History of CDR in the US


In 1978, Los Angeles started a team to better identify child abuse fatalities.


Teams expand to other states through grass roots efforts.


Landmark Missouri Child Fatality study validated that child abuse deaths are grossly underreported.  This leads to Missouri state law mandating reviews of all child deaths through age 14.

Child Death Review advocates, especially Michael Durfee of California and Gus Kolilis of Missouri, persistently encourage states to develop programs and begin to track implementation throughout the U.S.

U. S. Healthy People 2000 Objective in the Violence Section includes, “improve child death review systems.”


American Bar Association Center on Children and the Law receives Robert Wood Johnson Foundation funding for a Child Maltreatment Fatalities Project, and publishes Child Death Review Teams: a Manual for Design and Implementation and Child Fatality Legislation in the United States as resource to help organize child death review teams.


Dr. Michael Durfee et al published on the Origins and Clinical Relevance of Child Death Review Teams in JAMA. This publication describes the need to expand national implementation of CDR in response to a “critical need for the systematic evaluation and case management of suspicious child deaths.”

Maternal and Child Health Bureau (MCHB)/Health Resources and Services Administration (HRSA) convenes advisory group on CDR, which recommends that the primary purpose of CDR should be prevention and that teams should “implement the most expansive and comprehensive approach for identifying cases.”


Federal Child Abuse Prevention and Treatment Act (CAPTA) requires states to include information on child death review in their program plans.


Missing and Exploited Children Comprehensive Action Project holds two-day national training teleconference on child fatality review teams, with funding from the Department of Justice, Office of Juvenile Justice and Delinquency Prevention (OJJDP),

American Professional Society on the Abuse of Children forms Task Force on CDR and publishes special issue report on Child Fatalities.

Missouri convenes a national symposium on CDR. Forty-three states attend.


U.S. Advisory Board on Child Abuse and Neglect focuses on fatal abuse and in the report, A Nation’s Shame, findS that 45 states have some type of review program and recommends that there be a nationwide system of child death review teams to understand and reduce child abuse and neglect deaths.

Association of Maternal and Child Health Programs issues a paper recommending that MCHB assume leadership in assisting states in CDR development and that state Title V Directors develop CDR systems that focus on the prevention of all child deaths.


OJJDP funds the Interagency Council on Child Abuse and Neglect (ICAN) in Los Angeles to serve as a resource for CDR teams, with a focus on abuse and neglect. ICAN establishes the ICAN National Center for Child Fatality Review.  Funding continues through present day.

In the reauthorization of CAPTA, Congress requires each state to establish at least three Citizens Review Panels, and mandates that at least one of them review child maltreatment deaths and near deaths.


ABA Center on Children and the Law’s Child Fatality Project, with funding from the National Center on Child Abuse and Neglect in the Administration for Children, Youth and Families, holds national CDR training in Washington, DC and produces Child Fatality Training Curriculum and A Selected Annotated Bibliography of Resource Materials for Child Fatality Review Teams.

A number of states expand CDR reviews to all causes of child deaths (e.g. Arizona, Texas, Michigan, Colorado, Missouri, and Oregon.)  This trend continues today.

MCHB survey of state Title V programs finds that 15 of 41 state MCH programs are funding local CDR efforts.

MCHB convenes meeting of child death review, fetal infant mortality review and SIDS program experts to develop national recommendations for program coordination.


Midwest Coalition for Child Death Review is organized and holds its first annual meeting, and continues to meet annually thereafter.


U.S. Healthy People 2010 Injury Prevention Objective is changed to state: Extend state-level child fatality review of deaths to deaths due to external causes for children aged 14 years and under.

MCHB funds three states to develop review models integrating CDR, fetal infant mortality review, and/or maternal mortality review.

Southeast Coalition on Child Fatalities is organized and holds its first bi-annual conference.  Subsequent conferences are held in 2002 and 2005.

OJJDP establishes a national training program of several week-long training sessions on Child Death Investigation that include modules on child fatality review teams.


Western states meet for CDR training session in Lake Tahoe, coordinated by ICAN with funding from OJJDP.


National Fetal Infant Mortality Review Program publishes a special issue focused on the integration of CDR and FIMR.

MCHB awards three-year grant to Michigan Public Health Institute for National MCH Center for Child Death Review.


State Child Death Review program directors from 46 states convene in Chicago, funded through National MCH Center for Child Death Review.

National MCH Center for Child Death Review, with active participation of CDR staff from 25 states, develops National CDR Program Manual.

In the reauthorization of CAPTA, Congress recognizes that there may be a duplication of efforts in states with both Child Death Review and Citizens Review Panels and thus changes from mandatory to permissive the requirement of Citizen Review Panels to study child fatalities and near fatalities.  Fourteen states report that their child death review teams serve a dual function as a CAPTA Citizen’s Review Panel for Child Fatalities.

Results of a two-year study of the status of child death review teams in the U.S. are published in the American Journal of Preventive Medicine: Child Death Review, The State of the Nation.

Results of a review of child death review legislation conducted by researchers at the University of Louisville School of Medicine, funded by the U.S. Centers for Disease Control and Prevention and the Association of Teachers of Preventive Medicine, is published in the Journal of Law, Medicine and Ethics. 


Harborview Injury Center in Seattle obtains a grant from HRSA, MCHB, EMS-C to develop on-line decision-support site with an injury prevention focus for use by CDR teams, and develops strategies to facilitate effective prevention for CDR, using five Washington counties.

The State of Missouri, the National Child Death Review Resource Center and the Missouri Children’s Trust Fund sponsor the Second National Symposium on Child Death Review, attended by 350 persons from 36 states and three countries.

In February, the Association of State and Territorial Health Officers publishes Issue Brief, State Efforts to Improve Child Death Review, describing the status of CDR in the U.S. and stating that “CDR data and recommendations can help state and local public health agencies decide where to best invest their prevention dollars.”

National Conference of State Legislatures issues report, Preventing Child Fatalities, an overview of CDR; report includes list of state policy options for child death review.


Five regional meetings of state teams from the Northeast, Southeast, Midwest and West are held, with funding from MCHB through the National MCH Center for Child Death Review.

National MCH Center for Child Death Review’s Child Death Review Case Reporting System is launched as a pilot in 11 states.

New U.S. Healthy People 2010 Injury Prevention Objective is under consideration as measurable: Objective 15-6:  “Extend to 50, the number of states and the District of Columbia, where 100% of deaths to children aged 17 years and younger that are due to external causes, are reviewed by a child fatality review team, and 100% of all sudden and unexpected infant deaths (under one year of age) are reviewed.”

MCHB funds the National Center for Child Death Review for three more years, following a competitive review process.

All but one state (Idaho) report that they have state and/or local CDR teams reviewing child fatalities.


Five additional states join the CDR Case Reporting system.

Participating systems conduct an assessment of Version I of the Case Reporting system and improvements are made.

Healthy People 2010 Objective for CDR moves from the developmental stage to become an official objective.


Three additional states join the CDR Case Reporting system.


Center launches Version 2.0 of the CDR Case Reporting System

Six additional states join the CDR Case Reporting system.


National Symposium is held, bringing together CDR, MCH, and Injury Prevention leaders from every state through funding provided by HRSA/MCHB and the DOJ/OJJDP.

The CDC Division of Reproductive Health launches three-ear pilot to develop national SUID Case Registry, using child death review as the core reporting source.  The CDR Case Reporting System is expanded as Version 2.2S to include more data on SUIDs, and NCCDR and seven states are funded for the pilot project.

Senate Bill 1445 and House Bill 3212 are introduced in Congress. Bills include language to support state and local child death review and work of national CDR resource center.

NCCDR is awarded another three-year cooperative agreement, through June 2011.

Five additional states join the CDR Case Reporting system.


Healthy People 2010 Objective about child death review is expanded for Healthy People 2020 to

include SIDS and other Sudden Infant Deaths.

Five more states join Case Reporting System for total of 34.

Five national organizations including NCCDR form the National Coalition to End Child Abuse Deaths. The Coalition’s purpose is to elevate national attention and increase actions to prevent the more than 3,000 child abuse deaths each year in the US.


The U.S. Government Accountability Office publishes Child Maltreatment Fatalities Associated with Child Welfare Systems and reports to Congress, where NCCDR and others testify about fatal child abuse underreporting and a possible federal response.

NCCDR receives funding for its tenth year beginning July 1st.

National meeting of CDR state coordinators is held with funding from the CDC.  Forty-seven states are represented.

NCCDR is a founding member with other organizations of the Coalition Against Unsafe Sleep Environments (CAUSE) to bring attention to sudden and unexpected infant deaths (SUID) and encourage involvement of injury prevention professionals in addressing injury-related sleep-related deaths.

NCCDR adopts new name and branding; becomes the National Center for the Review and Prevention of Child Deaths.

Two additional states use the CDR Case Reporting System, and over 100,000 individual deaths are reported in the System.

NCRPCD sponsors national meeting of leaders from CDR and other review

processes, including FIMR, Domestic Violence, Citizens Review Panels, to foster coordination among review types.


NCRPCD supports meetings of four of the five regional coalitions of state CDR programs.

Center adopts Data Dissemination Policy containing procedure for researchers to apply to use CRS data for research, and appoints external committee of Federal partners, scientists and state CDR coordinators to consider and approve applications.

Idaho becomes 50th state to develop CDR program.

Three new states join SUID Case Registry.

Three additional states join the CDR Case Reporting system.

Sudden Unexpected Infant Deaths:  Sleep Environment and Circumstances, published in American Journal of Public Health.


Congress passes and President signs law establishing Commission to Eliminate Child Abuse

Fatalities.  President appoints NCRPCD Director to Commission.

With technical assistance from NCRPCD, Guam passes CDR legislation and begins the work to establish a CDR team.

Navajo Nation establishes its first CDR team.

Five additional states join the CDR Case Reporting system.

American Academy of Pediatrics (AAP) holds meeting of 30 pediatricians, Federal partners, and NCRPCD to develop AAP work to support Child Death Review.

Version 3.0 of Case Reporting System software is launched.  Forty-three states now use the system, and over 130,000 individual deaths are now in the database.

CDC with National Institutes of Health funds NCRPCD to develop CRS module on Sudden Death in the Young (SDY), to pilot the module in several states in 2014, and to establish tissue registry at University of Michigan to store DNA specimens of children who die of SDY.

CDC funds NCRPCD to develop curriculum on Safe Sleep for Native mothers with three tribes, in collaboration with Native American elders and grandmothers and using traditional native methods.

CDC funds NCRPCD to train Navajo tribe on Infant Death Scene Investigation.

Federal legislation to support Child Death Review is reintroduced in US Congress.