Pseudo-controversies in Abusive Head Trauma John E. Wright, MD, FAAP Medical Director, Broward County Child Protection team
Epidemiology • The incidence of inflicted head trauma during the first or second years of life has been estimated in various studies to range from 16.1 to 33.8 cases/100,000 infants/y • Abusive head trauma appears to be the leading cause of infant homicide in the United States.
Epidemiology, (cont.) • The incidence of traumatic brain injury and/or fracture due to abuse was 21.9/100,000 in children less than 36m and 50.0/100,000 in children less than 12m.
Broward County, FL • 109,060 total population under age 4 • 452,754 total population under 19. • State Child Protection System, Local system administered by Sheriff’s Office with expert consultation by CPT for mandatory referrals.
Personal intro • Practicing pediatrics in Fort Lauderdale since 1987. • First saw child abuse in training at U of M • Serves as medical director of Broward CPT from 1989 to 1991 and 1999 to present • Described “abusive head crushing”
Commonality Factors In Safety and Risk Assessments for Reports with Findings
Economic drivers of junk science • Individual cases are unique, but not generally without precedent • Data collection is time sensitive • Input from multiple sources some with agendae • System reacts to case: • Civil system of child protection • Criminal system of prosecution of perp Information is filtered and re-presented in an illogical fashion
Economic drivers of junk science in the courtroom • Systemic response is cumbersom and susceptible to sabotage at multiple steps • Alternative hypothesis are not subjected to any testing or reasonable filters of medical knowledge. Their intention is to raise confusion and doubt. • Courtroom diagnoses are proffered • A variety of logical errors are exploited in the theatrical conflagration that ensues • The media loves it: free entertainment.
Alternative hypothesis themes (in no particular order) • Biomechanical • Same “expert” will state that there’s not enough force and that the findings could be cause by minimum trauma. • Blame the victim: it’s not trauma • Coagulopathy, connective tissue defect, temporary brittle baby, Blame the environment • vitamin/nutrient deficiency, environmental toxin
Alternative hypothesis (cont.) • Any test not ordered in the acute phase. • CPR/resuscitation efforts • Seizure • Infection • Older injury • Birth trauma • Spontaneous x • Arteriovenous malformation
Irresponsible expert tricks • Divide and conquer • Tease out a few abnormalities and pretend that they were causative rather than the result of the head injury • You forgot to check…serum porcelain level • Find some obscure ill-defined case report from the medical literature that was probably in itself missed child abuse.
Dealing with Irresponsible Expert Testimony • Question to the visiting expert: What Information regarding this case have you brought with you from wherever? • Examine writings/written opinions/previous testimony. • John Plunkett, MD Sudden Death in an Infant Caused by Rupture of a Basilar Artery Aneurysm, Am J. Forensic Medicine and Pathology, 20(2):211-214, 1999. • Cites in abstract that morphologic findings of ruptured aneurysm include retinal hemorrhage. • In case report notes: The eyes were not examined.
Ad nominem attack Argument from authority Argument from adverse consequences Appeal to ignorance Special pleading Begging the question Observational selection Suppressed evidence Weasel words Statistics of small numbers Inconsistency Non sequitur Post hoc, ergo propter hoc Meaningless question Excluded middle or false dicotomy Slippery slope Confusion of correlation and causation Straw man Carl Sagan’s Baloney Detection Kit
7 warning signs of bogus science • 1. discoverer pitches the claim directly to the media • 2. discoverer says that a powerful establishment is trying to suppress his/her work. • 3. The scientific effect involved is always at the very limit of detection • 4. evidence for a discovery is anecdotal • 5. discoverer says a belief is credible because it has endured for centuries • 6. discoverer has worked in isolation. • 7. discoverer must propose new laws of nature to explain an observation
Mathematician, Mark Kac “Proof: That which convinces a reasonable person. Rigorous Proof: That which convinces an unreasonable person.” Legal standard of Proof: ?
Consilience: Scientific evidence is accretionary • “Interesting” • “Suggestive” • “Persuasive” • “Compelling” • “Obvious”
“Interesting” • Catherine Welch : April 10th 1828. “ I am a surgeon and live at Fulham…the Eyes were a good deal suffused with blood…I opened the body after the inquisition, the internal parts were perfectly healthy, except the vessels of the brain and lungs, being overloaded with blood.”
Interesting/suggestive “ I asked my husband what he had done and he said he had taken the baby by the shoulders and must have shaken it too much…” Ethel Muckle, a neighbour said when she asked Strand what he had done he said “… I only shook the baby…”
NYT 1937 Joseph MOLINARI Prosecutor Boyfriend confesses he shook to death a 15 month old baby because “it bit me” “Suggestive/compelling”
Suggestive Dr. John Caffey, Multiple Fractures in the long bones of infants suffering from chronic subdural hematoma, American Journal of Roentgenology, 1946. • Dr. Caffey described 6 cases of his own and 6 cases that had been reported to him by other physicians. • “In each case the unexplained fresh fracture appeared shortly after the patient had arrived home from the hospital. In one case the infant was clearly unwanted by both parents and this raised the question on intentional ill-treatment.”
Compelling/persuasive • Virginia Jaspers • August 23rd 1956 shook 11 day old Abbey Kasparov to death. • Killed three children in her care in New Haven, USA. • Said that she had to shake the children, to‘bring the bubble up’.
Guthkelch, Infantile Subdural Haematoma and its Relationship to Whiplash Injuries, BMJ 1971 • “One must keep in mind the possibility of assault in considering any case of infantile subdural haematoma, even when there are only trivial bruises or indeed no marks of injury at all, and inquire, however guardedly or tactfully, whether perhaps the baby’s head could have been shaken.”
On the Theory and Practice of Shaking Infants: AJDC, 1972 • “During the last 25 years substantial evidence both manifest and circumstantial, has gradually accumulated which suggests that the whiplash-shaking and jerking of abused infants are common causes of the skeletal as well as the cerebrovascular lesions; the latter is the most serious acute complication and by far the most common cause of early death.”
Abusive Head Injuries • Subdural hemorrhage • Retinal hemorrhage • Brain injury (diffuse axonal injury) • Secondary effects (include): • seizures, • hypoxic-ischemic, • toxic metabolytes, • Swelling • Coagulopathy • Loss of autoregulation
Duhaime, et al • Described 48 cases at CHOP between 1978 and 1985. Autopsy findings of 13 fatalities: all fatal cases had signs of blunt impact to the head. In half of these impact site found only on autopsy. • All deaths assoc. with uncontrolled increased intracranial pressure. Small subdural collections.
Duhaime et al. • Part 2 of her NEJM article used a model with a single velocity transducer and measured peak change in velocity in shaking vs. impact (g force). Suggesting that shaking alone was not sufficient to cause brain injury. She cited:
Thibault and Gennarelli: Biomechanics of diffuse brain injuries, Proceedings of the Fourth Experimental Safety Vehicle Conference. New York: Am Assoc. of Automotive Engineers, 1985. • Cited by Duhaime et al as basis for biomechanical thresholds. • Used adult monkeys (rhesus,
More recent biomedical analyses Computer model (2 dimentional model of an axial skull and brain slice subjected to two seconds of four cycles/sec shaking): produced brain strains sufficient to produce traumatic axonal injury in the corpus calosum and cerebral pedicles, cingulategyrus, inferior frontal lobe, and inferior occipital lobe and most bridging veins developed sufficient skull/brain displacement to predict vein rupture. p
Shaking can cause Retinal hemorrhage Hemorrhage outside of optic nerve sheath Subdural hemorrhage DAI Cerebral edema death Impact can cause Skull fractures Subgaleal hemorrhage Visible bruises, abrasions, skin fxs Epidural hem. Focal findings Coup/contracoup Cerebral edema death AHT: Shaking and/or Impact?
Shaken Adult Syndrome • Derrick J. Pounder, MB, MRC Path, American Journal of Forensic Medicine and Pathology, 18(4):321-24, 1997. • 30 year old Palestinian collapsed under interrogation by Israeli General Security Service, declared brain dead 3 days later. • Extensive anterior chest and shoulder bruises, acute subdural hemorrhage, DAI, RH. Wt. 44.3kg, Ht151cm • All 3 pathologists agreed that the death was unnatural and the result of brain damage due to rotational acceleration of the head without direct impact.
Shaken Adult Syndrome • Disclosed in court proceedings that interrogation began at 4:45 am and continued until 4:10 pm. • Shaken 12 times, 10x grabbed by clothing 2x grabbed by shoulders. • “Collapsed with clouded consciousness, mucous fluid came out of his nostrils and fluid came bubbling out of his mouth.”
Maya • 61/2 week old • Last seen frisky and healthy the night before • Couldn’t lift head, 2 legs rigid, 3rd leg weak, • Couldn’t swallow or move tongue • Had been isolated in a special pen with her 3 year old mother and another mother and cub
Maya, cont. • MRI scan: Cerebral edema, loss of gray/white matter differentiation, increased signal on T2 weighted sequence. No significant mass effect. Prognosis good. • Clinical improvement; growling and batting at IV tubing by day #5.
Animal Models: Observations of Nature • Nature films showing young male lions shaking lion cubs (mother’s new boyfriend) • The Functional Anatomy of the Woodpecker • Predator hunting behaviors involving shaking of smaller prey; canine, feline.
IRRESPONSIBLE MEDICAL TESTIMONY • Krous and Chadwick (1997) described several features including: • Physicians without adequate background (e.g. training, don’t do research or see patients with regard to issue) • Contrived or far-fetched theories of causation • Not reproducible • Selective use of the literature
SHAKEN BABY SYNDROME • Probably the diagnosis that brings out the most “junk science” in the court • Media: • Newspapers - usually do a pretty good job • National television networks - awful to mediocre to excellent (thanks CNN!)
CPR • Claim: causes rib fractures and retinal hemorrhages • Truth: • Rib fractures do not occur in infants and young children (they bend) • A few petechiae or spots in very rare cases of children with existing bleeding tendencies (e.g. sepsis, DIC)
RESCUE SHAKING • Claim: Shook to revive. Amateurs, panicky. • Truth: • Doesn’t happen in cases where reason for revival is known • Not enough force, unless they are claiming abuse
SUBDURAL HEMORRHAGES • Claim: caused by trivial trauma or CPR • Truth: • Subdurals rarely seen with short falls - especially if no fracture • CPR does not cause subdurals
SBS IS NOT REAL • Claim: SBS is not real, it is all impact or something else.
SBS IS REAL • Truth: • Hundreds of articles in medical literature • 2 position papers by AAP • Statements by National Association of Medical Examiners, Canadian Pediatric Society • Statements by US Advisory Board on Child Abuse and Neglect • NO statement to the contrary by any major medical association
SBS IS REAL • Truth: • ICD - 9 code for “shaken infant syndrome” • Over 600 participants at four USA SBS conferences • International conferences in Sydney, Edinburgh – Montreal in Sept. 2004
SBS IS REAL • Starling S, et al. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Archives of Pediatrics and Adolescent Medicine 158:454-458, 2004.
SBS IS REAL • Retrospective look at 81 cases of admitted brain injury to 90 cases of in which no abuse admission was made • 68% of the confessed perpetrators said no impact – only shaking • 91% of the cases in which timing was described – symptoms were immediate. In 9% the timing was unclear. • NONE were normal after the event
SBS IS REAL Conclusions: • Symptoms are immediate • Most perpetrators admit shaking without impact • Relative lack of skull/scalp findings (vs. impact admitted cases) = shaking alone can produce the findings of SBS
CONTRARIANS • Statement in a highly publicized case – “more recently it has been shown that short falls can some times cause serious or fatal injuries” • Talk about the “new science” • YET – no data that really supports this • Example that some just do not want to see child abuse, especially with “nice” people
Dr. Ronald Uzcinski • SBS not real • Can’t generate severe enough forces • F=ma “It’s all about physics” [View shared in part by Vincent DeMaio, John Plunkett]
Dr. Ronald Uzcinski • In a recent Naples FL case he said that burping an infant can cause bleeding in the head • Also the infant straining with a bowel movement
LANTZ ET AL. 2004 • Reported that a 40 pound TV falling on a month old caused perimacular folds • Prior to this, such folds seen only with shaken baby syndrome Lantz PE, Sinal SH, Stanton CA, Weaver RG. Perimacular retinal folds from childhood head trauma. BMJ (2004) 328:754-756.