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It can be a difficult process to determine if a child’s injuries are due to physical abuse (Chiesa & Duhaime, 2009; Adamsbaum, et al., 2010), especially because perpetrators do not necessarily admit to shaking, or otherwise injuring a child.
Child abuse of any kind is often suspected by healthcare providers when the caretaker report of what happened to the child varies greatly from the physical findings on examination or when the healthcare provider suspects that the child’s injuries could not have occurred as reported because of the child’s developmental age. Frequently caretakers report that the child was fine, but awoke from sleep with symptoms as described previously, with no symptoms prior to the nap. Other caretakers report that the child sustained the impact injury from a fall, such as from a couch, changing table or a bed.
Caretakers have confessed to having shaken the child, but this is not typical.
There is debate in the literature regarding the diagnosis of AHT. Some of the issues include (Christian, et al., 2009):
- Social issues such as removal of children from the home by Child Protective Services (CPS).
- Legal issues such as arrest and incarceration of perpetrators of AHT and loss of parental rights.
- Injuries in accidental and AHT overlap.
- The AHT is rarely witnessed.
- Accurate history of the trauma is not often given by the perpetrator.
- There is no definitive test to determine the accuracy of the diagnosis.
Additionally, the literature contains multiple references to other health conditions that can have similar presentations as AHT. These include: birth and other accidental trauma, congenital malformations, genetic and metabolic conditions, hematologic disorders, infectious diseases, toxins, complications of surgical intervention, vasculitides, oncologic processes and nutritional deficiencies (Chiesa & Duhaime, 2009).
AHT occurs most frequently and with most fatalities in children under 2 years old, however, provider s should consider intentional shaking as a mechanism of injury in the evaluation of abusive head injury in older children (Salehi-Had, 2006).
Most of the fatalities that occur as a result of child abuse and neglect are to children who have been victims of AHT. Younger children, under 2 years of age, as stated previously are at greatest risk for AHT. This is evidenced by the number of children, in 2008, when an estimated 1,740 children ages 0 to 17 died from all forms of abuse and neglect, not just AHT (CDC, 2010b):
- 80 percent of deaths occurred among children younger than age 4;
- 10 percent among 4-7 year-olds;
- 4 percent among 8-11 year-olds;
- 4 percent among 12-15 year-olds; and
- 2 percent among 16-17 year-olds.
Once the child is stabilized, a careful and well-documented history, as always, is the most critical element of the medical evaluation. Using quotes whenever possible, the pediatrician should document descriptions of the mechanisms of injury or injuries, onset and progression of symptoms, and the child's developmental capabilities. The physical examination should include detailed documentation, either by body diagrams and/or photographs, of any concerning cutaneous findings and should include a thorough search for other signs that may suggest a nontraumatic cause. If the child is verbal, it may be helpful to gather parental and patient histories separately. If abuse is a concern after this preliminary evaluation, consultation with a child abuse pediatrician, pediatric specialist, or pediatrician experienced in this area, if available, may be helpful in determining the best way to proceed with assessment (Kellogg, et al., 2007).
Once the clinician has assessed all the injuries, including approximate ages of injuries (when possible), a careful, complete, and detailed history should be obtained from the caregivers (Kellogg, et al, 2007).
Explanations that should alert the healthcare provider for the possibility of intentional trauma include (Kellogg, et al., 2007):
- No explanation or vague explanation for a significant injury;
- An important detail of the explanation changes dramatically;
- An explanation that is inconsistent with the pattern, age, or severity of the injury or injuries;
- An explanation that is inconsistent with the child's physical and/or developmental capabilities; and
- Different witnesses provide markedly different explanations for the injury or injuries.
Information regarding the child's behavior before, during, and after the injury occurred, including feeding times and levels of responsiveness, should be gathered.
Chiesa & Duhaime (2009) suggest careful assessment while obtaining a comprehensive history of the presenting illness. This includes:
- Details about the timeline of the exact events leading up to the present, including a detailed description of events before and after the child became symptomatic.
- The timeline of symptom development and escalation is also carefully obtained.
- What was the trauma, exactly what happened? What position was the child in? How did the child land? What the fall height was. How the child acted immediately afterwards? What did caretakers do?
- How has cared for the child? What is the relationship between caretakers and the child
- What is the child’s birth/past medical history, including prior trauma?
- What is the family’s medical history? Is there an history of bleeding diroders?
- It is best to ask open-ended questions to obtain specific answers, such as “What happened next? Or “What did you do then?” This is preferable over leading the person providing information. One does not want to suggest whether specific actions might have occurred.
- Identify any trigger for the abuse by the caretaker. Crying is often identified as a trigger.
Jenny (NCSBS, nd) reported on a study of AHT in children under 3 years of age who were evaluated at a Childrens Hospital from 1990 to 1995. Thirty-one percent of the children had previously been seen by a physician who did not recognize the AHT. Many of the children whose head injuries were missed were seen by doctors on multiple occasions after their injuries. For children whose head trauma was missed, the average length of time to diagnosis head trauma from the day of the first doctor visit was 7 days. When missed cases were compared to recognized cases, several factors were found to be significantly different.
Children with missed abusive head trauma were much younger than those in whom the diagnosis was recognized on the first physician visit. The mean age of the missed cases at the time of their first medical visit for head injury symptoms was 180 days. The mean age of the recognized cases was 278 days.
Abusive head trauma was missed significantly more often in children who were Caucasian than in children of minority races, and was more likely missed in families where both parents lived with the child. Not surprisingly, the severely injured children were more likely to be recognized as having head trauma at their first visit to the physician. At the first visit, children who were comatose, whose breathing was compromised, who were seizing or who had facial bruising were more likely to be accurately diagnosed.
Wood, et al. (2010) studied race and socioeconomic status and AHT. That research suggests that there is a bias in the evaluation of AHT, with African-American or publicly insured or uninsured patients receiving an overevaluation of AHT and Caucasian or privately insured patients being underevaluated for AHT. This is in direct conflict with the racial breakdown of abuse victims. In 2008, when an estimated 1,740 children ages 0 to 17 died from any cause of abuse and neglect (not just AHT) (CDC, 2010b):
- 39% of deaths were non-Hispanic White children.
- 30% of deaths were African-American children.
- 16% of deaths were Hispanic children.
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