................................................. 102 Mohave County and La Paz County CFR Team ................................................................................................. 105 Navajo County CFR Team .................................................................................................................................. 106 Pima County, Cochise County, and Santa Cruz County CFR Team ................................................................. 107 Pinal County CFR Team ..................................................................................................................................... 110 Yavapai County CFR Team................................................................................................................................. 111 Yuma County CFR Team .................................................................................................................................... 112 7|Page Executive Summary The Arizona Child Fatality (CFR) Program began collecting data in 1994 and has been conducting reviews of all child fatalities occurring within the state since.1 This statutorily driven program begins the review process at the local level where teams of multi-disciplinary professionals volunteer their time to meet and discuss child death cases. Reviews are conducted to analyze the manner and cause of each death with the intent to identify key factors of preventability. The State Team meets annually to review the results of the Local Team’s findings, discuss areas of prevention, and approve an annual report. The Department of Health Services provides assistance to both the State and Local Teams, manages the CFR database, and provides administrative support to the program through community partnerships. While the number of deaths has increased since last year; overall the numbers have decreased in the past five years. The number of child deaths deemed preventable in 2016 has gone up in the following categories: accidents (e.g. motor vehicle and accidental asphyxia) and homicides. Local teams found that in 2016, 42% 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 2016. 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 783 deaths that were reviewed in 2016. 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 for society as a whole. 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. Many people might not consider themselves prevention agents, but everyone has the ability to contribute through the various programs available in our society. Some examples of these programs include law enforcement officers who serve as car seat safety technicians, social workers who provide valuable insight into the signs and symptoms of abuse or neglect, and even a parent who simply takes the time to speak with their child daily about their daily stresses. Through the combined contributions of individuals, we collaboratively provide a positive impact on society as a whole. 1 The ACFRP reviewed each child death under the age of 18 that occurred in Arizona. Children who are residents of Arizona, but died out of the state are neither reviewed by the AFCRP nor included in this report. 8|Page This annual report provides recommendations which help to 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. 9|Page Report Highlights Natural Deaths (Deaths due to Medical Conditions) • • • • • Natural deaths decreased slightly from 2015 (n= 487) to 2016 (n= 484), and accounted for 62% of all child deaths in Arizona. Nine percent (n=42) of the natural deaths were determined by the team to be preventable and these deaths accounted for 3% of all deaths. Prematurity accounted for 33% (n=162) of all natural deaths. Congenital anomalies, perinatal conditions, infections, cancer, neurological disorders, and cardiovascular diseases were the other leading causes of natural death. Seventy-one percent (n=343) of children who died from natural causes were less than 1 year old. Hispanic, African American, and American Indian deaths were disproportionately higher than the percentages of the population they comprise. Unintentional Injury Deaths (Deaths due to Accidents) • • • • • • Unintentional injury deaths increased 12% from 2015 (n=160) to 2016 (n=179) and comprised 23% of all child deaths. CFR state team determined all unintentional injury deaths (n=179) were preventable and these deaths made up 54% of all preventable deaths. The leading cause of unintentional injury deaths was motor vehicle crashes and other transport which accounted for 70% of unintentional deaths. Thirty-five percent (n=62) of unintentional injury deaths occurred among children less than one year old. Boys accounted for sixty-one percent (n=106) of all unintentional injury deaths. African American and American Indian deaths were disproportionately higher than the percentages of the population they comprise. Prematurity • • • • • • Deaths due to prematurity decreased 8% from 2015 (n=177) to 2016 (n=162). Ten percent (n=17) of prematurity deaths were determined to be preventable and these death made up 5% of all preventable deaths. Thirty-five percent (n=57) of the deaths due to prematurity were associated with medical complications during pregnancy. Examples include placental abruption, pre-eclampsia, advanced maternal age, gestational diabetes, and preterm labor. Ninety-one percent (n=147) of prematurity deaths were born before the 28th week of pregnancy (classified as Extreme Prematurity). Twenty-three percent (n=37) of pregnant mothers had no prenatal care, a decrease of 26% (n=46) in 2015 and 18% (n=41) in 2014. Six percent (n=10) of the mothers had gestational diabetes and 30% (n=48) of the parents were first generation immigrants. 10 | P a g e • • The average maternal age for the prematurity related deaths was 29 years old. Hispanic and African American deaths were disproportionately higher than the percentages of the population they comprise. Sudden Unexpected Infant Deaths (SUID) and Sleep Related Suffocation Deaths • • • • • • SUID increased by 3% from 2015 (n=78) to 2016 (n=80) and accounted for 10% of all child deaths in Arizona. Ninety-three percent (n=74) of SUID deaths were preventable and these deaths account for 22% of all preventable deaths. The number of unsafe sleep deaths increased 7% from 2015 (n= 74) to 2016 (n=79). Fifty-one percent (n=41) infants died due to bed sharing with adults and/or other children. Sixty-seven percent (n=53) sudden unexpected of infant deaths were determined to be due to suffocation. In thirty-one percent (n=25) of sudden unexpected infant deaths the cause could not be determined because there was not sufficient information available to the teams regarding the death. However, these deaths were most likely also caused by suffocation. African American and American Indian infant deaths were disproportionately higher than the population they comprise. Maltreatment Deaths (Deaths due to Child Abuse and Neglect) • • • • • • • • Child fatalities due to maltreatment decreased 6% from 2015 (n=87) to 2016 (n=82) and accounted for 10% of all child deaths in Arizona. All maltreatment deaths were determined by the team to be preventable and these deaths made up 25% of all preventable deaths among children. Blunt force trauma, MVC, drowning, suffocation, and firearm related deaths accounted for seventy percent (n=57) of maltreatment deaths. Seventy-six percent (n=63) of children who died due to maltreatment were less than 5 years old. Child neglect caused or contributed to 80% of the deaths (n=66). In sixty-five percent (n=51) of maltreatment deaths, the perpetrator was the child’s mother or father. Substance use was a factor in fifty-eight percent (n=48) of maltreatment deaths. African American and American Indian deaths were disproportionately higher than the population they comprise. Motor Vehicle Crash (MVC) and Other Transport Deaths • • • Motor vehicle crash (MVC) and other transportation deaths increased 42% from 2015 (n= 50) to 2016 (n= 71) and accounted for 9% of all child deaths in 2016. Motor vehicle crash deaths made up 86% of all transport related deaths (n=61). All transport deaths were determined by the team to be preventable and these deaths made up 22% of all preventable deaths among children. 11 | P a g e • Thirty-six percent of motor vehicle crash deaths (n=21) occurred among children 15 through 17 years of age. • • Passengers accounted for 64% of motor vehicle crash deaths among children. American Indian and African American deaths were disproportionately higher than the percent of population they comprise. Homicides • • • • • • • Homicides increased 31% from 2015 (n=32) to 2016 (n=42) and accounted for five percent of all child deaths. All of the homicide deaths were determined by the team to be preventable and these deaths made up 13% of all preventable deaths among children. Fifty-seven percent (n=24) of the homicide deaths were due to child abuse/neglect. Blunt force trauma (n=19) and firearm related injury (n=19) were the most common methods used to carry out homicides. Forty-three percent of homicide deaths (n=18) occurred among children one through four years of age. Parents were the perpetrator in thirty-six percent (n=17) of the homicide deaths. African American and Hispanic deaths were disproportionately higher than the percent of population they comprise. Suicides • • • • • Child suicides decreased 19% from 2015 (n=47) to 2016 (n=38) and accounted for 5% percent of all child deaths. All of the suicide deaths were determined by the team to be preventable and these deaths made up 12% of all preventable deaths among children. A history of family discord was the most commonly identified preventable factor in suicides followed closely by drug/alcohol use and an argument with a parent. Seventy-four percent (n=28) of suicide deaths occurred in children 15 through 17 years of age. American Indian and Asian/Pacific Islander deaths were disproportionately higher than the percent of population they comprise. Firearm Deaths • • • • • Firearm deaths increased from 29% from 2015 (n=28) to 2016 (n=36) and accounted for five percent of all child deaths. All of the firearms deaths were determined by the team to be preventable and these deaths made up 11% of all preventable deaths among children. Drug abuse was identified as a preventable factor in 58% (n=21) of firearm related deaths. Eighty-one percent (n=29) of firearm related deaths occurred in children 15 through 17 years of age. Fifty-three percent (n=19) of the 36 children who died from firearms related deaths were 12 | P a g e Hispanic children. Drowning Deaths • • • • • • Drowning deaths decreased 10% from 2015 (n=30) to 2016 (n=27) and accounted for 3% of all child deaths. All of the drownings deaths were determined by the team to be preventable and these deaths made up 8% of all preventable deaths among children. Seventy-eight percent (n=21) of drowning deaths occurred in children one through four years of age. Seventy percent (n=19) of the deaths occurred in a pool or hot tub. Lack of supervision was a factor in 84% (n=24) of drowning deaths. White, non-Hispanic and Hispanic deaths were disproportionately higher than the percent of population they comprise. Substance Use Related Deaths • • • • • Substance use was a factor in 14% of all child fatalities (n=107). In 46% of substance use related deaths (n=56), the parent was misusing or abusing alcohol or drugs. In 33% of substance use related deaths (n=40) the child who died was misusing or abusing drugs. Forty-one percent of substance use related deaths (n=44) resulted in deaths due to unintentional injuries. Males were 1.7 times more likely to experience a substance use related death. Adolescents 15 through 17 years had the highest risk of experiencing a substance use related death (39%, n=42). Disparities • • • • • Deaths continued to be disproportionately higher among some race/ethnicities in Arizona during 2016 and varied by cause and/or manner of death. Hispanic child deaths were overrepresented in deaths due to natural causes, prematurity, drowning, and homicides. African American children were disproportionately more likely to die from natural causes, including prematurity, unintentional injuries such as motor vehicle crashes, drowning, SUID, maltreatment related deaths, and homicide. American Indian children were disproportionately more likely to die from natural causes including prematurity, unintentional injuries such as motor vehicle crashes, SUID, maltreatment, and suicides. White, non-Hispanic children comprised higher percentages of suicides, drownings, and firearm related deaths. 13 | P a g e Future Actions for Prevention The following are a summary of the overarching prevention recommendations found in the report: • • • • • • Promote public awareness of healthy behaviors prior to pregnancy for women of reproductive age, especially if they are at high risk for pregnancy complications. Promote safe sleep education on the dangers of bed sharing (infants sleeping with an adult or other child) and the "ABCs of safe sleep". The ABCs are that babies should sleep Alone, on my Back, and in a Crib in order to prevent sleep suffocation. Support and implement community suicide prevention and awareness programs, such as Mental Health First Aid and "Hear Something, Say Something", that educate families, community members, teachers, and students to recognize and seek for children who may be experiencing a mental health crisis such as depression and bullying 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 services for children, youth and their families. Support sufficient funding for substance abuse prevention and treatment programs. 14 | 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 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. Drowning death - Child dies from an accidental or intentional submersion in a body of water. 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. Injuries in-or-around the home related death – These are unintentional or undetermined deaths that occur in-or-around the home environment (e.g. bedroom, driveway, and yard). Homicide – Death resulting from injuries inflicted by another person with the intent to cause fear, harm or death. IHS – Indian Health Services Infant – A child younger than one year of age. 15 | P a g e 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 intent to kill oneself (e.g., suicide). 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. Maltreatment – An act of physical abuse or neglect against a child (please see the Technical Appendix and definitions for physical abuse, neglect, and perpetrator). 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. Neglect - This is defined as the failure to provide appropriate and safe supervision, food, clothing, shelter, and/or medical care when this causes or contributes to the death of the child. Perpetrator - Individual identified as possible perpetrator of physical, sexual or emotional abuse, or neglect. Caregiver may include individual providing supervision of child including parent’s boyfriend/girlfriend, friend, neighbor, child care provider, or other household member. Physical abuse - This means the infliction of physical harm whether or not the inflictor planned to carry out the act or inflicted harm. The abuse may have occurred on or around the time of death, but also will include any abuse that occurred previously if that abuse contributed to the child’s death. NOTE: Shooting deaths by a parent, guardian or caregiver will also be identified as this type of maltreatment. Prematurity death - A death that was due to a premature birth (less than 37-week gestation) and there were no underlying medical conditions that resulted in the death. 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) are considered when making this determination. 16 | P a g e 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 related deaths as deaths where substance use was found as a direct or contributing factor leading to child deaths. To identify substance use as a factor, each case was reviewed and determined whether any individual involved in the death of a child, including, but not limited to the child’s parent or caretaker, an acquaintance, stranger, or the child during or about the time of the incident leading to the death, used or abused substances, such as illegal drugs, prescription drugs, and/or alcohol. Suffocation/Asphyxia 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, 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, they prepare an annual report of review findings, and develop recommendations to reduce preventable child deaths. Suicide – Death from self-directed intentional behavior where the intent is to die as a consequence of that behavior. Sudden Unexpected Infant Death (SUID) – 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. Most of the SUIDs are due to suffocation and unsafe sleep environments.2 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 due lack of or conflicting information, or because it is not clear if it was an intentional or an unintentional injury. Unintentional injury (Accidents) – 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.” 2 See the Technical Appendix for further explanation of SUIDs and its subcategories. 17 | P a g e Introduction Injuries and medical conditions are among the leading causes of death for Arizona’s children. Unlike diseases, most injuries do not occur randomly. A thorough examination of each death reveals factors that are both predictable and preventable. Historical data shows that infants are most often injured by suffocation resulting from an unsafe sleep environment, toddlers are more likely to drown, and older children are more vulnerable to motor vehicle or firearm related injury. Analyzing risk factors allow injuries to be anticipated and thus prevented when the appropriate protective measures are in place. The Arizona Child Fatality Review (CFR) Program was established to review all possible factors revolving around a child’s death. The intent of the program is to identify ways of reducing or eliminating preventable fatalities for future generations. Legislation was passed in 1993 (A.R.S. § 36-342, 363501) authorizing the creation of the CFR Program. In 1994 the review process and data collection began. Today there are 11 local teams that conduct initial reviews with oversight from the State Team and its two committees. This report provides a comprehensive review of fatalities among children and youth through 17 years of age occurring in Arizona. Descriptive 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 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. Conducting a Case Review ••• According to the National Center for Child Death Review, there are six basic steps to conduct an effective review meeting: 1) Share, question, and clarify all case information. 2) Discuss the investigation. 3) Discuss the delivery of services (to family, friends, schoolmates, community). 4) Identify risk factors (preventable factors or contributing factors). 5) Recommend systems improvements (based on any identified gaps in policy or procedure). 6) Identify and take action to implement prevention recommendations. 18 | P a g e 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 by committees of the State Team. The review process begins when the death of a child under 18 years old is identified through a vital records report. The CFR program sends a copy of the 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 team in the county where the death occurred will conduct the review. These teams are located throughout the state and membership includes local representatives from the Arizona Department of Child Safety (DCS), the county medical examiner’s office, the county health department, local law enforcement, and the County Attorney’s Office. Membership also includes a pediatrician or family physician, a psychiatrist or psychologist, a domestic violence specialist, and a parent.3 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 of death by manner, age, gender, and race/ethnicity. Frequencies and cross-tabulation tables are shown throughout the report. Since most of the counts are small, tests for statistical significance are not done. The demographic and prevention information represented in this report are 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). Manner of death includes 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. 3 For a full list of participants see the Appendix of State and Local CFR Teams. 19 | P a g e Demographics During 2016, there were 783 fatalities among children younger than 18 years of age in Arizona, an increase from the 768 deaths in 2015. Males accounted for 58% of deaths (n=453) and females comprised the remaining 42% (n=330) (Figure 1). Figure 1. Number of Deaths among Children Ages 0-17 Years, by Age Group and Sex, Arizona, 2016 (n=783) 180 160 164 135 140 120 100 82 80 69 62 60 68 48 40 43 27 20 18 39 28 0 Birth-27 Days (n=299) 28-365 Days (n=144) 1-4 Years (n=117) Male (n=453) 5-9 Years (n=45) 10-14 Years (n=71) 15-17 Years (n=107) Female (n=330) The Arizona child mortality rate increased 2% from 2015 (47.2 deaths per 100,000 children) to 2016 (48.2 deaths per 100,000 children) (Figure 2). Over the last six years, the mortality rate has decreased 5.5% overall from 2011 (51.0 deaths per 100,000 children) to 2016 (48.2 deaths per 100,000 children). Figure 2. Mortality Rates per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 80.0 70.0 60.0 70.0 67.6 60.7 50.0 55.1 52.9 40.0 51.0 52.4 2011 2012 49.5 51.3 2013 2014 47.2 48.2 2015 2016 30.0 2006 2007 2008 2009 2010 20 | P a g e The infant mortality rate decreased 5% from 5.5 deaths per 1,000 live births in 2015 to 5.2 deaths per 1,000 live births in 2016. Figure 3 illustrates Arizona’s infant mortality rate compared to the U.S. mortality rate from 2006-2016. Arizona consistently has had lower infant mortality rates than the U.S. except in 2007 (Figure 3). Figure 3. Infant Mortality Rates per 1,000 Live Births, Less than 1 Year Old, Arizona & U.S., 2006-20164 7.5 7.0 6.7 6.5 6.0 5.5 6.8 6.7 6.9 6.4 6.4 6.3 5.9 6.2 6.1 6.0 6.0 5.9 5.8 5.0 6.0 6.0 6.0 6.0 5.5 5.3 4.5 6.0 5.2 4.0 2006 2007 2008 2009 2010 2011 2012 AZ Rate 2013 2014 2015 2016 U.S. Rate Over the last decade, the Arizona child mortality rate decreased in every age group. In 2016, the mortality rates for children 1 through 4 years of age, 10 through 14 years of age, and 15 through 17 years of age increased while the mortality rate for children aged 5 through 9 years from the last year decreased (Figure 4). Figure 4. Mortality Rates per 100,000 Children, Ages 1-17 Years, by Age Group, Arizona, 2006-2016 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 2006 2007 2008 1-4 Years 2009 2010 5-9 Years 2011 2012 10-14 Years 2013 2014 2015 2016 15-17 Years 4 Infant Mortality contains all babies less than 1 year of age that died in Arizona. Infants that are residence of Arizona, but died out of the state are not included in this mortality rate. 21 | P a g e Figure 5 shows the child mortality rates for the last eleven 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 below 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, nonHispanic and Hispanic mortality rates between 2013 and 2014 as well (see table 70 in the appendix for population denominators by race/ethnicity). Figure 5. Mortality Rates of Children Ages 0-17 Years, by Race/Ethnicity Group, per 100,000 Children, Arizona, 2006-2016 140.0 120.0 100.0 80.0 60.0 40.0 20.0 0.0 2006 2007 African American 2008 2009 2010 American Indian 2011 Asian 2012 2013 Hispanic 2014 2015 2016 White, non-Hispanic African American children comprised 6% of the Arizona child population in 2016 but made up 10% of all child fatalities. American Indian children comprised 9% of all children fatalities in 2016 but only made up 5% of the total child population (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. 22 | P a g e Figure 6. Percentage of Deaths among Children, Ages 0-17 Years by Race/Ethnicity Group Compared to Population, Arizona, 2016 (n=755)5 50% 45% 40% Fatalities Population 45% 44% 35% 42% 30% 30% 25% 20% 15% 10% 10% 5% 9% 6% 5% 3% 3% 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” is 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 deaths whose race/ethnicity is unknown or more than 2 races 23 | P a g e When discussing all deaths, the report is referring to the total 783 child deaths that took place in 2016. 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 determined as preventable by the teams. This is important so that efforts are targeted to the areas where prevention initiatives will be most effective. In 2016, CFR teams determined 330 child deaths were probably preventable (42%), 399 child deaths were probably not preventable (51%), and could not determine the preventability in 54 deaths (7%) (Figure 7). Figure 7. Number and Percentage of Deaths among Children Ages 0-17, by Preventability, Arizona, 2016 (n=783) 7%, (n=54) Probably Not Preventable 42%, (n=330) 51%, (n=399) Probably Preventable Could Not Determine CFR teams determined 100% of the unintentional injury deaths were preventable (n=179), 100% of homicides were preventable (n=42), and 100% of suicides were preventable (n=38). Only 9% of natural deaths were determined to have been preventable (n=42) (Figure 8). 24 | P a g e Figure 8. Number and Percentage of Preventable Deaths for Children Ages 0-17 Years, by Manner, Arizona, 2016 (n=330) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 100% 73% 9% Natural (n=42) Unintentional Injury (Accident) (n=179) Suicide (n=38) Homicide (n=42) Undetermined (n=29) Preventability varies by age group. Children between the ages of 5 through 9 years old had the lowest percentage of preventable deaths (5%, n=18). The highest percentage of preventable deaths was among youth between the ages of 15 through 17 years old (26%, n=86), and children 28 through 365 days (26%, n=85) (Figure 9). Figure 9. Percentage of Preventable Deaths for Children Ages 0-17 Years, by Age Group, Arizona, 2016 (n=330) 30% 26% 26% 25% 20% 20% 15% 10% 12% 10% 5% 5% 0% Birth-27 Days 28-365 Days (n=33) (n=85) 1-4 Years (n=67) 5-9 Years (n=18) 10-14 Years (n=41) 15-17 Years (n=86) 25 | P a g e Table 1 shows the leading five causes of death for children by age group in Arizona. Those boxes highlighted in red 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 firearm related injury, which was the most common cause of preventable death for teens 15 through 17 years of age. Motor vehicle crashes were the most common cause of preventable death among children 5 through 14 years old, and drownings were the most common cause of preventable death for children aged 1 through 4 years old. 26 | P a g e 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 decreased 11% from 2014 (n=546) to 2016 (n=484). Prematurity accounted for 33% (n=162) of natural deaths, other medical conditions accounted for 66% of natural deaths (n=320). Infants 0 through 27 days old composed 60% of all natural deaths (n=290). Hispanic children accounted for 49% (n=236) of natural deaths and were overrepresented compared to the 44% of the population they compose. White, non-Hispanic children made up 28% (n=137) of the deaths. Prematurity (n=162), congenital anomalies (n=104), and perinatal conditions (n=56) were the leading causes of natural death. Figure 10. Mortality Rates Due to Natural Causes per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 50.0 45.0 44.8 45.5 41 40.0 37.3 34.7 35.0 32.7 33.3 31.3 33.6 30.0 29.8 2015 2016 30.0 25.0 20.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 Prematurity For the purposes of this report, a death due to prematurity is when the infant was born before 37 weeks gestation and the infant did not have a lethal congenital malformation or other perinatal condition that was the primary cause of death. In 2016, twenty-one percent (n=162) of all Arizona child deaths were due to prematurity. When a premature birth is the result of a perinatal condition, the cause of death is classified as a perinatal condition, rather than prematurity. Forty-three percent (n=24) of deaths due to perinatal conditions (n=56) were less than 28 weeks gestation at birth. 27 | P a g e Over the last six years, the prematurity rate has declined and the rate has varied between 2.3 to1.9 deaths per 1,000 live births. The prematurity rate reached its lowest point in 2016. Figure 11. Prematurity Mortality Rate per 1,000 Live Births, Less than 1 Year Old, Arizona, 2006-2016 3.1 2.9 2.7 3.0 2.9 2.7 2.5 2.3 2.6 2.6 2.3 2.1 2.4 2.3 2.2 1.9 2.1 1.9 1.7 1.5 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 In 2016, Hispanic children remain at the highest risk in Arizona for prematurity related death. Fifty-two percent (n=84) of the prematurity related deaths were Hispanic infants compared to making up only 40% of the total birth population in 2016. Though the numbers are smaller, the percentage of African American child deaths had an even greater disparity based on the percentage of the population they represent. American Indian and Asian child deaths also had higher risk than White, non-Hispanic children (Figure 12). Figure 12. Percentage of Child Deaths due to Prematurity Compared to Percentage of Births, by Race/Ethnicity Group, Arizona 20166 60% 50% 40% % of Prematurity deaths in AZ for 2016 (n=162) 52% 45% % of Births in AZ for 2016 (n=84,404) 40% 30% 25% 17% 20% 10% 5% 8% 6% 5% 4% 0% Hispanic 6 White, non-Hispanic African American American Indian Asian Does not include the 11 deaths whose race/ethnicity is unknown or more than 2 races. 28 | P a g e Prevention Determining the exact cause of premature birth can be difficult. This report identifies the preventable risk factors that are known to be associated with premature births for each of the infant cases reviewed. The steady decrease in the prematurity rate supports continued 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 her partner, mother’s age, and domestic violence in the home. In 2016, the most common risk factors for prematurity deaths included medical complications during pregnancy (85%, n=138), preterm labor (70%, n=113), and no prenatal care (23%, n=37). There were 13 prematurity deaths with drug/alcohol abuse and 13 with smoking as a risk factor. The viability or survival rate of premature infants also depends on the gestational age at birth. When infants are less than 28 weeks of gestation at birth they are classified as extreme prematurity. Extreme prematurity accounted for 91% of prematurity deaths (n=147) (Table 2). Lack of prenatal care is a serious risk factor for premature birth. In twenty-three percent (n=37) of the prematurity deaths the mother reported that she did not receive any prenatal care. Fortythree percent of the mothers whose infants died due to prematurity started prenatal care within the first trimester of pregnancy (n=71). In two percent of the prematurity deaths, the mother was 16 through 19 years of age at the time of the birth (n=4). Fifty-one percent of the mothers were 20 through 29 years of age (n=82); thirty-seven percent were 30 through 39 years of age (n=60), and four percent of mothers were 40 years and older (n=7). In six percent of the cases the age of the mother was unknown (n=9). Eight percent of mothers had less than a high school education (n=13); forty-four percent completed high school (n=71); and thirty-four percent attended at least some college (n=55); four percent were post-graduates (n=7); and for another six percent the mother’s educational status was unknown (n=9). Table 2. Risk Factors for Prematurity Deaths, Arizona, 2016 Factor* Extreme Prematurity (born < 28 weeks of pregnancy) Medical complications during pregnancy Preterm labor No prenatal care Substance use Smoking Cervical insufficiency Chorioamnionitis (bacterial infection) *More than one factor may have been identified for each death Number 147 138 113 37 13 13 12 10 Percent 91% 85% 70% 23% 8% 8% 7% 6% 29 | P a g e One of the difficulties in adequately managing and preventing a premature birth is that the etiology often is multifactorial, leaving no single intervention strategy as best effective. 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.7 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.8 Some common maternal health conditions that may lead to pre-term birth include obesity, high blood pressure, and diabetes.9 Prematurity Prevention Recommendations 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. Stop smoking if you are pregnant in order to reduce pregnancy complications and have a healthy baby. Ensure 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. • • • • 7 8 9 http://economics.mit.edu/files/9922 http://www.amchp.org/Transformation-Station/Documents/AMCHP%20Preconception%20Issue%20Brief.pdf https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregcomplications.htm 30 | P a g e Unintentional Injury (Deaths Due to Accidents) The mortality rate for unintentional injury deaths increased 12% from 2015 (n=160) to 2016 (n=179) (Figure 13). Over the last six years, the unintentional mortality rate varied from 9.8 to 11.7 deaths per 100,000 children. Thirty-five percent of unintentional injury deaths occurred in children less than one year of age (n=62). Figure 13. Unintentional Injury (Accident) Mortality Rates per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 18.0 16.0 14.0 16.3 12.0 13.4 11.7 10.0 8.0 9.8 2008 9.6 9.8 10.2 2009 2010 2011 11.4 11.0 11.0 9.8 6.0 2006 2007 2012 2013 2014 2015 2016 In 2016, motor vehicle crashes (MVC) and suffocation were the leading causes of unintentional injury deaths and accounted for 70% of these deaths. Other injuries include drownings, poisoning, falls, or fire/burn, or firearm injuries (Figure 14). Figure 14. Leading Causes of Unintentional Injury (Accident) Deaths for Children Ages 0-17 Years, Arizona, 2016 16%, (n=28) 15%, (n=26) 30%, (n=55) Suffocation MVC Drowning Other Injury 39%, (n=70) 31 | P a g e Injury Deaths In-or-Around the Home Injury deaths in-or-around the home are unintentional or undetermined deaths that occur in-oraround 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 this section. Injury deaths in-or-around the home increased 3% from 2015 (n=142) to 2016 (n=146). Injuries in-or-around the home accounted for 19% of all Arizona child fatalities. Over the last six years, the injuries in-or-around the home mortality rate has gradually increased and varied between 7.3 to 9.0 deaths per 100,000 children. In 2014, the methodology for determining injury deaths in-or-around the home changed. The addition of new variables that was not included previously may account for the rise in injury deaths in-or-around the home over the last six years. Figure 15. Injury In-or-Around the Home Mortality Rate per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 10.0 9.0 9.5 8.0 7.0 6.0 8.2 8.2 7.1 8.7 8.2 7.1 9.0 8.0 7.4 7.3 2012 2013 5.0 4.0 2006 2007 2008 2009 2010 2011 2014 2015 2016 Prevention In 2016, children less than five years of age accounted for 84% of injury deaths in-or-around the home (n=123); and more than half of the deaths were infants less than one year (58%, n=85) (Figure 16). Males (63%, n=92) were 1.7 times more likely to experience an injury death in-oraround the home than females (37%, n=54). Majority of these deaths were among White, nonHispanic and Hispanic children. White-non Hispanic children (n=56) made up 38% of injury deaths in-or-around the home, 33% for Hispanic children (n=48), 14% for African American 32 | P a g e children (n=20), and American Indian children (n=15) made up 10%. Twenty percent of injury deaths in-or-around home were also classified as maltreatment deaths due to neglect by the child's caretaker (n=29). Figure 16. Number and Percentage of Injury Deaths In-or-Around the Home for Children Ages 0-17 Years, by Age Group, Arizona, 2016 3%, (n=<6) 9%, (n=12) < One Year 27%, (n=38) 1-4 Years 5-9 Years 61%, (n=85) 10-17 Years The most common cause of death was suffocation (n=54) accounting for 38% of fatalities, undetermined deaths (n=25) made up 17%, and drowning incidents (n=22) accounted for 15% of injury deaths in-or-around the home (Table 3). Table 3. Number and Percentage of Injury Deaths In-or-Around the Home, by Cause, Arizona, 2016 (n=146) Cause Number Percent Suffocation 54 38% Undetermined 25 17% Drowning 22 5% MVC/Transport 10 7% Poisoning 9 6% The most commonly identified preventable factors for injuries in-or-around the home in infants were unsafe sleep environments (44%, n=64), lack of supervision (38%, n=55), and bedsharing (26%, n=38) (Table 4). Table 4. Preventable Factors for Injury Deaths In-or-Around the Home, Arizona, 2016 Factor* Number Unsafe sleep environment 64 Lack of supervision 55 Bed-sharing 38 Substance use 34 Access to water 15 *More than one factor may have been identified for each death Percent 44% 38% 26% 23% 10% 33 | P a g e There are a variety of protective factors that can be implemented to reduce these types of deaths. This includes educating families about the dangers of unsafe sleep environments, the importance of placing the child on their back to sleep, explaining the risks of bed sharing, having proper pool fencing and providing adequate supervision to young children. Injury Prevention Recommendations in the Home Setting Prevent Infant Sleep Suffocation • • • • • • • • • • • • Practice the "ABCs of Safe Sleep". The ABCs are: babies should sleep alone, on their back and in a crib in order to prevent sleep suffocation Place babies to sleep every time in a crib or bassinette that has a firm mattress covered by a fitted sheet. Encourage parents to place their baby's crib or bassinette in their bedroom. Keep soft objects, such as crib bumpers, pillows, and loose bedding out of baby’s crib. Encourage pregnant women to quit smoking and to provide a smoke free environment for their babies after birth. Pediatricians and other professionals should ask about sleep practices and provide safe sleep education at infant health supervision visits. All hospitals that provide health care services to infants should establish policies that endorse and model the ABCs of safe sleep recommendations from birth. Parents should make sure all those who care for their infant understand safe sleep practices (use of a crib, avoidance of bed sharing, and positioning infants on their back to sleep every time). Only place infants on their stomach when they are awake and supervised. Early childhood home visitors should educate families about the risks of bed-sharing and check for safe sleep practices in the home. Arizona Perinatal Trust should continue to promote safe sleep guidelines in birthing hospitals. Childcare providers should establish policies that promote and enforce safe sleep practices. Prevent Injuries In-or-Around the Home • • • • • • Check smoke alarm batteries every six months to make sure they are working. Install safety gates to keep children from falling down staircases and window guards or stops to prevent falls from windows. Make sure that all medications, including vitamins and adult medicines, are stored out of reach and out of sight or children. Store poisonous items out of reach or use safety locks on cabinets within reach. These items also include liquid packets for the laundry and dishwasher. Save the Poison Help line in your phone: 1-800-222-1222. Put the toll-free number for the Poison Control Center into your home and cell phones Give young children your full and undivided attention when they are in the bathtub or 34 | P a g e • • • • around water. Install a four–sided isolation fence, with self–closing and self–latching gates, around backyard swimming pools. Pool fences should completely separate the house and play area from the pool. Secure TVs and furniture to the wall using mounts, brackets, braces, anchors or wall straps to prevent tip-overs. Avoid heatstroke-related injury and death by never leaving your child alone in a car, not even for a minute. Always lock your doors and trunks – even in your driveway. And keep your keys and key fobs out of the reach of kids. 35 | P a g e Sudden Unexpected Infant Death (SUID) and Sleep Related Suffocation 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. Many SUID cases are due to suffocation and unsafe sleep environments, but not all SUID cases are unsafe sleep related. The number of SUID cases increased 3% from 2015 (n=78) to 2016 (n=80). Over the last six years, the SUID mortality rate have declined 29% and varied between 0.87 to 1.3 deaths per 1,000 live births, while the mortality rates for unsafe sleep environment and suffocation have both increased and varied 0.60 to 0.95 deaths per 1,000 live births and 0.45 to 0.69 deaths per live births, respectively. Figure 17. Mortality Rates due to Sudden Unexpected Infant Death (SUID), Unsafe Sleep Environments, and Suffocation per 1,000 Live Births, Less than 1 Year Old Arizona, 2006-2016 1.6 1.39 1.4 1.41 1.2 1.0 0.8 0.6 0.93 1.33 0.99 0.87 0.86 1.3 0.0 1.33 0.95 0.88 0.60 0.83 0.45 0.24 2006 0.29 2007 0.87 0.75 0.4 0.2 SUID Unsafe Sleep Environment Suffocation 0.21 0.18 2008 2009 0.98 0.95 0.77 0.54 0.53 2012 2013 0.69 0.94 0.92 0.87 0.94 0.61 0.63 2015 2016 0.26 2010 2011 2014 In 2016, males accounted for 61% of SUID (n=49). White, non-Hispanic children accounted for 39% of SUID (n=31), Hispanic children accounted for 31% of SUID (n=25), African American children accounted for 15% of SUID (n=12), and American Indian children accounted for 10% of SUID (n=8). 36 | P a g e Prevention Local CFR teams determined seventy-four of the SUID deaths were preventable (93%) and these deaths accounted for 22% of all preventable deaths. The most commonly identified cause of SUID was sleep suffocation (67%, n=53). In 31% (n=25) the cause could not be determined. Although these deaths were most likely suffocation, teams would identify the cause of death as “undetermined” if there was not sufficient information available to conclusively identify the cause of death as suffocation (Table 5). The major risk factors in many SUIDs are situations where an infant is placed to sleep on his/her stomach or side; on an unsafe sleeping surface, such as an adult mattress, couch, or chair; soft objects, pillows, or loose coverings in a sleep environment; has been exposed to cigarette smoke either prenatally or postnatal; and bedsharing with an adult or other child. Table 5. Number and Percentage of Sudden Unexpected Infant Deaths, by Cause, Arizona, 2016 (n=80) Cause Number Percent Suffocation 53 67% Probable Suffocation 25 31% An unsafe sleep environment, including placement of infant in an unsafe sleep position, was associated with 99% of SUID fatalities (n=79) (Table 6). Bed-sharing with adults (93%, n=38) and/or other children (22%, n=9) accounted for 49% of SUID fatalities (n=41). Other factors of SUID fatalities include, 51% of infants died while sleeping in an adult bed (n=41), 16% infants died sleeping on a couch or a floor, and 30% died while sleeping on their side or stomach. The local teams determined 94% of unsafe sleep fatalities (n=73) were preventable. Table 6. Preventable Factors for Sudden Unexpected Infant Deaths, Arizona, 2016 Factor* Number Unsafe sleep environment 79 Bed-sharing 41 -With adult 38 -With child 9 Sleep Position 24 -On stomach 14 -On side 10 Substance use 16 *More than one factor may have been identified for each death Percent 99% 49% 93% 22% 30% 58% 42% 20% Table 6A. Caregiver Supervising Infant, Prior to Sudden Unexpected Infant Death, Arizona, 2016 Caregiver Number Percent Parent 62 78% -Mother 45 73% -Father 17 27% Other Relative (Grandparent, Cousin, or Sibling) 11 14% Other (Babysitter, Unlicensed Daycare, or Unspecified Caregiver) 7 9% 37 | P a g e These deaths could have potentially been prevented by using safe sleep practices. Safe sleep practices include placing young infants to sleep on their back instead of on their side or stomach, inside a crib, always using a firm sleep surface, and keeping soft objects as well as loose bedding out of the crib. In 2016 the American Academy of Pediatrics expanded their recommendations for a safe sleep environment. This included a shift from focusing only on SUID to focusing on a safe sleep environment that can reduce the risk of all sleep related infant deaths, including SUID. The recommendations include supine positioning, use of a firm sleep surface, breastfeeding, roomsharing without bed-sharing, routine immunizations, consideration of using a pacifier, and avoidance of soft bedding.10 Preventing Sleep related Suffocation Death • • • • • • • • • • • 10 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 bed-sharing and positioning infants on their back to sleep). Early childhood home visitors should educate families about and reinforce safe sleep practices. Health care providers, staff in newborn nurseries and NICUs should establish policies that endorse and model the ABC’s of safe sleep recommendations from birth. Encourage all health care providers working with parents to discuss safe sleep practices and risk factors at every visit. Always return the infant back to their safe sleep environment after breast/bottle feeding. Arizona Perinatal Trust should continue to promote safe sleep guidelines in birthing hospitals. Child care providers should establish policies that promote and enforce safe sleep practices. Support public awareness campaigns and distribution of resources regarding the risk factors associated with sudden unexplained and sleep related infant deaths. 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. http://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938 38 | P a g e Maltreatment Deaths (Deaths due to Child Abuse and Neglect) Ten percent (n= 82) of Arizona child fatalities in 2016 were due to maltreatment. From 2015 to 2016 the mortality rate due to maltreatment decreased 6% from 5.3 deaths per 100,000 children to 5.0 deaths per 100,000 children (Figure 18). In 2015, 87 children died due to maltreatment compared to 82 in 2016. In 2016, physical abuse such as blunt force trauma, or use of firearm weapon caused or accounted for 32% of maltreatment deaths (n=26) among children. Child neglect caused or accounted for 80% of the maltreatment deaths (n=66). Both physical abuse and neglect may have been present in a child’s death. It is important to note that while there have been some fluctuations in the rates between the years, the overall mortality rate due to maltreatment has increased by 16% since 2011.11 Males represented 54% (n=44) of the maltreatment deaths, versus 46% (n=38) among females. Thirty-four percent (n=28) of children who died due to maltreatment were Hispanic, 27% (n=22) were White, non-Hispanic, 22% (n=18) were African American, 11% (n=9) were American Indian, and 6% were among children who race/ethnicity group is multiple race or unknown. Seventy-seven percent of the children who died from maltreatment were less than five years old (n=63). Figure 18. Mortality Rates due to Maltreatment per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 6.0 5.5 5.6 5.0 4.5 4.0 3.5 3.0 3.6 3.8 4.3 4.3 4.3 2010 2011 2012 5.3 5.0 4.6 3.7 3.0 2.5 2.0 2006 11 2007 2008 2009 2013 2014 2015 2016 Please see the Technical Appendix for a full explanation and definition on maltreatment. 39 | P a g e Figure 19. Percentage of Maltreatment Deaths for Children Ages 0-17 Years, by Age Group, Arizona, 2016 (n=82) 40% 34% 35% 30% 27% 25% 20% 16% 15% 12% 11% 5-9 Years (n=10) 10-17 Years (n=9) 10% 5% 0% Birth-27 Days (n=13) 28-365 Days (n=22) 1-4 Years (n=28) In 2016, the leading manner of death for maltreatment fatalities in Arizona was unintentional injuries. Accidents resulted in forty-seven percent (n=38) of unintentional injuries. Homicides comprised thirty percent (n=25) of the maltreatment deaths. Fourteen percent (n=11) of maltreatment deaths were due to a natural manner (Figure 20). Examples of maltreatment deaths due to a natural manner of death include prenatal substance use resulting in premature birth or a caregiver’s failure to obtain medical care. Figure 20. Number and Percentage of Maltreatment Deaths for Children Ages 0-17 Years, by Manner, Arizona, 2016 (n=82) 9%, (n=7) 14% (n=11) Natural 30%, (n=24) Accident Homicide 47%, (n=37) Undetermined 40 | P a g e Blunt/sharp force trauma, MVC, drowning, prematurity, and firearm injury were the leading causes of maltreatment related deaths among children in Arizona (Table 7). Table 7. Maltreatment Deaths Among Children by Top Causes of Death, Arizona, 2016 (n=82) Cause Blunt/sharp Force Trauma MVC Drowning Prematurity Firearm Injury Suffocation All Other Injuries Number 19 14 10 7 7 7 18 Percent 23% 17% 12% 9% 9% 9% 22% Of the eighty-two maltreatment deaths, 76% of deaths (n=63) involved only one perpetrator, and 23% of deaths (n=19) involved two perpetrators. Forty-seven percent of maltreatment deaths involving two perpetrators were identified as the child’s mother and father. Overall, the child’s mother made up 54% (n=55) of perpetrators in maltreatment deaths, and the child’s father accounted for 20% of deaths (n=20) (Table 8). Table 8. Number and Percentage of Perpetrators Involved in Maltreatment Deaths Among Children, by Perpetrator Type, Arizona, 2016 (n=101) Perpetrator* Number Percent Mother 55 54% Father 20 20% Parent’s Partner 11 11% Relative (Sibling, Grandparent, Cousin, etc.) 10 10% Other Caregiver (Babysitter, Childcare, etc.) 5 5% *There may be more than one perpetrator for each death 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 Arizona Department of Child Safety (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 the 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; however calls to ADCS that did not meet criteria to be made into a report, and were taken as “information only”, are not included. 41 | P a g e In 2016, sixty-two percent (n=51) of the 82 children who died from maltreatment were from families with prior involvement with a CPS agency. Among the families who had prior involvement with CPS, 13% (n=11) of families had an open case at the time of the child’s death, and 40% (n=33) of families had no history of CPS involvement (Figure 21). The number of children from families with prior CPS involvement decreased from 53 in 2015 to 51 in 2016. The number of families with an open CPS case at the time of the child's death also decreased 35% from 2015 (n=17) to 2016 (n=11). Figure 21. Maltreatment deaths: involvement with any child protective services agency, Arizona, 2016 60 51 50 40 33 No CPS history 30 CPS history 20 11 10 Open CPS at time of death 0 2016 Prevention Child maltreatment is any act or series of acts of commission or omission by a parent or other caregiver (e.g., clergy, coach, and 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 maltreatment. These factors, usually in combination, may involve the parent or caregiver, the family, the child or the environment.12 • • • • 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 https://www.childwelfare.gov/pubpdfs/2011guide.pdf 42 | P a g e One hundred percent of child maltreatment deaths were determined to have been preventable (n=82). 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 58% (n=48) of the deaths. An unsafe sleep environment accounted for 11% (n=9) of maltreatment deaths, lack of supervision accounted for 10% (n=8) (Table 9). More than one factor may have been identified for each death. Table 9. Preventable Factors for Maltreatment Deaths Among Children, Arizona, 2016 Factor* Number Substance use 48 Lack of Supervision 9 Unsafe sleep environment 8 Lack of proper restraint use in a motor vehicle 6 *More than one factor may have been identified for each death Percent 58% 11% 10% 7% 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. Child Abuse and Neglect (Maltreatment) Prevention Recommendations • • • • • • • • • Report 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. Support sufficient funding for timely behavioral health treatment services for parents and their children. Support sufficient funding for substance abuse assessment and treatment services for parents and their children. Support increased funding for childcare assistance programs so that all low-income working families can have access to safe childcare for their children. If in need of safe childcare, parents and caregivers can contact these agencies: Arizona Childcare Resource & Referral (1-800-308-9000) or the Association for Supportive Child Care (1-800-535-4599) for assistance. These agencies will match parents seeking childcare with appropriate community resources. Ensure there is sufficient funding for the Arizona Department of Child Safety, Juvenile Court System, Attorney General’s Office and community based services to effectively prevent and respond to child abuse and neglect. The Arizona Congressional Delegation should support the development of a national child abuse registry that can provide critical information on past episodes of abuse and neglect that occurred in other jurisdictions and outside of Arizona. Pediatricians and other healthcare providers should implement the American Academy of Pediatrics recommendations to integrate postpartum depression surveillance. Encourage communities to support evidenced based programs focused on prevention such as home visiting. 43 | P a g e Motor Vehicle Crash and Other Transport Deaths Since 2012, motor vehicle crash (MVC) and other transport deaths among children were gradually declining. However, motor vehicle crash and other transport deaths increased 42% from 2015 (n=50) to 2016 (n=71); and accounted for 9% of all child deaths in Arizona. From 2011-2016, the motor vehicle crash and other transport mortality rate varied from 3.1 to 5.9 deaths per 100,000 children (Figure 22). Motor vehicle crashes alone accounted for 86% of transportation related deaths among children. The MVC mortality rate increased 53% from 2015 (n=40) to 2016 (n=61) (Figure 23). There are a number of risk factors that are associated with these deaths. • • • • • • Age and gender: males aged 15–17 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 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 Figure 22. Mortality Rate Due to Motor Vehicle Crashes (MVC) and Other Transport per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 11.0 10.0 9.0 9.9 8.0 7.0 7.2 6.0 5.0 4.0 4.8 5.4 4.8 3.0 3.7 4.3 4.9 3.5 2.0 2006 2007 2008 2009 2010 4.4 2011 2012 2013 2014 3.1 2015 2016 44 | P a g e Figure 23. Mortality Rate Due to Motor Vehicle Crashes (MVC) per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 10.0 9.0 8.0 8.7 7.0 6.0 6.2 5.0 4.7 4.0 4.7 3.0 3.6 3.7 3.9 3.8 3.5 2.0 2006 2007 2008 2009 2010 2011 2012 2013 3.0 2.8 2014 2015 2016 Prevention In 2016, local CFR teams determined that all of the motor vehicle crash and other transport fatalities were preventable (n=71) and accounted for 22% of all preventable deaths. Among these fatalities, certain groups still carry a larger part of the mortality burden and may benefit from targeted prevention initiatives. Hispanic, American Indian, and African American children represented a higher percentage of motor vehicle crash and other transport deaths when compared to their percentage of population in Arizona (Figure 24). Figure 24. Percentage of Motor Vehicle and Other Transport Deaths by Race/Ethnicity Group, Compared to Populations, Arizona, 2016 60% 50% MVC fatalities 48% 44% Population 42% 40% 30% 21% 20% 15% 10% 11% 5% 6% 3% 3% 0% Hispanic White, nonHispanic American Indian African American Asian/Pacific Islander 45 | P a g e Teenagers 15 through 17 years of age constituted 34% (n=24) of all motor vehicle crash and other transport fatalities (Figure 25). The second highest age group were those birth through four years of age which accounted for 32% (n=23) of all transport fatalities followed by children 10 through 14 years of age accounting to 24% (n=17) of transports deaths. Figure 25. Number of Motor Vehicle and Other Transport Deaths, Ages 0-17 Years, by Age Group, Arizona, 2016 (n=71) 30 25 24 23 20 17 15 10 7 5 0 0-4 Years 5-9 Years 10-14 Years 15-17 Years Hispanic children (n=34) accounted for 48% of all motor vehicle and other transport deaths, 21% for White, non-Hispanic children (n=15), 15% for American Indian children (n=11), and African American children (n=8) accounted for 11% of all transport fatalities. Of the children who died from motor vehicle crash and other transport deaths, 61% were vehicle passengers, 27% were pedestrians, and 13% were drivers. Passenger fatalities were more likely to occur among children 15 through 17 years of age (n=13), 10 through 14 years of age (n=12), and then 1 through 4 years of age (n=9). Pedestrian fatalities were more likely to occur among children 1 through 4 years of age (n=10). Driving fatalities were more likely to occur among children 15 through 17 years of age (n=9). Motor vehicle crashes accounted for 86% of all transport deaths (n=61). Hispanic children (n=30) accounted for 49% of motor vehicle crash fatalities, 16% for White, non-Hispanic children (n=10), 16% for American Indian children (n=10), and African American children (n=8) accounted for 11% of all motor vehicle crash fatalities. Of the children who died in motor vehicle crashes deaths, 64% were vehicle passengers, and 29% were pedestrians. Passenger fatalities were more likely to occur among children 15 through 17 years of age (n=13), 10 through 14 years of age (n=9), and then 1 through 4 years of age (n=8). 46 | P a g e Figure 26. Number and Percentage of Motor Vehicle Crash Deaths, Ages 0-17 Years, by Occupant, Arizona, 2016 (n=61) 7%, (n=<6) 29%, (n=18) Driver Passenger Pedestrian 64%, (n=39) Off-road vehicles (ORV) accounted for 13% of all transport deaths. Children 10 through14 years of age had more fatalities than all other ages. The operator or driver of the motorized vehicle accounted for 55% of ORV fatalities, while passengers accounted for 44% of ORV deaths. Majority of ORV deaths were among White non-Hispanic children. Majority of ORV fatalities were from an All-Terrain Vehicle (ATV) and occurred when the ATV rolled over and landed on descendent. The highest number of transport related deaths was due to lack of vehicle restraint. Additional preventable risk factors associated with transport related deaths in Arizona include speeding, reckless driving, driver inexperience, driver distraction, and substance use (impairment) (Table 10). Table 10. Preventable Factors for Transportation Related Deaths Among Children, Arizona, 2016 Factor* Excessive speed Lack of vehicle restraint Driver inexperience Reckless driving Substance use (Impairment) Driver distraction/ Driver fatigue *More than one factor may have been identified for each death Number 23 22 18 17 16 13 Percent 32% 31% 25% 24% 23% 18% 47 | P a g e Local CFR teams determined all of the motor vehicle crash and other transportation deaths were preventable, and accounted for 22% of all preventable deaths. Preventable factors include strengthening protective factors such as using proper child restraints every time a vehicle is in operation, not driving while impaired, and following passenger safety guidelines as well as established motor vehicle laws. The continuation of targeted education and awareness efforts to the most at risk populations is essential. Twenty-two children were known to have been improperly restrained or unrestrained in vehicles (31%) (Figure 27). This indicates that while child safety restraint laws have reduced the number of motor vehicle crash fatalities, further prevention efforts are still needed. Figure 27. Number of MVC and Other Transport Deaths with Improper or Unknown Restraint Use, Ages 0-17 Years, by Age Group, Arizona, 2016 (n=22) 8.2 8 8.0 7.8 7.6 7.4 7.2 7.0 7 7 0-4 Years 5-14 Years 6.8 6.6 6.4 15-17 Years Motor Vehicle and Other Transportation Prevention Recommendations • • • • • • 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 or under the influence of alcohol or other drugs that impair driving. Parents should establish written teenager-parent contracts that place restrictions on the teen driver. 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. 48 | P a g e • • 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. 49 | P a g e Suicides Suicides decreased 19% from 2015 (n=47) to 2016 (n=38) and accounted for 5% of all child deaths. Over the last six years, the mortality rate varied from 1.7 to 2.9 deaths per 100,000 children. 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, Ages 0-17 Years, Arizona, 2006-2016 3.0 2.9 2.9 2.8 2.6 2.4 2.4 2.2 2.0 2.0 1.7 1.8 2.3 2.0 1.7 1.6 1.6 2.3 1.5 1.4 1.2 1.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Majority of suicide deaths occur in males and the trend continued in 2016. Males comprised 66% of the suicide deaths (n=25) compared to 34% of suicide deaths (n=13) among females. The distribution of suicide by race/ethnicity varies year by year. White, non-Hispanic children made up 32% of the suicide deaths (n=12) and Hispanic children accounted for an additional 34% of suicide deaths (n=13) (Figure 29). 50 | P a g e America Indian children were overrepresented compared to their population and accounted for approximately 21% of the suicide deaths (n=8). Figure29. Percentage of Suicide Deaths by Race/Ethnicity Group, Compared to Populations, Arizona, 2016 (n=38) 50% 44% 45% 40% 35% 34% Suicides 42% Population 32% 30% 25% 21% 20% 15% 10% 5% 5% 3% 6% 5% 3% 0% Hispanic White, nonHispanic American Indian African American Asian/Pacific Islander Youth ages 15 through 17 years remained at highest risk for suicide death accounting for 74% of suicides deaths (n=28), while children 5 through 14 years of age made up 26% of suicide deaths (n=12). Fifty-five percent of suicide deaths were carried out by strangulation (n=21) and firearm injuries made up another thirty-two percent of deaths (n=12). Other injuries such as poisoning, cut/pierce, and fall are other injuries contributing to suicide deaths. 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 had a history of family discord (47%), were known to have a history of substance use (39%), and had an argument with parent (39%) (Table 11). 51 | P a g e Table 11. Factors That May Have Contributed to the Child’s Despondency Prior to Suicide, Arizona, 2016 Factor* Percent History of family discord 47% History of substance use 39% Argument with parent 39% History/recent break-up 21% History of parent divorce 18% Failure in school 13% History of issues related to sexual orientation 13% History of problems with the law 13% Argument with boyfriend or girlfriend 11% History of physical abuse <6% History of sexual abuse <6% Victim of bullying <6% *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 all suicides were preventable. Of the top preventable risk factors for child suicides, signs of suicide (53%, n=20) and) substance use was the most commonly identified (39%, n=15) (Table 12). Table 12. Preventable Factors for Child Suicides, Arizona, 2016 Factor* Number Signs of Suicide 20 Substance Use 15 *More than one factor may have been identified for each death. Percent 53% 39% Table 12A. Signs of Suicide, Arizona, 2016 (n=20) Factor* Number Talked about Suicide 19 Prior suicide threat made 17 Prior suicide attempt made 9 *More than one factor may have been identified for each death. Percent 95% 85% 45% 52 | P a g e 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. Suicide Prevention Recommendations • • • • • • • • 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. Schools can increase awareness about suicide prevention by connecting communities and families with resources. 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. Completely remove firearms from homes where children or adolescents are showing signs of mental health issues, depression, substance abuse, or suicide. Monitor your child’s social media for any talk about suicide and take immediate action. Teen Lifeline provides a Peer Counseling Hotline for teens in crisis: 602-248-8336 (TEEN) for Maricopa county or statewide 800-248-8336 (TEEN). Schools should work closely with suicide prevention groups to expand and implement bullying awareness and prevention programs such as the “See Something, Say Something”. Support funding for behavioral health and substance use assessment and treatment services for youth and their families. 53 | P a g e Homicides In 2016, forty-two children were victims of homicide in Arizona accounting for 6% of all child deaths. The mortality rate for homicide increased by 30% from 2015 to 2016 (Figure 30). Over the last six years, the homicide mortality rate has remained relatively static. Figure 30. Mortality Rate due to Homicides per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 4.0 3.8 3.9 3.5 3.5 3.0 3.1 3.0 2.6 2.5 2.6 2.6 2.2 2.2 2.0 2.0 1.5 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Unlike the previous two years, males (57%, n=24) were more likely to be victims of homicide than female (43%, n=18) in 2016. Hispanic children experienced the highest number of child homicides accounting for 45% (n=19) of deaths, followed by 24% (n=10) from African Americans, and 21% (n=9) from White, non-Hispanic children. Children aged 15 through 17 years of age had the highest number of homicide deaths (n=15) followed by children aged 1 through 4 years (n=10) (Figure 31). 54 | P a g e Figure31. Number of Homicides for Children Ages 0-17 Years, by Age Group, Arizona, 2016 (n=42) 16 15 14 12 10 10 9 8 8 6 4 2 0 <1 Year 1-4 Years 5-14 Years 15-17 Years 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 2016, blunt force trauma was used to commit 48% (n=20) of homicide deaths in children. Firearms was used to commit another 45% (n=19) of homicide deaths in children (Figure 32). Figure 32. Number of Homicides for Children Ages 0-17 Years, by Cause of Death, Arizona, 2016 (n=42) 25 20 20 19 15 10 5 3 0 Blunt Force Trauma Firearm Injury Other Injuries 55 | P a g e Of the forty-two homicide deaths, 88% were committed by a known aggressor. Thirty-six percent of perpetrators were identified as the child’s parents (n=17). There were several cases where more than one perpetrator was involved in the homicide death of the child. Also, there were several cases where the perpetrator killed more than one child (Table 13). Table 13. Homicides Among Children by Perpetrator, Arizona, 2016 (n=46) Perpetrator* Number Other (Acquaintance, or Stranger) 10 Mother 9 Father 8 Relative (Sibling, Grandparent, Cousin, etc.) 7 Parent’s Partner 6 Friend (Friend, Boy or Girlfriend) 6 *There may be more than one perpetrator for each death Percent 22% 20% 17% 15% 13% 13% All homicide deaths were determined by the team to be preventable and these deaths made up 13% of all preventable deaths among children. The most common preventable factor was drug involvement, followed by alcohol use and access to firearms (Table 14). Table 14. Preventable Factors for Child Homicides, Arizona, 2016 Factors* Substance Abuse Access to Firearms Lack of Supervision *More than one factor may have been identified for each death Number 35 19 10 Percent 83% 45% 44% Homicide Prevention Recommendations • • • 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. Support sufficient funding for behavioral health treatment services for children, youth and their families. Support sufficient funding for substance use assessment and treatment services for children, youth and their families. 56 | P a g e Drowning Deaths Drowning accounted for twenty-seven child deaths and 3% of all child deaths in Arizona in 2016. Drowning deaths decreased by 10 % from 2015 (n=30) to 2016. Over the last six years, the drowning rate was at its highest in 2012 and at its lowest in 2013. The drowning mortality rate decreased 23% from 2012 to 2016. Males composed 74% of drowning deaths. Figure 33. Mortality Rate due to Drowning per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 2.4 2.2 2.2 2.0 1.9 2.0 2.0 1.9 1.9 1.7 1.8 1.6 1.8 1.7 1.4 1.4 1.4 1.2 1.0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 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 2016, review teams determined all of the drowning deaths (n=27) were preventable and these deaths made up 8% of all preventable deaths. There are three main preventable factors associated with child drowning in Arizona (Table 15). Lack of supervision was the most commonly identified factor in 89% of drowning fatalities (n=24), followed by access to water accounting for 63% of the drowning fatalities (n=17). 57 | P a g e Table 15. Preventable Factors for Child Drowning, Arizona, 2016 Factor* Number Lack of supervision 24 Access to water 17 Percent 89% 63% *More than one factor may have been identified for each death The group at highest risk of drowning are children aged one through four years old, accounting for 78% of the drowning deaths in 2016 (n=21). White, non-Hispanic children made up 52% of the deaths (n=14); followed by Hispanic children who composed an additional 33% of the drowning deaths (n=9). Seventy percent (n=19) of children drowned in a pool, hot tub or spa. The second most prevalent place for drowning deaths was in open bodies of water (Table 16). Table 16. Location of Child Drowning Fatalities, Arizona, 2016 (n=27) Location Number Pool/hot tub/spa 19 Other (Bathtub, Open Water, etc.) 8 Percent 70% 30% Drowning fatalities in Arizona have been reduced overall in the past several years, but vigilance in promoting protective factors must continue. 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 and access to water are the leading risk factors 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. 58 | P a g e Drowning Prevention Recommendations • • • • • • • • 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. Know child and infant CPR. Secure public and private pools by installing fencing and self-latching gates that are kept in good repair. Support public drowning prevention education including public service announcements Support legislation regarding proper pool fencing. 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. Have children wear life jackets in and around natural bodies of water, such as lakes or the ocean, even if they know how to swim. Life jackets can be used in and around pools for young swimmers too. 59 | P a g e Firearm Related Deaths Firearm related fatalities increased by 29% from 2015 (n=28) to 2016 (n=36). In 2016, firearm related deaths accounted for 5% of all deaths. Over the last six years, the firearm mortality rate has steadily increased (Figure 34). Males were the victims (n=24) of 67% of firearm related fatalities compared to the 33% of female victims (n=12). Hispanic children were the most affected by firearm fatalities representing 53% of the deaths, and White, non-Hispanic children made up another 22% of deaths. Figure 34. Mortality Rates due to Firearms per 100,000 Children, Ages 0-17 Years, Arizona, 2006-2016 4.0 3.5 3.0 3.6 2.5 2.8 2.9 2.0 2.0 1.9 1.5 1.0 1.4 1.4 2010 2011 2.2 1.8 1.5 1.7 0.5 0.0 2006 2007 2008 2009 2012 2013 2014 2015 2016 60 | P a g e In 2016, children 15 through 17 years old accounted for 81% of firearm related deaths (n=29) (Figure 35). Figure 35. Number of Firearm Related Deaths for Children Ages 0-17 Years, by Age Group, Arizona, 2016 (n=36) 35 29 30 25 20 15 10 7 5 0 Birth-14 Years 15-17 Years Suicides and homicides accounted for 86% of firearm-related deaths in 2016. Thirty-three percent of firearm related deaths were a result of suicide (n=12) and fifty-three percent of firearm related deaths were homicides (n=19). Handguns accounted for 86% of the firearm related fatalities in 2016 (n=31) (Table 17). Table 17. Types of Firearms Involved in Child Deaths, Arizona, 2016 (n=36) Type Number Handgun 31 Other 5 Percent 86% 14% Thirty-three percent of firearm related deaths involved guns owned by parents. Thirty-six percent of other firearm related deaths were from guns stolen or from an unknown owner (Table 18). Table 18. Owners of Firearms Involved in Child Deaths, Arizona, 2016 (n=36) Owner Number Parent 12 Friend/Acquaintance 6 Unknown 13 Other 5 Percent 33% 17% 36% 14% 61 | P a g e In a majority of firearm related deaths, the storage location of the firearm was unknown to the review teams (44%, n=16). Eleven of the firearms were not stored in secured locations (31%) (Table 19). Table 19. Locations of Firearms Involved in Child Deaths, Arizona, 2016 (n=36) Location Number Not Stored/Unlocked cabinet 11 Unknown 16 Other 9 Percent 31% 44% 25% Prevention All of the firearms related deaths were determined to be preventable by review teams. Firearm related deaths made up 11% of all preventable deaths. Substance use was a risk factor identified in 58% of firearm related deaths (n=21) (Table 20). Table 20. Preventable Factors for Firearm Related Deaths Among Children, Arizona, 2016 Factor* Number Percent Substance Use 21 58% Not Stored/Unlocked 11 31% *More than one factor may have been identified for each death Firearm-Related Death Prevention Recommendations • • • • • • Advocate for sufficient pediatric mental health resources in both inpatient and outpatient settings. Develop adequate mental health screenings through prompt psychiatric consultation for emergency department psychiatric patients as well as school and community mental health services. Owners should store all firearms in a safe condition; unloaded and in a secure locked location. Collaborate with the firearm injury prevention programs. Enroll in firearm safety training courses. Hold community events promoting gun safety education. 62 | P a g e Substance Use Related Deaths The CFR program defines substance use related deaths as deaths where the child or any individual involved in the death of the child used or abused substances, such as alcohol, illegal drugs, and/or prescription drugs and this substance use was a direct or contributing factor in the child's death. To identify substance use related deaths, the CFR teams reviewed the records on each death for information on substance use by the child, the child’s parents or other caretakers, or others who were involved in the incidents leading to the death. In 2016, substance use was a factor in 14% of all child fatalities (n=107). Forty-one percent of substance use related deaths (n=44) resulted in deaths due to unintentional injuries. Males were 1.7 times more likely to experience a substance use related death(Figure 36). Children 15 through 17 years had the highest risk of experiencing a substance use related death (39%, n=42). Figure 36. Number and Percentage of Deaths for Children Ages 0-17 Years, where Substance Use was found as a Direct or Contributing Factor leading to Death, by Manner, Arizona, 2016 (n=107) 8%, 15%, (n=9) (n=16) 22%, (n=23) Natural Unintentional Injury Suicide Homicide 14%, (n=15) 41%, (n=44) Undetermined %, (n=9) 63 | P a g e Figure 37. Percentage of Deaths, where Substance Use was a Direct or Contributing Factor to Death of Children Ages 0-17 Years, by Age Group, Arizona, 2016 45% 39% 40% 35% 30% 25% 20% 17% 20% 13% 15% 10% 7% 5% 5% 0% Birth-27 Days (n=18) 28-365 Days (n=21) 1-4 Years (n=14) 5-9 Years (n=7) 10-14 Years (n=5) 15-17 Years (n=42) Of the substance use related deaths where substance use was found to be a direct or contributing factor in the child’s death, 20% of these deaths (n=21) were due to firearm injury, 19% of these deaths (n=20) were due to motor vehicle crashes and other transport, 12% of these deaths (n=13) were due to poisoning, and 11% of these deaths (n=12) were due to suffocation (Table 21). Table 21. Number and Percentage of Deaths where Substance Use was a Direct or Contributing Factor to the Death of Children, Arizona, 2016 Cause Number Percent Firearm Injury 21 20% MVC/Transport 20 19% Poisoning 13 12% Suffocation 12 11% Prematurity 11 10% Other Injury 9 8% Blunt Force Trauma 8 7% Undetermined 8 7% Medical* <6 <5% *Excluding SIDS and prematurity Of the substance use related deaths, marijuana was identified in 30% of deaths (n=46), alcohol was identified in 25% of deaths (n=38), opiates was identified in 10% (n=16), and 64 | P a g e methamphetamine was identified in 12% of deaths (n=19). In some cases more than one drug was found to be a direct or contributing factor in the death of a child. Table 22. Substances found as a Direct or Contributing Factor to Child Deaths, Arizona, 2016 Substance Used* Number Percent Marijuana 46 30% Alcohol 38 25% Other (Includes Unknown, Non-Opioid Prescribed, or other Illegal drugs 23 15% not listed in this table) Methamphetamine 19 12% Opiate (Includes Opioid Prescribed or Heroin) 16 10% Cocaine 11 7% *More than one substance may have been identified for each death A majority of substance use related deaths involved the child or the child’s parent as the main user contributing to the death of the child. In 46% of substance use related deaths (n=56), the parent was misusing or abusing alcohol or drugs. In 33% of substance use related deaths (n=40) the child who died was misusing or abusing drugs. Among substance use related deaths, where the parent’s substance use was found as a direct or contributing factor to child death, alcohol (39%, n=22) and marijuana (36%, n=20) were the most common substance identified. Parent use of alcohol was a contributing factor to motor vehicle crash deaths (n=9). Parent use of marijuana was a contributing factor to prematurity (n=6) and suffocation (n=5) deaths. Where the child’s substance use was found to be a direct or contributing factor to their death, other drugs (unknown, non-opioid prescribed, or other Illegal drugs, 35%, n=14) and marijuana (30%, n=12) were the most common substance identified (Figure 38). Child use of other drugs was a contributing factor to poisoning (n=6) and firearm injury related deaths. Child use of marijuana was also a contributing factor to firearm injury related deaths (n=7). 65 | P a g e Figure 38. Number of Substances found as a Direct or Contributing Factor to Child Deaths, by Parent or Child User, Arizona, 2016 Other 14 8 4 Cocaine 6 6 Opiate 8 Child 4 Methamphetamine Parent 11 10 Alcohol 22 12 Marijuana 0 5 10 20 15 20 25 Table 23. Substances Use found as a Direct or Contributing Factor to Child Deaths, by User, Arizona, 2016 Person* Number Percent Parent 56 46% Child (Self) 40 33% Acquaintance (Not a friend) 6 5% Friend ( Family Friend, Boy or Girlfriend) 6 5% Stranger 5 4% Other 9 7% *Some deaths involved more than one person misusing or abusing substances Substance Use Prevention Recommendations • • • • • Increase funding to support prevention and early intervention activities. Encourage health care providers to screen all children and adults for alcohol misuse and substance use. Provide affordable and accessible counseling and other interventions to substance users. Store all prescription medications in a locked cabinet and discard unused medications safely and properly when they are no longer being taken. Provide funding for community-based education on how to identify early symptoms of substance abuse in all communities in Arizona. 66 | 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 2011 through 2016, all deaths of Arizona residents and out-of-state residents aged birth through 17 were identified by underlying cause of death with International Classification of Disease codes, Version 10 (www.who.int/classifications/icd/en/). CFR local teams take the demographic and incident information from death certificates of children and youth aged birth through 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: (www.cdc.gov/nchs/injury/injury_matrices.htm). Deaths caused by injuries, where the intent is known, are identified using the definitions below and the 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 encounter while reviewing maltreatment cases involve physical abuse which includes internal abdominal and blunt force head injuries leading to a fatality. When reviewing neglect cases, CFR teams determine if parents or caregivers failed to provide 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 resulting from unsafe environments, and prenatal substance exposure. The circumstances surrounding maltreatment deaths can vary greatly. Some 67 | P a g e maltreatment fatalities are the result of long term abuse and neglect both unintentional and intentional, however some cases result of a single incident. To gain greater understanding of the contribution of abuse and neglect to child mortality, the Arizona CFR teams answer 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 a blunt force object 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 a child in a motor vehicle crash due to the actions of a parent who drove while intoxicated would be considered a maltreatment fatality. Examples of neglect contributing to a child’s death include, but are not limited to the following: • • • Any death in which intoxication by drugs (prescription, over-the-counter, legal or illegal) or alcohol of the parent, guardian, or caregiver contributed to the death. Sleep related deaths when a parent/guardian/caregiver bed-sharing with or places an infant into an unsafe sleep environment while under the influence of drugs (prescription, over-the-counter, legal or illegal) or alcohol, or knowingly allows a child to be placed into an unsafe sleep environment under the care of someone under the influence of drugs (prescription, over-the-counter, legal or illegal) or alcohol. Natural deaths when medical neglect contributed to the death including failure to comply with a prescribed treatment plan, failure to obtain treatment, and/or failure to provide necessary medications e.g. an asthma related death where a caregiver did not provide the child with an inhaler. 68 | P a g e • • • • • • • Prenatal exposure to illicit drug use or alcohol that causes or contributes to the death of the child e.g. a child born prematurely due to prenatal drug exposure to methamphetamines. Motor Vehicle Crash:  Parent/caregiver/supervisor drives under the influence of alcohol or drugs (prescription, over-the-counter, legal or illegal) with child passenger or knowingly allows child to be a passenger with driver under the influence.  If a child under the age of five years was a passenger and was not properly restrained (situations where a child was placed in the right type of restraint but the seat may not have been properly installed are not included as maltreatment).  Parent/caregiver/supervisor drives recklessly with child passenger and it was related to the child’s death. Drowning:  Parent/caregiver/supervisor leaves a child near or in a body of water such as a pool, lake, or river without sober and inadequate adult supervision. This is if the child’s age, mental capacity, or physical capacity puts the child at risk of drowning e.g. child is under the age of 5, and/or is unable to swim.  Parent/caregiver/supervisor leaves infant or toddler in a tub, unsupervised. Gunshot wound when a parent/caregiver/supervisor leaves a loaded weapon unsecure where a child would have access to the weapon. Exposure when a parent/caregiver/supervisor leaves young a child/infant alone in a car or outdoors. Poisoning when a parent/caregiver/supervisor allows medication or dangerous household products to be accessible to a child or teen with known behavioral health issues e.g. If there is a teen in the household with history of substance abuse or suicidal ideation and prescription medication, such as opiates, are not in a secured location. Suicide when a parent/caregiver/supervisor failed to secure hazards e.g. unsecured weapon, prescription drugs or did not seek care for the child when aware of any suicidal ideation. 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. 69 | P a g e 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 unexpected infant deaths and sleep related suffocation 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 that supports the infant’s airway was obstructed, it will be (2) If there is not enough evidence to determine intent, but the cause of death of (3) If all evidence is reviewed and cause of death is suspected, but there is not enough deemed as asphyxia or suffocation with an accidental manner; suffocation is clear then it will be labeled with an undetermined manner of death. 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 of age, 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). In addition, some natural cause of death if the death was sudden and unexpected and the infant was in a sleep environment. 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 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. 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 Arizona Infant Death Checklist, and completing 70 | P a g e both local and state level reviews of all identified SUID cases. In 2016, of the 80 deaths where a death scene investigation was completed, authorities filled out an infant death checklist in 51 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 classification. However, the use of 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: Local CFR team review 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 are omitted. All cases reviewed by the CFR team are kept completely confidential. Information shared in the meetings is protected under ARS 36-3502 and shall not 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. The State CFR team reviews the data from the local review teams, including the local review team recommendations, to develop recommendations for the annual report. 71 | P a g e Review Process Local teams conduct case reviews 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 circumstances surrounding the child’s death. Additionally, the birth certificate is reviewed if the child was younger than one year of age at the time of their death. Legislation requires that hospitals and state agencies release this information to the Arizona CFR Program’s local teams. Note: Statute requires team members to maintain confidentiality and they are prohibited from contacting the child’s family for any reason. During the review, team members from representing agencies provide information on each case as applicable. If an agency representative is unable to attend, 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 (CDR). This database is a comprehensive tool that provides the ability to enter the many variables resulting from each case review. Some of the detailed case information captured includes the demographics of the child, caregiver information, information concerning the supervisor of the child when the fatality occurred, incident information, investigation of the incident, cause and manner of the death, and any other circumstances surrounding the fatality. The CDR database 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 data is put through a system of quality assurance checks by the State CFR Program Office and the resulting dataset is used to produce the statistics found in this report. The State Team meets annually to review the analysis of these findings. State Team membership is statutorily driven and requires 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 Arizona Health Care Cost Containment System Division of Developmental Disabilities in the Arizona Department of Economic Security Department of Child Safety Governor’s Office of Youth, Faith, and Family 72 | P a g e • • • • • • • • • • • • • Administrative Office of the Courts Parent assistance office of the Supreme Court Arizona Chapter of the American Academy of Pediatrics Medical Examiner who is a forensic pathologist 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. The statute also charges the State Team to educate the public regarding the incidence and causes of child fatalities as well as the public's role in preventing these deaths. 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 by an intoxicated caregiver would be counted in the sections addressing firearm injuries, 73 | P a g e 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. 74 | P a g e Appendix of Summary Tables The following section of this report provides additional data tables for both individual and agency use. These tables can be used as reference to guide prevention efforts within their respective organizations. The CFR program completed reviews for 100 percent of Arizona’s child fatalities from 2011 through 2016 and included the data for comparative analysis. 13 Table 21. Number and Percentage of Deaths Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % 0-27 Days 334 40% 325 38% 298 37% 341 41% 287 38% 299 38 28-365 Days 175 21% 171 20% 156 19% 183 22% 178 23% 144 18 1-4 Years 106 13% 120 14% 130 16% 95 11% 101 13% 117 15 5-9 Years 54 6% 63 7% 47 6% 56 7% 51 7% 45 6 10-14 Years 72 9% 75 9% 77 9% 70 8% 46 6% 71 9 15-17 Years 96 11% 100 12% 103 13% 89 11% 104 13% 107 14 Total 837 854 811 834 768 783 Table 22. Mortality Rates per 100,000 Population Among Children by Age Group, AZ, 2011- 2016 Age Group 2011 2012 2013 2014 2015 2016 <1 Year* 5.9 5.8 5.3 6.0 5.5 5.2 1-4 Years 28.6 33.6 37.0 27.1 29.1 34.1 5-9 Years 11.8 13.7 10.1 12.1 11.0 9.8 10-14 Years 15.9 16.5 16.9 15.3 10.0 15.5 15-17 Years 35.2 37.0 37.7 32.5 38.1 38.8 Total 51.0 52.4 49.5 51.3 47.3 48.2 *Neonatal/post-natal periods deaths are combined and represent infant mortality rate per 1,000 births Table 23. Number and Percentage of Deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % African American American Indian Asian Hispanic White, non-Hispanic 2 or more Races Total 13 65 80 19 374 293 6 837 8 10 2 45 35 1 73 91 30 376 268 16 854 9 11 4 44 31 2 78 76 16 343 280 18 811 10 9 2 42 35 2 75 66 14 366 285 28 834 9 8 2 44 34 3 68 68 17 332 253 30 768 9 9 2 43 33 4 75 70 25 350 235 28 783 10 9 3 45 30 4 For all tables in this Appendix, data with a count less than six are denoted as <6 and are suppressed due to concern with individual identification. 75 | P a g e Table 24. Mortality Rates per 100,000 Children by Race/Ethnicity Group, AZ, 2011- 2016 Race/Ethnicity Group* 2011 2012 2013 2014 2015 African American 77.3 96.9 103.3 67.3 74.4 American Indian 64.7 92.5 76.7 53.4 78.6 Asian 39.6 69.0 35.7 22.3 32.0 Hispanic 55.5 55.0 49.6 57.7 46.9 White, non-Hispanic 41.2 36.8 38.5 41.0 36.7 *Does not include 126 cases for the category for 2 or more races 2016 79.9 80.8 46.4 49.5 34.4 Table 25. Number and Percentage of Deaths Among Children by County of Residence, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 County # % # % # % # % # % # % Apache 15 2 9 Cochise 15 2 17 Coconino 19 2 20 Gila 9 1 14 Graham <6 <6 6 Greenlee <6 <6 <6 La Paz <6 <6 8 Maricopa 478 57 500 Mohave 23 3 21 Navajo 26 3 28 Pima 109 13 91 Pinal 51 6 48 Santa Cruz <6 <1 9 Yavapai 14 2 24 Yuma 33 4 26 Outside AZ 29 3 32 Total 837 854 -Counts <6 have been suppressed 1 2 2 2 1 <6 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 <6 <6 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 <6 <6 60 3 2 13 6 <1 3 3 2 17 15 20 6 <6 <6 <6 445 19 21 85 52 <6 20 34 24 768 Table 26. Mortality Rates per 100,000 Children by Cause of Death, AZ, 2011- 2016 Cause 2011 2012 2013 2014 Injury In-or-Around the Home 8.2 7.4 7.3 8.0 Maltreatment 4.3 4.3 5.6 4.6 MVC/Transport 3.7 3.9 3.5 3.0 Homicide 2.6 2.6 3.1 2.2 Suicide 2.0 1.7 1.5 2.3 Firearms 1.4 2.0 1.8 1.5 Drowning 1.9 2.2 1.4 1.9 SUID* 1.33 0.95 0.87 0.98 *SUID rates are per 1,000 births 2 2 3 <1 <6 <6 <6 58 2 3 11 7 <1 3 4 3 24 13 17 7 <6 <6 <6 488 13 13 91 38 6 20 22 26 783 2015 8.7 5.3 2.8 2.0 2.9 1.7 1.8 0.91 3 2 2 1 <6 <6 <6 62 2 2 12 5 1 3 3 3 2016 9.0 5.0 4.4 2.6 2.3 2.2 1.7 0.94 76 | P a g e Table 27. Number of Child Deaths by Age Group and Manner, AZ, 2016 Manner Birth-27 28-365 1-4 5-9 10-14 15-17 Days Days Years Years Years Years Natural 290 53 53 29 34 25 Accident 8 53 47 10 22 38 Homicide 0 8 10 <6 <6 15 Suicide 0 0 <6 <6 9 28 Undetermined <6 29 7 0 <6 <6 Total 299 144 117 45 71 107 -Counts <6 have been suppressed Total 484 179 42 38 40 783 Table 28. Number and Percentage of Deaths Among Children Birth Through 17 Years by Manner, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Manner # % # % # % # % # % # % Natural 537 64 542 63 513 63 546 66 487 64 484 62 Accident 167 20 190 22 186 23 180 22 160 21 179 23 Undetermined 52 6 45 5 36 5 34 4 42 5 40 5 Homicide 42 5 43 5 51 6 36 4 32 4 42 5 Suicide 38 5 33 4 25 3 38 5 47 6 38 5 Total 836 853 811 834 768 783 Table 29. Number of Deaths Among Children Birth to 17 Years by Cause and Manner, AZ, 2016 Cause Natural Medical* 320 Prematurity 162 MVC/Transport 0 Suffocation 0 Undetermined <6 Firearm 0 Drowning 0 Strangulation 0 Blunt Force Trauma 0 Poisoning 0 Other Non-Medical 0 Fire/Burn 0 Fall/Crush 0 Other Injury 0 Total 484 *Excluding SIDS/prematurity Accident 0 0 70 55 0 <6 26 <6 0 8 <6 <6 <6 <6 179 Suicide 0 0 <6 0 0 <12 0 21 0 <6 0 0 <6 0 38 Homicide 0 0 0 0 0 19 <6 <6 20 <6 0 0 0 <6 44 Undetermined 0 0 0 0 39 0 0 0 0 <6 0 0 0 0 40 Total 320 162 71 55 41 36 27 24 20 13 <6 <6 <6 <6 783 -Counts <6 have been suppressed 77 | P a g e Table 30. Number and Percentage of Deaths Among Children Birth Through 17 Years by Cause, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Cause # % # % # % # % # % # % Medical* 342 41 353 41 303 37 326 39 310 40 320 41 Prematurity 199 24 192 22 210 26 222 27 177 23 162 21 MVC/Transport 70 8 88 10 80 10 57 7 50 6 71 9 Suffocation 50 6 53 6 48 6 72 9 65 8 55 7 Firearm 23 3 32 4 29 4 25 3 28 4 36 5 Drowning 32 4 36 4 23 3 31 4 30 4 27 3 Blunt Force 26 3 19 2 28 3 19 2 11 1 20 3 Trauma Strangulation 27 3 20 2 18 2 14 2 17 2 24 3 Undetermined 46 6 40 5 35 4 31 4 43 6 41 5 Other Non<6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Medical Poisoning 10 1 7 1 14 2 9 1 15 2 13 2 Fire/burn 6 1 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Exposure 0 0 <6 <6 <6 <6 <6 <6 6 1 <6 <6 Fall/crush <6 <6 <6 <6 <6 <6 7 <1 <6 <6 <6 <6 Other Injury 0 0 <6 <6 <6 <6 8 1 12 2 <6 <6 SIDS <6 <6 0 0 <6 <6 0 0 0 0 0 0 Total 837 853 811 834 768 783 *Excluding SIDS and prematurity -Counts <6 have been suppressed Table 31. Number and Percentage of Natural Deaths Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % 0-27 Days 318 59 315 58 289 56 332 61 279 58 290 60 28-365 Days 91 17 84 16 79 15 89 16 94 19 53 11 1-4 Years 40 8 57 11 62 12 40 7 40 8 53 11 5-9 Years 26 5 37 7 25 5 29 5 26 5 29 6 10-14 Years 34 6 36 6 36 7 37 7 20 4 34 7 15-17 Years 27 5 13 2 22 4 19 4 27 6 25 5 Total 536 542 513 546 487 484 78 | P a g e Table 32. Number and Percentage of Natural Deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % African American 43 8 48 9 52 10 48 9 42 9 35 7 American Indian 42 8 45 8 38 7 34 6 40 8 38 8 Asian/Pacific Islander 13 2 20 4 10 2 12 2 14 3 19 4 Hispanic 256 48 266 49 234 46 252 46 235 48 236 49 White, non-Hispanic 179 33 152 28 169 33 178 33 133 27 137 28 2 or more Races <6 <6 11 2 10 2 22 4 23 5 19 4 Total 536 542 513 546 487 484 -Counts <6 have been suppressed Table 33. Number and Percentage of Unintentional (Accident) injury deaths Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % 0-27 Days 7 4 <6 <6 6 3 6 3 <6 3 8 4 28-365 Days 38 23 48 25 44 23 63 35 53 33 54 30 1-4 Years 47 28 39 21 46 25 36 20 39 24 47 27 5-9 Years 22 13 22 12 20 11 21 12 18 11 10 6 10-14 Years 22 13 27 14 24 13 17 9 12 8 22 12 15-17 Years 31 19 50 26 46 25 37 21 33 21 38 21 Total 167 190 186 180 160 179 -Counts <6 have been suppressed Table 34. Number and Percentage of Unintentional (Accident) injury deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % African American 12 7 13 7 15 8 18 10 12 8 26 15 American Indian 20 12 24 13 21 11 25 14 17 11 17 10 Asian <6 <6 7 4 <6 <6 <6 <6 <6 <6 <6 <6 Hispanic 62 37 69 36 70 38 71 39 62 39 71 40 White, non-Hispanic 69 41 75 39 70 38 62 34 60 38 58 33 2 or more Races <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Total 167 190 186 180 160 179 -Counts <6 have been suppressed 79 | P a g e Table 35. Number and Percentage of Injury Deaths In-or-Around the Home Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % 0-27 Days 11 8 6 5 6 5 8 6 8 6 8 6 28-365 Days 67 49 70 58 67 56 84 65 79 56 77 53 1-4 Years 36 27 7 22 33 28 21 16 30 21 38 26 5-9 Years 7 5 7 6 <6 <6 6 5 6 4 <6 <6 10-14 Years <6 <6 <6 <6 <6 <6 6 5 <6 <6 7 5 15-17 Years 10 7 8 7 11 9 <6 <6 15 11 12 8 Total 136 121 120 130 142 146 -Counts <6 have been suppressed Table 36. Number and Percentage of Injury Deaths In-or-Around the Home Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % African American 10 7 11 9 13 11 14 11 11 8 20 14 American Indian 12 9 11 9 12 10 14 11 14 10 15 10 Asian <6 <6 <6 <6 <6 <6 0 0 <6 <6 <6 <6 Hispanic 57 42 44 36 40 33 52 40 51 36 48 33 White, non-Hispanic 53 39 50 41 50 42 47 36 58 41 56 39 Total 136 121 120 130 142 146 -Counts <6 have been suppressed Table 37. Number of Sudden Unexplained Infant Deaths Among Children by Age Group, AZ, 2011- 2016 Age Group 2011 2012 2013 2014 2015 < 1 year 114 81 74 85 78 2016 80 Table 38. Number and Percentage of Sudden Unexplained Infant Deaths Among Children by Race/Ethnicity Group, AZ, 2011-2016 2011 2012 2013 2014 2015 Race/Ethnicity Group # % # % # % # % # % African American 13 11 8 10 11 15 8 9 7 9 American Indian 13 11 7 9 6 8 9 11 <6 <6 Asian 0 0 <6 <6 0 0 0 0 0 0 Hispanic 50 44 31 38 22 30 36 42 32 42 White, non-Hispanic 38 35 31 38 34 46 29 34 30 39 2 or more Races 0 0 <6 <6 <6 <6 <6 <6 <6 6 Total 114 81 74 85 77 -Counts <6 have been suppressed 2016 # % 12 15 8 10 <6 <6 24 30 31 39 <6 <6 79 80 | P a g e Table 39. Number and Percentage of Maltreatment Deaths Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 Age Group # % # % # % # % # % 0-27 Days 7 10 9 13 13 14 10 13 10 11 28-365 Days 29 40 23 33 29 32 26 35 29 33 1-4 Years 22 30 23 33 31 34 23 31 31 36 5-9 Years 7 10 7 10 <6 <6 9 12 8 9 10-14 Years <6 <6 <6 <6 11 12 7 9 <6 <6 15-17 Years <6 <6 <6 <6 <6 <6 0 0 6 7 Total 73 69 92 75 87 -Counts <6 have been suppressed # 13 22 28 10 <6 <6 82 2016 % 16 27 34 12 <6 <6 Table 40. Number and Percentage of Maltreatment Deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity # % # % # % # % # % # % African American 6 8 <6 <6 11 12 8 11 11 13 18 22 American Indian <6 <15 13 19 15 16 8 11 13 15 9 12 Asian <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Hispanic 34 47 29 42 34 37 29 39 31 36 28 33 White, non-Hispanic 21 29 21 30 27 29 29 39 31 36 22 28 2 or more Races <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Total 73 69 92 75 87 82 -Counts <6 have been suppressed Table 41. Number and Percentage of Motor Vehicle Deaths Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % 0-27 Days <6 <6 <6 <6 0 0 0 0 <6 <6 <6 <6 28-365 Days <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 1-4 Years 15 21 11 13 18 23 10 18 13 26 19 27 5-9 Years 13 19 12 14 17 21 12 21 9 18 7 10 10-14 Years 17 24 21 24 20 25 9 16 8 16 17 24 15-17 Years 21 30 38 43 24 30 25 44 18 36 24 34 Total 70 88 80 57 50 71 -Counts <6 have been suppressed 81 | P a g e Table 42. Number and Percentage of Motor Vehicle and Other Transport Deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % American Indian 13 19 18 21 12 15 10 18 12 24 11 24 Hispanic 28 40 32 36 28 35 23 40 20 40 34 40 White, non-Hispanic 24 34 29 33 29 36 17 30 10 20 15 20 Other <6 7 9 10 11 14 7 12 8 16 11 16 Total 70 88 80 57 50 71 -Counts <6 have been suppressed Table 43. Number and Percentage of Suicides Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # <10 Years <6 <6 0 0 <6 <6 0 0 0 0 <6 10-14 Years 13 33 9 27 8 32 11 29 12 26 9 15-17 Years 25 64 24 73 17 68 27 71 35 74 28 Total 39 33 25 38 47 38 -Counts <6 have been suppressed Table 44. Number and Percentage of Suicides Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 Race/Ethnicity Group # % # % # % # % # % African American <6 <6 <6 <6 <6 <6 0 0 <6 <6 American Indian 7 18 9 27 <6 20 <6 8 <6 11 Hispanic 10 26 <6 15 8 32 13 34 10 31 White, non-Hispanic 19 49 17 52 9 36 21 55 30 28 Other <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Total 39 33 25 38 47 -Counts <6 have been suppressed % 3 24 74 2016 # % <6 <6 8 21 13 34 12 32 <6 <6 38 Table 45. Number and Percentage of Homicides Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % 0-27 Days <6 <6 <6 <6 <6 <6 0 0 0 0 0 0 28-365 Days 12 29 10 23 7 14 7 19 <6 9 8 21 1-4 Years 12 29 17 40 16 31 14 39 18 56 10 23 5-9 Years <6 <10 <6 <7 <6 <6 <6 14 <6 <16 <6 <12 10-14 Years <6 <6 <6 <6 9 18 <6 11 <6 <6 <6 <12 15-17 Years 11 26 9 21 16 31 6 17 <6 <16 15 35 Total 42 43 51 36 32 42 -Counts <6 have been suppressed 82 | P a g e Table 46. Number and Percentage of Homicides Deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % African American <6 10 <6 <12 <6 <6 <6 <12 9 28 10 24 American Indian 6 14 <6 <12 9 18 <6 <12 <6 <12 <6 <6 Asian <6 <6 <6 <6 0 0 0 0 0 0 <6 <6 Hispanic 23 55 19 44 23 45 18 50 10 31 19 45 White, non-Hispanic 8 19 12 28 14 27 10 28 9 28 9 21 2 or more Races <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Total 42 43 51 36 32 42 -Counts <6 have been suppressed Table 47. Number and Percentage of Drowning Deaths Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % 0-27 Days 0 0 0 0 0 0 0 0 0 0 0 0 28-365 Days <6 <10 <6 <15 0 0 <6 <6 <6 <7 <6 <6 1-4 Years 18 56 18 50 19 83 18 58 20 67 21 78 5-9 Years 7 22 <6 <15 <6 <6 <15 13 6 20 <6 <6 10-14 Years <6 <6 <6 <15 0 0 <6 13 <6 <6 0 0 15-17 Years <6 <6 <6 <15 <6 13 <6 10 <6 <6 <6 15 Total 32 36 23 31 30 27 -Counts <6 have been suppressed Table 48. Number and Percentage of Drowning Deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % African American <6 <6 <6 8 <6 <6 6 19 <6 <13 <6 <8 American Indian <6 <6 <6 11 0 0 <6 <6 0 0 <6 <6 Asian <6 <9 <6 8 <6 13 0 0 0 0 <6 <6 Hispanic 11 34 9 25 14 61 7 23 10 33 9 33 White, non-Hispanic 15 47 17 47 <6 22 17 55 16 53 14 52 2 or more Races <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Total 32 36 23 31 30 27 -Counts <6 have been suppressed 83 | P a g e Table 49. Number and Percentage of Firearm-Related Deaths Among Children by Age Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Age Group # % # % # % # % # % # % <10 Years <6 <25 <6 <20 <6 10 <6 <20 <6 11 <6 <12 10-14 Years <6 <25 <6 <20 <6 17 6 24 6 21 <6 <12 15-17 Years 15 65 22 69 21 72 14 56 19 68 29 81 Total 23 32 29 25 28 36 -Counts <6 have been suppressed Table 50. Number and Percentage of Firearm-Related Deaths Among Children by Race/Ethnicity Group, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Race/Ethnicity Group # % # % # % # % # % # % African American <6 <6 <6 10 <6 <7 <6 <6 <6 <6 6 17 American Indian <6 <6 <6 <6 <6 <6 <6 <6 <6 <16 <6 <6 Asian <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Hispanic 14 61 9 28 15 52 10 40 6 21 19 53 White, non-Hispanic 7 30 18 56 9 31 14 56 18 64 8 22 2 or more Races <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Total 23 32 29 25 28 36 -Counts <6 have been suppressed 84 | 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 2011 through 2016 are included in the following tables in order to provide comparison data. 14 Table 51. Number of Deaths Among Children Ages Birth Through 27 Days by Cause and Manner, AZ, 2016 Cause Natural Suicide Homicide Undetermined Total Accident Medical* 145 Prematurity 145 MVC/Transport 0 Suffocation 0 Undetermined 0 Other 0 Total 290 *Excluding SIDS and prematurity -Counts<6 have been suppressed 0 0 <6 6 0 <6 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 <6 0 <6 145 145 <6 6 <6 <6 299 Table 52. Number and Percentage of Deaths Among Children Ages Birth Through 27 Days by Cause, AZ, 2011- 2016 2011 # % Cause Prematurity 181 54 Medical* 143 43 Undetermined <6 <6 SIDS 0 0 MVC/Transport 0 0 Other <6 <6 Suffocation <6 <6 Exposure 0 0 Drowning 0 0 Total 334 *Excluding SIDS and Prematurity -Counts <6 have been suppressed 14 2012 # 172 143 <6 0 <6 0 <6 0 0 325 2013 % 53 44 <6 0 <6 0 <6 0 0 # 188 102 <6 <6 <6 <6 <6 <6 <6 298 2014 % 63 34 <6 <6 <6 <6 <6 <6 <6 # 195 138 <6 0 0 <6 <6 0 0 341 % 57 40 <6 0 0 <6 <6 0 0 2015 # % 152 52 128 44 <6 <6 0 0 <6 <6 <6 <6 <6 <6 0 0 0 0 288 2016 # 145 145 <6 0 <6 <6 <6 0 0 299 % 48 48 <6 0 <6 <6 <6 0 0 For all tables in this Appendix, 2016 data with a count less than six are denoted as <6 and are suppressed due to concern with individual identification. 85 | P a g e Table 53. Number and Percentage of Deaths Among Children Ages Birth Through 27 Days by Manner, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Manner # % # % # % # % # % # % Natural 318 95 315 58 289 97 332 97 280 97 290 97 Undetermined 8 2 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Accident 7 2 <6 <6 6 2 6 2 <6 <6 8 3 Homicide <6 <6 <6 <6 <6 <6 0 0 0 0 0 0 Suicide 0 0 0 0 <6 <6 0 0 0 0 0 0 Total 334 325 298 341 288 299 -Counts <6 have been suppressed 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, AZ, 2016 Cause Natural Accident Suicide Homicide Undetermined Total Suffocation 0 46 0 0 0 46 Medical 37 0 0 0 0 37 Prematurity 16 0 0 0 0 16 Blunt Force Trauma 0 0 0 8 0 8 MVC/Transport 0 <6 0 0 0 <6 Drowning 0 <6 0 0 0 <6 Exposure 0 <6 0 0 0 <6 Underdetermined 0 0 0 0 29 29 Other 0 <6 0 0 0 <6 Total 53 54 0 8 29 144 -Counts <6 have been suppressed 86 | P a g e Table 55. Number and Percentage of Deaths Among Children Ages 28 Days Through 365 Days by Cause, AZ, 2011- 2016 2011 Cause # % Suffocation 34 19 Medical 75 43 Undetermined 29 17 Prematurity 17 10 Blunt Force Trauma 9 5 MVC/Transport <6 <6 Drowning <6 <6 Firearm <6 <6 Exposure 0 0 Strangulation 0 0 Poisoning 0 0 Fire/Burn 0 0 SIDS <6 <6 Other Injury 6 <1 Fall/Crush 0 0 Total 175 -Counts <6 have been suppressed 2012 # 44 68 26 17 6 <6 <6 <6 <6 <6 0 0 0 0 0 171 % 26 40 15 10 4 <6 2 <6 <6 <6 0 0 0 0 0 2013 # 41 60 26 18 6 <6 0 <6 <6 <6 0 0 0 0 0 156 2014 % 26 38 17 12 4 <6 0 <6 <6 <6 0 0 0 0 0 # 59 64 23 25 6 <6 <6 <6 <6 0 0 <6 0 0 0 183 % 32 35 13 14 3 <6 <6 <6 <6 0 0 <6 0 0 0 2015 # % 51 29 68 38 27 15 25 14 <6 <6 <6 <6 <6 <6 0 0 <6 <6 0 0 <6 <6 0 0 0 0 0 0 0 0 178 2016 # 46 37 29 16 8 <6 <6 0 <6 0 0 0 0 <6 0 144 % 32 26 20 11 6 <6 <6 0 <6 0 0 0 0 <6 0 Table 56. Number and Percentage of Deaths Among Children Ages 28 Days Through 365 Days by Manner, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Manner # % # % # % # % # % # % Natural 92 53 84 49 79 51 89 49 94 53 53 37 Accident 38 22 48 28 44 28 63 34 53 30 53 37 Undetermined 32 18 29 17 26 17 24 13 28 16 29 20 Homicide 12 7 10 6 7 4 7 4 <6 <6 9 6 Suicide 0 0 0 0 <6 <6 0 0 0 0 0 0 Unknown <6 <6 0 0 <6 <6 0 0 0 0 0 0 Total 175 171 156 156 178 144 -Counts <6 have been suppressed 87 | 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, AZ, 2016 Cause Natural Medical* 50 Drowning 0 MVC/Transport 0 Undetermined <6 Blunt Force Trauma 0 Prematurity <6 Strangulation 0 Suffocation 0 Poisoning 0 Other Injury 0 Other Non-Medical 0 Exposure 0 Total 53 *Excluding SIDS and Prematurity -Counts <6 have been suppressed Accident Suicide Homicide Undetermined Total 0 20 19 0 0 0 <6 <6 0 <6 0 0 47 0 0 0 0 0 0 0 0 0 0 0 0 0 0 <6 0 0 7 0 0 0 <6 0 0 0 10 0 0 0 6 0 0 0 0 <6 0 0 0 7 50 21 19 8 7 <6 <6 <6 <6 <6 0 0 117 Table 58. Number and Percentage of Deaths Among Children Ages One Through Four Years by Cause, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Cause # % # % # % # % # % # % Medical* 40 38 57 48 62 48 40 42 40 40 50 43 Drowning 18 17 18 15 19 15 18 19 20 20 21 18 MVC/Transport 15 14 11 9 18 14 10 11 13 13 19 16 Undetermined <6 5 <6 <6 6 5 26 4 <6 <6 8 7 Blunt Force Trauma 10 9 9 8 14 11 10 11 9 9 6 5 Firearm <6 <6 <6 <6 <6 <6 <6 1 0 0 <6 <6 Poisoning <6 <6 <6 <6 <6 <6 0 0 <6 <6 <6 <6 Fire/burn <6 <6 <6 <6 <6 <6 0 0 0 0 <6 <6 Fall/crush <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Strangulation <6 <6 <6 <6 <6 <6 0 0 <6 <6 <6 <6 Prematurity <6 <6 <6 <6 <6 <6 <6 <6 0 0 <6 <6 Suffocation 8 8 <6 <6 <6 <6 <6 <6 6 6 <6 <6 Other Injury 0 0 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Other non-Medical 0 0 <6 <6 <6 <6 <6 <6 <6 <6 0 0 Total 106 120 130 95 101 117 *Excluding SIDS and Prematurity -Counts <6 have been suppressed 88 | P a g e Table 59. Number and Percentage of Deaths Among Children Ages One Through Four Years by Manner, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Manner # % # % # % # % # % # % Natural 40 38 57 48 62 48 40 42 40 40 53 45 Accident 47 44 39 33 46 35 36 38 39 39 47 40 Homicide 12 11 17 14 16 12 14 15 18 18 10 9 Undetermined 7 7 7 6 6 5 <6 5 <6 <6 7 6 Suicide 0 0 0 0 <6 <1 0 0 0 0 0 0 Unknown 0 0 0 0 <6 <1 0 0 0 0 0 0 Total 106 120 130 95 101 117 -Counts <6 have been suppressed Children, 5 through 9 Years of Age Table 60. Number of Deaths Among Children Ages Five Through Nine Years by Cause and Manner, AZ, 2016 Cause Natural Suicide Homicide Undetermined Total Accident Medical* 29 0 0 0 0 29 MVC/Transport 0 7 0 0 0 7 Firearm 0 <6 0 <6 0 <6 Drowning 0 <6 0 0 0 <6 Undetermined 0 0 0 0 0 0 Fire/Burn 0 0 0 0 0 0 Exposure 0 0 0 0 0 0 Strangulation 0 0 <6 0 0 <6 Fall/Crush 0 <6 0 0 0 <6 Other Injury 0 0 0 0 0 0 Total 29 10 <6 <6 0 45 *Excluding SIDS and prematurity -Counts <6 have been suppressed 89 | P a g e Table 61. Number and Percentage of Deaths Among Children Ages Five Through Nine Years by Cause, AZ, 2011-2016 2011 2012 2013 2014 2015 2016 Cause # % # % # % # % # % # % Medical 26 48 37 59 24 51 30 54 25 49 29 64 MVC/Transport 13 34 12 19 17 36 12 21 9 18 7 16 Drowning 7 13 <6 <6 <6 <6 <6 <6 9 12 <6 <6 Firearm <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Blunt Force Trauma <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Fire/Burn <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 0 0 Strangulation <6 <6 0 0 <6 <6 <6 <6 0 0 <6 <6 Other 0 0 0 0 <6 <1 <6 <2 <6 2 0 0 Undetermined <6 <6 <6 <6 <6 <6 0 0 <6 <6 0 0 Fall/Crush 0 0 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Prematurity 0 0 0 0 <6 <1 0 0 0 0 0 0 Suffocation <6 <6 0 0 <6 <6 <6 <6 0 0 0 0 Poisoning 0 0 0 0 <6 <6 0 0 0 0 0 0 Total 54 63 47 56 51 45 *Excluding SIDS and Prematurity -Counts <6 have been suppressed Table 62. Number and Percentage of Deaths Among Children Ages Five Through Nine Years by Manner, AZ, 2011-2016 2011 2012 2013 2014 2015 2016 Manner # % # % # % # % # % # % Natural 26 48 37 59 25 53 29 52 26 51 29 64 Accident 22 41 22 35 20 43 21 38 18 35 10 22 Undetermined <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 0 0 Homicide <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Suicide <6 <6 0 0 0 0 0 0 0 0 <6 <6 Total 54 63 47 56 51 45 -Counts <6 have been suppressed 90 | 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, AZ, 2016 Cause Natural Medical* 34 MVC/Transport 0 Strangulation 0 Firearm Injury 0 Poisoning 0 Other Injury 0 Undetermined 0 Exposure 0 Drowning 0 Suffocation 0 Total 34 -Counts <6 have been suppressed Accident 0 17 0 <6 <6 <6 0 <6 0 0 22 Suicide 0 0 8 0 <6 0 0 0 0 0 9 Homicide 0 0 <6 <6 0 <6 0 0 0 0 <6 Undetermined 0 0 0 0 0 0 <6 0 0 0 <6 Total 34 17 9 <6 <6 <6 <6 <6 0 0 71 Table 64. Number and Percentage of Deaths Among Children Ages 10 Through 14 Years by Cause, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Cause # % # % # % # % # % # % Medical* 34 47 35 47 34 44 36 51 19 41 34 48 MVC/Transport 17 24 21 28 20 26 9 13 8 17 17 24 Strangulation 10 14 7 9 7 9 <6 <6 <6 <6 9 13 Firearm <6 <6 <6 <6 <6 <6 <6 6 6 9 6 13 Other Injury 0 0 0 0 <6 <6 <6 <6 <6 <6 <6 <6 Fall/Crush 0 0 0 0 <6 <6 <6 <6 <6 <6 <6 <6 Poisoning 0 0 0 0 <6 <6 <6 <6 <6 <6 <6 <6 Blunt Force Trauma <6 <6 0 0 <6 <6 <6 <6 0 0 <6 <6 Exposure 0 0 0 0 <6 <6 0 0 <6 <6 0 0 Suffocation <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 0 0 Drowning <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 0 0 Undetermined <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Fire/burn <6 <6 <6 <6 <6 <6 <6 <6 0 0 0 0 Total 72 75 77 70 46 71 *Excluding SIDS and Prematurity -Counts <6 have been suppressed 91 | P a g e Table 65. Number and Percentage of Deaths Among Children Ages 10 Through 14 Years by Manner, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Manner # % # % # % # % # % # % Natural 34 47 36 48 36 47 37 53 20 44 34 48 Accident 22 31 27 36 24 31 17 24 12 26 22 31 Suicide 13 18 9 12 8 20 11 16 12 26 9 13 Homicide <6 <6 <6 3 9 23 <6 <6 <6 <6 <6 6 Undetermined <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Total 72 75 -Counts <6 have been suppressed 77 70 46 71 Children, 15 through 17 Years of Age Table 66. Number of Deaths Among Children Ages 15 Through 17 Years by Cause and Manner, AZ, 2016 Cause Natural Accident Suicide Homicide Total Firearm Majority Majority 29 Medical* Majority 25 MVC/Transport Majority 24 Strangulation Majority 13 Poisoning Majority 8 Total 25 38 28 15 107 *Excluding SIDS and prematurity -Counts by manner were too low to release for each Cause of Death. For each Cause of Death, the manner that had the most death for that cause has been provided 92 | P a g e Table 67. Number and Percentage of Deaths Among Children Ages 15 Through 17 Years by Cause, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Cause # % # % # % # % # % # % Firearm 15 16 22 22 21 20 14 16 19 18 29 27 Medical* 25 26 13 13 21 20 18 20 25 24 25 23 MVC/Transport 21 22 38 38 24 23 25 28 18 17 24 22 Strangulation 13 14 9 9 10 10 9 10 11 11 13 12 Poisoning 9 9 6 6 12 12 7 8 11 11 8 7 Other 0 0 <6 <6 <6 <6 <6 <6 8 8 <6 <6 Exposure 0 0 0 0 <6 <6 <6 <6 <6 <6 0 0 Drowning <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Undetermined <6 <6 <6 <6 <6 <6 0 0 <6 <6 <6 <6 Fall/Crush <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 Blunt Force Trauma <6 <6 <6 <6 <6 <6 0 0 0 0 <6 <6 Fire/Burn <6 <6 0 0 <6 <6 <6 <6 <6 <6 <6 <6 Suffocation <6 <6 <6 <6 <6 <6 <6 <6 <6 <6 0 0 Total 96 100 103 89 93 104 107 *Excluding SIDS and Prematurity -Counts <6 have been suppressed Table 68. Number and Percentage of Deaths Among Children Ages 15 Through 17 Years by Manner, AZ, 2011- 2016 2011 2012 2013 2014 2015 2016 Manner # % # % # % # % # % # % Accident 31 32 50 50 46 45 37 42 33 32 38 36 Suicide 25 26 24 24 17 17 27 30 35 34 28 26 Natural 27 28 13 13 22 21 19 21 28 26 25 23 Homicide 11 11 9 9 16 16 6 7 <6 <6 15 14 Undetermined <6 <6 <6 <6 <6 <6 0 0 <6 <6 <6 <6 Unknown 0 0 <6 <6 <6 <6 0 0 0 0 0 0 Total 96 100 103 89 105 107 0 -Counts < 6 have been suppressed 93 | 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 2011 through 2016 were provided by the Arizona Department of Health Services Bureau of Public Health Statistics. Population estimates for 2014 and forward 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, AZ, 2011- 2016 County 2011 2012 2013 2014 2015 2016 Apache 22,808 21,843 21,493 21,271 21,132 20,848 Cochise 30,099 30,434 30,621 29,190 28,906 28,463 Coconino 31,716 31,310 31,463 31,097 30,902 30,498 Gila 11,451 11,317 11,351 11,062 11,091 11,085 Graham 10,718 10,623 10,818 10,871 10,874 10,693 Greenlee 2,463 2,408 3,016 2,952 2,967 2,950 La Paz 3,682 3,685 3,708 3,682 3,693 3,639 Maricopa 1,014,790 1,008,347 1,015,472 1,016,044 1,021,299 1,023,035 Mohave 41,301 40,338 39,786 39,076 38,404 37,694 Navajo 31,901 31,551 31,463 30,868 30,682 30,463 Pima 226,652 223,677 223,639 222,413 2,208,66 219,206 Pinal 101,929 102,591 103,403 99,111 99,049 98,531 Santa Cruz 14,752 14,396 14,369 14,304 14,243 14,065 Yavapai 40,305 39,602 39,417 38,243 37,841 37,671 Yuma 56,547 56,415 57,367 56,542 56,255 55,887 Total 1,641,114 1,628,539 1,637,386 1,626,726 1,628,204 1,624,728 Table 70. Population of Children Ages 0 through 17 by Race/Ethnicity, AZ, 2011- 2016 Race/Ethnicity African American American Indian Asian Hispanic White, non-Hispanic Total 2011 84,112 123,712 47,936 673,462 711,892 1,641,114 2012 75,371 98,426 43,453 683,843 727,446 1,628,539 2013 75,491 99,014 44,838 691,459 726,558 1,637,386 2014 111,448 123,657 62,673 634,110 694,838 1,626,726 2015 91,399 86,548 53,073 707,456 689,731 1,628,204 2016 93,897 86,600 53,827 706,954 683,450 1,624,728 94 | P a g e Table 71. Population of Children Ages 0 Through 17 Years by Age Group, AZ, 2011- 2016 Age Group <1 Year 1-4 Years 5-9 Years 10-14 Years 15-17 Years Total 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 2015 86,222 346,443 463,564 458,966 273,009 1,628,204 2016 86,540 343,263 460,863 457,960 276,102 1,624,728 Table 72. Number of Resident Births, AZ, 2011- 2016 2011 85,142 2012 85,675 2013 84,963 2014 86,648 2015 85,024 2016 84,404 Table 73. Number of Births by Race/Ethnicity, AZ, 2011- 2016 Race/Ethnicity African American American Indian Asian Hispanic White, non-Hispanic Total 2011 4,290 5,787 3,493 32,217 39,355 85,142 2012 4,674 5,547 4,674 33,030 38,800 85,675 2013 4,726 5,476 3,466 33,075 38,220 84,963 2014 4,522 5,145 3,169 33,715 40,097 86,648 2015 4,361 4,984 3,235 34,264 38,180 85,024 2016 4,388 5,030 3,350 33,874 37,762 84,404 95 | P a g e Twenty-Fourth Annual Report  Appendix of State and Local CFR Teams Arizona Department Health Service, State CFR Team Chairperson: Mary Ellen Rimsza, MD, FAAP American Academy of Pediatrics Members: David K. Byers Jeff Hood Robert D. Jones (Proxy) Arizona Department of Juvenile Corrections Flor Olivas ITCA Tribal Epidemiology Center Cdr. Stacey Dawson Phoenix Indian Medical Joanna K. Kowalik Pamela Tom (Proxy) Arizona Department of Economic Security Division of Developmental Disabilities Mark K. Perkovich Law Enforcement (AZ POST) Tim Flood, MD Marguerite Sagna (Proxy) Arizona Department of Health Services Jakenna Lebsock John Raeder Myriah Mhoon (Proxy) Governor’s Office for Children, Youth and Families David Foley Navajo Tribe Representative Gaylene Morgan Rachel Metelits (Proxy) Office of the Attorney General Beth Rosenberg Karen McLaughlin (Proxy) Director of Child Welfare & Juvenile Justice Children's Action Alliance Diana Gomez, MPH Stacey Gagnon, BSN, RN (Proxy) Yuma County Department of Public Health Services Susan Newberry, MEd Maricopa County CFR Team Christi Shelton Arizona Department of Child Safety Nancy Molever (proxy) Administrative Office of the Courts Clinical Administrator Eric Tack, MD (Proxy) AHCCCS Division of Behavioral Health 96 | P a g e Twenty-Fourth Annual Report  Patricia Tarango, MS Tomi St. Mars, MSN, RN (proxy) Arizona Department of Health Services Bureau of Women’s and Children’s Health Nicola Winkel, MPA Kelly Ann Beck (proxy) Arizona Coalition for Military Families David Winston, MD, PhD Forensic Pathologist Pima County Forensic Science Center Hilary Weinberg Arizona Prosecuting Attorney’s Advisory Council 97 | P a g e Twenty-Fourth Annual Report  Apache County, CFR Team Chairperson/Coordinator: Matrese Avila Apache County Youth Council, Apache County Drug Free Alliance Daniel Brown St. John’s Police Department Members: Scott Poche Little Colorado Behavior Health Center Mike Sweetser Interim Chief, Eagar Police Department Chief Mike Nuttall Springerville Police Department Kelli Sine-Shields Apache County Public Health Department Abbey Walker DCS Case Manager Christie Orona DCS Supervisor Jim Staffnik, PhD St. Johns Middle School Verlyn D. Walker Apache County Medical Investigator Debbie Padilla Apache County Public Health Department 98 | P a g e Twenty-Fourth Annual Report  Coconino County, CFR Team Chairperson: Heather Williams Injury Prevention Program Manager Coconino County Public Health Services Co-Chair: Larry Czarnecki, MD Coconino County Medical Examiner Members: Bill Ashland RN EMS Flagstaff Medical Center Brian Fagan Federal Bureau of Investigations Antony Judson DCS Case Manager Glen Austin, MD Pediatrician, Flagstaff Pediatric Care Myra Ferechil Coconino County Victim/Witness Services Jane Nicoletti-Jones Coconino County Attorney Orlando Bowman Navajo Nation Criminal Investigator Deborah Fresquez Coconino County Victim/Witness Services John Philpot, Major Arizona Department of Public Safety Corey Cooper Health Educator Coconino County Public Health Services District Aaron Goldman Psychiatrist, Victoria Tewa Casey Rucker Detective Flagstaff Police Department Kristen Curtis, Admin Specialist Coconino County Public Health Services District Diana Hu, MD Tuba City Regional Health Care Corporation Cindy Sanders, BSN, RN Flagstaff Medical Center NICU Jim Driscoll Sheriff, Coconino County Sheriff’s Office Shannon Johnson Tuba City Regional Medical Center Trauma Cindy Trembley DCS Case Manager 99 | P a g e Twenty-Fourth Annual Report  Gila County, CFR Team Chairperson: Edna Welsheimer Executive Director, Time Out Shelter Rachel Cliburn Director, Gila County Public Health Coordinator: Kathleen Kelly, RN Members: Chris Hagenian DCS Investigator Shelley Sorocco-Spence Gila County Children's Advocacy Program Kristin Crowley Gila Community College Yvonne Harris DES Jason Stein DCS Program Manager Tanya Dean San Carlos Apache Tribe Social Services Brian Mabb Payson High School Principal Tilla Warner Child Help Kristin Klee Martinez DES Child Division James West American Red Cross Disaster Team Roscoe Dabney III Retired Tribal Police Officer Donald Engler Payson Chief of Police Robin Miller Administrator Legal Advocate, Time Out Shelter Lisa Evans Payson High School Director of Special Services Ashley Oviedo Banner Hospital Emergency Room Rita Green, R.N. Martin Rubio DCS Investigator Chris Hagenian DCS Investigator Mary Schlosser Sheriff Tonto Apache Tribe 100 | P a g e Twenty-Fourth Annual Report  Graham County, & Greenlee County, CFR Team Chairperson/Coordinator: Brandie Lee CASA of Graham County Jeanette Aston Domestic Violence Specialist Mt. Graham Safe House Members: Brian Douglas Health Director Graham County Health Department Scott Bennett County Attorney Graham County Attorney’s Office Richard Keith, MD Pediatrician Gila Valley Clinic Dr. Bart Carter County Medical Examiner Melissa Lunt, RN Graham County Health Department Josh McClain Detective Safford Police Department Victoria Torres DCS Supervisor 101 | P a g e Twenty-Fourth Annual Report  Maricopa County, CFR Team Chairperson: Mary Ellen Rimsza, MD, FAAP American Academy of Pediatrics Coordinator: Susan Newberry, MEd Assistant Coordinator: Arielle Unger, BS Members: Angelica M Baker Phoenix Children’s Hospital Kimberly Choppi, MSN-Ed, RN, Michelle Fingerman, MS CPEN Director, Childhelp National Maricopa Integrated Health System Child Abuse Hotline Sergeant Adam Barrett Phoenix Police Department Andrea Clark, RN Phoenix Children’s Hospital Elisha Franklin, MC, LASAC Chicanos Por La Causa Wendy Bernatavicius, MD Phoenix Children’s Hospital Shawn Cox, LCSW Victim Services Division Chief Maricopa County Attorney’s Office Jerry Gissel Chief of the Office of Child Welfare Investigations Arizona Department of Child Safety John Bobola US Consumer Product Safety Commission Frances Baker Dickman, PhD, JD Dyanne Greer, MSW, JD Deputy County Attorney Family Violence Bureau Maricopa County Attorney’s Office Sergeant Jesse Boggs Chandler Police Department Paul S. Dickman, MD Phoenix Children’s Hospital University of Arizona College of Medicine Phoenix Children’s Hospital Sergeant Brian Hansen Phoenix Police Department Megan Carey, MC Arizona Department of Child Safety Ilene Dode, PhD, LPD CEO Emeritus Ryan Herold, RN Mesa Fire and Medical Department 102 | P a g e Twenty-Fourth Annual Report  Jennifer R. Hunter Northwest Section Chief Counsel Child and Family Protection Division Arizona Attorney General’s Office Detective Chris Loeffler Phoenix Police Department Julie M. Rhodes Assistant Attorney General Arizona Attorney General’s Office Brett Hurliman, MD Phoenix Children's Hospital Sergeant Eric Lumley Phoenix Police Department Louise Roskelley Tiffaney Isaacson Water Safety Coordinator Phoenix Children’s Hospital Peggy McKenna, MSC, MFT Arizona Department of Child Safety Fred Santesteban Larel Jacobs, MC Childhelp National Child Abuse Hotline Sandra McNally, MA, LISAC La Frontera Arizona, EMPACT Suicide Prevention Center Michele F. Scott, MD Phoenix Children’s Hospital Jeffrey Johnston, MD Maricopa County Chief Medical Examiner Casey Melsek, MSW, CPM Arizona Department of Child Safety James Simpson Southeast Section Chief Counsel Child and Family Protection Division Arizona Attorney General’s Office A. Min Kang, MD, MPhil, FAAP Detective Keith Moffitt University of Arizona College of Phoenix Police Department Medicine-Phoenix Banner University Medical Center Phoenix Banner Poison and Drug Information Center Phoenix Children’s Hospital David Solomon, MD Phoenix Children’s Hospital Justin Kern Assistant Director Aquatics and Safety Education Arizona State University Kimberly Pender Office of Child Welfare Investigations Arizona Department of Child Safety Julie Soto, MC Mercy Maricopa Integrated Care Karin Kline, MSW Arizona State University Center for Child Well-Being Leslie Quinn, MD, FAAP Banner Health System Cardon Children’s Medical Center Margaret Strength, MSW Arizona Department of Child Safety Crystal Langlais, MPH Phoenix Children’s Hospital Leah Reach, BSHS Katrina Taylor Childhelp National Child Abuse Hotline 103 | P a g e Twenty-Fourth Annual Report  Denis Thirion, MA La Frontera Arizona, Empact Suicide Prevention Center Mary G Warren, Ph.D, IMH-E Prevent Child Abuse Arizona Stephanie Zimmerman, MD Phoenix Children’s Hospital Marcella Valenzuela Confirmation Supervisor TASC Solutions 104 | P a g e Twenty-Fourth Annual Report  Mohave County, & La Paz County CFR Team Chairperson: Vic Oyas, MD Havasu Rainbow Pediatrics Coordinator: Anna Scherzer Mohave County Department of Public Health Members: Dawn Abbott Mohave Mental Health Clinic, Inc. Detective Todd Foster Kingman Police Department Melissa Register Mohave County Probation Department Sara Colbert Mohave County Probation Department Joshua Frisby Probation Officer Mohave County Probation Department Jason Schmitz Kingman Police Department Craig Diehl, MD Lake Havasu Pediatrics Dennis Gilbert Kingman Police Department Charles Solano Colorado River Indian Tribal Police Department Steven Draper La Paz County Sheriff’s Department Sgt. Mike Godfrey Kingman Police Department Detective Eric Teague Bullhead City Police Department Lt. Jerry Duke Bullhead City Police Department Patty Mead, RN, MS Mohave County Health Department Debra Walgren M.Ed., CPM Arizona Department of Child Safety Heather Miller Hospital EMS Kingman Regional Medical Center Daniel Winder Fire Department EMS Kingman Fire Department Natalie Eggers Mohave County Probation Department Detective TJ Frances Lake Havasu City Police Department Archaius Mosley, MD Mohave County Medical Examiner’s Office Karen Foster Mohave County Parent & Community Susan Plourde Mohave County Medical Examiner’s Office 105 | P a g e Twenty-Fourth Annual Report  Navajo County, CFR Team Chairperson: Janelle Linn, RN Navajo County Public Health Services Coordinator: Abbi Cluff, RN Navajo County Public Health Services Members: Tom Barela, MD Retired Pediatrician Danielle Poteet, RN Summit Regional Medical Center ER and Injury Prevention Amy Stradling Navajo County Public Health Injury Prevention Kenneth Brown WMAT Social Services Gregory Sehongva Tribal Public Health Technician Hopi Nation Indian Health Services Andrea Tsatoke, MPH Indian Health Services District Injury Prevention Coordinator Trent Clatterbuck Lead Medical Examiner Investigator ABMDI Certified Navajo County Medical Examiner’s Office Scott Self Assistant Medical Examiner Investigator Navajo County Medical Examiner’s Office Kateri Piecuch Arizona Department of Economic Security Administration for Children, Youth, and Families Dr. Jerry Sowers, DO Retired Family Practice Physician 106 | P a g e Twenty-Fourth Annual Report  Pima County, Cochise County, & Santa Cruz County CFR Team Chairperson: Dale Woolridge, MD Department of Emergency Medicine University of Arizona Coordinator: Becky Lowry University of Arizona Members: Nicole Abdy, MD Department of Pediatrics University of Arizona Detective Josh Cheek Tucson Police Department Detective Pierre De la Ossa Tucson Police Department Albert Adler, MD Indian Health Services Detective Ken Chruscinski Department of Public Safety Lisa Emery Arizona DHS Child Care Licensing Dawn Aspacher Pima County Attorney’s Office Sgt. David Contreras Tucson Police Department Deputy Miguel Flores Pima County Sheriff’s Department Carol Baker, RN Pima County Health Department Sgt. Luis Cornidez Pima County Sheriff’s Office Detective Marty Fuentes Tohono O’odham Police Department Kathy Benson, RN Retired School Nurse Rosanna Cortez Victim Services Pima County Attorney’s Office Amy Gomez Victim Services Liaison Emerge Kathy Bowen, MD Pediatrician Rachel Cramton, MD Department of Pediatrics University of Arizona Detective John Gonzales Tucson Police Department Megan Carr Oro Valley Police Department Deputy Jason Davila Pima County Sheriff’s Office Alan Goodwin Pima County Attorney’s Office Christine Chacon Casa de los Ninos Detective Lisa Davila Tucson Police Department Lori Groenewold, MSW Children’s Clinics for Rehabilitation 107 | P a g e Twenty-Fourth Annual Report  Karen Harper Southern Arizona Child Advocacy Center Detective Ryan Lara Tucson Police Department Michelle Nimmo Attorney General’s Office Captain Ryder Hartley Northwest Fire Department Chan Lowe, MD Department of Pediatrics University of Arizona Susanne Olkkola Department of Emergency Medicine UA College of Medicine Sharon Hitchcock, RN College of Nursing University of Arizona Mary McDonald, RN, BSN Pre-hospital Manager Tucson Fire Department Marie Olson, MD Pediatric Hospitalist University of Arizona Detective Molly Ingram Benson Police Department Sgt. Cindy Mechtel Tucson Police Department Karen Owen, BSN, RNC Karen Ives Office of Child Welfare Connie Miller University of Arizona College of Medicine Detective Tristan Pittenridge Tucson Police Department Kim Janes Division Manager Pima County Health Department Detective Mark Munoz Tucson Police Department Lauren Pylipow Pima County Attorney’s Office Detective James Johnston Tucson Police Department Detective Brenda Navarro Tucson Police Department Beth Ratcliff Pediatric ED Manager Tucson Medical Center Lynn Kallis Pilot Parents Program of Southern Arizona Sgt. Juan Navarro Pima County Sheriff’s Office Emily Rebio Pima County Health Department Tracy Koslowski Public Education/Information Manager Drexel Heights Fire Dept. Brenda Neufeld, MD Indian Health Services Sue Rizzi Pima Community College Leah Robeck, MSW Division of Children, Youth and Families Arizona Department of Economic Security Pepper Sprague Retired Teacher Rodrigo Villar, MD Indian Health Services 108 | P a g e Twenty-Fourth Annual Report  Audrey Rogers Pima County Vital Records Helena Seymour Arizona Attorney General’s Office Chris Williams Department of Child Services Melissa Rosinski Pantano Behavioral Health Chris Williams Department of Child Services Commander Donald Williams US Public Health Services Indian Health Services Adam Rossi Pima County Attorney’s Office Detective Rhonda Thrall Tucson Police Department Melissa Zukowski, MD Department of Pediatrics Tucson Medical Center 109 | P a g e Twenty-Fourth Annual Report  Pinal County, CFR Team Chairperson/Coordinator: Lindsey Wicks Pinal County Public Health Services Members: Graham Briggs Pinal County Health Department Dr. Shauna McIsaac Pinal County Public Health Scott Smith Pinal County Adult Probation Ty Coleman Casa Grande Police Department Jimmy Orozco Gila River Police Dept. Tasha Spears Pinal County Advocacy Center Sean P. Coll Pinal County Attorney’s Office Sonia Ortega Pinal County Sheriff’s Valorie Stading Pinal County Medical Examiner’s Office Sara Curiel DCS- Casa Grande Rob Pisano Pinal County Sheriff’s Office Mark Tercero Coolidge Police Dept. Matt Duran Casa Grande Police Dept. Leslie Quinn, MD Banner Health Brian Walsh Casa Grande Police Department Paul Dudish Pinal County Sheriff’s Office Brain Romer Gila River Police Dept. Rachel Zenuk Pinal County Public Health Christopher Fox Casa Grande Police Department Joanna Sanchez Pinal County Advocacy Center Jabette Franco Pinal County Health Department Nick Schweers Pinal County Public Health Services Cori Gagen Pinal County Health Department Kristen Sharifi Pinal County Attorney’s Office 110 | P a g e Twenty-Fourth Annual Report  Yavapai County, CFR Team Chairperson: Kathy McLaughlin Community at large – Family advocacy Coordinator: Stacey Gagnon, RN, BSN Yavapai County Community Health Services Administrative Specialist: Carol Espinosa Yavapai County Community Health Services Members: Julie Bloss DCS Representative Henry Kaldenbaugh, MD Pediatrician Consultant Officer M. J. Williams Prescott Valley Police Department Jerry Bruen Yavapai County Attorney’s Office Dawn Kimsey DCS Representative Missy Sikora Yavapai Family Advocacy Center Sue Carlson Mental Health/ Counselor Joseph Lopez Yavapai County Medical Examiner’s Office Joan Drydyk Community Member Dennis McGrane Yavapai County Attorney 111 | P a g e Twenty-Fourth Annual Report  Yuma County, CFR Team Chairperson: Patti Perry, MD Yuma Regional Medical Center/Cactus Kids Coordinator: Ryan Butcher Yuma County Health District Jay Carlson Yuma County Sheriff’s Office Chip Schneider Amberly’s Place Karla Garcia Intern Amberly’s Place Members: Jennifer Stanton, RN Yuma Regional Medical Center Robert Vigil Medical Examiner’s Office Yuma County Sheriff’s Office Nathan Williams Police Officer Yuma Police Department 112 | P a g e