“Triad Only” Defined

The model of shaken baby syndrome that has been winning in court for the past 30 years says that only violence can create this distinctive cluster of symptoms inside the skull of an infant:

• subdural hematoma (blood pooled between the two outermost layers of the meninges, the 3-ply membrane that encases the brain and spinal fluid)
• retinal hemorrhages (bleeding in the retina, at the back of the eyeball)
• encephalopathy (loosely speaking, brain swelling)

I use the term “triad only” to mean a diagnosis of infant shaking based on the presence of the triad alone, with no scrapes, bruises, grasp marks, or fractures that might reveal an assault.

At the Eleventh International Conference on Shaken Baby Syndrome, in Atlanta, Georgia, in 2010, I heard a number of speakers say that they never prosecute “triad-only” cases, but my files tell a different story.  See, for example, the rubber-band case.

Also beginning in 2010, child abuse experts started characterizing “the triad” as a defense concept that over-simplifies the condition for purposes of courtroom attack. In a keynote speech at the Atlanta conference, for example, Dr. Robert Block, then president-elect of the American Academy of Pediatrics, said:

“Only people who are NOT active physicians working with children, naive journalists, and professors with a biased agenda would propose that only three signs and symptoms support a diagnosis.”    – Dr. Robert Block

I have many, many printed examples, however, of statements from organizations like the National Center on Shaken Baby Syndrome articulating the triad as proof of infant shaking. In the Executive Summary published after the Second National Conference on Shaken Baby Syndrome/Abusive Head Trauma in 1998, for example, prosecutor Rob Parrish summarized expert opinion at the time:

Often referred to as the “triad”, consensus continues to be that a collection of (1) damage to the brain, evidenced by severe brain swelling and/or diffuse traumatic axonal injury; (2) bleeding under the membranes which cover the brain, usually subdural and/or subarachnoid bleeding; and, (3) bleeding in the layers of the retina, often accompanied by other ocular damage, when seen in young children or infants, is virtually diagnostic of severe, whiplash shaking of the head. Most presenters agreed that in the absence of a major rollover or side-impact motor vehicle accident, this unique constellation of injuries is not seen in other forms of accidental trauma.

Because it is an especially reputable example, I also quote here from an editorial that ran in 2004 in the British Medical Journal, “Shaken Baby Syndrome: Pathological Diagnosis Rests On the Combined Triad, Not On Individual Injuries” (Harding B., Risdon R.A., Krous H.F., BMJ 2004 328; 720-721):

“In shaken baby syndrome, it is the combined triad of subdural hematoma and retinal haemorrhage with brain damage, as well as the characteristics of each of these components that allow a reconstruction of the mechanism of injury, and assessment of the degree of force employed.”

And in 1998, after the Louise Woodward trial, several dozen child abuse experts signed a letter to the editor of Pediatrics objecting to the credibility given by the media to defense arguments. This quote is from that letter (Chadwick, D.L. et al., “Shaken Baby Syndrome: A Forensic Pediatric Response,” Pediatrics 1998 101(2); 321–3230):

“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 do so in the peer-reviewed literature, before speculating on other causes in court.”

All of which makes me wonder how Dr. Christopher Greeley can defend his statement in a 2014 editorial denouncing critics of shaking theory that (“‘Shaken Baby Syndrome’ and Forensic Pathology,” Forens Sci Med Path, 2014, 10; 253):

2015 update:  For the stories of two people with enormous community support convicted in the past year based only on the triad, please see “Does the Brain Injury Prove Abuse, or Not?”

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

copyright 2012 Sue Luttner