Shaken: A Diagnosis on Trial
First, I must make clear that child abuse is a real problem: People do punch, slam, shake, and throw their children, with devastating results.
That said, more than a decade of research has convinced me that well-intentioned child-abuse experts working with a flawed model of a complex physiological condition are tearing apart benign families and sending innocent people to prison in unsettling numbers.
The widely accepted model of SBS suffers from two misconceptions:
- Timing of the symptoms. Classic thinking is that an assault violent enough to produce the symptoms of SBS would cause an immediate and dramatic change in the victim’s consciousness. Therefore, the adult caring for the child when the breathing problems and seizures begin is presumed to be guilty of assault. But time has provided documented cases of the symptoms’ emerging definitively only hours after the injury. See, for example, the letter below.
- Specificity of the symptoms. Although doctors outside the child-abuse arena are now recognizing more and more medical conditions that can mimic SBS, the three intracranial symptoms that define the condition can still result in conviction, even if the child shows no bruises, fractures, red marks, or other signs of an assault.
If you’re eager for a detailed academic treatment of the subject from an authority with great credentials, see Professor Deborah Tuerkheimer’s first law-review article on the subject. For a quick summary, see her New York Times op ed piece from the fall of 2010.
An example of medical professionals’ not recognizing the subtle symptoms of a fatal pediatric head injury across many hours of hospitalization:
The American Journal of Forensic Medicine and Pathology © 2002 Lippincott Williams & Wilkins, Inc. Volume 23(1), March 2002, p. 105 Symptoms Following Head Injury (Letters to the Editor) Huntington, Robert W. III M.D. Madison, Wisconsin, U.S.A. To the Editor: A recent proposed position paper regarding pediatric non- accidental abuse head injury would allege that we may depend on symptoms to appear immediately upon injury (1). I have a concern about that claim, which I will explain with the CASE REPORT A 13-month-old Hispanic girl was brought to the University of Wisconsin Hospital on the morning of September 18, 1999. The complaint was of vomiting that had lasted for 24 hours. She was described as irritable, sleepy, and vomiting. In our emergency room she was noted to have extensive bruises on the cheeks, chest, back, and arms; the mother attributed these to bites by a 3-year-old housemate. She was admitted and given intravenous fluids. She was sedated with pantothal followed by head computed tomography, which was negative. She was then admitted to the pediatric ward. The resident who saw her described her in the chart and in discussion as being fussy and clingy, but interactive and responsive. Because of the numerous bruises, the police were notified and took pictures. At about 2:00 the following morning, a nurse coming in to care for the child noted that she had decreased respirations. It was then shown that she was unresponsive and had a right dilated unreactive pupil with a sluggish left pupil. She was taken emergently to the pediatric intesive care unit, where she was intubated and given mannitol. A subsequent computed tomography scan showed very poor differentiation of the gray/white matter interface. A Codman catheter was placed and then replaced with a ventriculostomy tube after an intracranial pressure of 21 mm Hg was noted. On the evening of the day after admission, a cerebral blood flow study showed no cerebral blood flow. She was pronounced brain dead. In the interim, her mother had fled town and has not been found since. An autopsy was done on September 20, 1999. This showed hemorrhage in the left optic nerve sheath and left retinal hemorrhages as well as marked cerebral edema and thin widespread subdural hemorrhage. Diffuse axon injury was demonstrated with amyloid precursor protein antibody. My point is that the child did have some symptoms, but clearly the severe intracranial injury symptoms, which were confirmed on repeat computed tomography and autopsy, were delayed for several hours, during which time she was under our view and review in the hospital. Others have noted similar problems (2). Robert W. Huntington III, M.D. REFERENCES 1. Case ME, Graham MA, Handy TC, Jentzen JM, Monteleone JA. Position paper on fatal abusive head injury in infants and young children. Am J Foresnci Med Pathol 2001; 23: 112-22. 2. Gilliland MGF. Interval duration between injury and severe symptoms in non-accidental head trauma in infants and young children. J Forensic Sci 1998; 43: 723-5.
copyright 2011 Sue Luttner