The "New Science" of Abusive Head Trauma.

Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.

What are we trying to measure? The problems of case ascertainment.

To determine the incidence of a particular phenomenon, one has to know how that phenomenon is defined. The term "shaken baby syndrome" (SBS) came into general usage in the 1980s, followed by shaken impact syndrome (SIS), inflicted childhood neurotrauma, abusive head trauma (AHT), inflicted traumatic brain injury (inflicted TBI), non-accidental head injury (NAHI), and others. Several means of defining this clinical syndrome have been suggested. Keenan has proposed a research definition. Minns has offered a pure clinical definition, and Livingston and Childs suggest a definition that combines the clinical and radiologic features with the history of events leading to the condition. By using these definitions, eight articles describing SBS, published in the last 20 years, were analyzed for these characteristics. A definition of shaken baby syndrome reflecting the common themes in these clinical reports is offered.

Medical training in child maltreatment.

Training of medical professionals about child maltreatment may provide useful insights into the means of incorporating violence detection and prevention into healthcare practice. Despite major progress since Caffey and Kempe identified child abuse as a medical issue, more needs to be done to ensure that proper recognition, diagnostic, and reporting strategies are used when faced with the possible abuse and neglect of children. Systematic data concerning training programs are lacking. The perceived needs include more consistent education for medical professionals, more federal support for clinical research funding, higher reimbursement rates from third-party payers for clinical care for maltreated children, board certification for doctors who want to specialize in this field, and medical licensure requirements for continuing education in child and family violence. It is clear that interpersonal violence, whether it is child maltreatment, intimate partner violence, or elder abuse, is a significant public health problem in the United States, requiring support for the education and training of medical professionals.

What is the system of care for abused and neglected children in children's institutions?

OBJECTIVES: The objectives of this study were to describe the number of children with suspected abuse or neglect (CAN) cared for in selected children's hospitals, to determine how they are tracked and followed, and to better describe the composition, function, and financial support of child protection teams (CPTs). METHODS: A self-administered survey was mailed to child abuse contact leaders at institutions that were members of the National Association of Children's Hospitals and Related Institutions in 2001. Responses from rehabilitation hospitals and those that did not indicate whether a CPT was present were excluded. RESULTS: One hundred thirty-four of 157 leaders responded. One hundred twenty-two (91%) met study criteria. Eighty-eight hospitals (72%) had a CPT-54% were pediatric facilities, 59% had >100 beds, and 89% had a pediatric residency. Compared with institutions without a CPT, institutions with a CPT were less likely to be located in the South (28% vs 70%) and more likely to have >200 beds (26% vs 1%), a medical school affiliation (92% vs 74%), and a pediatric residency (98% vs 68%). Sixty-one percent of institutions cared for <300 suspected CAN cases, and 66% had 5 or fewer CAN-associated deaths the previous year. Institutions with a CPT used more comprehensive documentation for CAN, including special CAN forms (55% vs 21%) and photographs (77% vs 53%). They also more commonly referred CAN cases to law enforcement (58% vs 35%) or a CAN clinic for follow-up (52% vs 26%). Fifty-two percent of CPTs had an annual budget of $500 000 or less. The most common primary source of financial support for CPTs was the hospital (51%), although funding was usually composed of a combination of funds from the hospital, patient fees, and state government. Functions performed by CPTs included consulting on cases of CAN (89%), functioning as a liaison with child protective services (85%), tracking cases of abuse or neglect (70%), providing quality assurance on CAN cases (63%), and filing reports with child protective services (61%). Twenty-four hour consultative coverage was provided by most CPTs (79%), for which 94% provided phone consultation and 81% provided in-person consultation when necessary. CONCLUSIONS: The institutions surveyed cared for many children suspected of abuse and neglect. Thirty-eight percent did >300 evaluations per year. In general, institutions with CPTs provided more comprehensive documentation and follow-up of children suspected of having been abused or neglected than institutions without CPTs. Whether this is associated with better outcomes for children suspected of abuse or neglect is unknown.