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Pseudo-controversies in Abusive Head Trauma John E. Wright, MD, FAAP Medical Director, Broward County Child Protection team.

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Presentation on theme: "Pseudo-controversies in Abusive Head Trauma John E. Wright, MD, FAAP Medical Director, Broward County Child Protection team."— Presentation transcript:

1 Pseudo-controversies in Abusive Head Trauma John E. Wright, MD, FAAP Medical Director, Broward County Child Protection team

2 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 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. Abusive head trauma appears to be the leading cause of infant homicide in the United States.

3 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. 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.

4 Broward County, FL 109,060 total population under age 4 109,060 total population under age 4 452,754 total population under ,754 total population under 19. State Child Protection System, Local system administered by Sheriffs Office with expert consultation by CPT for mandatory referrals. State Child Protection System, Local system administered by Sheriffs Office with expert consultation by CPT for mandatory referrals.

5 Personal intro Practicing pediatrics in Fort Lauderdale since 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

6 Commonality Factors In Safety and Risk Assessments for Reports with Findings Safety Factors in Verified and indicated reports AGE <= 4 Increased Vulnerabilit y Dom. Violence Hist. Criminal History Mental Health / Drugs Prior Report s Pattern of Incident s Unrelated visitor / or biologically unrelated person in household Percentage:

7 Economic drivers of junk science Individual cases are unique, but not generally without precedent Individual cases are unique, but not generally without precedent Data collection is time sensitive Data collection is time sensitive Input from multiple sources some with agendae Input from multiple sources some with agendae System reacts to case: System reacts to case: Civil system of child protection Civil system of child protection Criminal system of prosecution of perp Criminal system of prosecution of perp Information is filtered and re-presented in an illogical fashion

8 Economic drivers of junk science in the courtroom Systemic response is cumbersom and susceptible to sabotage at multiple steps 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. 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 Courtroom diagnoses are proffered A variety of logical errors are exploited in the theatrical conflagration that ensues A variety of logical errors are exploited in the theatrical conflagration that ensues The media loves it: free entertainment. The media loves it: free entertainment.

9 Alternative hypothesis themes (in no particular order) Biomechanical Biomechanical Same expert will state that theres not enough force and that the findings could be cause by minimum trauma. Same expert will state that theres not enough force and that the findings could be cause by minimum trauma. Blame the victim: its not trauma Blame the victim: its not trauma Coagulopathy, connective tissue defect, temporary brittle baby, Coagulopathy, connective tissue defect, temporary brittle baby, Blame the environment vitamin/nutrient deficiency, environmental toxin vitamin/nutrient deficiency, environmental toxin

10 Alternative hypothesis (cont.) Any test not ordered in the acute phase. Any test not ordered in the acute phase. CPR/resuscitation efforts CPR/resuscitation efforts Seizure Seizure Infection Infection Older injury Older injury Birth trauma Birth trauma Spontaneous x Spontaneous x Arteriovenous malformation Arteriovenous malformation

11 Irresponsible expert tricks Divide and conquer Divide and conquer Tease out a few abnormalities and pretend that they were causative rather than the result of the head injury 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 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. Find some obscure ill-defined case report from the medical literature that was probably in itself missed child abuse.

12 Dealing with Irresponsible Expert Testimony Question to the visiting expert: What Information regarding this case have you brought with you from wherever? Question to the visiting expert: What Information regarding this case have you brought with you from wherever? Examine writings/written opinions/previous testimony. 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): , John Plunkett, MD Sudden Death in an Infant Caused by Rupture of a Basilar Artery Aneurysm, Am J. Forensic Medicine and Pathology, 20(2): , Cites in abstract that morphologic findings of ruptured aneurysm include retinal hemorrhage. Cites in abstract that morphologic findings of ruptured aneurysm include retinal hemorrhage. In case report notes: The eyes were not examined. In case report notes: The eyes were not examined.

13 Carl Sagans Baloney Detection Kit Ad nominem attack Ad nominem attack Argument from authority Argument from authority Argument from adverse consequences Argument from adverse consequences Appeal to ignorance Appeal to ignorance Special pleading Special pleading Begging the question Begging the question Observational selection Observational selection Suppressed evidence Suppressed evidence Weasel words 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

14 7 warning signs of bogus science 1. discoverer pitches the claim directly to the media 1. discoverer pitches the claim directly to the media 2. discoverer says that a powerful establishment is trying to suppress his/her work. 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 3. The scientific effect involved is always at the very limit of detection 4. evidence for a discovery is anecdotal 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

15 Mathematician, Mark Kac Proof: That which convinces a reasonable person. Rigorous Proof: That which convinces an unreasonable person. Legal standard of Proof: ?

16 Consilience: Scientific evidence is accretionary Interesting Interesting Suggestive Suggestive Persuasive Persuasive Compelling Compelling Obvious Obvious

17 Interesting Catherine Welch : April 10 th Catherine Welch : April 10 th I am a surgeon and live at Fulham…the 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.

18 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… 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… … I only shook the baby…

19 Suggestive/compelling NYT 1937 NYT 1937 Joseph MOLINARI Prosecutor Boyfriend confesses he shook to death a 15 month old baby because it bit me

20 Suggestive Dr. John Caffey, Multiple Fractures in the long bones of infants suffering from chronic subdural hematoma, American Journal of Roentgenology, Dr. Caffey described 6 cases of his own and 6 cases that had been reported to him by other physicians. 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. 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.

21 Virginia Jaspers Virginia Jaspers August 23 rd 1956 shook 11 day old Abbey Kasparov to death. August 23 rd 1956 shook 11 day old Abbey Kasparov to death. Killed three children in her care in New Haven, USA. Killed three children in her care in New Haven, USA. Said that she had to shake the children, tobring the bubble up. Said that she had to shake the children, tobring the bubble up. Compelling/persuasive

22 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 babys head could have been shaken. 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 babys head could have been shaken.

23 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. 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.

24 Abusive Head Injuries Subdural hemorrhage Subdural hemorrhage Retinal hemorrhage Retinal hemorrhage Brain injury (diffuse axonal injury) Brain injury (diffuse axonal injury) Secondary effects (include): Secondary effects (include): seizures, seizures, hypoxic-ischemic, hypoxic-ischemic, toxic metabolytes, toxic metabolytes, Swelling Swelling Coagulopathy Coagulopathy Loss of autoregulation Loss of autoregulation

25 Duhaime, et al Described 48 cases at CHOP between 1978 and 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. Described 48 cases at CHOP between 1978 and 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. All deaths assoc. with uncontrolled increased intracranial pressure. Small subdural collections.

26 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: 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:

27 Thibault and Gennarelli: Biomechanics of diffuse brain injuries, Proceedings of the Fourth Experimental Safety Vehicle Conference. New York: Am Assoc. of Automotive Engineers, Thibault and Gennarelli: Biomechanics of diffuse brain injuries, Proceedings of the Fourth Experimental Safety Vehicle Conference. New York: Am Assoc. of Automotive Engineers, Cited by Duhaime et al as basis for biomechanical thresholds. Cited by Duhaime et al as basis for biomechanical thresholds. Used adult monkeys (rhesus, Used adult monkeys (rhesus,

28 More recent biomed studies.

29 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, cingulate gyrus, inferior frontal lobe, and inferior occipital lobe and most bridging veins developed sufficient skull/brain displacement to predict vein rupture. p

30 AHT: Shaking and/or Impact? Shaking can cause Shaking can cause Retinal hemorrhage Retinal hemorrhage Hemorrhage outside of optic nerve sheath Hemorrhage outside of optic nerve sheath Subdural hemorrhage Subdural hemorrhage DAI DAI Cerebral edema Cerebral edema death death Impact can cause Skull fractures Subgaleal hemorrhage Visible bruises, abrasions, skin fxs Epidural hem. Focal findings Coup/contracoup Cerebral edema death

31 Shaken Adult Syndrome Derrick J. Pounder, MB, MRC Path, American Journal of Forensic Medicine and Pathology, 18(4):321-24, Derrick J. Pounder, MB, MRC Path, American Journal of Forensic Medicine and Pathology, 18(4):321-24, year old Palestinian collapsed under interrogation by Israeli General Security Service, declared brain dead 3 days later. 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 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. 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.

32 Shaken Adult Syndrome Disclosed in court proceedings that interrogation began at 4:45 am and continued until 4:10 pm. 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. 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. Collapsed with clouded consciousness, mucous fluid came out of his nostrils and fluid came bubbling out of his mouth.

33 Maya 61/2 week old Last seen frisky and healthy the night before Couldnt lift head, 2 legs rigid, 3 rd leg weak, Couldnt swallow or move tongue Had been isolated in a special pen with her 3 year old mother and another mother and cub

34 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.

35 Animal Models: Observations of Nature Nature films showing young male lions shaking lion cubs (mothers new boyfriend) Nature films showing young male lions shaking lion cubs (mothers new boyfriend) The Functional Anatomy of the Woodpecker The Functional Anatomy of the Woodpecker Predator hunting behaviors involving shaking of smaller prey; canine, feline. Predator hunting behaviors involving shaking of smaller prey; canine, feline.

36 IRRESPONSIBLE MEDICAL TESTIMONY Krous and Chadwick (1997) described several features including: Krous and Chadwick (1997) described several features including: Physicians without adequate background (e.g. training, dont do research or see patients with regard to issue) Physicians without adequate background (e.g. training, dont do research or see patients with regard to issue) Contrived or far-fetched theories of causation Contrived or far-fetched theories of causation Not reproducible Not reproducible Selective use of the literature Selective use of the literature

37 SHAKEN BABY SYNDROME Probably the diagnosis that brings out the most junk science in the court Probably the diagnosis that brings out the most junk science in the court Media: Media: Newspapers - usually do a pretty good job Newspapers - usually do a pretty good job National television networks - awful to mediocre to excellent (thanks CNN!) National television networks - awful to mediocre to excellent (thanks CNN!)

38 CPR Claim: causes rib fractures and retinal hemorrhages Claim: causes rib fractures and retinal hemorrhages Truth: Truth: Rib fractures do not occur in infants and young children (they bend) 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) A few petechiae or spots in very rare cases of children with existing bleeding tendencies (e.g. sepsis, DIC)

39 RESCUE SHAKING Claim: Shook to revive. Amateurs, panicky. Claim: Shook to revive. Amateurs, panicky. Truth: Truth: Doesnt happen in cases where reason for revival is known Doesnt happen in cases where reason for revival is known Not enough force, unless they are claiming abuse Not enough force, unless they are claiming abuse

40 SUBDURAL HEMORRHAGES Claim: caused by trivial trauma or CPR Claim: caused by trivial trauma or CPR Truth: Truth: Subdurals rarely seen with short falls - especially if no fracture Subdurals rarely seen with short falls - especially if no fracture CPR does not cause subdurals CPR does not cause subdurals

41 SBS IS NOT REAL Claim: SBS is not real, it is all impact or something else. Claim: SBS is not real, it is all impact or something else.

42 SBS IS REAL Truth: Truth: Hundreds of articles in medical literature Hundreds of articles in medical literature 2 position papers by AAP 2 position papers by AAP Statements by National Association of Medical Examiners, Canadian Pediatric Society Statements by National Association of Medical Examiners, Canadian Pediatric Society Statements by US Advisory Board on Child Abuse and Neglect Statements by US Advisory Board on Child Abuse and Neglect NO statement to the contrary by any major medical association NO statement to the contrary by any major medical association

43 SBS IS REAL Truth: Truth: ICD - 9 code for shaken infant syndrome ICD - 9 code for shaken infant syndrome Over 600 participants at four USA SBS conferences Over 600 participants at four USA SBS conferences International conferences in Sydney, Edinburgh – Montreal in Sept International conferences in Sydney, Edinburgh – Montreal in Sept. 2004

44 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: , Starling S, et al. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Archives of Pediatrics and Adolescent Medicine 158: , 2004.

45 SBS IS REAL Retrospective look at 81 cases of admitted brain injury to 90 cases of in which no abuse admission was made 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 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. 91% of the cases in which timing was described – symptoms were immediate. In 9% the timing was unclear. NONE were normal after the event NONE were normal after the event

46 SBS IS REAL Conclusions: 1. Symptoms are immediate 2. Most perpetrators admit shaking without impact 3. Relative lack of skull/scalp findings (vs. impact admitted cases) = shaking alone can produce the findings of SBS

47 CONTRARIANS Statement in a highly publicized case – more recently it has been shown that short falls can some times cause serious or fatal injuries 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 Talk about the new science YET – no data that really supports this YET – no data that really supports this Example that some just do not want to see child abuse, especially with nice people Example that some just do not want to see child abuse, especially with nice people

48 Dr. Ronald Uzcinski SBS not real SBS not real Cant generate severe enough forces Cant generate severe enough forces F=ma Its all about physics F=ma Its all about physics [View shared in part by Vincent DeMaio, John Plunkett]

49 Dr. Ronald Uzcinski In a recent Naples FL case he said that burping an infant can cause bleeding in the head 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 Also the infant straining with a bowel movement

50 LANTZ ET AL Reported that a 40 pound TV falling on a month old caused perimacular folds 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 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:

51 LANTZ ET AL In an editorial in the BMJ, Geddes and Plunkett extrapolated this to retinal hemorrhages and said whole concept of SBS is untrue In an editorial in the BMJ, Geddes and Plunkett extrapolated this to retinal hemorrhages and said whole concept of SBS is untrue Comment: Based on one controversial case of a TV crush injury? Comment: Based on one controversial case of a TV crush injury?

52 GEDDES Has published several articles showing deep brain damage with shaking Has published several articles showing deep brain damage with shaking Thinks secondary to hypoxia Thinks secondary to hypoxia Has speculated that mild shaking might cause more SBS than we think Has speculated that mild shaking might cause more SBS than we think Has claimed microscopic intradural hemorrhages present in many situations (most think of this as an artifact – not the larger SDH of SBS) Has claimed microscopic intradural hemorrhages present in many situations (most think of this as an artifact – not the larger SDH of SBS)

53 GEDDES Why not same findings in drownings if hypoxia is the mechanism? What about retinal hemorrhages? Why not same findings in drownings if hypoxia is the mechanism? What about retinal hemorrhages? While her speculation is seemingly opposite of others saying shaking not enough to cause serious brain damage, they seem to have no problem disputing mainstream SBS wisdom While her speculation is seemingly opposite of others saying shaking not enough to cause serious brain damage, they seem to have no problem disputing mainstream SBS wisdom

54 GEDDES Retracted her hypothesis in British court Retracted her hypothesis in British court But others still use it But others still use it

55 Dr. Tom Nakagowa If f = ma, and a = gravity (a constant) If f = ma, and a = gravity (a constant) Then f ~ m Then f ~ m Then bigger m leads to bigger f Then bigger m leads to bigger f The bigger you are, the harder you fall The bigger you are, the harder you fall When adults fall off couches, they hit the floor much harder. When adults fall off couches, they hit the floor much harder.

56 Dr. Tom Nakagowa Why do adults commit suicide by jumping off of bridges/buildings – when the couch or bed would do? Why do adults commit suicide by jumping off of bridges/buildings – when the couch or bed would do?

57 Geddes notion Single shake models Time (# of shakes) Force Human range BIOMECHANICS OF SHAKING

58 KEY DAMAGE ISSUES It is the brain damage that causes serious injury or death. Not the secondary injuries of bleeding in the retina or intracranial spaces It is the brain damage that causes serious injury or death. Not the secondary injuries of bleeding in the retina or intracranial spaces Not a mass effect issue Not a mass effect issue SBS brain injury is not superficial, but involves deeper structures. (Pattern of atrophy in survivors is different than seen with isolated contact injuries.) SBS brain injury is not superficial, but involves deeper structures. (Pattern of atrophy in survivors is different than seen with isolated contact injuries.)

59 KEY DAMAGE ISSUES Arguments against mainstream opinion tend to focus on the secondary injuries (especially SDH) and lightly dismiss the brain injury and retinal hemorrhages Arguments against mainstream opinion tend to focus on the secondary injuries (especially SDH) and lightly dismiss the brain injury and retinal hemorrhages

60 SHORT FALLS CAN KILL Van EE and others (engineers, physicists) do models and claim short falls can kill Van EE and others (engineers, physicists) do models and claim short falls can kill Truth: Truth: They do not apparently know or care about real world data They do not apparently know or care about real world data

61 ACCIDENTAL FALLS Claim: Short falls cause serious or fatal injuries. SBS injuries look like short fall injuries. Claim: Short falls cause serious or fatal injuries. SBS injuries look like short fall injuries. Truth: Truth: Frequently the excuse Frequently the excuse Extensive review of fall studies does not support serious injuries (e.g. Helfer et al, 1977; Chadwick et al, 1991; see Alexander, Levitt, and Smiths upcoming chapter). Extensive review of fall studies does not support serious injuries (e.g. Helfer et al, 1977; Chadwick et al, 1991; see Alexander, Levitt, and Smiths upcoming chapter).

62 ACCIDENTAL FALLS (CONT) Experience shows that children are constantly having short falls without serious injury Experience shows that children are constantly having short falls without serious injury Like a single shake Like a single shake Retinal hemorrhages almost never seen and should not be extensive Retinal hemorrhages almost never seen and should not be extensive Strong evidence of impact Strong evidence of impact

63 ACCIDENTAL FALLS (CONT) About 1% of children falling 3 feet to a hard surface will have a short fracture to the side of the head About 1% of children falling 3 feet to a hard surface will have a short fracture to the side of the head They do not have significant brain injury They do not have significant brain injury

64 ACCIDENTAL FALLS Killer beds, killer couches Killer beds, killer couches Patterns of injury with accidental impacts do not look like SBS Patterns of injury with accidental impacts do not look like SBS

65 DUHAIME ET AL, 1987 Study found 13 dead SBS victims - all had signs of head impact Study found 13 dead SBS victims - all had signs of head impact Models and testing suggested that shaking alone not sufficient to cause serious injury or death Models and testing suggested that shaking alone not sufficient to cause serious injury or death Forces are immense Forces are immense SBS cases should be called shaken-impact syndrome SBS cases should be called shaken-impact syndrome

66 DUHAIME ET AL, (CONT.) At least a dozen data-based studies since then all have found shaking is sufficient. No other study shows impact is necessary. At least a dozen data-based studies since then all have found shaking is sufficient. No other study shows impact is necessary. Thus there is no controversy Thus there is no controversy It does not matter in court anyway - it is all violent abusive head trauma It does not matter in court anyway - it is all violent abusive head trauma

67 DUHAIME ET AL, (CONT.) Note: Duhaime says the forces are worse than the most violent shaking Note: Duhaime says the forces are worse than the most violent shaking Those who think shaking is sufficient also believe in extreme forces being necessary Those who think shaking is sufficient also believe in extreme forces being necessary Thus the perpetrator was violently abusive Thus the perpetrator was violently abusive Duhaime AC, Gennarelli TA, Thibault LE, Bruce BA, Margulies SS, Wiser R. The shaken baby syndrome. A clinical, pathological, biomechanical study. J Neurosurg (1987) 66:

68 RE-BLEEDS Claim: These cases have an old injury (timing is too uncertain to establish perpetrator) and a re-bleed of the subdural causes new subdurals, retinal hemorrhages, and can be fatal Claim: These cases have an old injury (timing is too uncertain to establish perpetrator) and a re-bleed of the subdural causes new subdurals, retinal hemorrhages, and can be fatal [Dr. Jan Leetsma often claims this, Plunkett and Uzcinski sometimes also] [Dr. Jan Leetsma often claims this, Plunkett and Uzcinski sometimes also]

69 RE-BLEEDS Truth: Truth: Any scab will ooze blood with small trauma prior to complete healing Any scab will ooze blood with small trauma prior to complete healing After several weeks of healing, a subdural hematoma will form delicate new blood vessels After several weeks of healing, a subdural hematoma will form delicate new blood vessels Minor head trauma can cause re-bleed Minor head trauma can cause re-bleed No associated retinal hemorrhages or cerebral edema No associated retinal hemorrhages or cerebral edema

70 RE-BLEEDS Slow process Slow process Possibly expanding head size Possibly expanding head size Increasing lethargy Increasing lethargy Diminished appetite Diminished appetite

71 RE-BLEEDS VS. SBS Re-bleeds should not be sudden or fatal Re-bleeds should not be sudden or fatal SBS is primarily a brain injury, re-bleeds are not SBS is primarily a brain injury, re-bleeds are not The presence of old injuries, new intracranial bleeding, retinal hemorrhages,and clinical signs of brain injury = old and new SBS The presence of old injuries, new intracranial bleeding, retinal hemorrhages,and clinical signs of brain injury = old and new SBS Second shaking needs to be violent as well Second shaking needs to be violent as well

72 VACINNATIONS Claim: DPT shot causes SBS Claim: DPT shot causes SBS [Vera Schribner – paleoarcheologist from Australia is active on the internet] [Vera Schribner – paleoarcheologist from Australia is active on the internet] Truth: No Truth: No No mechanism for this No mechanism for this No evidence for this No evidence for this

73 METABOLIC DISEASE Claim: metabolic diseases mimic SBS Claim: metabolic diseases mimic SBS e.g. Glutaric aciduria e.g. Glutaric aciduria unspecified others unspecified others

74 METABOLIC DISEASES Truth: Truth: Name the metabolic condition Name the metabolic condition Bleeding diseases usually cause fatty livers Bleeding diseases usually cause fatty livers SBS is not a bleeding disease SBS is not a bleeding disease Metabolic diseases do not suddenly appear and disappear Metabolic diseases do not suddenly appear and disappear

75 CHILD IS TOO OLD FOR SBS Claim: SBS happens only to children under 1 or 2 years of age Claim: SBS happens only to children under 1 or 2 years of age Truth: Truth: Most under 1 year, some between 1-2 years, less 2 year olds, rare 3 or 4 year olds Most under 1 year, some between 1-2 years, less 2 year olds, rare 3 or 4 year olds Physiologically can happen at any age Physiologically can happen at any age SIZE is the issue SIZE is the issue

76 CHILDREN ARE UNIQUELY VULNERABLE Claim: children are easily damaged because of weak neck muscles, large heads, etc. Claim: children are easily damaged because of weak neck muscles, large heads, etc. Truth: Truth: No literature to support assertion of weak neck muscles No literature to support assertion of weak neck muscles No data to show that childs physiology puts them at extra risk No data to show that childs physiology puts them at extra risk

77 CHILDREN ARE UNIQUELY VULNERABLE Brain fits inside skull - no room to bang around in it Brain fits inside skull - no room to bang around in it Adults could not resist a 2000 pound gorilla, and their physiology would not help Adults could not resist a 2000 pound gorilla, and their physiology would not help Note: this claim blames the victim! Note: this claim blames the victim!

78 RETINAL HEMORRHAGES ALWAYS MEAN SBS Claim: Child savers always say retinal hemorrhages = SBS Claim: Child savers always say retinal hemorrhages = SBS Truth: Truth: Not true (MVC may cause retinal hemorrhages) Not true (MVC may cause retinal hemorrhages) It is the type and pattern of retinal hemorrhages (extensive, to the periphery, different layers) that is even stronger evidence It is the type and pattern of retinal hemorrhages (extensive, to the periphery, different layers) that is even stronger evidence

79 RETINAL HEMORRHAGES ALWAYS MEAN SBS BUT: BUT: We too often list differential diagnoses that make no sense for children in general, or for the clinical circumstances of the case We too often list differential diagnoses that make no sense for children in general, or for the clinical circumstances of the case Such mindless differentials can cause court confusion Such mindless differentials can cause court confusion

80 LUCID INTERVAL Claim: Can not time when the injury occurred clinically. May act fairly normal for awhile before sudden collapse. Claim: Can not time when the injury occurred clinically. May act fairly normal for awhile before sudden collapse. Truth: Truth: NO NO Not the finding in known accidental injuries Not the finding in known accidental injuries Assumes bleeding, not brain injury is the issue. Assumes bleeding, not brain injury is the issue.

81 MODELS

82 CONSUMER PRODUCT SAFETY COMMISSION When studying playground falls When studying playground falls They did calculations They did calculations Decided that falls as little as 2 inches onto a hard surface might cause serious or fatal injuries! Decided that falls as little as 2 inches onto a hard surface might cause serious or fatal injuries! Quoted by Iowa State University

83 MODELS Models attempt to describe reality – but they are NOT reality Models attempt to describe reality – but they are NOT reality They are always an approximation They are always an approximation They may be helpful They may be helpful They are often too simple They are often too simple They may be wrong or insufficient They may be wrong or insufficient

84

85

86

87 MODELS THAT ARE TOO SIMPLE F = ma. SBS is like a fall Clinical injury pattern is not that of a fall Clinical injury pattern is not that of a fall Are the histories by perpetrators of shaking really wrong? (Maybe those killer couches really did it.) Are the histories by perpetrators of shaking really wrong? (Maybe those killer couches really did it.)

88 MODELS THAT ARE TOO SIMPLE The amount of force reduces to a single unit (often a g force) 42? 42? Which of 100 billion neurons is being described? Which of 100 billion neurons is being described? Which of 1000s of forces is being selected? Which of 1000s of forces is being selected? Complex motions: how much force does it take to walk? Complex motions: how much force does it take to walk?

89 MODELS THAT ARE TOO SIMPLE F = ma. SBS is like a fall As Chadwick (1991) showed, third story falls have a <1% death rate (without RH), yet SBS has a 25% death rate (with RHs in about 90% of cases). SBS is a different entity. As Chadwick (1991) showed, third story falls have a <1% death rate (without RH), yet SBS has a 25% death rate (with RHs in about 90% of cases). SBS is a different entity. The simple fall notion ignores individual brain cells/layers. Usually this model focuses on SDH only. The simple fall notion ignores individual brain cells/layers. Usually this model focuses on SDH only.

90 MODELS THAT ARE TOO SIMPLE F = ma. SBS is like a fall Corresponds to a single shake Corresponds to a single shake No one really thinks that a single shake causes SBS – the argument sets up a strawman No one really thinks that a single shake causes SBS – the argument sets up a strawman Example: Duhaime et al (1987) used a doll model and showed that stopping suddenly (impact) creates more G forces than stopping slower (end of shake in air). Obvious finding. Does not speak to repetitive injuries at all (for which no animal data is shown). Example: Duhaime et al (1987) used a doll model and showed that stopping suddenly (impact) creates more G forces than stopping slower (end of shake in air). Obvious finding. Does not speak to repetitive injuries at all (for which no animal data is shown).

91 MODELS THAT ARE TOO SIMPLE F = ma. SBS is like a fall Sets up idea that shaking is not enough – the perpetrator must have been exceptionally violent! Sets up idea that shaking is not enough – the perpetrator must have been exceptionally violent! (Not what is argued by defense witnesses who want it both ways – violent shaking is not enough force, but mild impacts can cause everything.) (Not what is argued by defense witnesses who want it both ways – violent shaking is not enough force, but mild impacts can cause everything.)

92 MODELS THAT ARE TOO SIMPLE APNEA MODEL Key brain cells are damaged and apnea results Key brain cells are damaged and apnea results May need only minimal forces – Geddes argument in several of her papers May need only minimal forces – Geddes argument in several of her papers This is stated as a conclusion without data. This is stated as a conclusion without data.

93 MODELS THAT ARE TOO SIMPLE APNEA MODEL Apnea is a common clinical entity in the NICU – not common outside of it Apnea is a common clinical entity in the NICU – not common outside of it The pattern of brain injury and bleeding in SBS does not correspond to injuries seen by other apnea causes The pattern of brain injury and bleeding in SBS does not correspond to injuries seen by other apnea causes However: hypoxic/ischemic injuries are part of the evolution of most SBS injuries to the brain (but a small number of children die very quickly before much bleeding or cerebral edema) However: hypoxic/ischemic injuries are part of the evolution of most SBS injuries to the brain (but a small number of children die very quickly before much bleeding or cerebral edema)

94 MODELS THAT ARE TOO SIMPLE APNEA MODEL Missing in such histories: why the apnea in the first place? Missing in such histories: why the apnea in the first place? AAP is against apnea monitors – they dont really work AAP is against apnea monitors – they dont really work

95 A MORE REALISTIC MODEL Motions Motions Arc in the AP direction (raises angular acceleration to the 4 th power – not terminal impact) Arc in the AP direction (raises angular acceleration to the 4 th power – not terminal impact) Head pivots on the neck Head pivots on the neck Neck can bend to the left and/or right side Neck can bend to the left and/or right side All this happens on a body that is moving back and forth All this happens on a body that is moving back and forth Motions are repetitive Motions are repetitive

96 A MORE REALISTIC MODEL Result: a repetitive, 3-dimensional series of complex motions with features of reinforcement, resonance, and consecutive damage Result: a repetitive, 3-dimensional series of complex motions with features of reinforcement, resonance, and consecutive damage The complex of motions explains why one side of the brain (or one eye) is exposed to somewhat different forces and asymmetry may be seen The complex of motions explains why one side of the brain (or one eye) is exposed to somewhat different forces and asymmetry may be seen Explains direct brain injury, intracranial bleeding, and retinal hemorrhages (presumably vitreous traction/mechanical rotational flow stresses) Explains direct brain injury, intracranial bleeding, and retinal hemorrhages (presumably vitreous traction/mechanical rotational flow stresses)

97 DIFFICULT DIAGNOSIS? Claim: SBS is a difficult diagnosis Claim: SBS is a difficult diagnosis Truth: Truth: Often made by local physicians without undue difficulty Often made by local physicians without undue difficulty Paramedics and residents often make the diagnosis Paramedics and residents often make the diagnosis No medical condition truly mimics SBS No medical condition truly mimics SBS

98 NEW DIAGNOSIS? Claim: SBS is a new diagnosis to medicine Claim: SBS is a new diagnosis to medicine Truth: Truth: Tardieu (1860) described cases Tardieu (1860) described cases Caffey (1946) clearly described cases Caffey (1946) clearly described cases Guthkelch (1971) first linked shaking to the injuries Guthkelch (1971) first linked shaking to the injuries

99 NEW DIAGNOSIS? SBS has been recognized longer than: SBS has been recognized longer than: AIDS AIDS Lyme disease Lyme disease Gulf War syndrome Gulf War syndrome Ebola virus Ebola virus Infectious cause for ulcers Infectious cause for ulcers


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