New Jersey's Statewide Child Fatality Near Fatality Review Board- Suicide Subcommittee: Implementation and Impact

Body of Abstract: Across the United States in 2022 (the most recent data available), suicide was the third leading cause of death of children aged 15-19, but the second leading cause of death for 10–14-year-olds (CDC, WISQARS, 2024). There was an almost 50% increase in rates of suicide for youth ages 12-17 from 2011 to 2021 (Saunders & Panchal, 2023), while the rate of suicide nearly tripled (0.9 to 2.9/100,000) for children ages 10-14 from 2007 through 2018 (Curtin & Garnett, 2023). While each state is federally mandated to have a child fatality review team (New Jersey, 2007), in 2016 New Jersey created a suicide-focused-subcommittee as an extension of the New Jersey Child Fatality Near Fatality State Review Board. Prior to the creation of the subcommittee, suicide cases were reviewed by the state regional teams. Unfortunately, from 2014 to 2015, New Jersey experienced a 46.7% (2014:15 to 2015: 22) increase in the number of suicides under the age of 18; thus, New Jersey decided to create a specialized statewide team to solely review the cases of suicide for youth 17 years old or under. The legislation that developed the state-wide review board was used to model the suicide-subcommittee team. Membership included prevention partners with expertise in their field including: ex-officio members from key state offices (Departments of Health, Human Services, Children and Families, Youth and Family Services, attorney general, state police, child advocate, medical examiner, New Jersey Taskforce on child abuse and neglect) and governor appointed public members (i.e., prosecutors association, law guardian, pediatrician, psychologist, social worker, public school educator and, provider with substance use experience). In existence since 2016, the Child Fatality Near Fatality Review Board (CFNFRB) – Suicide Subcommittee has reviewed 96 cases (24 per year, 22-26/year) and deemed 24% preventable. Based on reviews, the CFNFRB-Suicide Subcommittee provided recommendations to state child-serving systems, professional organizations, law enforcement, and the medical examiner’s office on issues believed related to preventability.

This presentation will discuss the creation of New Jersey's Child Fatality Near Fatality Review Board – Suicide Subcommittee outlining the model of the subcommittee and its membership and special guests. The multidisciplinary nature of the sub-committee allows for a wide-range of perspectives and dialogue breaking down silos between systems to implement future change and best practices. Details will be provided about the process and types of records (i.e. medical examiner reports, law enforcement/prosecutors office reports/records, school records, primary care/hospital records, mental health/NJ Department of Children and Families, Children’s System of Care documents and Department of Protection and Permanency case notes, obituary, and other documents) gathered for review. The presentation will provide case examples to demonstrate the typical review process for a case including identification of risk and protective factors and the vote of preventability. Challenges implementing a suicide-specific focused Child Fatality and Near-Fatality Review Board will be identified. Finally, the presentation will provide examples of the impact of the CFNFRB-SSC including creation of annual reports, identification of trends leading to recommendations for systems change and information shared (i.e., Hiding in Plain Sight Conference). The presentation will conclude with a Q&A, where participants will be able to ask specific questions of the panelists on specific programs and/or steps taken to collaborate, implement and evaluate the program.

Learning Objectives:

• Summarize the importance of a suicide subcommittee on a statewide child fatality review board
• List the benefits of a multi-disciplinary team’s review and analysis of the risk and protective factors for child suicide from a systems perspective
• Identify supplemental information that can be used to support/refute the ruling of suicide by the medical examiner.
• Summarize the benefits of a child fatality review board-suicide subcommittee and its influence for systems change to prevent child suicide.