Multidisciplinary Child Protection Team Research Articles

The patchy landscape of supervision for child protection professionals in Albania

ABSTRACT To provide a snapshot of the state of child protection supervision in Albania, this article presents findings from a small-scale study undertaken to explore the views and experiences of professionals in multidisciplinary child protection teams. Our aims were to provide a description of current supervisory practice and explore perceptions and experiences of supervision. Data were collected via five key informant interviews and surveys completed by 17 frontline workers. We found a patchy landscape of understanding and provision of supervision in Albania.

ICD-10 codes for surveillance of non-fatal abusive head trauma in Aotearoa New Zealand: a retrospective cohort study

ObjectivesTo assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New...

The characteristics of children referred to a child protection team in Japan and factors associated with decision-making: A retrospective study using a medical database

BackgroundDespite the potential efficacy of hospital-based multidisciplinary child protection team (CPTs), research analyzing Japanese CPT databases is scarce. ObjectiveWe aimed to describe the characteristics of children and families reported to a CPT in Japan and investigate factors associated with the substantiation of maltreatment. Participants and settingThis retrospective, cross-sectional study took place in a national children's hospital in Japan and included 350 children who were reported to CPTs between April 2014 and March 2018. MethodsUnivariable and multivariable logistic regression analyses were conducted using the CPT database and medical records. ResultsAmong 350 cases, 33.4 % were substantiated. Children of <6 years of age comprised 73.4 % of the cases. The majority (67.7 %) received an injury-related diagnosis and physical maltreatment was suspected in 68.3 % of cases. In the univariable analysis, older age, a primary diagnosis other than injury, reporting department, psychological maltreatment, witnessing intimate partner violence, maltreatment by relatives other than biological father or mother, developmental disability, emotional/behavioral difficulty or psychological disorder, maternal/paternal psychological difficulty, and maternal history of maltreatment were significantly associated with substantiation. When adjusted for demographic, child and familial factors, a diagnosis other than injury (AOR 2.02, 95 % CI = 1. 11–3.65) and parental psychological difficulties (AOR 2.49, 95 % CI = 1.37–4.55) were independently associated with substantiation. ConclusionMost cases reported to our CPT were young children with an injury-related diagnosis. Substantiation was associated with a diagnosis other than injury and parental psychological difficulties. Further prospective and comprehensive studies are needed to establish universal guidelines for databases of hospital-based CPTs.

The Typology and Topography of Child Abuse and Neglect: The Experience of a Tertiary Children's Centre.

Effective child protection systems and processes require reliable and accurate data. The aim of this study was to determine what data could be extracted from hospital records in a single site that reflected a child’s journey from admission with suspected abuse to the decisions regarding substantiation made by the multidisciplinary child protection team. A retrospective study of the case records of 452 children referred to a major UK children’s tertiary centre for suspected child maltreatment was undertaken. Child maltreatment was substantiated in 65% of referred cases, with the majority of referrals coming from children living in the most deprived neighbourhoods in the country. Domestic violence and abuse and the child’s previous involvement with statutory bodies were associated with case substantiation. Physical abuse predominated, with soft tissue injuries, including dog bites and burns, most frequent. Burns were related almost exclusively to supervisory neglect. There were also cases of medical neglect. Emotional abuse was associated with exposure to domestic violence and abuse and to self-harm. The strengths and limitations for single-centre data systems were explored, concluding with a recommendation to establish an agreed national and international minimum data set to protect children from maltreatment.

Incidence of hospitalization for abusive head trauma in Chiba City, Japan.

This study aimed to examine the incidence of abusive head trauma (AHT) admissions by calculating admission rates of AHT cases among infants <12 months old in a population-based sample in Chiba city, Chiba prefecture, Japan. We retrospectively examined medical records of infants admitted to all pediatric secondary and tertiary hospitals in Chiba city between 2011 and 2015. We collected 13 AHT cases, as assessed by hospital-based multidisciplinary child protection teams. One experienced pediatric radiologist and two pediatricians evaluated the case histories and computed tomography images of cases to evaluate them clinically as "strongly" or "moderately" suspected AHT. The overall incidence per 100 000 person-years was 34.5 cases (95% confidence interval (CI): 18.4-59.1), of which 13.3 (95% CI: 4.3-31.0), were strongly suspected to be AHT and 21.3 (95% CI: 9.2-41.9) were moderately suspected. There were no statistical differences in computed tomography findings between severe and moderately suspected AHT. The incidence of hospitalization of infants with AHT was similar to that reported in population-based studies in other countries.

Physical child abuse demands increased awareness during health and socioeconomic crises like COVID-19

Background and purpose - Physical abuse of children, i.e., nonaccidental injury (NAI) including abusive head trauma (AHT) is experienced by up to 20% of children; however, only 0.1% are diagnosed. Healthcare professionals issue less than 20% of all reports suspecting NAI to the responsible authorities. Insufficient knowledge concerning NAI may partly explain this low percentage. The risk of NAI is heightened during health and socioeconomic crises such as COVID-19 and thus demands increased awareness. This review provides an overview and educational material on NAI and its clinical presentation.Methods - We combined a literature review with expert opinions of the senior authors into an educational paper aiming to help clinicians to recognize NAI and act appropriately by referral to multidisciplinary child protection teams and local authorities.Results - Despite the increased risk of NAI during the current COVID-19 crisis, the number of reports suspecting NAI decreased by 42% during the lockdown of the Danish society. Healthcare professionals filed only 17% of all reports of suspected child abuse in 2016.Interpretation - The key to recognizing and suspecting NAI upon clinical presentation is to be aware of inconsistencies in the medical history and suspicious findings on physical and paraclinical examination. During health and socioeconomic crises the incidence of NAI is likely to peak. Recognition of NAI, adequate handling by referral to child protection teams, and reporting to local authorities are of paramount importance to prevent mortality and physical and mental morbidity.

599 A Retrospective Outcome Analysis of the Involvement of Department of Child Services in Suspected Cases at a Major Regional Pediatric Burn Center

Abstract Introduction Cases of child abuse are an important manifestation of pediatric burns owing to their nature and all too common occurrence. In our institution, the Department of Child Services (DCS) is often frequently involved in minimally suspicious cases in conjunction with or even before the internal child protective team involvement. To our knowledge, there is no recent literature evaluating the outcome of DCS involvement in suspected cases in pediatric burn populations. Methods We performed a retrospective chart analysis of the pediatric burn patient database at our institution from 2017–2020. We identified 116 out of 565 patients who matched our criteria for the involvement of DCS. We collected the following information: age, race, address at time of injury, payer source, where DCS involvement was initiated, and the outcome of the investigation. Results We found that 20.5 % of all the pediatric burn patients admitted from 2017–2020 had DCS involvement. Of the total admitted patients only 3.8% were removed from the previous caregivers. The factors that were found to be statistically significant were male sex, age under 3 years, Caucasian child with single parent and living in an urban setting. A higher incidence was noted in the capital city area compared to the rest of the state. There was no statistical difference noted among races, location of DCS notification, and payer source. Conclusions We conclude that vigilance and early reporting is essential in detecting child abuse. Involvement of the multidisciplinary child protection team at our institution may reduce the burden on DCS. Screening out high risk factors such as age less than 3 years old, male sex, and single parent of Caucasian race may assist in detecting the non-accidental burn victims. We will target prevention educational outreach programs to the community to decrease the occurrence of child abuse in the future.

Health professionals' perception of the New Zealand National Child Protection Alert System: An online survey.

To describe the multi-disciplinary child protection teams which administer the National Child Protection Alert System in District Health Boards in New Zealand and the understanding and perceptions of that system held by team members. This is a mixed-method observational study. In December 2016 and January 2017, all child protection alert system multi-disciplinary team members were invited to participate in an online survey. Quantitative data were expressed with simple descriptive statistics. Qualitative findings were analysed using thematic analysis. Ninety-one (56.9%) of 160 team members nationwide completed the survey. All 20 District Health Boards and multiple disciplines were represented. Most respondents agreed that they received good information to make decisions (74/90, 82.2%), that it was usually easy to reach consensus (82/91, 90.1%), that the system helped to keep children safe (72/91, 79.1%) and that it did not stigmatise families (49/91, 53.9%). Qualitative analysis identified considerable variation in understanding of the system and a need for more training to support more consistent implementation of the system. Overall, health professionals responsible for the child protection alert system regard it positively but express a need for more training for team members and front-line staff to maximise the system's potential and minimise any risk of stigmatisation.

Physical child abuse demands increased awareness during health and socioeconomic crises like COVID-19

Background and purpose — Physical abuse of children, i.e., nonaccidental injury (NAI) including abusive head trauma (AHT) is experienced by up to 20% of children; however, only 0.1% are diagnosed. Healthcare professionals issue less than 20% of all reports suspecting NAI to the responsible authorities. Insufficient knowledge concerning NAI may partly explain this low percentage. The risk of NAI is heightened during health and socioeconomic crises such as COVID-19 and thus demands increased awareness. This review provides an overview and educational material on NAI and its clinical presentation.Methods — We combined a literature review with expert opinions of the senior authors into an educational paper aiming to help clinicians to recognize NAI and act appropriately by referral to multidisciplinary child protection teams and local authorities.Results — Despite the increased risk of NAI during the current COVID-19 crisis, the number of reports suspecting NAI decreased by 42% during the lockdown of the Danish society. Healthcare professionals filed only 17% of all reports of suspected child abuse in 2016.Interpretation — The key to recognizing and suspecting NAI upon clinical presentation is to be aware of inconsistencies in the medical history and suspicious findings on physical and paraclinical examination. During health and socioeconomic crises the incidence of NAI is likely to peak. Recognition of NAI, adequate handling by referral to child protection teams, and reporting to local authorities are of paramount importance to prevent mortality and physical and mental morbidity.

The national child protection alert system in New Zealand: A prospective multi-centre study of inter-rater agreement

BackgroundThe New Zealand health system assigns a unique identifier to every user of health services. The National Child Protection Alert System enables an alert to be placed against this identifier, making child protection information available to health providers throughout the country. Local health-based multi-disciplinary teams receive requests for an alert and decide whether an alert should be placed, but the proportion of requests accepted for an alert varies widely across New Zealand. ObjectiveTo examine whether eliminating variation in information presented to multi-disciplinary teams eliminates variation in the proportion accepted for an alert. Participants and settingHealth professionals working in multi-disciplinary child protection teams in publicly funded healthcare services across New Zealand. MethodsAll multi-disciplinary teams were asked to consider a set of 25 standardized child protection cases following their usual practice. The proportion accepted for an alert was compared by agreement analysis. ResultsEighteen of 20 teams completed the study. The proportion accepted for an alert varied from 48 to 96% (median 88%, inter-quartile range 73–89%). The proportion where the local team agreed with the majority decision varied from 64 to 96% (median 88%, inter-quartile range 81–96%). The kappa coefficient for inter-rater agreement varied from 0.25 (95% CI 0.00–0.76) to 0.83 (95% CI 0.52 to 1.00). The overall kappa coefficient was 0.37. ConclusionsEliminating variation in information provided does not eliminate variation in the proportion accepted for an alert. More research is needed into factors influencing alert decisions in the New Zealand National Child Protection Alert System.

A Multidisciplinary Child Protection Team Improves the Care of Nonaccidental Trauma Patients

We initiated a multidisciplinary Child Protection Team (CPT) as a subgroup of our pediatric multidisciplinary trauma peer review committee. Meetings are held monthly. Nonaccidental trauma (NAT) patients from the preceding month are reviewed. The meeting has two parts. During the open part, detectives and child protective services (CPS) workers are invited to discuss specific cases. The closed part focuses on improvement of specific processes and future outcomes. Attendance is recorded and minutes are kept. We sought to review accomplishments of this group. We retrospectively reviewed the minutes from our CPT meetings conducted between February 2014 and April 2015. We tracked attendance, cases reviewed, process improvement projects, and corrective action plans. Meeting attendance was very good-78 per cent. During the 15-month study period, we had 141 suspected NAT patients; 96 were reviewed at our meetings. CPS workers attended 53 per cent of the meetings; 13 investigations were discussed. We established a clinical practice guideline for the evaluation of NAT patients. We created a mechanism to improve compliance with follow-up skeletal surveys. Six corrective letters were sent to individuals notifying them of care concerns and opportunities for improvement. Equipment needs were identified, and we obtained a digital camera and speaker phone. We have conducted multiple educational sessions to increase awareness. Our CPT meeting has improved the care of our NAT patients and provided better communication between our hospital staff and CPS workers. We have improved inhospital processes for our NAT patients. We have provided educational opportunities to outside care providers.

Team leadership across contexts: a qualitative study

Purpose– The purpose of this paper is to compare leadership functions from different team contexts considering context characteristics that contribute to team effectiveness.Design/methodology/approach– A qualitative study was conducted. Seven leaders of multidisciplinary child protection teams (MDTs) and nine managers of an information technology (IT) company took part in semi-structured interviews. The data were analyzed using content analysis with ATLAS.ti.Findings– Results showed that the two types of teams used different performance criteria, with teams from non-profit contexts lacking defined performance criteria. The results also showed that transition leadership functions are more frequently mentioned by IT than by MDT leaders. Moreover, interpersonal leadership functions emerged as independent functions that may occur in both the transition and action phases.Research limitations/implications– Context is paramount for performance criteria definition and for the relevance of certain team leadership functions over others. It also presents some suggestions for improvement to the model of Morgesonet al.(2010a).Practical implications– The results support the idea that there are differences in the leadership functions that are most valued by leaders, depending on the specific team’s context. Results also showed that some non-profit and less task-structured teams lack the specific performance criteria that could help them make more successful interventions.Originality/value– This paper reviews context literature, it shows that the emphasis on team leadership functions can vary across contexts and to the knowledge it is the first that compares the model of Morgesonet al.(2010a) in different contexts.

Multidisciplinary child protection decision making about physical abuse: Determining substantiation thresholds and biases

The current study examined the threshold at which multidisciplinary child protection team (CPT) professionals substantiate physical abuse allegations and the extent that they utilize potentially biased constructs in their decision making when presented with the same case evidence. State legal definitions of child maltreatment are broad. Therefore, the burden of interpretation is largely on CPT professionals who must determine at what threshold physical acts by parents surpass corporal discipline and constitute child physical abuse. Biased or subjective decisions may be made if certain case-specific characteristics or CPT professionals' personal characteristics are used in making physical abuse determinations. Case vignettes with visual depictions of inflicted injuries were sent to CPT professionals in Florida and their substantiation decisions, personal beliefs about corporal discipline, and coercive discipline were collected. Results of the study demonstrated relatively high agreement among professionals across vignettes about what constitutes physical abuse. Further, CPT professionals strongly considered their perceptions of the severity of inflicted injuries in substantiation decisions. Although case specific characteristics did not bias decisions in a systematic way, some CPT professional characteristics influenced the substantiation of physical abuse. Practice implications and future directions of research are discussed.

Abusive head trauma in infants and why we CAN afford to prevent it

Abusive head trauma in infants and why we CAN afford to prevent it

The contribution of a hospital child protection team in determining suspected child abuse and neglect: Analysis of referrals of children aged 0–9

Background Hospital professionals have a unique opportunity to identify victims of child abuse and neglect (CAN). The hospital multi-disciplinary Child Protection Team (CPT) offers a means for optimizing procedures, maximizing caution and enhancing decision-making. Objective The current study describes cases of children aged 0–9 years referred to the CPT, to identify the contribution of the CPT to the assessment process in determining reasonable suspicion of child abuse or neglect. Methods The files of all 990 cases of children aged 0–9 referred to the CPT from 1991 thru 2006 were abstracted. Results Nearly equal rates of boys and girls were referred to the CPT, and the average age was 2.4 years (SD 2.6), with over two-thirds aged 0–2. Half of the cases arrived at the hospital due to accident or trauma, and nearly one-third due to illness. Eighty-five neonates were referred due to parental risk factors identified at birth. The most common reasons prompting referral to the CPT were medical indication and parent behavior, with parents most often the suspected source of danger. Over half of the cases (566) were reported to authorities. Nearly half of those reported were cases of suspected physical neglect, 21.5% were suspected of physical abuse, and 7.6% of sexual abuse. There were significant differences in the patterns of reporting and types of suspicion both for the various age groups (p < 0.001) and the genders (p < 0.001), as well as by age-gender groups (shown in the first figure). Conclusions The current findings illuminate the various factors and steps involved in the hospital CPT's assessment of preliminary suspicions of CAN raised by front-line clinicians. It is recommended that standardized criteria be developed based on current state-of-knowledge.

Bladder Rupture After Minor Accidental Trauma

This case series describes 2 separate occurrences of bladder rupture occurring from minor accidental trauma in young children. Both cases presented with surgical abdomen, gross hematuria, and pseudorenal failure. After evaluation by a multidisciplinary child protection consultation team, the mechanism of injury for both cases was found to be a minor accidental trauma not initially reported by the child or families involved. This case series illustrates the importance of considering trauma in any child that presents with abdominal pain. Evaluation by a multidisciplinary child protection team is necessary to help differentiate accidental from nonaccidental trauma.

Munchausen Syndrome by Proxy

1. Patrick Brown, MD 2. Cheryl Tierney, MD, MPH 1. Baystate Medical Center Springfield, Mass Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000:781– 783 Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting. Stirling J and the Committee on Child Abuse and Neglect. Pediatrics. 2007;119 :1026– 1030[OpenUrl][1][Abstract/FREE Full Text][2] Munchausen Syndrome by Proxy. Hettler J. Pediatr Emerg Care. 2002;18 :371– 374[OpenUrl][3][CrossRef][4][PubMed][5][Web of Science][6] Different Interpretations of Munchausen Syndrome by Proxy. Meadow R. Child Abuse Neglect. 2002;26 :501– 508[OpenUrl][7][CrossRef][8][PubMed][9][Web of Science][10] The term Munchausen syndrome has long been recognized in adult patients who fabricate symptoms for the purpose of adopting the sick role and submitting themselves to unnecessary medical procedures. In pediatrics, this condition takes a different spin when a parent presents with a story of symptoms in his or her child, who then becomes the focus of medical investigation. Because the patient is not directing the signs and symptoms of the condition, the name of this condition is Munchausen syndrome by proxy (MSBP). MSBP was introduced in the medical literature in 1977 by … [1]: {openurl}?query=rft.jtitle%253DPediatrics%26rft.stitle%253DPediatrics%26rft.issn%253D0031-4005%26rft.aulast%253DStirling%26rft.auinit1%253DJ.%26rft.volume%253D119%26rft.issue%253D5%26rft.spage%253D1026%26rft.epage%253D1030%26rft.atitle%253DBeyond%2BMunchausen%2BSyndrome%2Bby%2BProxy%253A%2BIdentification%2Band%2BTreatment%2Bof%2BChild%2BAbuse%2Bin%2Ba%2BMedical%2BSetting%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2007-0563%26rft_id%253Dinfo%253Apmid%252F17473106%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=119/5/1026&atom=%2Fpedsinreview%2F30%2F10%2F414.atom [3]: {openurl}?query=rft.jtitle%253DPediatric%2Bemergency%2Bcare%26rft.stitle%253DPediatr%2BEmerg%2BCare%26rft.aulast%253DHettler%26rft.auinit1%253DJ.%26rft.volume%253D18%26rft.issue%253D5%26rft.spage%253D371%26rft.epage%253D374%26rft.atitle%253DMunchausen%2Bsyndrome%2Bby%2Bproxy.%26rft_id%253Dinfo%253Adoi%252F10.1097%252F00006565-200210000-00012%26rft_id%253Dinfo%253Apmid%252F12395011%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [4]: /lookup/external-ref?access_num=10.1097/00006565-200210000-00012&link_type=DOI [5]: /lookup/external-ref?access_num=12395011&link_type=MED&atom=%2Fpedsinreview%2F30%2F10%2F414.atom [6]: /lookup/external-ref?access_num=000178625100011&link_type=ISI [7]: {openurl}?query=rft.jtitle%253DChild%2Babuse%2B%2526%2Bneglect%26rft.stitle%253DChild%2BAbuse%2BNegl%26rft.aulast%253DMeadow%26rft.auinit1%253DR.%26rft.volume%253D26%26rft.issue%253D5%26rft.spage%253D501%26rft.epage%253D508%26rft.atitle%253DDifferent%2Binterpretations%2Bof%2BMunchausen%2BSyndrome%2Bby%2BProxy.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0145-2134%252802%252900326-5%26rft_id%253Dinfo%253Apmid%252F12079086%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [8]: /lookup/external-ref?access_num=10.1016/S0145-2134(02)00326-5&link_type=DOI [9]: /lookup/external-ref?access_num=12079086&link_type=MED&atom=%2Fpedsinreview%2F30%2F10%2F414.atom [10]: /lookup/external-ref?access_num=000175949600006&link_type=ISI

An emergency department intervention to protect an overlooked group of children at risk of significant harm

Background:Parental psychiatric disorder, especially depression, personality disorder and deliberate self-harm, is known to put children at greater risk of mental illness, neglect or physical, emotional and sexual abuse. Without a...

Evaluation and follow-up of cases diagnosed as child abuse and neglect at a tertiary hospital in Turkey

Aim: Data on child maltreatment in Turkey would appear to be scarce. This manuscript aims to address the prevalence and severity of child maltreatment in Turkey. Materials and methods: We report on 215 cases at the Ministry of Health’s Ankara Training and Research Hospital that were followed-up by the multidisciplinary Child Protection Team (CPT) between 1 January 2001 and 31 December 2005. The data collected on subjects included characteristics of the victims and the perpetrators, family demographics, maltreatment types, medical findings, mortality rate, and outcomes for the victim and the perpetrator. Results: Age and gender distribution of the victims were 6.8 ± 5.8 years and 58.1% girls. The perpetrators in 53.0% of the cases were the fathers, in 18.6% the mothers, and others in 28.4%. The categories of maltreatment were neglect in 39.5% of cases, physical abuse in 29.8%, psychological abuse in 21.4%, and sexual abuse in 9.3%. One hundred twenty cases (55.3%) were efficiently followed-up by the regional Social Service Agency (SSA). Re-abuse was reported in 8.3% of them. Following initial investigation of the 84 perpetrators, who were reported to the Forensic Medicine Institution by the Police Department, 17.8% were acquitted, 11.9% were convicted, and no legal action was taken for the rest. Conclusion: The knowledge and experience of the physician are extremely important for the diagnosis of child abuse and neglect. This study shows that a team approach to suspected cases of child abuse and neglect improves recognition and the reporting process.

Nonaccidental head trauma as a cause of childhood death

The authors present the demographic and clinical information in 36 children who died as a result of abusive head trauma at a Level 1 pediatric trauma center between January 1, 1997, and January 1, 2004. Abusive head trauma was defined as radiographic evidence of intracranial injury and documentation from a multidisciplinary child protection team that the injury was nonaccidental. There was no sex bias for the children in the 1st year of life (nine girls, nine boys). In children older than 1 year of age, boys were much more likely to be victims (14 boys, four girls). At the time of admission, every child exhibited a seriously impaired level of consciousness and 81% had retinal hemorrhages. Injuries to other organ systems were rare (17%). The most common abnormality found on neuroimaging studies was subdural hematoma. Six children underwent craniotomy for extraaxial hematomas. Death occurred within 24 hours after hospital admission in one half of the cases. Abusive head trauma was the cause of death in 36 (86%) of the 42 children whose deaths were classified as nonaccidental at the Children's Hospital in Denver between 1997 and 2003. The authors were unable to identify anything that could have been done from a medical or neurosurgical viewpoint to prevent the deaths of these children after they came to medical attention.