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Pseudo-controversies in Abusive Head Trauma

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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 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.

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

5 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”

6 Safety Factors in Verified and indicated reports
Commonality Factors In Safety and Risk Assessments for Reports with Findings Safety Factors in Verified and indicated reports AGE <= 4 Increased Vulnerability Dom. Violence Hist. Criminal History Mental Health / Drugs Prior Reports Pattern of Incidents Unrelated visitor / or biologically unrelated person in household Percentage: 31 15 48 50 13 73 49 25 6

7 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

8 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.

9 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

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

11 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.

12 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): , 1999. Cites in abstract that morphologic findings of ruptured aneurysm include retinal hemorrhage. In case report notes: The eyes were not examined.

13 Carl Sagan’s Baloney Detection Kit
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

14 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

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” “Suggestive” “Persuasive” “Compelling” “Obvious” Mathetician Mark Kac

17 “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.”

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…” Ethel Muckle, a neighbour said when she asked Strand what he had done he said “… I only shook the baby…”

19 “Suggestive/compelling”
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, 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.”

21 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’.

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 baby’s 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.”

24 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

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. 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:

27 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,

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 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

31 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 kg, 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.

32 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.”

33 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

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 (mother’s new boyfriend) The Functional Anatomy of the Woodpecker Predator hunting behaviors involving shaking of smaller prey; canine, feline.

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

37 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!)

38 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)

39 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

40 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

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

42 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

43 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

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: , 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 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

46 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

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” 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

48 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]

49 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

50 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:

51 LANTZ ET AL. 2004 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?

52 GEDDES Has published several articles showing deep brain damage with shaking Thinks secondary to hypoxia 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)

53 GEDDES 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

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

55 Dr. Tom Nakagowa If f = ma, and a = gravity (a constant) Then f ~ m
Then bigger m leads to bigger f The bigger you are, the harder you fall 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?

Geddes notion Single shake models Time (# of shakes) Force Human range

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 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.)

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

60 SHORT FALLS CAN KILL Van EE and others (engineers, physicists) do models and claim short falls can kill Truth: 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. Truth: 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 Smith’s upcoming chapter).

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

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

64 ACCIDENTAL FALLS “Killer beds”, “killer couches”
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 Models and testing suggested that shaking alone not sufficient to cause serious injury or death Forces are immense 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. Thus there is no controversy 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 Those who think shaking is sufficient also believe in extreme forces being necessary 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 [Dr. Jan Leetsma often claims this, Plunkett and Uzcinski sometimes also]

69 RE-BLEEDS Truth: 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 Minor head trauma can cause re-bleed No associated retinal hemorrhages or cerebral edema

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

71 RE-BLEEDS VS. SBS Re-bleeds should not be sudden or fatal
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 Second shaking needs to be violent as well

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

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

74 METABOLIC DISEASES Truth: Name the metabolic condition
Bleeding diseases usually cause fatty livers SBS is not a bleeding disease 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 Truth: 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 SIZE is the issue

Claim: children are easily damaged because of weak neck muscles, large heads, etc. Truth: No literature to support assertion of “weak” neck muscles No data to show that child’s physiology puts them at extra risk

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 Note: this claim blames the victim!

Claim: Child “savers” always say retinal hemorrhages = SBS Truth: 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

BUT: 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

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


When studying playground falls They did calculations 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
They are always an approximation They may be helpful They are often too simple They may be wrong or insufficient




F = ma. SBS is like 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.)

The amount of force reduces to a single unit (often a “g” force) 42? Which of 100 billion neurons is being described? Which of 1000’s of forces is being selected? Complex motions: how much force does it take to walk?

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. The simple fall notion ignores individual brain cells/layers. Usually this “model” focuses on SDH only.

F = ma. SBS is like a fall Corresponds to a single shake 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).

F = ma. SBS is like a fall 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.)

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

APNEA MODEL 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 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)

APNEA MODEL Missing in such histories: why the apnea in the first place? AAP is against apnea monitors – they don’t really work

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

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

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

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

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