Preventing abusive head trauma resulting from a failure of normal interaction between infants and their caregivers

Abstract

Head trauma from abuse, including shaken baby syndrome, is a devastating and potentially lethal form of infant physical abuse first recognized in the early 1970s. What has been less recognized is the role of the early increase in crying in otherwise normal infants in the first few months of life as a trigger for the abuse. In part, this is because infant crying, especially prolonged unsoothable crying, has been interpreted clinically as something wrong with the infant, the infant's caregiver, or the interactions between them. Here, we review an alternative developmental interpretation, namely, that the early increase in crying is a typical behavioral development in normal infants and usually does not reflect anything wrong or abnormal. We also review evidence indicating that this normal crying pattern is the most common trigger for abusive head trauma (AHT). Together, these findings point to a conceptualization of AHT as the consequence of a failure in an otherwise common, iterative, and developmentally normal infant-caregiver interaction. They also imply that there is a window of opportunity for prevention of AHT, and potentially other forms of infant abuse, through a public health primary universal prevention strategy aimed at changing knowledge and behaviors of caregivers and society in general concerning normal development of infants and the significance of early increased infant crying. If effective, there may be important implications for prevention of infant abuse nationally and internationally.infant development | colic | excessive crying | child maltreatment | parenting A busive head trauma (AHT), also known more commonly as shaken baby syndrome (SBS), is a devastating and potentially lethal form of infant physical abuse (1). The outcomes are grim. In recognized cases, AHT typically results in death or extremely damaging injuries. About 18-25% of babies who are shaken and hospitalized die (2-7). As many as 80% of survivors have significant lifelong brain injuries (3,8,9). Although currently under study, there are no published estimates of lifetime costs per victim specific to AHT. However, the conservative estimated lifetime costs per victim is $210,012 for nonfatal child maltreatment or $1,272,900 for a death from child maltreatment (in 2010 dollars) for a total estimated economic burdern in the US for one year of $124 billion (10). Given its relative severity compared to other forms of maltreatment, these per victim estimates are likely to underestimate the lifetime costs for AHT victims. Of course, the "costs" go far beyond financial considerations, and include the destruction of families and the failure of society's moral obligation to protect defenseless infants.Preventing child maltreatment of any kind is challenging (11) because of the lack of specific stimuli for abuse, the density and difficulties of modifying risk factors in which families of maltreated children are often embedded, and the challenges of getting appropriate supports to the families. However, the convergence of our increasing un...

Prematurity and neonatal comorbidities as risk factors for nonaccidental trauma

“…NAT has been described as a failure in the normal infant-caregiver interaction [7]. Prematurity, then is a strong candidate for predisposing infants to such abuse.…”

“…Beyond the infantcaregiver separation required for medical interventions and hospital stays because of such comorbidities, it could also be speculated that a child with comorbidities may exhibit increased crying. Such crying has been implicated as a stimulus for abuse [7].…”

“…Key to prevention is the identification of at-risk children. A recent review has explained abusive trauma as a consequence of a failure in the normal infant-caregiver interaction [7]. In this light, risk factors for NAT can be understood as variables that create barriers to the formation of this normal relationship.…”

Abusive Head Trauma in Turkey and Impact of Multidisciplinary Team Establishment Efforts on Case Finding and Management: Preliminary Findings

“…The baby's normal pattern of crying has been reported as the main trigger for the occurence of AHT (18). In the current study, the most common risk factors were determined to be families with low parental education level (23.8%) and having a maximum of three children under seven years of age (22%).…”

Identifying Characteristics in Abusive Head Trauma: A Single-Institution Experience

“…However, we did not find a statistically significant difference in injury severity between males and females. Barr [13] states two speculations on why males were more likely to be AHT victims. One possibility is that there is a difference in crying between males and females, which Barr [13] indicates there is no evidence to support such a theory, or caregivers are more frustrated by male crying than female crying referring to the belief that ‘men do not cry'.…”