Media articles and legal cases continue to portray a purported controversy about the validity of the abusive head trauma (AHT) diagnosis. This “controversy” has translated into variable court outcomes. More concerning, data indicate that this misinformation is starting to impact child protection proceedings and future criminal prosecutions.
Thus, a revised AAP policy statement on AHT reminds pediatric practitioners of their fundamental responsibilities: high vigilance for the diagnosis and strong advocacy for the protection of children.
The policy Abusive Head Trauma in Infants and Children, from the AAP Council on Child Abuse and Neglect, is available at https://doi.org/10.1542/peds.2020-0203 and will be published in the April issue of Pediatrics.
In chatrooms and courtrooms, the science underlying AHT sometimes is misrepresented as “flawed,” “insufficient” or, more egregiously, as “an article of faith.” Although other authors have discussed the various rationales for these forums to portray a controversy, clinicians must be aware of the challenges such misinformation can present in the protection of children.
The revised AHT policy statement advises pediatric practitioners to be prepared to educate courts and community stakeholders on the science girding the diagnosis, as well as the extraneous or pseudoscientific theories sometimes offered as explanations for the findings seen in AHT.
Given the gravity of and anxiety caused by courtroom testimony, the policy highlights the prudence in consulting with a child abuse pediatrician prior to such efforts.
Scientific advancements
To help educate on the current evidence base underlying AHT, the policy statement reviews some recent advancements in AHT science, including the following:
- how refinements in our understanding of retinal hemorrhage patterns have increased the specificity of certain patterns (multilayered, too numerous to count and extending to the periphery) for AHT;
- how improvements in research on short falls have increased our epidemiologic precision for estimating the rarity of those accidental events to result in serious injuries or death in infants and young children; and
- how progress in the study of collective variables have identified clinical decision rules that can assist pediatric practitioners in determining whether to undertake AHT evaluations or obtain neuroimaging in suspected cases.
“The science behind abusive head trauma is very strong, even more so than when we issued our last policy 10 years ago,” said AAP President Sara “Sally” H. Goza, M.D., FAAP. “It’s our duty to distribute this information to our member pediatricians because we want to protect children, and we want accurate diagnoses.”
Challenges, responsibilities
The AHT diagnosis, like any child maltreatment diagnosis, is emotionally charged and strains the physician-parent relationship. Thus, the revised AHT policy statement highlights the importance of pediatric practitioners being thorough, neutral and open-minded.
“The role of the pediatric practitioner is not to apportion blame or investigate potential criminal activity but to identify the medical problem, evaluate and treat the child’s injuries, and offer honest medical information to parents, families, investigators, and attorneys/judges,” the statement notes.
Diagnosing AHT is difficult and complex. When feasible, it should be undertaken in a multidisciplinary team setting that includes social workers, investigators and pediatric practitioners. Ultimately, though, the policy concludes, “diagnosing AHT requires the same meticulousness, thoughtfulness, and comprehensiveness as any other medical diagnosis — no more and no less.”
Finally, the policy is a reminder of two other key pediatric practitioner functions: prevention and providing a medical home.
AHT prevention strategies can include implementing hospital and/or community-based education programs on the dangers of shaking, supporting targeted home-visiting programs such as nurse-family partnerships or advocating for legislative initiatives such as those that provide economic support for families (i.e., paid family leave or earned income tax credit). Additionally, prevention efforts can be as simple as knowing the detailed psychosocial makeup of patient families and whether numerous adverse childhood experiences pervade a child’s environment.
AHT leads to significant morbidity and mortality. An estimated one-third of children with AHT will have significant, lifelong disability. Because short- and long-term complications commonly occur, providing a medical home for patients with AHT ensures the best possible outcomes.
AHT is a challenging, impactful diagnosis for patients, families, pediatric practitioners and communities. The policy is a reminder for pediatric practitioners to remain vigilant for the diagnosis and strongly advocate for vulnerable infants and children.
Recommendations
The following are among the policy’s recommendations for pediatric practitioners:
- Perform a thorough, objective evaluation of infants and children who present with signs and symptoms of potential AHT. Consult subspecialists in areas such as radiology, ophthalmology, neurosurgery and general pediatric surgery for assistance.
- Consider contacting a subspecialist in child abuse pediatrics to ensure completeness of the medical evaluation and an accurate diagnosis.
- Continue to use the term abusive head trauma in diagnosis and medical communications, rather than a term that implies a single-injury mechanism, such as shaken baby syndrome.
- Report cases to child protective services when there is reasonable suspicion or reasonable cause to believe AHT has occurred. Be prepared to educate investigative agencies on the medical information that forms the basis of the suspicion.
- If called on to interact with legal and child protective agencies, be versed in the science underpinning AHT. Be prepared to educate stakeholders on supported and unsupported theories of causation commonly proffered in court.
- Educate parents and caregivers about safe approaches to soothing an infant, coping with crying and the dangers of shaking or striking a baby or impacting a baby’s head against a surface.
Dr. Narang is a lead author of the policy statement. He is a former member of the AAP Council on Child Abuse and Neglect and the Committee on Medical Liability and Risk Management.
