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Abusive Head Injuries

Head injuries can occur in children for a variety of reasons; they could be the result of an accident, like falling down the stairs, or they could be caused by medical ailments. In some cases of pediatric head trauma, however, abuse may be a factor.

Defining Abusive Head Trauma

The CDC considers abusive head trauma to be “an injury to the skull or intracranial contents of an infant or young child.” These types of injuries may be caused by inflicted blunt impact or even violent shaking, also known as shaken baby syndrome. According to the CDC, abusive head trauma “is a leading cause of physical child abuse deaths in children under 5” within the United States, and it accounts for nearly a third of deaths caused by child maltreatment. Most victims are younger than one year old.

About half of the children injured by pediatric abusive head trauma die before they reach age 21. Survivors are likely to suffer a reduction in their overall quality of health (eg, develop disabilities such as blindness or hearing impairment), the article “Pediatric Abusive Head Trauma” explains.

Failure to thrive, in conjunction with developmental delays, is also a common manifestation of abusive head trauma in young children.

There are several factors surrounding head injuries that could suggest the involvement of potential child abuse. As outlined in STM Learning’s clinical reference Abusive Head Trauma, three prominent indicators that investigators and physicians should be on the lookout for are an inconsistent history, physical evidence of abuse, and delayed action from caretakers.

Inconsistent History

To keep themselves out of trouble, adults who are guilty of perpetrating abuse often fabricate their explanations of how the child’s injuries occurred. Common reports include that the infant fell from a couch or bed, or the adult may describe shaking the child while playing. Although this may be the case in some circumstances, these stories often do not support a severe injury. 

Fabrication can be identified when stories do not match up between different caregivers or change over time in separate recollections of the event. Explanations that do not align should be a red flag to investigators. Abuse may also be suspected in situations where a caregiver blames another child for the incident, or if a given explanation does not align with the developmental capability of the child (eg, the child fell off something they shouldn’t have been able to climb).

Additionally, if a child appears to have experienced trauma, but the adult’s report of the events would not have caused traumatic injury, this can be another sign that abuse may have occurred.

Physical Evidence

In cases of head trauma in children, injuries or scars in other areas of the body are also usually present. When the shaking of an infant takes place, rib fractures and retinal hemorrhages can often be identified.

Perpetrators of pediatric abusive head trauma are usually a caregiver or parent. Male guardians (fathers, stepfathers) make up the majority of offenders. If the caregiver in question is able to provide an explanation for the head injury without giving a reason for the child’s coexisting injuries, this may be a sign they are attempting to cover up abuse. 

During diagnosis and treatment, inconsistencies with the injuries may also be found in biomechanics, epidemiology, and temporal issues discovered by first responders, physicians, and other people involved in the child’s treatment. 

Delayed Action

Delayed action in seeking medical attention for a child can be a clear indicator that abuse may have been involved in the injury, particularly if the caregiver does not give reason for the delay. The failure to get help for an injured child could also be considered medical neglect depending on the situation. 

Adults who are guilty of perpetrating abuse typically minimize the severity of the injury while providing their report of the incident, and they may not reveal or explain an injury until inconsistencies are noticed in the child’s history. Caregivers also may downplay the severity of the child’s injury as a way to feel less guilty about the events that took place or to underscore that abuse occurred.


Resources

Those involved in the diagnosis and treatment of child head injury have several factors to consider before deciding if the caregiver abused the child. STM Learning has several publications available to help physicians make that decision, including our Pediatric Abusive Head Trauma Pocket Atlases and the third volume of our Child Abuse Pocket Atlas series, which focuses specifically on head injuries.

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