Child Fatality Task Force
September 24, 2012
Minutes – Approved October 22, 2012
Members: Sen. Austin Allran, Sen. Bob Atwater, Sen. Stan Bingham, Cindy Bizzell, Dr. Elaine
Cabinum-Foeller, Rep. Dale Folwell, Trishana Jones (for Beth Froehling), Martha Sue Hall,
Paula Hildebrand, Rep. Craig Horn, Kevin Kelley, Dr. Martin McCaffrey, Karen McLeod, Earl
Marrett, Stephanie Nantz, Dr. Deborah Radish, Susan Robinson, Dr. Kevin Ryan, Rep. Paul
Stam, Angie Stephenson, Dr. Sarah Verbiest
Alan Dellapenna, Michelle Hughes, Belinda Pettiford
Guests: Carolyn Abdullah, Brenda Edwards, Marni Eisner, Dr. Dana Hagele, Catherine Joyner,
Cary Joureeny, Sarah McCracken Cobb, Amy Hattem, Jinx Keenan, Andrea Lewis, Amy
Mullenix, Amy O’Neal, Ann Nichols, Jan Parker, Melissa Radcliff, Krista Ragan, Kelly
Ransdell, Rosie Allen Ryan, Rob Thompson, Lynne Walter, Jennifer Woody, Jacob Yanicas,
Italics indicates by phone
Karen McLeod opened with a moment of silence.
Martha Sue Hall moved and Rep. Craig Horn seconded approval of minutes which were
unanimously affirmed.
Elizabeth Hudgins reported that CFTF co-chairs serve two year terms. As announced at the last
meeting, Ms. McLeod’s term was ending. She was willing to serve two more years. No one had
self-nominated or asked that someone else be contacted. Sen. Bingham moved and Kevin Kelley
seconded that Ms. McLeod be elected for another term as CFTF Co-chair. The motion was
unanimously affirmed.
Ms. McLeod noted that the day’s meeting was focusing on toxic stress – its different impacts on
children and their life trajectories, proven treatment methods, and policies to help build
resiliency to stressors.
All presentations are on the CFTF website under “Presentations.”
What Is Toxic Stress and Why Is It Bad
Michelle Hughes noted that healthy child development was the ultimate prize since the future
prosperity of North Carolina relies on the health and well-being of our next generation.
Healthy child development helps lay a strong foundation. Just as a solid foundation is critical to a
house, well-developed brain architecture is critical for a child. Our brains develop until about age
25, with many essential connections being made in the early years.
The building blocks for brains are called “neurons” and every experience – good and bad –
contributes to the developing or pruning of those neurons. Good experiences happen when
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children are responded in a positive way – for example when a baby coos and an adult smiles or
coos back. This is much like “serve and return” in a tennis game. Factors such as maternal
depression or low teacher ratios in child care facilities can interfere with the “serve and return”
young children need for sound development (as mothers are too depressed to be responsive or
teachers too thinly spread to pay attention to each child).
Toxic stress can hinder development. Examples of toxic stress include persistence violence,
natural disasters, untreated substance abuse or mental illness and domestic violence.
Brain scans show that abused and neglected children have less developed brains in the prefrontal
cortex, where rational decision making occurs. In contrast, the brain stem, sometimes called the
reptilian brain, is overdeveloped. That means that children may respond in “fight or flight” mode
in what seems like an inappropriate way (such as starting a fight over someone cutting in front of
them in the lunch line.)
A large scale study (17,000) of middle aged adults with health insurance shows that adults who
(based on self-report) suffered an Adverse Childhood Experience (ACE) were far more likely to
suffer depression or alcoholism, attempt suicide, or have chronic conditions, such as heart
disease and chronic obstructive pulmonary disease. The more ACEs a person had, the more
likely they were to have such conditions. Examples of ACE include abuse, domestic violence,
untreated household substance abuse or mental illness, incarcerated family member or divorce.
Dr. McCaffrey said that the ACE study was disputed and asked if it controlled for issues such as
genetic propensity for heart disease, noting that that sample size alone does not make for a good
study. Dr. Hagele responded that the massive sample size should help equally spread out such
risk factors; it is a large and compelling study documenting a strong correlation between
accumulation of risk factors and certain negative health conditions.
Dr. McCaffrey also had concerns about the wiring analysis. The studies he has seen have
concerns about the lack of taking genetics into account. Dr. Hagele said the studies she had seen
were very well done and looked at matched sets for genetic predisposition; abuse and other
trauma was associated with statistically significant changes in brain density. Also neuronal death
affects coagulation levels.
Dr. McCaffrey noted that cortisol level research was hit or miss and still in the hypothetical
stage. While the work was interesting, it was not definite. Dr. Hagele responded that a number of
well controlled biological and other studies linked increased cortisol to health outcomes.
Clinically, she sees that children with elevated stress levels have health conditions.
Dr. McCaffrey asked if this research had been sufficient to change the minds of previous naysayers? Have they now come out in support of these theories? Dr. Hagele noted that research
across a variety of fields points to stress and elevated cortisol as important factors in health.
Michelle Hughes added this research was embraced at a federal level and is being used by
federal agencies to guide child welfare policies. Karen McLeod contributed that building off
such research was also often incorporated into federal grant requirements.
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Dr. Elaine Cabinum-Foeller noted that bad stress does not affect everyone the same way; what
might be tolerable for one child may be toxic for another.
Sen. Bingham asked about the average age of the ACE participant and learned it was around 50.
Life Course
Dr. Sarah Verbiest provided an overview of the life course approach. This framework offers a
model for understanding what keeps some groups of people or populations from reaching their
full health potential and how health and disease happen over a life time. A key component of this
approach is about how decreasing risk and increasing protective factors can help improve health
over the life-course of an individual. This improved health in turn creates the foundation for the
health of that individual’s children someday. While the research is still growing, this is an
approach that has been embraced by the US Department of Health and Human Services/Health
Resources and Services Administration.
Public policy can decrease the risk or increase protective factors and may make it less likely that
someone may be unhealthy.
A risk factor does not mean that a given result will happen – but the odds of it happening are
increased. An example is a woman with a family history of breast cancer is statistically
significantly more likely to develop breast cancer herself, but may never contract the disease.
Breastfeeding and having a healthy lifestyle and weight are behaviors that can help reduce her
risk of disease. Having a genetic predisposition towards a condition does not mean that the
condition will happen. Certain environmental factors play a role. For example, someone with a
genetic predisposition towards tobacco addiction will not become addicted if they never try a
cigarette. Epigenetics means “beyond genetics” and studies how certain triggers can affect genes
– even genes of the next generation. This is an emerging area of research and focus. Other
theories that are part of the life course approach include the impact of cumulative stress, critical
periods of development, and the socio ecological model. Early programming is another facet of
this approach. One example is demonstrated by Barker’s Theory which suggests that if a
mother’s nutrition is suboptimal prior to pregnancy, then when she becomes pregnant her
developing fetus might not have adequate nutrition which could result in constricted pancreas,
lungs or other organ development and also low birth weight. This in turn can put the child at risk
for heart disease, diabetes and stroke when they become an adult. Dr. McCaffrey asked if it
related to low-birthweight or prematurity. Dr. Verbiest re-iterated the association to low
birthweight.
The implications of this work suggest the offspring of healthy people are more likely to be
healthy. As such the health of adolescents and young men and women is very important – not
only for their own well-being but for that of children they may have in the future.
Rep. Stam asked about preconception health generally. If a woman has health risks, if she
mitigates those risks before becoming pregnant, is that likely to improve birth outcomes? Dr.
Verbiest noted that any time in life was a good time to improve health behaviors however this is
particularly important for women and men of reproductive age as their health not only impacts
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them but the families they hope to have in the future. Since about half of pregnancies are
unintended supporting health for all young adults is important.
Dr. Verbiest continued. Health is not just a function of individual behaviors but is affected by
community and policies. How well you eat may be a function of with whom you eat and what is
available in your neighborhood. Tobacco use may be a coping mechanism for stress and anxiety.
Workplaces may have policies to allow smoking as an acceptable way to take a break, but not
going for a brief walk. Tobacco tax policy can affect how easy it is for people to obtain tobacco
products and it has been shown that for each small increase in a tobacco tax a certain percentage
of pregnant women and youth stop smoking.
Dr. Verbiest concluded that positive experiences and protective factors can increase one’s ability
to achieve optimal health while accumulated experiences associated with toxic stress and other
risks can deteriorate the health of an individual and their children.
Rep. Stam shared a recent study that found life expectancy was falling for lower educated
women. Dr. Verbiest noted that was why it was important to pay attention to access to health
care for women and to look at the larger issues that impact families and communities. In North
Carolina an average of 2 babies die each day. One way to look at these deaths is as one would
look at the canaries in the coal mine. We spend a lot of time trying to save the “canaries” but it
what we need to do is go into the mine. A final note, Dr. Verbiest noted that the pathways or a
person’s life trajectory are not set in stone.
Sen. Allran asked if there was any research on prescription drugs during pregnancy, including
on-line resources. Dr. Verbiest noted that some drugs were known to be harmful and that it was
important for women to consult with a doctor. Dr. Hagele noted that resources were also
available on-line. Dr. Ryan added there were many drugs where the affects for pregnant women
are not known as many people don’t want to do research on this population.
Rep. Folwell wondered if as a society we were less interested in infant mortality and low
birthweight. It seemed that it had been an area of focus without much improvement for many
years. Dr. Verbiest noted that the life course approach was considered a promising way to make
progress in the years to come.
Rep. Folwell had questions about the need to regulate lead paint, especially for isolated or
remote surfaces, such as steeples or the inside of motorcycle hubcaps.
Sen. Atwater asked if prescription drugs inserts or labels warned about risks of use during
pregnancy. Many do but women and/or their doctors may not know they are pregnant. Dr.
McCaffrey noted that mothers needed treatment too and that often meant weighing the risks and
benefits of certain drugs.
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Public Health Approach to Treating Chronic and Traumatic Stress
Dr. Dana Hagele is a child abuse pediatrician and co-director of the NC Child Treatment
Program. She presented on the key elements and outcomes of the program as a successful model
for treating and helping children overcome the negative impacts of toxic stress.
Examples of chronic stress include exposure to domestic violence, being abused or neglected.
Examples of traumatic stress include experiencing a natural disaster, seeing someone you loved
killed, and being abused.
Well-controlled studies show that untreated abuse and other toxic stressors are linked to IQ, and
social and physical functioning. It isn’t just something “kids get over” but rather a condition that
follows children across a lifetime. It extracts a personal and financial toll for both families and
society. The good news is that it is treatable.
Child functioning is often related to parent functioning. Community based services for children
and their families are often the optimal level of treatment, but too often not available in
communities. This leaves doctors with few options, including medication or congregant care,
such as therapeutic foster care or Psychiatric Residential Treatment Facilities. Alternatively, if
the trauma response is resulting is sufficiently anti-social behavior, the youth may become
involved with the juvenile justice system and maybe housed in Youth Development Center.
Community-based, evidence-based child mental health interventions have been proven to work.
These therapies are time limited – generally 20-30 sessions. They often involve the child and
parent (or another adult). They generally rely on therapies other than drugs and produce
demonstrable outcomes. Nationally, about 80% of children and parents get better. In NC, given
our strong implementation platform, closer to 90% get better. They are far less expensive than
“higher end” treatments, such as Psychiatric Residential Treatment Facilities and are also more
appropriate for more children.
Certain elements are essential to the success of these interventions, such as well-trained
clinicians. Even once trained, doctors must continue to be coached and supported to remain
effective. Doctors and others in the community need to know to refer to the specially trained
clinicians. The Child Treatment Program is a collaborative effort among Duke, UNC and the
National Center for Child Traumatic Stress. It helps provides those supports through an
implementation platform to help assure program fidelity and strong outcomes. Funding has come
through a patchwork of sources, most recently the Division of Social Services.
The Child Treatment Program costs less than $1800 per patient. In contrast, Medicaid Claims
data shows that the state paid $100 million for 1400 children in Psychiatric Residential
Treatment Facilities last year.
Sen. Bingham asked if some types of abuse or stress were more likely to need treatment. Dr.
Hagele noted that a variety of factors were in play. Sustained or one time? Abuse by a stranger or
someone who was supposed to be protecting the child? How resilient is the child prior to the
event? The age of the child is a factor. Environment also is a factor – being in a high combat
situation, such as in a home with domestic violence, makes anything else that much worse.
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Dr. Verbiest noted the link with life course – how this therapy was about changing life
trajectories.
Sen. Allran asked how children were identified in need of these services Dr. Hagele noted that
the initial referral may be for something else – if the disorder shows up as aggression, then they
may be referred by parent who will report that the school noted problems. Karen McLeod added
that lack of good, consistent screening was a challenge. She commended the Division of Social
Services for their work to screen more foster children.
Dr. Ryan asked if there was an estimate to the true size of the problem, given lack of screening
and referral. Dr. Hagele announced a group of experts was convening in a few weeks to begin
developing assessment tools to improve the trauma focus of the system to hopefully lead to
fewer initial misdiagnoses.
Promoting Protective Factors
Carolyn Abdullah from Prevent Child Abuse NC presented on what communities are doing
across the nation to help build protective factors of children and families.
The Center for Study of Social Policies has determined certain key protective factors that help
inoculate many children from having stressful events turn toxic:
 Parental resilience
 Social connections of parents (to advice, child care, etc.)
 Concrete supports in times of need
 Knowledge of parenting skills and child development
 Social and emotional competence of children
 Nurturing and attachment between children and parents
Many states are using protective factors framework to craft policies. Certain federal grants rely
on these criteria. Also, many states, such as North Carolina, are infusing this information into
professional development opportunity of staff. Parent Cafes and Community Cafes are
structured formats to involve more parents and/or community members in helping to promote
protective factors.
Michelle Hughes noted that the Cafes seemed a strong strategy for creating a grassroots
community base. Ms. Abdullah noted that was especially true for the Community Café, but even
that needed someone, generally a staff person with public or nonprofit agency, to organize it.
Karen McLeod summarized the big picture of the day noting that toxic stress and trauma creates
negative impacts, potentially life-long, for children. Evidence-based treatment and prevention
options can help mitigate and improve results. It is more effect and less expensive to intervene
earlier and avoid high-end placements, such as Psychiatric Residential Treatment Facilities.
Resources should be allocated to favor earlier and more effective treatments.
Sen. Allran raised concerns about information he was hearing that all children were given a test
or questionnaire in schools and then those answers were provided to a guidance counselor who
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may then prescribe drugs. Dr. Hagele noted that a school may urge a parent to seek medical
treatment for a child with behavior issues. The parent may then (perhaps inaccurately) say that
the schools say that the child needs medication. Dr. Cabinum-Foeller said that there was not
universal screening. Referral through the schools was generally more desirable than letting the
situation get worse so that the referral comes through the court. Rep. Folwell clarified that the
public schools would never prescribe a medication.
He also added that a recent study from NCSU, Notre Dame and Michigan found that ADHD was
often overdiagnosed and that was related to children starting school too young (which is why he
sponsored legislation on the age of children entering kindergarten).
Sen. Allran told about a friend of the family who was misdiagnosed with ADHD when she had
bipolar disorder. Because her real ailment was untreated, she attempted suicide.
Karen McLeod noted that was an example of why strong assessment was important. Paula
Hildebrand added that the mental health component of public education was very complex.
Committee Reports
Intentional Death Prevention: Dr. Cabinum-Foeller reported that last year IDPC took a step back
to look at violence against children, including homicide by parent or caregiver, juvenile
delinquency, child welfare and youth suicide. The mantra for the committee has become
“prevention is prevention is prevention.” The first meeting of this year included a presentation
from CCNC on monitoring work they are doing on the use of certain antipsychotic drugs
prescribed to foster children, improvements in homicide by parent or caregiver both throughout
NC and on military bases in NC, and Child Advocacy Centers.
The Committee also elected to bring to the full CFTF a recommendation that the CFTF endorse
efforts of Prevent Child Abuse NC requests the Medical Board to strongly encourage medical
professionals to recognize and report suspected child abuse and neglect.
Sen. Allran seconded the recommendation.
Rep. Stam was concerned about the wording that “all” professionals would be encouraged to
recognize and report abuse. Some professionals may not work with children and the statement
could open some doctors up to lawsuits.
Rosie Allen Ryan, President of PCANC, explained that the exact wording was still in
development. Specifically, the word “all” was a part of on-going discussion. The doctors and
other professionals working with PCA feel that the medical community has an ethical obligation
that goes beyond their specific field of practice. PCA will work with the Medical Board on the
final wording.
Dr. McCaffrey reiterated that such wording could be a problem for gerontologists and would
anticipate they may not like it.
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Dr. Cabinum-Foeller noted that doctors often held themselves to a higher ethical standard.
Additionally, all citizens are required by law to report – so the duty to report already exists for
gerontologists.
Dr. McCaffrey noted that elder and sex abuse should be reported as well, so why was child abuse
being lifted out and apart?
Rep. Horn offered a substitute motion that the
Child Fatality Task Force recommends that the word “all” be deleted from the final draft of
the Prevent Child Abuse NC recommendation to the Medical Board to strongly encourage
medical professionals to recognize and report child abuse and neglect.
Martha Sue Hall called the question. The substitute motion was unanimously affirmed.
Unintentional Death: Alan Dellapenna reported for the Committee. The previous meeting
focused on unintentional poisoning, the fastest growing cause of child death in NC. On a national
level, poisoning is overtaking motor vehicle crashes as the leading cause of injury death for all
ages. He clarified that prescription narcotics were driving the problem. Teens get the drugs from
medicine cabinets of families and friends. Family and friends get the substances from doctors
and prescriptions. The committee heard a variety of recommendations on how to curb doctor
shopping and shore up our monitoring system. These recommendations will be considered in
more detail at the November meeting. Martha Sue Hall encouraged all members to work with
the media in their area to get the word out about Saturday’s Operation Medicine Drop drug takeback event.
Perinatal Health: Belinda Pettiford reported for the committee. This committee has received the
most recommendations through the application process and she and co-chair Dr. Verbiest are in
the process of reviewing them. The September 5th meeting focused on updates on exciting work
being done through state and federal initiatives in NC, including advancing birth equities ,
promoting breastfeeding, reducing catheter infections (through the Perinatal Quality
Collaborative of NC) and other activities. We also heard an update to how Healthy Start is
adjusting to the loss of over $900,000. The next Perinatal Health Committee meeting will be
Wednesday, October 10th.
Directors Report
Elizabeth Hudgins reported on applications received: 28 submissions covering about 40-45
recommendations. UDC had 6 applications covering about 15 recommendations, most
addressing poisoning. IDPC received 5 applications with 5 recommendations, most dealing with
funding issues. PHC received 17 applications with about 25 recommendations, almost half
dealing with breastfeeding and many noting funding concerns.
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