Presentation on theme: "Pseudo-controversies in Abusive Head Trauma"— Presentation transcript:
1 Pseudo-controversies in Abusive Head Trauma John E. Wright, MD, FAAPMedical Director,Broward County Child Protection team
2 EpidemiologyThe 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/yAbusive 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 MServes as medical director of Broward CPT from 1989 to 1991 and 1999 to presentDescribed “abusive head crushing”
6 Safety Factors in Verified and indicated reports Commonality Factors In Safety and Risk Assessments for Reports with FindingsSafety Factors in Verified and indicated reportsAGE <= 4Increased VulnerabilityDom. Violence Hist.Criminal HistoryMental Health / DrugsPrior ReportsPattern of IncidentsUnrelated visitor / or biologically unrelated person in householdPercentage:31154850137349256
7 Economic drivers of junk science Individual cases are unique, but not generally without precedentData collection is time sensitiveInput from multiple sources some with agendaeSystem reacts to case:Civil system of child protectionCriminal system of prosecution of perpInformation 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 stepsAlternative hypothesis are not subjected to any testing or reasonable filters of medical knowledge. Their intention is to raise confusion and doubt.Courtroom diagnoses are profferedA variety of logical errors are exploited in the theatrical conflagration that ensuesThe media loves it: free entertainment.
9 Alternative hypothesis themes (in no particular order) BiomechanicalSame “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 traumaCoagulopathy, connective tissue defect, temporary brittle baby,Blame the environmentvitamin/nutrient deficiency, environmental toxin
10 Alternative hypothesis (cont.) Any test not ordered in the acute phase.CPR/resuscitation effortsSeizureInfectionOlder injuryBirth traumaSpontaneous xArteriovenous malformation
11 Irresponsible expert tricks Divide and conquerTease out a few abnormalities and pretend that they were causative rather than the result of the head injuryYou forgot to check…serum porcelain levelFind 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 attackArgument from authorityArgument from adverse consequencesAppeal to ignoranceSpecial pleadingBegging the questionObservational selectionSuppressed evidenceWeasel wordsStatistics of small numbersInconsistencyNon sequiturPost hoc, ergo propter hocMeaningless questionExcluded middle or false dicotomySlippery slopeConfusion of correlation and causationStraw man
14 7 warning signs of bogus science 1. discoverer pitches the claim directly to the media2. 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 detection4. evidence for a discovery is anecdotal5. discoverer says a belief is credible because it has endured for centuries6. 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…theEyes were a good deal suffused withblood…I opened the body after theinquisition, the internal parts were perfectlyhealthy, except the vessels of the brain andlungs, 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 sheasked Strand what he had done he said“… I only shook the baby…”
19 “Suggestive/compelling” NYT 1937Joseph MOLINARIProsecutorBoyfriend confesseshe shook to death a 15month old babybecause “it bit me”
20 SuggestiveDr. 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 JaspersAugust 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,SwellingCoagulopathyLoss of autoregulation
25 Duhaime, et alDescribed 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,
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 causeRetinal hemorrhageHemorrhage outside of optic nerve sheathSubdural hemorrhageDAICerebral edemadeathImpact can causeSkull fracturesSubgaleal hemorrhageVisible bruises, abrasions, skin fxsEpidural hem.Focal findingsCoup/contracoupCerebral edemadeath
31 Shaken Adult SyndromeDerrick 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, Ht151cmAll 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 SyndromeDisclosed 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 tongueHad 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 WoodpeckerPredator hunting behaviors involving shaking of smaller prey; canine, feline.
36 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 causationNot reproducibleSelective use of the literature
37 SHAKEN BABY SYNDROMEProbably the diagnosis that brings out the most “junk science” in the courtMedia:Newspapers - usually do a pretty good jobNational 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 knownNot 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 fractureCPR does not cause subdurals
41 SBS IS NOT REALClaim: 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 AAPStatements by National Association of Medical Examiners, Canadian Pediatric SocietyStatements by US Advisory Board on Child Abuse and NeglectNO 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 conferencesInternational conferences in Sydney, Edinburgh – Montreal in Sept. 2004
44 SBS IS REALStarling 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 REALRetrospective look at 81 cases of admitted brain injury to 90 cases of in which no abuse admission was made68% of the confessed perpetrators said no impact – only shaking91% 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 impactRelative lack of skull/scalp findings (vs. impact admitted cases) = shaking alone can produce the findings of SBS
47 CONTRARIANSStatement 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 thisExample 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 UzcinskiIn a recent Naples FL case he said that burping an infant can cause bleeding in the headAlso the infant straining with a bowel movement
50 LANTZ ET AL. 2004Reported that a 40 pound TV falling on a month old caused perimacular foldsPrior to this, such folds seen only with shaken baby syndromeLantz PE, Sinal SH, Stanton CA, Weaver RG. Perimacular retinal folds from childhood head trauma. BMJ (2004) 328:
51 LANTZ ET AL. 2004In an editorial in the BMJ, Geddes and Plunkett extrapolated this to retinal hemorrhages and said whole concept of SBS is untrueComment: Based on one controversial case of a TV crush injury?
52 GEDDESHas published several articles showing deep brain damage with shakingThinks secondary to hypoxiaHas speculated that mild shaking might cause more SBS than we thinkHas claimed microscopic intradural hemorrhages present in many situations (most think of this as an artifact – not the larger SDH of SBS)
53 GEDDESWhy 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 fThe bigger you are, the harder you fallWhen adults fall off couches, they hit the floor much harder.
56 Dr. Tom NakagowaWhy do adults commit suicide by jumping off of bridges/buildings – when the couch or bed would do?
57 BIOMECHANICS OF SHAKING Geddes notionSingle shake modelsTime (# of shakes)ForceHuman range
58 KEY DAMAGE ISSUESIt is the brain damage that causes serious injury or death. Not the secondary injuries of bleeding in the retina or intracranial spacesNot a mass effect issueSBS 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 ISSUESArguments 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 KILLVan EE and others (engineers, physicists) do models and claim short falls can killTruth:They do not apparently know or care about real world data
61 ACCIDENTAL FALLSClaim: Short falls cause serious or fatal injuries. SBS injuries look like short fall injuries.Truth:Frequently the excuseExtensive 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).
62 ACCIDENTAL FALLS (CONT) Experience shows that children are constantly having short falls without serious injuryLike a single shakeRetinal hemorrhages almost never seen and should not be extensiveStrong 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 headThey 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, 1987Study found 13 dead SBS victims - all had signs of head impactModels and testing suggested that shaking alone not sufficient to cause serious injury or deathForces are immenseSBS 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 controversyIt 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 shakingThose who think shaking is sufficient also believe in extreme forces being necessaryThus the perpetrator was violently abusiveDuhaime 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-BLEEDSClaim: 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-BLEEDSTruth:Any scab will ooze blood with small trauma prior to complete healingAfter several weeks of healing, a subdural hematoma will form delicate new blood vesselsMinor head trauma can cause re-bleedNo associated retinal hemorrhages or cerebral edema
70 RE-BLEEDS Slow process Possibly expanding head size Increasing lethargyDiminished appetite
71 RE-BLEEDS VS. SBS Re-bleeds should not be sudden or fatal SBS is primarily a brain injury, re-bleeds are notThe presence of old injuries, new intracranial bleeding, retinal hemorrhages,and clinical signs of brain injury = old and new SBSSecond 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: NoNo mechanism for thisNo evidence for this
73 METABOLIC DISEASE Claim: metabolic diseases mimic SBS e.g. Glutaric aciduriaunspecified others
74 METABOLIC DISEASES Truth: Name the metabolic condition Bleeding diseases usually cause fatty liversSBS is not a bleeding diseaseMetabolic diseases do not suddenly appear and disappear
75 CHILD IS TOO OLD FOR SBSClaim: SBS happens only to children under 1 or 2 years of ageTruth:Most under 1 year, some between 1-2 years, less 2 year olds, rare 3 or 4 year oldsPhysiologically can happen at any ageSIZE is the issue
76 CHILDREN ARE UNIQUELY VULNERABLE Claim: children are easily damaged because of weak neck muscles, large heads, etc.Truth:No literature to support assertion of “weak” neck musclesNo data to show that child’s physiology puts them at extra risk
77 CHILDREN ARE UNIQUELY VULNERABLE Brain fits inside skull - no room to bang around in itAdults could not resist a 2000 pound gorilla, and their physiology would not helpNote: this claim blames the victim!
78 RETINAL HEMORRHAGES ALWAYS MEAN SBS Claim: Child “savers” always say retinal hemorrhages = SBSTruth: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
79 RETINAL HEMORRHAGES ALWAYS MEAN SBS BUT:We too often list differential diagnoses that make no sense for children in general, or for the clinical circumstances of the caseSuch mindless differentials can cause court confusion
80 LUCID INTERVALClaim: Can not time when the injury occurred clinically. May act fairly normal for awhile before sudden collapse.Truth:NONot the finding in known accidental injuriesAssumes bleeding, not brain injury is the issue.
82 CONSUMER PRODUCT SAFETY COMMISSION When studying playground fallsThey did calculationsDecided 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 approximationThey may be helpfulThey are often too simpleThey may be wrong or insufficient
87 MODELS THAT ARE TOO SIMPLE F = ma. SBS is like a fallClinical injury pattern is not that of a fallAre 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?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?
89 MODELS THAT ARE TOO SIMPLE F = ma. SBS is like a fallAs 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.
90 MODELS THAT ARE TOO SIMPLE F = ma. SBS is like a fallCorresponds to a single shakeNo one really thinks that a single shake causes SBS – the argument sets up a strawmanExample: 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 fallSets 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.)
92 MODELS THAT ARE TOO SIMPLE APNEA MODELKey brain cells are damaged and apnea resultsMay need only minimal forces – Geddes argument in several of her papersThis is stated as a conclusion without data.
93 MODELS THAT ARE TOO SIMPLE APNEA MODELApnea is a common clinical entity in the NICU – not common outside of itThe pattern of brain injury and bleeding in SBS does not correspond to injuries seen by other apnea causesHowever: 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 MODELMissing in such histories: why the apnea in the first place?AAP is against apnea monitors – they don’t really work
95 A MORE REALISTIC MODEL Motions Arc in the AP direction (raises angular acceleration to the 4th power – not terminal impact)Head pivots on the neckNeck can bend to the left and/or right sideAll this happens on a body that is moving back and forthMotions are repetitive
96 A MORE REALISTIC MODELResult: a repetitive, 3-dimensional series of complex motions with features of reinforcement, resonance, and consecutive damageThe complex of motions explains why one side of the brain (or one eye) is exposed to somewhat different forces and asymmetry may be seenExplains 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 difficultyParamedics and residents often make the diagnosisNo medical condition truly mimics SBS
98 NEW DIAGNOSIS? Claim: SBS is a new diagnosis to medicine Truth: Tardieu (1860) described casesCaffey (1946) clearly described casesGuthkelch (1971) first linked shaking to the injuries
99 NEW DIAGNOSIS? SBS has been recognized longer than: AIDS Lyme disease Gulf War syndromeEbola virusInfectious cause for ulcers