Abusive Head Trauma

Current Perspectives on Abusive Head Trauma

It is widely accepted that shaking a young child or infant is dangerous, yet education alone seems to be insufficient in preventing incidences of abusive head trauma (AHT). The main goal for professionals, caregivers, and parents alike is the elimination of child maltreatment. The rate for reports of maltreatment in 2000—12.2 per thousand—was the second lowest over the past decade; however, these are real children suffering physical and emotional pain. To prevent further occurrences of child maltreatment, caregivers must be given affirmative ways to handle the stresses of caring for children and provided incentives to consider those alternatives when faced with stressful situations.

AHT is a problem best addressed by a multidisciplinary team, including medical, investigative, legal, social service, and prevention professionals. This team approach has been formed over the course of the field’s history, from the first recognition of maltreatment in children through the development of its current level of knowledge and expertise.

Physical abuse by a caregiver has been recognized as a cause of traumatic injury in infants and children for nearly half a century. In 1961, the term battered child syndrome was coined by Dr. C. Henry Kempe as the title of the first multidisciplinary conference on the newly recognized problem of child abuse.1 This conference is credited with eliciting a great outcry on behalf of abused children and garnering much-needed support for further study of the problem. In 1962, the results of this conference were published in the Journal of the American Medical Association (JAMA),[2] and in 1968 the first edition of the text The Battered Child was published with Drs. Ray Helfer and Henry Kempe as editors. This landmark text contained contributions from many of Helfer and Kempe’s colleagues, not only in pediatrics but also in radiology, mental health, law, and social services. The latest edition,1 published in 1997, continues to present a multidisciplinary picture of the field of child maltreatment.

The term child maltreatment has replaced the original battered child syndrome term as a less offensive and all-encompassing way of describing the variety of injuries and illnesses in children caused by their caregivers. Thousands of children each year are seriously or permanently injured or killed by their caregivers. Many types of abusive injury have been described and studied since the 1960s, including skin surface injuries (ie, bruises, lacerations, and burns), bony trauma (ie, fractures), abdominal trauma, genital injuries, and head injuries, which are most frequently lethal. Any type of abusive injury should be regarded as serious and worthy of attention and study; however, abusive head trauma is the primary cause of death from abuse in infants and young children.3,4 In 2000 a total of 1200 children in the United States died from abuse or neglect. Statistics on these deaths are collected through the National Child Abuse and Neglect Data System, but may underestimate the actual problem because of a lack of national definitions as well as nonuniform child fatality investigation and autopsy methods throughout the United States. Most of these child abuse fatalities in infants and children younger than 2 years result from AHT. The entire multidisciplinary field of child maltreatment now exists due to the efforts of pioneering professionals, including thousands of professionals from the fields of law enforcement, medicine, law, social services, mental health, education, rehabilitation, prevention, and child advocacy. Over the last 4 decades, this field of study and service, which has been called by various names—child abuse, forensic pediatrics, and child maltreatment—has evolved into specialized subfields. This text focuses on that of abusive head injuries in infants and children, but injuries of many types are produced by maltreatment.

In 1946 pediatrician and radiologist Dr. John Caffey first questioned the association of bony injuries with head injuries in infants. He reported on 6 infants who suffered long-bone fractures and subdural hematomas.⁴ In none of his 6 cases was a history given to reasonably account for the presence of these injuries. One of the infants in Caffey’s 6 cases was noted to be “clearly unwanted by both parents,” causing the doctor to raise the question of possible intentional infliction of injury on the child. Caffey concluded in his report that the subdural hematomas and the long-bone fractures were caused by the same traumatic forces. He was the first to report such an association in medical literature. The presence of unrecognized traumatic injury in infants also caught the attention of Dr. Frederic Silverman, who in 1953 reported finding unsuspected fractures on routine presurgical radiographs in infants,6 reinforcing not only the prior radiographic findings of Caffey but also the lack of a credible history given by caregivers to account for the injuries. Woolley and Evans7 authored a paper describing 9 years of injury data from the Children’s Hospital of Michigan. They found that many children had skeletal injuries associated with trauma, but no history of a traumatic event was obtained from caregivers. Some of these children also had associated subdural hematomas. An unknown syndrome was postulated to describe these “nontraumatic findings.” In summarizing the study the authors stated, “It is difficult to avoid the overall conclusion that skeletal lesions having the appearance of fractures—regardless of history of injury or the presence or absence of intracranial bleeding—are due to undesirable vectors of force.” Public acknowledgement of maltreatment in children as a problem8 nudged the medical profession into paying closer attention to the possibility of child abuse as a cause of traumatic injury, even in the absence of a clear history of trauma. Twenty-six years after Caffey’s first report, following the important contributions of researchers such as Guthkelch9 and Ommaya,10-12 Caffey’s often-cited article, “On the Theory and Practice of Shaking Infants: Its Potential Residual Effects of Permanent Brain Damage and Mental Retardation” appeared in the American Journal of Diseases in Children. Just 1 year previously, Guthkelch’s article on the relationship of subdural hematomas found in infants to the mechanism of whiplash injuries was published in the British Medical Journal.9 By that time Caffey was convinced that the cause of these head injuries in infants was manual shaking by their caregiver. He recognized that the history given by these caregivers was falsified and theorized that they did so out of fear of recrimination for causing the injuries. In addition, Caffey noted the frequent presence of retinal hemorrhages and the absence of external injuries in some cases. The outcomes for his group of patients included permanent brain damage, mental retardation, and death. In 1974 Caffey14 used the term whiplash shaken infant syndrome to describe this constellation of intracranial injuries, long-bone fractures, and frequently found retinal hemorrhages. The term shaken baby syndrome (SBS) came into general usage in the 1980s and remains a well-recognized means of describing this deadly constellation of findings.

Forensic Investigations

According to the Uniform Crime Reports (UCR) compiled by the United States Department of Justice in the year 2000,1/496 children from birth to the age of 4 years were murdered (Table 21-1). Of these, 38 died from firearms, 18 by knives and cutting instruments, 34 by strangulation or asphyxiation, 16 by fire or explosives, 4 by narcotics or poison, and 79 by unknown or other weapons. However, the vast majority (305) died of blunt force trauma delivered by an object, hands, or feet. According to the UCR, 30 of the 305 children were killed by blunt force trauma in the presence of babysitters. Twenty-four of the 30 were killed by non–family members, who were twice as likely to be male than female offenders. According to this same study in 2000, the number of child murders committed by other children aged 4 years and younger was only 1. As children aged, this number increased only slightly (2 murders by children aged 5 to 8 years; 13 by children aged 9 to 12 years, 12 of which were committed by males). However, by the time children entered their teen years, these numbers increased at a greater rate. Between the ages of 13 and 16 years, 415 murders were committed (370 by males); and between the ages of 17 and 19 years, 1651 murders were committed. An overwhelming number of these teenage murders were committed by firearms versus blunt force trauma (954 committed by firearms versus 238 by all other types of weapons). These statistics support the knowledge that children in the United States aged 1 through 4 years are not being killed by other children. According to this same UCR report of homicides in the year 2000, not only are more young children killed by males than females, but more die from forms of blunt force trauma than all other types of trauma combined. Therefore, any time children younger than 4 years die from blunt force trauma not associated with motor vehicle collisions, the investigators must suspect abuse.

Children are more likely to die from blunt force trauma than adults. Blunt force trauma causes the majority of homicides in children aged 4 years and younger. In comparison, of all murders committed in the United States in 2000, 65.6% were committed with firearms, 13.5% with cutting instruments, and 11.7% by blunt objects or blunt trauma.

The nation’s UCR does not break down the death of children by suspect any further than to differentiate between murders by babysitters or other offenders. When the UCR was developed in the 1930s under FBI Director J. Edgar Hoover, child abuse was not recognized as a Part I crime, like aggravated assault (Table 21-2). Therefore, the UCR does not place the same emphasis on children who survive attempted murder by blunt force trauma (child abuse) as on adults who survive attempted homicide (aggravated assault). Consequently, other sources must be used to identify offender behavior in child abuse.

Prosecuting a Case

The Backdrop of Criminal Prosecution

Criminal prosecution of all child physical abuse or homicide cases is complicated by a belief held by the general public that any caregiver would never intentionally inflict harm on a child. The thought of the violence involved in serious or fatal head injury cases is so foreign to most people that they approach the task of being a juror on such cases with abnormal skepticism. Many also have preconceived notions that anyone who is capable of inflicting severe violence against infants or toddlers must have a history of anger-control problems as well as abuse of children and must appear to be a hardened criminal.

In fact, almost all surveys documenting the incidence of serious head injuries inflicted on young children illustrate that natural parents are the most frequent perpetrators of even fatal head injuries. Those who shake babies or cause other fatal head injuries often do not have a history of abusing children.^1,2 One of the first things prosecutors must do in the process of educating juries is to disavow jurors of the notion that child abusers look like criminals and that no caregiver would ever intentionally or knowingly inflict harm on a young child or infant. Although serious or fatal head injuries are rarely premeditated, the violence involved indicates at least a reckless disregard for the safety of children and in many cases an awareness of the risk of serious injury or death. The American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect recognized this in 1993:

While caretakers may be unaware of the specific injuries they may cause shaking, the act of shaking/slamming is so violent that competent individuals observing the shaking would recognize it as dangerous. . . . In some cases it is not clear whether there was an intent to inflict serious harm on the infant by shaking or a desire to stop the crying. In other cases, the careless disregard for the child’s safety and the force required to account for the intracranial and extracranial injuries suggest an intent by the caregiver to severely injure, if not kill, the infant or child.³

In a 2001 statement on abusive head trauma (AHT), the Committee on Child Abuse and Neglect of the AAP was even more concise, “The act of shaking leading to shaken baby syndrome is so violent that individuals observing it would recognize it as dangerous and likely to kill the child.” ⁴ Every criminal trial of an AHT case involves 2 key areas of inquiry. First, what happened to the child? Was the injury inflicted or could it have been caused by an accident, a disease process, or something else? If it was an inflicted injury, what type of mechanism would cause such an injury and what force would be involved? When was the injury likely inflicted? What is the significance of the entire collection of injuries found by medical professionals, when considered together? Secondly, if it was an inflicted injury, who committed the act that resulted in the injury? Once it is determined who likely committed the act, what does the evidence show concerning that person’s mental state at the time of the act? Were the injuries caused in a single loss of impulse control, or is there evidence that they were caused during extended beating or torturing of the child? Is there evidence that more than one person caused injury to the child, or that several persons acted together in harming the child? Is there evidence of chronic abuse of the victim, implying that the primary caregivers have been engaged in a pattern of abuse over time? These cases succeed or fail based on the prosecutors’ skill in providing the jury with information they need to resolve both of these key areas of inquiry. In addition, the elements of the crime must be proven beyond a reasonable doubt.

Although there are no reliable incidence surveys that take into account all inflicted child head injuries throughout the United States, those few surveys that have been conducted indicate that males, particularly natural fathers, are by far the most common perpetrators of such injuries to children.^1,5,6 In a small sample, boyfriends of the mother were most often perpetrators of fatal abuse. Often perpetrators are those who are young and not prepared to be a parent or who are surprised by the stresses involved with caring for an infant. The peak age for serious head injuries due to shaking of infants is between 2 and 4 months, the same age in development when babies are likely to cry, sometimes without apparent reason, even when all their needs have been met.⁷

Despite the prevalence of infants in serious or fatal head injury cases, there is no particular age limit for victims. The key factor seems to be disparity between size and strength of the perpetrator and the victim.8 Those who have handled several cases of AHT in children quickly recognize that there is no “profile” of these perpetrators. The only common denominator seems to be caregivers’ inability to quiet crying babies or, with older children, their reaction to toileting accidents or other perceived misbehaviors. Many perpetrators express feelings that they should have been able to quiet the baby and when they could not do so, they “just lost it” and did something they did not intend.⁹ For example, “Elijah’s Story” is a videotaped confession of a man who shook his baby to death in 1998. Many cases involve evidence that victims have been chronically abused, but those cases do not represent the majority.¹⁰ During the trial process, prosecutors must disavow jurors of the belief that defendants fit a perpetrator profile. Although fatal outcomes are rarely intended by those who commit these acts, prosecutors must convince jurors that these caregivers are no less culpable than those who commit intentional assaults, because the violence of the act of shaking or impacting a baby’s head is so extreme that anyone who is not mentally compromised must recognize it as dangerous.¹¹ For example, in People v Sargent, it was stated that “any reasonable person would recognize that shaking a four-and-ahalf- month-old . . . with the force equivalent to dropping him out of a second story window, was a circumstance or condition likely to result in great bodily harm.” This education process begins during jury selection, evolves through the opening statement and the introduction of expert medical testimony, and is reemphasized in the closing argument.

Although criminal cases in the United States must establish the guilt of the accused “beyond a reasonable doubt,” AHT cases involving young victims often must be proved beyond any doubt. Jurors and judges often cannot believe that anyone who appears “normal” to them could engage in such violence, and will often accept even implausible alternative explanations if those explanations fit within their general view of the world. This backdrop makes prosecution of this type of criminal child abuse among the most difficult tasks of prosecuting attorneys. The only way to succeed in these prosecutions is to obtain the best experts to make clear there is only one plausible conclusion concerning the cause of the injuries to the child and to establish that the mechanism and timing of those injuries indicates the defendant as the perpetrator of that violence. With the increasing use by criminal defendants of medical witnesses to support unscientific and untested theories as alternative expla- Abusive Head Trauma in Infants and Children: A Medical, Legal, and Forensic Reference nations to inflicted injuries, prosecutors must be prepared not only to generally educate triers of fact, but also to emphasize the critical points of the medical evidence through several experts, visual demonstrations, and illustrative aids refuting and exposing unscientific, speculative “possibilities” offered by opposing and sometimes irresponsible expert witnesses.

Working with Investigators and Consultants

The paradigm for most criminal investigations in the United States is to have the peace officer finish an investigation, then request a meeting with the prosecutor to review the investigative results and decide whether criminal charges should be filed. This traditional approach does not work well with serious cases of child abuse. These cases are so unique and challenging that most experienced child abuse prosecutors recommend that prosecuting attorneys work with investigators from the initial report of abuse until the trial and sentencing process is concluded. Experienced prosecutors also recommend that the same prosecutor should remain through every stage of the criminal case, even in jurisdictions in which normally 1 attorney files the charge and proves the case at a preliminary hearing and another attorney takes over to conduct the trial.¹² Legal complications are often raised at the outset of investigations, beginning with the investigator’s first contact with the child’s caregivers. Prosecutors can assist in guiding those early steps of the investigation in a way that will maximize the chance to obtain evidence that is admissible in a criminal trial. Even very experienced homicide detectives are often surprised to find that traditional methods for conducting a criminal investigation either do not work or are counterproductive in serious cases of child abuse.

Many local prosecutors across the country have formed or participate in interdisciplinary teams intended to bring together child protective service (CPS) workers, law enforcement investigators, medical professionals, mental health providers, educators, and others who play a role in ensuring that justice is appropriately sought for severely abused children. Such teams have been commonly reported on for improvement in professionalism and success rates in handling child abuse reports.12 The team approach to investigation can maximize the government’s ability to protect the victim and other children from further abuse and results in a balanced, wellinformed approach to criminal justice intervention in each case.

Before approaching the task of proving AHT cases involving young children, investigators and prosecutors should obtain a basic education on medical issues common to all of these cases. New research is being published consistently that advances the collective knowledge of all professionals in the field of maltreatment. Just as medical professionals continually update their knowledge by attending training conferences and reading new articles in the literature, attorneys must keep abreast of new developments related to AHT. To successfully prove AHT cases in court, prosecutors must understand which types of injuries to children’s heads might be consistent with accidental falls and which injuries or sets of injuries are consistent with abusive trauma. This general, foundational knowledge must be acquired before prosecutors try to grasp the unique medical issues and challenges raised by each case. Prosecutors must understand the basic differences in the effects of violent impact to children’s heads compared to violent rotational forces applied through shaking. Since both mechanisms are often involved in a single case, prosecutors must not limit themselves to alleging and proving shaken baby syndrome if in fact there are findings that go beyond that narrow form of AHT.

The medical field has reached substantial consensus concerning many of the issues pertinent to criminal cases.^3,4,13 However, each case inevitably presents new permutations of the core issues of mechanism of injury, degree of force involved in