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Enhancing Fatality Review with Lessons from Brain Science

NCJ Number
Date Published
January 2021
40 pages

This report provides guidance to child death review (CDR) teams based on factors in child brain development that will enable CDR teams to better understand and identify factors that affect outcomes in child death cases and guide the development of community and state prevention efforts.


This report notes that by informing stakeholders of community factors in a child’s development that build resilience and safety, CDR teams can contribute to reducing health risks to children in the community. Fatality review is based in the social-ecological model, which identifies the interplay between risk factors across the four levels of individual, relationship, community, and society. The most effective protective interventions for children must consider factors that influence individuals, their relationships, the community, and society. A section of the report that provides an overview of brain science considers the development of healthy brain architecture, the impact of racism on the developing brain, stress responses, and adverse and positive childhood experiences. Other sections of this report address fatality review findings and recommendations under the social-ecological model and brain science. Practical guidance in implementing the social-ecological model addresses key questions a CDR team should ask during the investigation and the review meeting, data collection, and building individual and community resilience. Online access is provided to resources in Colorado’s efforts to build a child fatality prevention system that addresses the economic, social, and environmental conditions that support health and well-being. 2 figures and 4 online resources