Shaken Baby Syndrome: Investigating the Abusive Head Trauma Controversy

Description:

Since the early 2000s, a growing body of scientific studies in neuropathology, neurology, neurosurgery, biomechanics, statistics, criminology and psychology has cast doubt on the forensic reliability of medical determinations of Shaken Baby Syndrome (SBS), more recently termed Abusive Head Trauma (AHT). Studies have increasingly documented that accidental short falls and a wide range of medical conditions, can cause the same symptoms and findings associated with this syndrome. Nevertheless, inaccurate diagnoses, unrealistic confidence expression, and wrongful convictions continue to this day. Bringing together contributions from a multidisciplinary expert panel of 32 professionals across 8 countries in 16 different specialties, this landmark book tackles the highly controversial topic of SBS, which lies at the intersection of medicine, science, and law. With comprehensive coverage across multiple disciplines, it explains the scientific evidence challenging SBS and advances efforts to evaluate how deaths and serious brain injuries in infants should be analysed and investigated.

About This Book

This book tackles a highly controversial subject at the intersection of medicine, science, and law. We therefore want to make clear from the outset what this book is about and what it does and does not put into question.

Child abuse is a pervasive societal issue that has only recently received the consideration it deserves. Effective child protection systems are essential to detect and protect abused children.

Shaking is a form of physical child abuse that predominantly affects children under two years of age. Half a century ago, the British paediatric neurosurgeon Dr Norman Guthkelch noticed that many parents and caregivers were shaking their infants as a means of discipline [5]. Abusive shaking is assumed to be widespread around the world [8]. Sometimes parents and caregivers inflict intentional head trauma on infants and cause severe injuries.

The Importance of Clear Definitions

This book is not about child abuse in general; it is about the scientific reliability of a causal link between abusive shaking and a constellation of intracranial findings in infants. We wish to be precise with our definitions in order to facilitate rational discussion. In this book we employ the following definition: ‘Shaken baby syndrome’ (SBS) is the medical hypothesis according to which, with a few rare exceptions, all infants presenting with retinal and subdural haemorrhage possibly associated with bridging vein thrombosis with no history or evidence of major trauma are presumed to have been violently shaken moments before showing neurological compromise [1].

The medical establishment distanced itself from the term ‘shaken baby syndrome’ in the early 2010s and has instead been promoting an alternative terminology and definition: ‘Abusive Head Trauma (AHT) is the current most appropriate and inclusive diagnostic term for infants and young children who suffer from inflicted intracranial and associated spinal injury’ [2].

The Danger of Ambiguous Terms

Because they conflate a criminal act with a constellation of medical findings, both terms are highly ambiguous and lead to confusion. As Guthkelch himself declared 40 years after propounding his shaking hypothesis, the use of a more neutral term, such as ‘retino-dural haemorrhage of infancy’ (RDHI), is recommended. This term describes medical findings without presuming a unique aetiology [6]. The newer term ‘abusive head trauma’ (AHT) continues to purport to ‘diagnose’ abuse yet widens the range of associated medical findings and their potential causes (not only shaking but also impact) to such a degree as to be unhelpful.

This book uses the term SBS because it is specific and it encapsulates the very kernel of the issue: the claim that certain intracranial findings can alone (with no or minimal evidence of external trauma) be used as proof that shaking has occurred and that it was an intentional (or knowing or reckless or negligent) and hence abusive act. Our definition of SBS makes clear why it is at the intersection of medicine (retino-dural haemorrhage is a medical finding), science (a causality hypothesis that would require robust evidence), and law (the observation of specific medical findings indicates with near certainty that a crime has occurred).

The Core Issue: ‘Triad’-Based Medical Determinations of Abuse

Many physicians believe they can reliably determine that abuse has occurred based solely on the presence of RDHI. The term ‘triad’ is sometimes used to refer to the association of the two medical findings of RDHI with encephalopathy.

This belief relies on the false assumption that subdural and retinal haemorrhage are almost always traumatic in infants. Yet, as this book will show, the evidence base of a causal link between abusive shaking and RDHI is weak.

Furthermore, many other explanations for these medical findings (differential diagnoses) have been demonstrated over the years. The oft-repeated claim that these ‘rare’ causes are always meticulously excluded before concluding abuse as a default determination is misleading [3]. Few of these medical conditions are commonly accepted or examined but, most importantly, a determination by exclusion is dangerous as it ignores all potential explanations yet unidentified by medical science. It is this idea of a systematic default determination of abuse based on specific intracranial findings, now denied by some of the very same authors who supported it in the past, that we challenge in this book [7].

We also challenge the more general claim that medicine can reliably ‘diagnose’ child abuse. This usurps the role of the courts; abuse is a legal determination, not a medical diagnosis [4]. This book does not dispute that physical abuse is a likely determination in children with multiple unexplained traumatic injuries. That uncontroversial claim is not our focus.

A Legitimate Controversy

We recognise that many would prefer not to see the publication of this book, claiming that challenges to SBS by ‘denialists’ are dangerous and create the risk of encouraging abusive caregiver behaviour.

We do not deny that child abuse occurs.

We do not want anyone to read this book as presenting any claim that violently shaking or abusing a child is safe. Abusive behaviours are dangerous and must be prevented. Perpetrators must be criminally prosecuted.

We do not want anyone to believe this book could help actual perpetrators be exculpated. Rather, this book should help courts make the most informed decisions in each case by comprehending the real state of current scientific knowledge regarding RDHI, SBS, and AHT.

We do maintain that failure to engage in legitimate scientific inquiry and debate, and to rely prematurely on an inadequately supported hypothesis to remove children from their parents or send caregivers to prison, is itself abusive, unscientific and dangerous.

There are those who claim that challengers of SBS are attempting to create a medical controversy where there is none, in order to confuse judges and juries [2]. According to them, there is a near-universal consensus on the validity of SBS/AHT, a ‘diagnosis’ that is purportedly supported by dozens of professional societies around the world.

We do assert there is a legitimate controversy about SBS [4, 7]. As this book will show, many professionals do not agree with the ‘consensus’. More importantly, even a true medical consensus would not compensate for the dearth of valid, high-quality science to support SBS. Unfortunately, the lack of reliable scientific evidence is only apparent via a comprehensive, if not systematic, review of the thousands of relevant publications in the medical literature, especially outside of the narrow field of child abuse paediatrics.

The few who have had the time and energy to thoroughly review the literature have come to challenge the very hypothesis they initially believed in. Many of them have participated in writing this book in the hope of helping their colleagues comprehend the controversy with an open and critical mind.