D R A N D R A L E R O U X - K E M PI N S T I T U T E O F S O C I A L & C U LT U R A L A N T H R O P O L O G Y,

F R E I E U N I V E R S I TÄT B E R L I N & FA C U LT Y O F L A W, S T E L L E N B O S C H U N I V E R S I T Y

D R L E N É B U R G E RD I V I S I O N O F F O R E N S I C M E D I C I N E , D E PA R T M E N T O F PAT H O L O G Y,

FA C U LT Y O F M E D I C I N E A N D H E A LT H S C I E N C E S , S T E L L E N B O S C H U N I V E R S I T Y &

W E S T E R N C A P E F O R E N S I C PAT H O L O G Y S E R V I C E

SHAKEN BABY SYNDROME

INTRODUCTION

Shaken Baby Syndrome Violent & repetitive shaking of an infant (<2 years) and the

causative role of the relative impact upon the release of shaking that causes intracranial injuries and haemorrhages, including retinal haemorrhages and that can lead to severe disabilities or even the death of the child

Also referred to as Whiplash Shaken Infant Syndrome or Abusive Head Trauma Triggered by

inconsolable crying of a child high levels of frustration of parent/carer behaviour contradicting expectations of the parent/caregiver

HISTORY

1946 John Caffey – case studies of children with multiple fractures and subdural

hematomas 14 November 1956 Virginia Jaspers sentenced to 10-22 years’ imprisonment after admitting that she

violently shook baby Jennifer Malkan “…causing her head to bob back and forth after which the baby lost her breath

and her eyes were funny in her head…” 1962 Henry Kempe – battered child syndrome and abusive head trauma

1971 Norman Guthkelch – describe shaking as a mechanism for intracranial injuries in

infants and young children 1974 John Caffey – Whiplash Shaken Infant Syndrome “vigorous manual shaking of infants by the extremities or shoulders, with

whiplash-induced intracranial and intraocular bleeding, but with no external signs of head trauma”

HISTORY II

1985 Head trauma – most frequent cause of permanent damage

or death among abused infants / children2009

Abusive Head Trauma is the leading cause of death from trauma and a major cause of disability in children <2 years

20 – 30 per 100 000 infants under the age of 1 year

BUT since 1987 The relationship between shaking and intracranial injury

has come under intense scrutiny and criticism

DIAGNOSING SHAKEN BABY SYNDROME

The triad Subdural haemorrhage Retinal haemorrhage Encephalopathy Long bone fractures No external sign of impact – Ontario triad

DIAGNOSING SHAKEN BABY SYNDROME

The triad Subdural haemorrhage Retinal haemorrhage Encephalopathy Long bone fractures No external sign of impact – Ontario triad

DIAGNOSING SHAKEN BABY SYNDROME

The triad Subdural haemorrhage Retinal haemorrhage Encephalopathy Long bone fractures No external sign of impact – Ontario triad

Subdural haemorrhag

e: The anatomy & pathology

Subdural haemorrhag

e: The anatomy & pathology

Subdural haemorrhag

e: The anatomy & pathology

Retinal haemorrhag

e: The anatomy & pathology

Retinal haemorrhag

e: The anatomy & pathology

Encephalo-pathy:

The anatomy & pathology

THE TRIAD

Encephalopathy Intraparenchymal shears Subarachnoid haemorrhages Diffuse axonal injury Hypoxic ischemic injury Diffuse brain swelling

ASSOCIATED PATHOLOGY

Rib fracturesLong bone fractures

Warning

Associated pathology

Click icon to add picture

Associated pathology

ASSOCIATED PATHOLOGY

ASSOCIATED PATHOLOGY V

MEDICAL HISTORY

No history of trauma‘Minor’ traumaStories change as time goes onShaking (?)

OUTCOMES

Fatality unknown – 11% to 23% ?Roughly 1/3 good outcome1/3 mildly to moderately disabled1/3 severely disabled

OTHER VOICES

Duhaime 1987 Shaken impact syndrome

Runyan 2008 Between 2% - 4.4% of parents admit to shaking their

children < 2 to discipline them (USA) 42% children < 3 in slums of India

OTHER VOICES

Geddes Very little axonal injury Neck injury Sub-/intradural haemorrhage Hypoxia

OTHER VOICES

TRADITIONAL MODEL

Injury

Scalp and skull injury Hypoxia

Diffuse brain swelling

Bridging vein and retinal injury

SDH and RH

GEDDES MODEL

Injury

Apnoea

Hypoxia

Brain swelling

SDH and RH

WHERE ARE WE NOW?

1996: triad caused by shaking useless: Motor vehicle accident Fall from a multi-story building

Jenny 2011: The triad is a myth!Guthkelch 2012: “Shaken Baby Syndrome is

an undesirable phrase and that there was not a vestige of proof when the name was suggested that shaking, and nothing else, caused the triad.”

DIFFERENTIAL DIAGNOSIS

Other trauma – even minorBleeding disordersVascular lesions in brainBirth injuries and re-bleedsInfectious diseasesMetabolic abnormalitiesHypoxia

LITIGATING SHAKEN BABY SYNDROME

Questions? Amount of force Duration of shaking Nature of the shaking Correlation between the

shaking of a child & the injuries that manifest

Early prominent cases 1998

Louise Woodward (USA) Helen Stacey (UK)

1999 Louise Sullivan (UK)

UNITED STATES OF AMERICA

Cavazos v Smith 132 S.Ct. 2 (31 October 2011) Shirley Ree Smith, grandmother of Etzel Smith accused of causing his death Battle between the experts

Prosecution Brain haemorrhages; bruise and abrasion on the lower back of the baby’s head Shaking itself was so severe that the brain directly tears in vital areas, causing

death with very little bleeding Defence

No retinal haemorrhage; minimal subdural/subarachnoid haemorrhage, no brain swelling and no fractures, sprains or other indications of trauma

California Court of Appeal Guilty

Ninth Circuit court Not guilty – no physical evidence of tearing or shearing and no other evidence

supporting death by violent shaking US Supreme Court

Majority – Guilty Minority – Not guilty

Medical evidence not conclusive and non-medical evidence not indicative of Shaken Baby Syndrome

UNITED KINGDOM

R v Harris & others [2005] EWCA Crim 1980 (21 July 2005)

Four appeals against four different convictions based on the triad of injuries associated with Shaken Baby Syndrome

New evidence – Geddes I, II & III and the ‘unified hypothesis’ Geddes I, II & III and the ‘unified hypothesis’

Dr Jennian Geddes: “the unified hypothesis was never advanced with a view to being proved in court”

Minimal force necessary Unknown and would probably never be known If everyday accidents caused this particular pathology, such cases would be

extremely common instead of quite rare. Obligations of expert witnesses

Independent Objective and unbiased opinions Also disclose dissenting facts and opinions Also disclose when research findings are inconclusive Should be allowed to change their mind

SOUTH AFRICA

The triad of encephalopathy, subdural haemorrhages & retinal haemorrhages are not dispelled

BUT the presence of the triad alone – or its individual components – are not enough to diagnose abuse/shaken baby syndrome

SA Willers & AM Willers (No. 14/5829/95) Couple was convicted of the abuse of four of their five children Injuries – extradural haematoma, various bone fractures, rib fractures,

bruises Importance of case

Not one of the injuries was witnessed by anyone other than the accused After 8 weeks of medical expert testimony no clarity as how any one of the

injuries had occurred was reached Pattern of injuries was important Rarity of finding large bruises or fractures of long bones and ribs in very

small infants who are non-mobile was accepted by the court as being indicative of non-accidental injury

RECOMMENDATIONS: COLLECTING INFORMATION

Collect as much information as possible Physical, environmental & historical context

Be sensitive to risk factors Male infants under the age of 6 months Parental risk factors: Parental age, educational level, marital status,

welfare status, employment status, history of substance abuse, mental health problems, history of spousal abuse and/or domestic violence, previous referral to child protection services

Confessions Few confessions relative to the large number of alleged shaking injury

cases Clinical definitions of ‘shaking’ in medical literature and how it is

understood by lay people who are experiencing severe stress and trauma are ambiguous

Coercive interrogation techniques Plea-and-sentence-agreements

RECOMMENDATIONS: RAISING AWARENESS

Shaking as an appropriate response

More socially acceptable and physically less dangerous

Usually have no intention of hurting the child

Awareness campaigns should be coupled with programmes focussing on early detection and intervention

CONCLUSION

“While we support…[the] commitment to the prevention of child abuse, this commitment should not substitute subjective beliefs for objective scientific evidence. Instead, the commitment must be to getting it right…it is inappropriate for medical professionals to diagnose shaking or abusive head trauma based solely or primarily on the presence of subdural haemorrhage, retinal haemorrhage and/or encephalopathy. When a child abuse referral or diagnosis is made based on these findings, it should be clearly disclosed that there are many possible causes for these findings; that the issues are complex and poorly understood; and that shaken baby syndrome diagnosis based exclusively or primarily on these findings rests on good-faith beliefs and hypotheses, rather than science.” Findley, Barnes, Moran, and Squier ‘Shaken baby syndrome,

abusive head trauma, and actual innocence: Getting it right’ Houston Journal of Health Law and Policy (2012) Vol. 12, 209-312, 300.