Category Archives: AHT

December 3, 2012 · 9:32 am

A Critical Look at a Key Witness

Photo by Cheryl Havared Harrell

Photo by Cheryl Havard Harrell

The case of Jeffrey Havard in Mississippi could be the tip of a wrongful-conviction iceberg, according to an excellent in-depth report by Radley Balko at the Huffington Post.

Havard has been on death row since 2002, convicted of murdering the 6-month-old daughter of his girl friend. Havard said he was lifting the little girl from the tub after a bath when she slipped from his hands, hitting her head on the toilet as she fell. Private medical examiner Dr. Steven Hayne, however, concluded the girl had died of shaken baby syndrome. The Mississippi Innocence Project has been fighting the conviction.

The reporter calls SBS “a diagnosis that comes with the implication that the last person to be alone with the child was the one who killed her,” observing:

“Because the symptoms can only be produced by violent shaking, the diagnosis also comes with a built-in indictment of the suspect’s state of mind. It’s a diagnosis that does much of the prosecutor’s work for him.”

Balko has written about Hayne several times over the past decade, as the medical examiner has become more controversial. Hayne has apparently been the favorite pathologist of Mississippi prosecutors for years, reliably providing autopsy reports and testimony that work in the courtroom. New information about Hayne is now available—ironically, through the discovery phase of a defamation suit Hayne pressed against the Missippi Innocence Project after they started questioning his work. Balko writes:

“What they’ve found since implicates not only Hayne, but a host of police officials, prosecutors, even judges who knew Hayne was deficient and offering dubious testimony, but did nothing to stop it. ‘We’ve known for a while that there was a problem here,’ says Tucker Carrington, the director of the project. ‘But I really had no concept of the depth and breadth of the malfeasance. This isn’t just Hayne. It’s … well, it’s almost everybody. The state has known all along that it was pulling the wool over everyone’s eyes.’”

According to Balko, Hayne was already under a serious cloud at the time of Havard’s trial, yet the court refused Havard the money to pay for a second opinion. The story is astonishing, and I recommend reading it:  http://www.huffingtonpost.com/radley-balko/steven-hayne-jeffrey-havard_b_2213976.html

2 Comments

Filed under abusive head trauma, AHT, Innocence Project, SBS, shaken baby syndrome

Tagged as , , ,

November 29, 2012 · 3:08 pm

Another SBS Tragedy, Reflected and Amplified

I want to cry. I want to scream.

The November 26 issue of The New Yorker features a disturbing essay by a young man still reeling from the shock he faced in 2007, when his mother was convicted of shaking an infant she’d been babysitting. Victor Zapana would like to believe his mother is innocent, it seems, but he leans toward guilt.

According to the article, Zapana is the only child of a singular marriage: His father emigrated to the U.S. from Peru in the 1980s and joined the military as a route to citizenship. He met his wife, the author’s mother, while on a tour of duty in South Korea. His native language is Spanish, hers is Korean, and the couple communicates with each other in imperfect English—as their son describes it, “half thoughts, mangled clichés, fragments lacking prepositions.”

In March of 1999, when Victor Zapana was nine years old, his mother was caring for an eight-month-old baby in their home, a job she’d had for five months. She said the boy’s left hand started to shake, as if he was having a seizure, and she called the child’s mother to come pick him up and take him to the hospital. The boy was, indeed, seizing, and the incident left with him permanent and profound brain damage. Doctors diagnosed shaken baby syndrome.

Zapana was on a field trip with his fourth-grade class that afternoon. He claims no memory of sitting at the police station later that night, reportedly in tears, while police questioned his mother. The trial was delayed eight years for various reasons—including his father’s deployment to Iraq—and during the interval, Zapana’s parents didn’t tell him about the pending charges. He learned about the trial only after his mother had been found guilty and remanded to custody. He writes of those first conversations with his parents, in which his father tried to explain the unexplainable:

“Mom has lost a criminal case,” he said, “She’s going to jail.”

What criminal case?

“Mom didn’t want to make you worried,” Papá said. “She wanted to protect you. Everything is going to be all right.”

The verdict made no sense, Papá continued. She had told him she didn’t do it. He knew she didn’t do  it. Calling collect from Rikers a few days later, my mother told me, sobbing, that she was innocent. Feigning composure, I told her that I loved her and hoped to see her soon. I couldn’t bear to say that I didn’t believe her. The question of her guilt was bound up for me in a larger betrayal:  the very fact that the trial was taking place had been kept from me. Maybe she’d wanted to protect me, but it felt like an act of deception, a family conspiracy. How could I believe her?

After a few years, he writes, “I began to feel that I wasn’t being fair to my mother…. I hadn’t seen what happened. I’d read only the news stories and blog posts, and I hadn’t spent much time even with these:  looking at them made me physically sick.”

A college student at that point, he started reading the court documents and trial transcripts, and was disappointed to find nothing that he thought definitively proved his mother either guilty or innocent. The prosecution had called to the stand a series of medical experts who agreed that the child must have been shaken, immediately before the seizures started. After taking out a second mortgage to pay for legal fees, Zapana’s father could afford to hire one pediatric neurologist, who testified that the assault could have occurred before the child was in Ms. Zapana’s care. The expert had reached his conclusions based on a single CAT scan, however, and had reviewed neither the follow-up MRI nor the medical records, and the prosecution easily undermined his credibility on cross-examination.

Zapana also read about child-care provider Audrey Edmunds, freed in 2008 after the Wisconsin Innocence Project took up her case. The appeal was based on new evidence in support of the “lucid interval,” the same defense his mother’s attorney had used, unsuccessfully. Zapana learned that other Innocence Projects across the country were taking on shaken baby cases, but he remained unconvinced, writing,”Still, the new research only opens possibilities. It might establish reasonable doubt, but for a son craving certainty it proves neither guilt nor innocence.”

Zapana’s  mother is getting out early next year, and has instructed his father to sell their house:  She wants to start a new life.

“I wish I could move on as well,” Zapana writes, “but reading the testimony has forced me to recognize that I may  never know what happend on March 3, 1999…. Occasionally, I consider the possibility that [my mother] was wronged.”

My heart breaks for everyone in this story:  The author, who came of age under a looming cloud he must have felt but knew nothing about; his mother, who I’m guessing believed she would be found innocent, and who I hope doesn’t read her son’s essay; the author’s father, a military veteran who’s holding it together, not easily but apparently without complaint; the disabled child and his family, whose chances for normal lives have all been lost, and their hearts embittered by what could easily be a misdiagnosis.

The essay doesn’t offer many medical details, mentioning only bleeding and swelling of the brain and “massive” retinal hemorrhages. I conclude that this shaking diagnosis was based entirely on the brain injury, with  no bruising, fractures, grip marks, or other signs of assault—exactly the kind of troubling shaken baby conviction that Professor Deborah Tuerkheimer was writing about in her 2009 New York Times op ed piece, Anatomy of a Misdiagnosis.

I’m hoping the author keeps researching. It doesn’t sound like he’s read Tuerkheimer’s law-review articles on the subject, such as  The Next Innocence Project:  Shaken Baby Syndrome and the Criminal Courts. Maybe he will find the profile of Dr. John Plunkett in Minnesota Medicine and the analysis of shaken baby syndrome soon to be published in the Houston Journal of Health Law and Policy, now available at this link: Shaken Baby Syndrome, Abusive Head Trauma, and Actual Innocence:  Getting It Right.

Mostly I  hope his family has the chance to heal from the shattering of faith they’ve suffered, at the hands of sincere physicians and prosecutors who have been trained with a widely accepted but inaccurate model of a complex physiological condition.

-Sue Luttner

If you are not familiar with the specifics of the shaken baby debate, please see the home page of this blog site.

6 Comments

Filed under abusive head trauma, AHT, Innocence Network, Innocence Project, SBS, shaken baby syndrome, Victor Zapana, Yoon Zapana

Tagged as , , ,

November 15, 2012 · 5:49 pm

Old Theories Die Hard

The Wrongful Convictions blog has pointed out a careful and well-researched article by Michael Barajas at the San Antonio Current, featuring four women found guilty in 1997 and 1998 of aggravated sexual assault on two sisters, 7 and 9 years old at the time. During a week-long visit with their aunt, prosecutors said, in between trips to the pool and to Walmart, the girls had been held down by the women and raped repeatedly with small objects: syringes, vials of white powder, a gun.

Two years ago the Innocence Project of Texas took up the cases of the “San Antonio Four,” a group of friends who have maintained their innocence throughout long prison terms. One of the presumed victims, now an adult, has recanted her tale, which she says was coerced by her father after the visit.

Dr. Nancy Kellogg, head of the child-abuse unit at the Univeristy of Texas Health Science Center, testified during the trials that the thickness of the sisters’ hymens was a sign of trauma, and that reddening of the younger girl’s hymen was evidence of assault and a white line on the older girl’s was a scar. While child-abuse experts once taught that such findings resulted from sexual encounters, by the late 1990s methodical clinical examinations had revealed that normal hymens come in all shapes and sizes, with features that include streaks, fringes, bumps, and even perforations. The findings listed in Kellogg’s reports  are now considered “normal,” as they were by most experts at the time of the trial.

Outside the jury’s hearing, Dr. Kellogg had also testified that the unusual situation of multiple female perpetrators made her think it was a case of Satanic ritual abuse. Like Dr. Kellogg’s opinions on pre-adolescent genitalia, belief in child sexual abuse by Satanic cults had also been discredited by 1997:  In 1991, FBI special agent Kenneth Lanning published a landmark statement in the journal Child Abuse and Neglect, in which he reflected on eight years of looking unsuccessfully for evidence of the bloody rituals commonly reported in cult-abuse cases. Lanning’s objection was that child sexual abuse is a real problem, and blaming it on elusive cults wastes resources and impedes the credibility of the child-protection movement. You can find Lanning’s 1992 report to the FBI (I presume it’s the real thing) on the Ross Internet Archives.  For my own research into this arena, see chapter 3 of my upcoming book.

Dr. Kellog was and is an active and respected member of the child-protection community, as chronicled on her UT faculty web profile. She was the lead author on the 2007 clinical report from the American Academy of Pediatrics Committee on Child Abuse and Neglect, “Evaluation of Suspected Child Physical Abuse,” published in the journal Pediatrics and quoted regularly. I’m thinking it’s a safe bet that she had read Lanning’s work at the time of her 1997 testimony, and I conclude she had not yet abandoned her faith in the reality of Satanic ritual abuse.

Looking for the silver lining in all this, I propose that the same reluctance to change one’s mind is at work in the shaken baby syndrome debacle. In the 1980s, a wave of pre-school teachers and other caretakers went to jail based on bizarre and lurid tales of cult abuse, and uncounted pre-schools simply closed as the witch hunts spread. Now the Innocence Project of Texas is revisiting one of the last convictions based on medical and social beliefs that were accepted at the time but have since been abandoned. I fear that the misconceptions about shaken baby syndrome will be harder to overcome, both because the concept is more plausible than human sacrifices in secret underground tunnels and because the convictions have been going on for so long that the theory seems to its adherents to have been proven.

The good news since the 1980s is two-fold:  First, there is an Innocence Project of Texas willing to re-open these cases in San Antonio, which, like shaken baby prosecutions, hinged on sincere but unproven medical opinion. Second, the community of child-protection experts has changed course in the past, even after sending people to prison on the basis of accepted but flawed common knowledge.

It won’t be easy, but I’m hoping they can do it again.

If you’re not familiar with the debate surrounding shaken baby syndrome, please see the home page of this blog site. 

-Sue Luttner

7 Comments

Filed under abusive head trauma, AHT, SBS, shaken baby syndrome

Tagged as , , , ,

November 6, 2012 · 4:49 pm

Witnessed Shaking: Reports and Reflections

Police in Concord, New Hampshire, reported last week that a woman had brought them a 3-month-old baby whom she had seen being shaken. According to  WMUR, Channel 9, police took the child to the hospital, where doctors found bruising on the child’s ribs but apparently no brain injuries. The Union Leader coverage adds that the witness is not the child’s mother.

This case prompted a colleague of mine to pull out her notes from a talk given in 1996 at the First National Conference on Shaken Baby Syndrome, in Salt Lake City, Utah, by pediatric  nurse practitioner Julie Pape from the Children’s Hospitals and Clinics of Minnesota.

With pediatrician Dr. Carolyn Levitt, Pape had collected 12 cases in which children under the age of two were brought to the child-protection team for evaluation after witnesses reported seeing them shaken. These children were examined not because of physical signs or symptoms, Pape emphasized, but because of the witnessed assault. “Those people who were observing the events felt as though that episode of shaking had to be significant enough or violent enough to cause injury in the child.”

All of the children had complete skeletal x-rays, and six of them had both CT scans and retinal exams:  No subdural hematomas, brain swelling, or retinal hemorrhages were found in any of the children, although bruises and fractures were found in some.

The cases:

  • A 19-year-old uncle left alone with a 7-week-old told the child’s mother that he had shaken the baby. He reported shaking the infant four or five times, after which “he became scared, because he thought that he may have injured the baby.” The only physical finding was a bruise on the child’s ankle, which the uncle acknowledged he may have caused when he picked up the baby.
  • A suicidal teen-aged mother reported shaking her 5-month-old son. Examination revealed old soft-tissue injuries, some bruising, and a burn.
  • An employee at a juvenile residential home reported seeing a young mother shake her 6-week-old daughter. A bone scan revealed three leg fractures but the CT scan and retinal exam were negative.
  • A bank teller reported seeing a mother shake her 12-month-old daughter in a stroller. Doctors found no broken bones or soft-tissue damage.
  • A mother brought her 17-month-old daughter to the clinic with a report that she seen the biological father shake and spank the girl. The skeletal survey was negative, and old bruises were inconclusive for abuse.
  • A single mother called her own father and told him she had shaken her 8-month-old daugher, in her walker. The grandfather called the child’s pediatrician, who reported the case to CPS. A skeletal exam, a CT scan, and a retinal exam produced no physical findings.
  • A mother reported she had seen the father of her 4-month-old son shake the infant. The father’s hands were around the child’s rib cage, she said, and the boy’s head was “bobbing back and forth.” The skeletal, CT, and retinal exams were all negative.
  • During a hospital visit for a burn injury, the mother of an 11-month-old patient reported that she had seen the boy’s father shake him 10 months earlier, when the infant was one month old. The skeletal survey, CT scan, and retinal exam were negative, but the boy had some soft tissue injury.
  • A mother brought in her 17-month-old daughter after a visitation with the girl’s father, because of bruises. The grandparents reported that they had seen the father shaking the girl on previous occasions. A skeletal survey revealed healing  arm and leg fractures.
  • The paternal grandparents of a 17-month-old boy and a 5-month-old girl called CPS to say they’d seen the children’s mother shaking them and throwing them onto the couch while the three were visiting. The children were removed from the mother at the AMTRAK station. Skeletal surveys showed no fractures, and doctors found no bruising.
  • A mother reported seeing the father of her 9-month-old daughter shake the little girl during an argument that also involved a gun to the mother’s head. The child protection team did a skeletal survey, head CT, and retinal exam, “and as is consistent with many of the other kids in this study, we did not find any physical findings,” Pape reported.

None of the 12 children was admitted to the hospital, although one returned for a follow-up bone scan.

Noting that “children who have a history of being shaken do not always sustain physical injury,” Pape advocated a “consistent medical approach” to these cases, as further examination did uncover evidence of past abuse in some cases.

“We also need to listen to these histories and not ignore them,” Pape said. “If a parent is saying, or if anyone is saying, that they have witnessed an act that is violent enough that they think this child could be injured, we need to pay attention to that. And that’s not necessarily because we think these might be shaken babies, because obviously we are learning that this is not how children who are diagnosed with SBS present. However, these children might be children who are battered and at risk.”

Also, if these really are shaken babies, Pape clarified, “We don’t want these children to go on and then have physical findings because someone may have shaken this child and then decided that if I shook the child this hard and it didn’t have physical findings then it should be OK.”

This study doesn’t seem to have been published, and I haven’t seen anything like it in the literature. As far as I know, there have been no witnessed shakings that were followed by findings of brain swelling and brain bleeding. If anyone knows of one, please leave a comment.

I’ve seen nanny-cam footage of violent treatment that seems to include shaking (this YouTube video, for example), and news reports of the resulting prosecutions (like this one).  Has any of these cases ever resulted in the triad?

Curiouser and curiouser.

2 Comments

Filed under abusive head trauma, AHT, SBS, shaken baby syndrome

Tagged as

· 11:05 am

A Word From the Hangbin and Ying Li Rescue Committee

The second-degree murder trial of Hangbin Li, the immigrant father in the news last month for turning down a generous plea bargain,  has been postponed due to the storms in New York, but is now scheduled for later this week.

Mid-November update: The trial is now scheduled for January, 2013.

Hangbin Li and his common-law wife Ying Li were accused of shaking their daughter Annie to death in 2008. While the couple has spent years in jail, denying the charges and waiting for trial, their community has rallied around them. Now their friend Michael Chu has released a statement of support, which he hopes to distribute widely before trial, on behalf of the Hangbin and Ying Li Rescue Committee:

Shaken Baby Syndrome Accusations:
A Modern Day Witch Hunt?

Abuse of children is a real problem. People who commit the crime deserve the full fury of law. However, it is very important that evidence based science instead of the old SBS dogma be used in distinguishing cases where abuse actually occurs as opposed to trauma occurring for other reasons. In the Li’s case, 5 months after the passing away of their beloved daughter Annie, and still in deep bereavement over the loss of their beloved child, Hangbin and Ying were incarcerated, not knowing why.

Last month (October), which is almost 5 years after their initial incarceration, Hangbin was offered a plea bargain which was really tempting. This poor young man was offered the choice of immediate freedom at the price of his innocence. The mental torture he suffered was inhumane. “To be or not to be, that is the question.” He called family members, supporters and friends for advice. He asked me and my wife, “If I were your son, what would you tell me?” We cried. Oh God, what this man has suffered I would not wish my worst enemy to go through.

Finally, Hang Bin made a decision. While he almost ended up accepting the offer, a sudden idea struck him. As a victim of false SBS allegations, he felt that no one else should suffer as he did. From various literatures, he had learned that the number of people who have been wrongly accused of SBS is far more than he imagined. He started to ask himself these questions: Does this (false allegation/conviction) have to go on and on? Why do I have to admit to something I did not do? Do innocent people have to be accused and convicted of something they have not done and do nothing about it? On top of that, he has already lost Annie; he can’t afford to lose Ying and his second daughter Angela (he will be deported when the court releases him if he admits to any charge against him). They are the love of his life.

Baby Annie was born with mutated gene and had spent her first few days in the NICU. In a DNA test done on Annie’s tissue a couple of months back, defective gene relating to OI (Osteogenesis Imperfecta) had been detected. “ It would be important to understand other inherited conditions in Annie’s family that might have created a situation that looked like shaken baby syndrome but was in fact, attributed to something else,” said Dr. Sessions Cole, director of newborn medicine at St. Louis Children’s Hospital.

If one would just spend some time researching the SBS literature and talk to the wrongly accused in depth, he/she will be taken aback at the absurdity of the triad based SBS assumptions which the prosecutors resorted to in the conviction of many parents/caregivers. You can’t help but ask one question again and again: Given the wide array of solid scientific research that questions the validity of SBS theory, why does the judicial system still choose to turn a deaf ear to evidence based science? Even former supporters of the SBS theory such as the renowned Dr. Norman Guthkelch and Dr. Patrick Barnes, are now advising caution before choosing a SBS diagnosis. Dr. Guthkelch is credited with founding the syndrome in 1971.

How can the criminal justice system and law enforcement officers, hold high the banner of justice on one hand, but on the other, refuse to look at truth? How many ears must one law officer have before he can hear innocent people cry? How many wrongful imprisonments will it take till he knows that too many people have been falsely convicted? This is a very serious question that every concerned citizen should think about. The protection of children is a measure of society’s progress. There are people who abuse children. They should be given the gravest penalty that the law allows. But do we have the right to punish the innocent just because we know that there are heinous child abusers out there so that scarifying the innocent can be justified in the name of protecting children? A humanistic society should not allow that.

We need a rigid diagnostic protocol to be applied to SBS cases to prevent medical professionals from jumping to conclusions as soon as they see the 3 symptoms of shaken baby syndrome. Dr. Guthkelch says it’s time to get all interested parties together to get them to agree on what can be said with scientific certainty about shaken baby syndrome. How much longer do we have to wait until this is accomplished? The sword of Damocles could fall on anyone as long as the triad based diagnosis is allowed to reign supreme.

Hangbin & Ying Li Rescue Committee/Michael Chu

For more information on this case, see the New York Times coverage from last winter, at http://www.nytimes.com/2012/01/15/nyregion/what-happened-to-baby-annie.html?pagewanted=1&_r=2&sq=li%20hangbin&st=cse&scp=1

1 Comment

Filed under abusive head trauma, AHT, Hangbin Li, parents accused, SBS, shaken baby syndrome, Ying Li

October 29, 2012 · 3:24 pm

Case Dismissed Against Drayton Witt

Drayton Witt and his wife, after his release in the spring

The Arizona Superior Court dismissed charges today against Drayton Witt, convicted in 2002 of second-degree murder in the death of his son Steven, the Arizona Justice Project has announced.

As reported in the Arizona Republic in September, Steven Witt suffered a short lifetime of health challenges, starting with breathing problems at birth and including unexplained seizures that had him hospitalized for a week when he was four months old. At five months, he suffered another seizure while in the care of his father and collapsed.

Despite Steven’s health history, doctors at the Phoenix Children’s Hospital insisted that bleeding and swelling found in the boy’s brain meant he’d been abused, and Drayton Witt was convicted of second-degree murder. The Arizona Justice Project took up his case in 2008, under the leadership of attorney Carrie Sperling.

In the spring of 2012, Witt’s legal team petitioned successfully to vacate his conviction. The state did not oppose that decision, but began moving to retry the case. Then last week the district attorney’s office filed a motion to dismiss the charges without prejudice. This morning the court approved that motion, but specified that the dismissal was “with prejudice,” meaning that the state is barred from pressing this case again.

I wrote a bit more about this case earlier in the year, in this post.

2 Comments

Filed under abusive head trauma, AHT, Drayton Witt, parents accused, SBS, shaken baby syndrome

October 18, 2012 · 2:13 pm

Separating the Sheep From the Wolves

Gray fox at a wildlife rescue center in Lafayette, CA

I have returned sobered from the Twelfth International Conference on Shaken Baby Syndrome/Abusive Head Trauma, Sept 29–Oct 1 in Boston.

Dr. Robert Block, President of the American Academy of Pediatrics (AAP), opened the conference with an address titled “While We Argue, Children Die:  The Consequences of Misinformation,” arguing that the press has been getting it wrong by reporting that shaken baby syndrome is now in doubt.

If the number of shaking diagnoses is not decreasing, Block said, then “the assertion that there has been a significant shift in medical opinion and medical thinking is false and it is not supported in basis of fact.”

Block protested that an upcoming law-journal article misrepresents the intent of the 2009 AAP position statement recommending that doctors drop the term “Shaken Baby Syndrome” in favor of “Abusive Head Trauma.” The goal of the new name, Block said, was “not to detract from shaking as a mechanism of abusive head trauma as much as to broaden the terminology to account for the multitude of primary and secondary injuries that result from abusive head trauma.”

The article Block cited—“Shaken Baby Syndrome, Abusive Head Trauma, and Actual Innocence:  Getting It Right”—was written by law professors Keith Findley and David Moran, with pediatric radiologist Patrick Barnes and pediatric neuropathologist Waney Squier, in response to an earlier article in the same journal —“A Daubert Analysis of Abusive Head Trauma/Shaken Baby Syndrome“—by pediatrician, attorney, and pediatrics professor Sandeep Narang. Dr. Narang had proposed in that piece, as he did again at the Boston conference, that the diagnosis of child abuse is best left to the experts who have devoted their careers to studying it.*

Like Dr. Narang, Block emphasized the importance of clinical experience. The experts have seen “thousands and thousands of children, of all ages, in all stages of health, from perfectly healthy to perfectly dead,” Block said, “Without that experience one cannot understand, get involved in, begin or end that science that we so desperately need.”

Arguing that child-protection doctors are forced to spend their time fighting baseless attacks, Block asked, “Can the media, and the folks who feed the media, be held responsible for injuries to, and deaths of, children?”

Block encouraged the building of multi-disciplinary bridges, where physicians from different specialties can share experiences and learn from each other. Conversation is difficult “with people who are emotionally invested,” he said, and he would welcome the entry of the Institute of Medicine and the National Academy of Sciences into the arena.

Monday morning’s keynote address—”A Wolf in Sheep’s Clothing:  Denialism in Child Abuse Pediatrics” by Dr. Christopher Greeley, professor of pediatrics at the University of Texas Health Science Center—reaffirmed that there is no disagreement within the medical community about abusive head trauma.

“I believe this not to be a medical debate,” Dr. Greeley opened, but “a legal debate with a white coat on.”

Greeley proposed that critics of the known science behind shaken baby syndrome have fallen for the allure of their own personal narratives. “They think, ‘This is Galileo trying to prove his case to the people,’” he explained. “They think, ‘I have this knowledge and it’s being squashed by misguided authority.’”

Alluring at it is, that narrative is false, he said. “Are we the overbearing establishment? Is Dr. Block our pope?”

Dr. Greeley characterized those who question SBS theory as denialists, and he outlined their tactics:

  • Manufacture of doubt—emphasizing small areas of disagreement to give the impression of fundamental flaws
  • Identification of conspiracies
  • Creation of impossible expectations—demanding that the child abuse literature  provide the same kind of evidence produced by drug trials, for example
  • Use of fake experts
  • Misrepresentation and logical fallacies—the “straw man,” for example
  • Selectivity of citation

Dr. Greeley’s slide show of media denialism included offerings from major news outlets (the 2008 Discover magazine piece by Mark Anderson, Prof. Deborah Tuerkheimer’s 2010 New York Times op ed, Emily Bazelon’s New York Times Magazine cover story, and the Frontline/ProPublica/NPR critique of child death investigations) as well as small internet voices (the Medill Innocence Project, MedicalMisdiagnosisResesarch, Medical Veritas [which seems to be an anti-vaccine organization], this blog, and the EBMSI conferences), plus a radio commentary by Phyllis Schlafly.

In the professional arena, Dr. Greeley lambasted the 2003  literature review by Dr. Mark Donohoe, “Evidence-Based Medicine and Shaken Baby Syndrome,” which had concluded that “the commonly held opinion that the finding of subdural hematoma and retinal hemorrhage in an infant was strong evidence of SBS was unsustainable, at least from the medical literature.”

Donohoe had searched the Biomednet Medline database using only the phrase “Shaken Baby Syndrome,” Greeley pointed out, four years before the phrase was officially adopted into the Medical Subject Headings maintained by the National Library of Medicine. Donohoe did not search for terms like “abusive head trauma,” “child abuse,” “subdural hematoma,” or any of the other phrases that might have captured additional relevant articles, Greeley charged, and then he didn’t even read all of the articles he found. Although Donohoe’s search was conducted in 1998, the article wasn’t published until 2003. Greeley said that his own search using Donohoe’s described strategy, even limiting the time range to 1966-1998, produced far more citations than the 54 Donohoe reported.

“Donohoe is a horrible paper and you should never cite it,” Greeley summarized. Noting that Supreme Court Justice Ruth Bader Ginsburg had in fact referenced Donohoe in her minority opinion in the Shirley Ree Smith decision, he speculated, “Surely Justice Ginsburg didn’t read this paper…  or she wouldn’t have cited it.”

He also criticized medical-journal articles by Drs. Pat Barnes, Waney Squier, Jennian Geddes, and Steven Gabaeff and the “Getting It Right” law-journal article by Findley et al.

In other sessions I heard speakers explain that Vitamin D levels in a newborn are unrelated to bone fragility, hypoxia does not cause subdural hematoma, and physicians always do a complete work-up for other conditions that might cause the symptoms before diagnosing abuse. While I’m still puzzling over the medical possibilities, I know from personal experience that the third point is an unattained ideal.

I had hoped the conversation was opening up, but it’s hard to feel encouraged after being dismissed as a denialist. More to come.

* Dr. Narang’s article posits that there is no real medical debate about AHT and concludes:

“It is understandable that lawyers will look for opportunities to create doubt in the minds of jurors. However, the only way to appropriately improve the chances for justice in the courts with respect to AHT is to assure that an unbiased, financially-unmotivated, medical expert testifies to the current state of medical evidence.”

8 Comments

Filed under abusive head trauma, AHT, American Academy of Pediatrics, National Center on Shaken Baby Syndrome, SBS, shaken baby syndrome

September 28, 2012 · 9:55 am

When Pie in the Sky Turns Out to Be Dawning Knowledge

With the Twelfth International Conference on Shaken Baby Syndrome/Abusive Head Trauma coming up this weekend, I’ve been reviewing the literature and sorting my thoughts. What I see is an odd mix of new thinking and old stances.

In the June 2012 issue of Pediatric Radiology, for example, Dr. Thomas Slovis and his colleagues open their editorial, “The creation of a non-disease: an assault on the diagnosis of child abuse,” with a triad I’m not familiar with, but it’s got a classic ring to it:

The triad of subdural hematoma, retinal hemorrhage and multiple fractures in a child has been extensively documented to strongly suggest non-accidental trauma. Based on confessional evidence, a medical workup excluding diseases that can present with some of these abnormalities, and almost 50 years of scientific medical supportive literature, the diagnosis of abuse is being made with increasing medical certainty [1–7].*

With that diagnostic guideline in place, the authors object to “a small group of individuals” who have “created controversy where there should be none” and “perverted cases by using incomplete statements of the facts and unproven hypotheses to obscure the straightforward historical and physical findings utilized to make the diagnosis of child abuse.”

The paper describes a recent training that included these presentations:

  • Pediatrician and geneticist Dr. Ingrid Holm explaining that vitamin D levels have not been scientifically connected with fractures in the fetus or neonate, presumably a counter to the rickets work of Drs. Pat Barnes, Kathy Keller, David Ayoub and others; and
  • Pediatric radiologist Dr. Gary Hedlund noting that  ”intracranial venous thrombosis alone” is not known to be associated with subdural hematoma, possibly a response to many of Dr. John Plunkett’s diagnoses, with the additional observation “that one of the commonest causes of intracranial venous thrombosis is trauma, and that trauma does cause subdural hemorrhage.”

The key point about the non-disease commentary, though, is near the introduction, in an off-hand reference to new understandings in the field:

[The seminar]  presented the scientifically accepted methodology for the diagnosis of nonaccidental trauma with emphasis on the pathophysiology of various injuries, and covered areas where new data have changed our understanding (e.g., subdural hematoma can occur from bleeding dural veins and not only bridging veins) [20–22].

20. Mack J, Squier W, Eastman JT (2009) Anatomy and development of the meninges: implications for subdural collections and CSF circulation. Pediatr Radiol 39:200–210

21. Nelson MD Jr (2009) Unraveling the puzzle. Pediatr Radiol 39:199

22. Slovis TL, Chapman S (2009) The pathophysiology does not denote the mechanism. Pediatr Radiol 39:197–19

What we have here is an editorial criticizing and dismissing the defense experts in the shaken baby syndrome debate, but with the concession that Drs. Mack, Squier and Eastman were correct in their 2009 proposition, also published in “The neuropathology of infant subdural hemorrhage,” Forensic Sci Int 2009, soi:10.1016 j.forscicnt.2009.02.005, that subdural collections could result from seeping out of the dural tissues. At the time it was published, that paper received a scathing review in The Quarterly Update, a guide to the child-abuse literature published four times a year by Dr. Robert Reece at Tufts University School of Medicine. Dr. Lucy Rorke-Adams objected in the Quarterly (Winter 2010, Vol. XVII, No. 1, p. 14) that the authors “reject the mountains of evidence that tears of bridging veins consequent to trauma are the primary cause of SDH,” adding in the Reviewer’s Notes:

This concept, initially proposing a non-traumatic pathogenesis of SDH in infants, namely hypoxia, advanced by Geddes et al. in a severely flawed paper with no credibility whatsoever and later repudiated by her, is not being allowed to rest in the dustbin of junk science.10-11  The disciples of Geddes cannot allow this to happen, else they will be unable to introduce “reasonable doubt” when tetifying on behalf of perpetrators of abusive head injury to infants. Hence, they are flooding the literature with pie-in-the-sky claims that totally lack any evidence base.

10.  Geddes JF, Tasker Rc, Hackshaw AK et al. Dural haemorrhage in non-tramatic infant deaths:  Does it explain bleeding in ‘shaken baby syndrome’? Neuropathol Appl Neurobiol 2009;29:14-22

11. Jenny C. The timtimidation of British pediatricians. Pediatrics 2007;119:797-799

This transition, from “pie-in-the-sky” to “new data have changed our understanding,” strikes me as a change in the recognized model of abusive head trauma. It reminds me of comments made by a number of presenters at the 2010 NCSBS conference, when the take-home message was that the “triad” (the AHT triad, that is:  subdural hematoma, retinal hemorrhages and brain swelling) was a straw man invented by defense experts to discredit shaken baby syndrome theory.

But I also have notebooks from prior conferences, when the triad was, indeed, considered enough.  I will close this posting with a quote from a letter published in Pediatrics in 1998, signed by 70 child-abuse physicians, including a few of those 2010 presenters, objecting to the defense testimony in the Louise Woodward trial:

The shaken baby syndrome (with or without evidence of impact) is now a well characterized clinical and pathological entity with diagnostic features in severe cases virtually unique to this type of injury – swelling of the brain (cerebral edema) secondary to severe brain injury, bleeding within the head (subdural hemorrhage), and bleeding in the interior linings of the eyes (retinal hemorrhages). Let those who would challenge the specificity of these diagnostic features first do so in the peer-reviewed literature, before speculating on other causes in court.

My point is that the model is evolving in the face of new evidence.  What I don’t understand is the reluctance of the child-abuse community to look back at possible mistakes in the past.

I’m off to the conference now and not likely to be blogging on the road, but you never know.

* Citations from the opening quote of the Slovis et al. article:

  1. Caffey J (1946) Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR 56:163–173
  2. Silverman FN (1953) The roentgen manifestations of unrecognized skeletal trauma in infants. AJR 69:413–427
  3. Woolley PV Jr, Evans WA Jr (1955) Significance of skeletal lesions in infants resembling those of traumatic origin. JAMA 158:539–543
  4. Kempe CH, Silverman FN, Steele BF et al (1962) The battered-child syndrome. JAMA 181:105–112
  5. Silverman FN (1972) Unrecognized trauma in infants, the battered child syndrome, and the syndrome of Ambroise Tardieu. Rigler lecture. Radiology 104:337–353
  6. Faure C, Kalifa G, Sellier N (1994) Les responses de l’imagerie medicale chez l’enfant battu. Syndrome de Silverman-Ambroise Tardieu. J Radiol 75:619–627
  7. Kleinman PK (ed) (1998) Diagnostic imaging of child abuse, 2nd edn. Mosby, St. Louis

1 Comment

Filed under abusive head trauma, AHT, SBS, shaken baby syndrome

September 10, 2012 · 2:00 pm

Medill Innocence Project Starts Posting

Journalism students at the Medill Innocence Project have started adding content to a blog devoted to their shaken baby syndrome project.

The first stories went up in late August, print-only updates about their efforts to re-examine the case of Jennifer Del Prete, an Illinois child-care provider convicted of shaking an infant in 2002.

Dr. A. Norman Guthkelch, May 2012

The Audio Podcast

On Friday an excellent podcast appeared, “Setting the Record Straight,” based on an interview with Dr. A. Norman Guthkelch. The pioneering pediatric neurosurgeon who first proposed that shaking an infant can trigger subdural hematoma is now speaking out about the over-diagnosis of infant shaking.

The audio treatment includes a riveting exchange between Dr. Guthkelch and Carrie Sperling, the Innocence Project attorney who contacted him about the troubling case of Drayton Witt. Dr. Guthkelch says that the Witt case opened his eyes to how shaken baby syndrome theory is being used in the courtroom. The piece is even stronger for the inclusion of an interview with Dr. Robert Block, president of the American Academy of Pediatrics and a staunch defender of the classic model.

The Human-Interest Video

Earlier last week a video went up, “Tia’s Story,” a moving visit with Jennifer Del Prete’s 23-year-old daughter. The treatment does not consider the legal issues, but showcases another way in which a hasty diagnosis of infant shaking destroys families.

The Database Update

The site also features an announcement about the database project, started at the beginning of this summer, with some background on the issues.

5 Comments

Filed under abusive head trauma, AHT, SBS, shaken baby syndrome

August 28, 2012 · 10:19 am

Evidence-Based Medicine and Shaken Baby Syndrome

Drs. John Galaznik and John Plunkett, at the EBMSI conference

Evidence-based medicine (EBM) is a formal discipline intended to sort out what doctors really know from what they simply believe, “to differentiate objective data from opinion,” explained forensic pathologist Dr. John Plunkett at the second Evidence Based Medicine and Social Investigation conference earlier this month. “Evidence should always trump opinion,” he noted.

As detailed below, the EBM movement relies more on scientifically controlled research—and less on expert opinion and case studies—than the traditional approach.

The highest level of certainty under EBM guidelines applies more readily to drug trials, Plunkett said, where researchers can use large populations and appropriate controls, than to shaken baby syndrome research. “Nothing in the child-abuse literature is going to come anywhere near to Level I,” he conceded, on either side of the shaking debate. “There is not going to be a major bulletin about this.”

The arena itself constrains researchers’ ability to study infant head trauma, Plunkett said, and so the results are not reliable, with the exception of “the biomechanical studies that have been repeated over and over with the same results”—that is, that shaking without impact should not cause subdural hematoma.

Plunkett said he himself misunderstood the role of rotation for many years, even after he started doubting classic shaking theory in the 1980s. “I had been taught that rotation causes subdural hematoma, so I was looking for rotation in a fall,” he explained. “I didn’t realize it until 13 years ago:  Impact causes rotation.”

A number of test-dummy videos shown during the conference illustrated his point:  When a dummy’s head hit the floor, it would bounce back up, in an arc constrained by the neck, finally hitting the floor again at least once.

Rotational motion resulting from linear impact, from F.A. Bandak, Forensic Science International, 151 (2005) p. 75

Biomechanical engineers use the term “impulse loading” to describe the rotational forces caused by the head’s motion at the end of its tether, that is, the neck, which is attached to the trunk.

“Everything caused by impulse loading can be caused by impact,” Plunkett declared. “The reverse in not true.” While impact can cause subdural hematoma, retinal hemorrhage, and encephalopathy, for example, shaking cannot cause skull fracture.

There is simply no need to presume shaking, he said, when a child with the triad shows evidence of an impact.

Nor is shaking necessary to explain subdurals when the child shows no evidence of impact, because “Subdural collections occur without trauma.”  A number of metabolic and infectious diseases can cause them, as well as vascular malformations and any interruption of oxygen to the brain. Some causes, like Saggittal Sinus Thrombosis, are easy to diagnose, Plunkett said, but “Superficial Cortical Venous Thrombosis is routinely missed.”

He dismissed ruptured bridging veins as the source of small subdural hematomas, the “thin film” hematomas often associated with a shaking diagnosis. “Bridging veins are large-caliber conduits,” he said, carrying 5 to 10 ml. of blood per minute. “If one of these things is ruptured, you’re going to get a lot of bleeding, and you’re going to get it really fast.” He described stretch tests in which researchers were able to suspend 4 ounces—the equivalent of a stick of butter, which represents about 500 pounds per square inch—from a harvested bridging vein without snapping it.

“How do you break those without impact?” he asked, answering himself: “You don’t.”

When faced with the triad and no clear explanation, Plunkett concluded, “The default diagnosis is ‘I don’t know,’ not ‘Abusive  Head Trauma.’”

Evidence-based medicine guidelines vary in different places and contexts, but the U.S. Preventive Services Task Force defines these levels of reliability for published medical literature (from Wikipedia):

  • Level I: Evidence obtained from at least one properly designed randomized controlled trial.
  • Level II-1: Evidence obtained from well-designed controlled trials without randomization.
  • Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
  • Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
  • Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

If you are not familiar with the debate surrounding shaken baby syndrome, please see the home page of this site.

-Sue Luttner

18 Comments

Filed under abusive head trauma, AHT, Dr. John Plunkett, EBMSI conference, SBS, shaken baby syndrome