Transcript Pseudo-controversies in Abusive Head Trauma

Pseudo-controversies in
Abusive Head Trauma
John E. Wright, MD, FAAP
Medical Director,
Broward County Child Protection team
Epidemiology
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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.)
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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
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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
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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
AGE <= 4
Unrelated visitor / or
biologically unrelated
person in household
Pattern of Incidents
49
73
100
90
80
70
60
50
40
30
20
10
0
31
2515
13
Increased Vulnerability
48
Dom. Violence Hist.
50
Prior Reports
Criminal History
Mental Health / Drugs
Unrelated
Safety Factors
Pattern visitor / or
Increased Dom.
Mental Prior
in Verified and
Criminal
of
biologically
AGE <= 4 Vulnerabilit Violence
Health / Report
indicated
History
Incident unrelated
y
Hist.
Drugs
s
reports
s
person in
household
Economic drivers of junk
science
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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
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Economic drivers of junk
science in the courtroom
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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)
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Biomechanical
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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
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Alternative hypothesis (cont.)
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Any test not ordered in the acute phase.
CPR/resuscitation efforts
Seizure
Infection
Older injury
Birth trauma
Spontaneous x
Arteriovenous malformation
Irresponsible expert tricks
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Divide and conquer
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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
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Question to the visiting expert: What Information
regarding this case have you brought with you from
wherever?
Examine writings/written opinions/previous testimony.
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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.
Carl Sagan’s Baloney Detection
Kit
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Ad nominem attack
Argument from authority
Argument from adverse
consequences
Appeal to ignorance
Special pleading
Begging the question
Observational selection
Suppressed evidence
Weasel words
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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
7 warning signs of bogus
science
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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
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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”
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“Interesting”
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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…”
“Suggestive/compelling”
NYT 1937
Joseph MOLINARI
Prosecutor
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Boyfriend confesses
he shook to death a
15
month old baby
because “it bit me”
Suggestive
Dr. John Caffey, Multiple Fractures in the long bones of
infants suffering from chronic subdural hematoma,
American Journal of Roentgenology, 1946.
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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
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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
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“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
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“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
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Subdural hemorrhage
Retinal hemorrhage
Brain injury (diffuse axonal injury)
Secondary effects (include):
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seizures,
hypoxic-ischemic,
toxic metabolytes,
Swelling
Coagulopathy
Loss of autoregulation
Duhaime, et al
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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.
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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:
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Thibault and Gennarelli: Biomechanics of
diffuse brain injuries, Proceedings of the
Fourth Experimental Safety Vehicle
Conference. New York: Am Assoc. of
Automotive Engineers, 1985.
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Cited by Duhaime et al as basis for
biomechanical thresholds.
Used adult monkeys (rhesus,
More recent biomed
studies.
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.
AHT: Shaking and/or Impact?
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Shaking can cause
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Retinal hemorrhage
Hemorrhage outside of
optic nerve sheath
Subdural hemorrhage
DAI
Cerebral edema
death
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Impact can cause
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Skull fractures
Subgaleal hemorrhage
Visible bruises, abrasions,
skin fxs
Epidural hem.
Focal findings
Coup/contracoup
Cerebral edema
death
Shaken Adult Syndrome
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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.
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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
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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
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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.
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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
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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
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Krous and Chadwick (1997) described
several features including:
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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
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Probably the diagnosis that brings out the
most “junk science” in the court
Media:
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Newspapers - usually do a pretty good job
National television networks - awful to
mediocre to excellent (thanks CNN!)
CPR
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Claim: causes rib fractures and retinal
hemorrhages
Truth:
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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
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Claim: Shook to revive. Amateurs,
panicky.
Truth:
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Doesn’t happen in cases where reason for
revival is known
Not enough force, unless they are claiming
abuse
SUBDURAL HEMORRHAGES
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Claim: caused by trivial trauma or CPR
Truth:
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Subdurals rarely seen with short falls especially if no fracture
CPR does not cause subdurals
SBS IS NOT REAL
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Claim: SBS is not real, it is all impact or
something else.
SBS IS REAL
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Truth:
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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
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Truth:
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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
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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
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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:
1.
2.
3.
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
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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
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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
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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
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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.
LANTZ ET AL. 2004
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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?
GEDDES
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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)
GEDDES
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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
GEDDES
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Retracted her “hypothesis” in British court
But others still use it
Dr. Tom Nakagowa
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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.
Dr. Tom Nakagowa
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Why do adults commit suicide by jumping
off of bridges/buildings – when the couch
or bed would do?
BIOMECHANICS OF SHAKING
Single shake
models
Force
Human range
Geddes notion
Time (# of shakes)
KEY DAMAGE ISSUES
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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.)
KEY DAMAGE ISSUES
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Arguments against mainstream
opinion tend to focus on the
secondary injuries (especially
SDH) and lightly dismiss the
brain injury and retinal
hemorrhages
SHORT FALLS CAN KILL
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Van EE and others (engineers, physicists)
do models and claim short falls can kill
Truth:
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They do not apparently know or care about
real world data
ACCIDENTAL FALLS
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Claim: Short falls cause serious or fatal
injuries. SBS injuries look like short fall
injuries.
Truth:
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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).
ACCIDENTAL FALLS (CONT)
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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
ACCIDENTAL FALLS (CONT)
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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
ACCIDENTAL FALLS
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“Killer beds”, “killer couches”
Patterns of injury with accidental impacts do
not look like SBS
DUHAIME ET AL, 1987
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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
DUHAIME ET AL, (CONT.)
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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
DUHAIME ET AL, (CONT.)
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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) 66:309-15.
RE-BLEEDS
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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]
RE-BLEEDS
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Truth:
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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
RE-BLEEDS
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Slow process
Possibly expanding head size
Increasing lethargy
Diminished appetite
RE-BLEEDS VS. SBS
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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
VACINNATIONS
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Claim: DPT shot causes SBS
[Vera Schribner – paleoarcheologist from
Australia is active on the internet]
Truth: No
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No mechanism for this
No evidence for this
METABOLIC DISEASE
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Claim: metabolic diseases mimic SBS
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e.g. Glutaric aciduria
unspecified others
METABOLIC DISEASES
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Truth:
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Name the metabolic condition
Bleeding diseases usually cause fatty livers
SBS is not a bleeding disease
Metabolic diseases do not suddenly appear
and disappear
CHILD IS TOO OLD FOR SBS
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Claim: SBS happens only to children
under 1 or 2 years of age
Truth:
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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
CHILDREN ARE UNIQUELY
VULNERABLE
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Claim: children are easily damaged
because of weak neck muscles, large
heads, etc.
Truth:
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No literature to support assertion of “weak”
neck muscles
No data to show that child’s physiology puts
them at extra risk
CHILDREN ARE UNIQUELY
VULNERABLE
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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!
RETINAL HEMORRHAGES
ALWAYS MEAN SBS
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Claim: Child “savers” always say retinal
hemorrhages = SBS
Truth:
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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
RETINAL HEMORRHAGES
ALWAYS MEAN SBS
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BUT:
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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
LUCID INTERVAL
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Claim: Can not time when the injury
occurred clinically. May act fairly normal
for awhile before sudden collapse.
Truth:
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NO
Not the finding in known accidental injuries
Assumes bleeding, not brain injury is the
issue.
MODELS
CONSUMER PRODUCT SAFETY COMMISSION
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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
MODELS
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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
MODELS THAT ARE TOO SIMPLE
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.)
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?
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.
 The simple fall notion ignores individual
brain cells/layers. Usually this “model”
focuses on SDH only.
MODELS THAT ARE TOO SIMPLE
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).
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!
 (Not what is argued by defense witnesses
who want it both ways – violent shaking is
not enough force, but mild impacts can
cause everything.)
MODELS THAT ARE TOO SIMPLE
APNEA MODEL
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Key brain cells are damaged and apnea
results
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May need only minimal forces – Geddes
argument in several of her papers
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This is stated as a conclusion without
data.
MODELS THAT ARE TOO SIMPLE
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)
MODELS THAT ARE TOO SIMPLE
APNEA MODEL

Missing in such histories: why the apnea
in the first place?

AAP is against apnea monitors – they
don’t really work
A MORE REALISTIC MODEL

Motions





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
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)
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
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
NEW DIAGNOSIS?

SBS has been recognized longer than:
AIDS
 Lyme disease
 Gulf War syndrome
 Ebola virus
 Infectious cause for ulcers
