Confessions are uncommon in abusive head trauma (AHT) cases, and there is debate over whether shaking alone can cause the injuries characteristic of AHT. The objective of this article is to correlate legal statements by perpetrators with medical documentation to offer insights into the mechanism of injury.
In this retrospective observational study we examined forensic evidence from 112 cases referred for AHT over a 7-year period. We compared 29 cases in which a perpetrator confessed to violence toward the child with 83 cases in which there was no confession. Inclusion criteria were subdural hematoma (SDH) on computed tomography and perpetrator admission of a causal relationship between the violence inflicted and the child's symptoms. Groups were compared by using Student's t test for age and Fisher's exact test for gender, death, fractures, retinal hemorrhages, ecchymoses, symptoms, and SDH patterns. All medical records from birth to diagnosis, imaging studies, and written investigation reports were reviewed.
All confessions came from forensic investigations. There was no statistically significant difference between the 2 groups for any of the variables studied. Shaking was described as extremely violent (100%) and was repeated (55%) from 2 to 30 times (mean: 10) because it stopped the infant's crying (62.5%). Impact was uncommon (24%). No correlation was found between repeated shaking and SDH densities.
This unique forensic case series confirms the violence of shaking. The high frequency of habitual AHT is a strong argument for reporting suspected cases to judicial authorities and helps to explain the difficulty in dating the injuries.
Comments
Confessions to shaking-type AHT
Conflict of Interest:
Formerly employed as a detective specialising in the investigation of child abuse and neglect.
Challenging the reliability of shaking confesssions as predictor of abuse
Dear Dr. Adamsbaum,
I read your recent study: “Abusive Head Trauma: Judicial Admissions Highlight Violent and Repetitive Shaking”.
I am one of many who do not believe that SBS is a real entity and that shaking is insufficient to cause brain injury without significant and obvious neck injury in a previously healthy child.
The thing I am writing about concerns your conclusion. If the physical findings were the same in both the confession and nonconfession group wouldn’t it be appropriate to conclude that shaking (as purported to be the cause of the findings in both groups), is not a variable that determines the presence of absence of the findings you measured, which were present, as you said, in both groups equally.
With the findings the same in both groups, your analysis of the nonconfession group as shakers, then becomes predicated on the belief or assumption that all the nonconfessors are liars and that they really did shake the babies but they won’t admit it. This seems farfetched considering that many cases of impact or medical problems produce the findings you ascribe to shaking and not every person who denies shaking is likely to be a liar or a person who is in a high risk category to abuse nor likely to abuse. In fact as you know many accused shakers seem to be the polar opposites of abusers, loving and experienced caregivers, who are very unlikely to “snap”, the key assumption in so many cases where allegations of abuse are made (probably including many of the 83 subjects who would not admit to shaking and probably denied doing anything to the babies and reported falls or other medical symptoms that are generally dismissed, for the most part out of hand).
If you did not rule in neck injury (Bandak) for all the brain injured babies, then the previous well documented findings that shaking produces about 10 g’s of force only and is insufficient to cause brain injury at it’s established threshold of 100g’s, renders the likelihood that shaking caused these injuries to zero.
I you have any thoughts about this I would be interested in hearing from you. As you know Leestma has studied shaking and confessions, and retrospective characterization of consoling and resuscitative shakes often are inappropriately taken as confessions of shaking. However, no matter whether a person says they shook a baby 1 or 30 times, if there are no neck injuries, which have a much lower threshold for damage then the brain, then shaking did not injure the brain of the previously healthy child, something else did (previous brain trauma as from birth (Rooks) with residual damage, infectious disease, cerebritis causing SDH and increased ICP, DIC, etc. and very often impact, either witnessed or occult).
I would hope that you and others will apply an depth evaluation of all other factors in the absence of neck injury for these cases since shaking is virtually certain to not the be the cause of IC pathology unless the child has had a previous brain injury, or if there is no previous injury, severe neck damage must be present to validate an abusive shaking event.
Best wishes,
Steven C. Gabaeff, M.D., F.A.A.E.M.
916 485 6706
[email protected]
Refs
Bandak FA. Shaken baby syndrome: A biomechanics analysis of injury mechanisms. Forensic Science International 151 (2005) 71–79.
Commonwealth v Ann Power, 2005. Report to the Middlesex County District Attorney’s Office Cambridge Massachusetts by Carole Jenny dated
December 29, 2005. Letters 319
Klinich K., Hulbert, G., Schneider, L., 2002. Estimating infant head injury criteria and impact response using crash reconstruction and finite element modeling. Stapp Car Crash Journal 46
Leestma JE. Case analysis of brain -injured admittedly shaken infants: 54 cases. Am J Forensic Med Pathol 2005; 26: 199– 212.
Leestma JE. SBS: Do confessions by alleged perpetrators validate the concept? J Am Phys Surg 2006;11:14-16.
Prange MT, Coats B, Duhaime A-C, Margulies SS. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. J Neurosurg 2003;
99:143-50.
Rooks VJ, Eaton JP, Ruess L, Petermann GW, Keck-Wherley J, Pedersen RC. Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR Am J Neuroradiol. 2008 Jun;29(6):1082-9
Conflict of Interest:
I have an active practice in Clincal Forensic Medicine for 22 years and Emergency Medicine for 32 years
A Window into AHT
Dear Editors: We would like to thank and commend Drs’ Adamsbaum, Grabar, Mejean, and Rey-Salmon for their report summarizing work over a 7 years period. Among the gut-wrenching confessions and inflicted trauma descriptions presented in the report, we found of particular interest, the documentation of retinal hemorrhages (Rh) in these cases. Specifically, the fact that in 5 of 29 cases no Rh was seen. In fact, 1 case in this series with no Rh documented did die (Case 25).
Although Drs. Kempe et al. (1962) in their seminal report did not describe ocular findings in the Battered Child Syndrome, Rh was found in 2 of 6 original “battered babies” reported by Dr. Caffey in 1946. Indeed, by 1974, Dr. Caffey himself believed that the “routine careful examination of the ocular fundi of all infants should provide a superior screening method” for AHT. On the other hand, just as the diagnosis of head injuries has reached a new level of sophistication with the utilization of MRI technologies, the characterization of orbital tissue injury in AHT has gone beyond mere presence or absence of Rh. As we examine the eyes closer, we find some characteristic and statistical differences in types of orbital tissue injury resulting from alleged AHT and clear accidental trauma. For example, perimacular folds and retinoschisis or the splitting of the retinal layers by hemorrhage are exceedingly rarely reported in the literature to result from accidental trauma. A recent review by Levin (2009) underscores the current sophistication of an ophthalmologist’s view of ocular injury in pediatric head injury. Furthermore, post-mortem examination of children who died of alleged AHT has also reached new levels of detail and sophistication. Wygnanski-jaffe et al. (2006) reported a comparison of post-mortem ocular and orbital findings in children who died of alleged AHT and those who died in accidents. Beyond Rh, they described regional optic sheath hemorrhage, regional orbital hemorrhage, and extraocular muscle hemorrhage.
Our questions for Drs’ Adamsbaum et al. include the following? Did an ophthalmologist with experience with this problem, apart from pediatric ophthalmology or retinal fellowship training, examine the eyes of these children after pupil dilation and using indirect ophthalmoscopy? Furthermore, in those children with abnormal retinal/ocular findings were retinal/ocular photography used to document the findings? In addition, we wondered about cases 5 and 14 (and indeed case 25) who died with undetermined Rh diagnosis and had post-mortem examinations whether the eyes were sent to an ophthalmic pathologist with expertise in this problem? Were there specific post-mortem evaluation of the eyes for Rh, optic sheath hemorrhage, orbital hemorrhage around the optic nerve, and extraocular muscle hemorrhage?
Finally, we would like to suggest that if perhaps as Drs’ Adamsbaum et al. had suggested that there may be a limit to the ability of brain imaging to discriminate between acute and chronic abuse and abuse and benign external hydrocephalus, then perhaps more sophistication in the documentation of ocular tissue injury, both pre and post-mortem, may offer a better “window” into the types of traumatic brain injury that affect children. Just as Drs. Kempe et al. recognized that “radiologic manifestations” of skeletal trauma are specific, we are recognizing more and more that ophthalmoscopic manifestations of AHT may also be quite specific. Moreover, we suggest that continued support for scientific inquiries into the mechanisms of ocular injury in trauma will surely continue to contribute to our understanding of pediatric traumatic brain injury and specifically, to AHT.
Conflict of Interest:
Clinicians and researchers with interest in AHT
Repeated non-fatal shakings
The information about the repeated shakings, with reversible loss of consciousness is a startling revelation from the confessions. This brings up the question of what physiologic mechanism produced this effect, the most likely being concussion or hypoxia from chest compression or other interference of respiration.
Concussion would be consistent with the prevailing hypothesis that shaking produces closed craniocerebral impact trauma, which has come under serious questioning. In the absence of actual head impact, I would favor the asphyxia mechanism, bringing this mode of injury into the same arena as the well known suffocation homicides, which are also believed to sometimes involve a repeated non-fatal precedent.
Further interrogation of perpetrators who convincingly confess to this mechanism of injury could throw more light on the possibility that asphyxia plays a significant part in the physiologic insults produced by shaking.
Dimitri L. Contostavlos, M.D. Forensic Pathologist
Conflict of Interest:
None declared