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In 1997, in the child abuse case involving British nanny Louise Woodward, the words shaken baby syndrome leapt from medical textbooks into international prominence. Woodward was accused of shaking infant Matthew Eappen, fatally injuring him. In the 11 years since Woodward was convicted of second-degree murder and then released on a lesser sentence for involuntary manslaughter, a debate has simmered in the child abuse world, and it is now rising to a boil.
On one side of the courtroom, representing mainstream medical opinion, are those who believe shaken baby syndrome (SBS) is a valid diagnosis. They say that decades of clinical experience and criminal confessions—in which a parent has admitted to shaking a child with symptoms of SBS—bolster their case to the point of near-certainty. On the other side, a growing number of skeptics are now claiming that the evidence for the syndrome rests on dubious medical ground with questionable biophysical models supporting it.
Each side, too, is battling for the moral high ground. Those who give credence to SBS say they are using modern diagnostic technology (magnetic resonance imaging in particular) to catch child abusers who might once have gone unpunished. The skeptics, on the other hand, say that innocent families around the world have been left in ruins by prosecutors and child protective agencies who have wrongfully accused parents and child-care workers of child abuse.
Shaken baby syndrome excites such controversy partly because it invokes the specter of horrible cruelty to an innocent, often in the immediate wake of the child’s death. Yet in the classic SBS case, signs of child abuse that one might expect—suspicious bruises, burns, cuts, or other injuries—are missing. According to the 2001 textbook The Shaken Baby Syndrome: A Multidisciplinary Approach, “It is this absence of external signs of abuse which makes the early diagnosis of SBS so difficult.”
It is important to clarify that DISCOVER is weighing the science behind the textbook definition of shaken baby syndrome, not delving into casework involving children who do display “external signs of abuse.” This article is about the evidence for and against a specific syndrome, not the vital importance of child abuse prevention.
The Centers for Disease Control and Prevention reports that as of 2005 there were between 1,200 and 1,600 confirmed SBS cases per year. While no official statistics are available on SBS prosecutions, Toni Blake of the American legal consulting firm 2nd Chair Services says that at least 2,000 to 3,000 lawyers and defendants have contacted her over the past decade to request assistance on SBS trials and appeals around the country. In 2007, she says, “we saw one of these cases overturned about once a month.”
As with baby Matthew Eappen in the Woodward case, SBS typically first presents itself when an infant is brought to a hospital or doctor’s office suffering a life-threatening condition such as convulsions, an inability to eat or to be awakened, or difficulty breathing. (SBS can also present with seemingly less serious symptoms, such as changes in feeding behavior.) The 2001 SBS textbook cites two studies (from the journals Annals of Emergency Medicine and Developmental Medicine and Child Neurology) showing that between 15 percent and 33 percent of SBS-symptomatic infants died, while one-third to one-half suffered permanent injury such as paralysis or mental retardation. Although many infants are hospitalized with life-threatening conditions, it is only on closer examination—CT or MRI scans of the infant’s head and ophthalmological examination of the infant’s eyes—that a diagnosis of shaken baby syndrome comes into play.
“The thing we pick up on most easily is the bleeding,” says Randell Alexander, chief of the division of child protection and forensic pediatrics at the University of Florida at Jacksonville College of Medicine. “You see intracranial bleeding, between the brain and the skull...and then the other thing you see in about 90 percent of the cases is retinal hemorrhages.”
Once a doctor says that an infant must have been shaken, it triggers a hunt for the shaker. In one diagnostic step, the legal system is brought to bear on the baby’s family and anyone else near the infant at the time of the supposed shaking.
The symptomatic triad of bleeding between the brain and skull (known as subdural or subarachnoid hematomas), bleeding behind the retinas, and brain swelling is both the core of an SBS diagnosis and the point of departure for the syndrome’s skeptics. The medical proof that shaking alone can cause these internal head injuries is questionable, the skeptics say, when many other things, from infections to malnutrition to falls onto a hard surface, are known to be causes of similar symptoms in infants.
One such skeptic testified for the prosecution in the Woodward case but later changed his stance. Pediatric neuroradiologist Patrick Barnes of Stanford University said in an e-mail interview, “It is known from case records that SBS is misdiagnosed/overdiagnosed. It is not only a problem in medicine but a problem in the justice system.”
Nevertheless, “we’re not teaching Pat Barnes’s point of view in medical schools,” Alexander says. “What [SBS skeptics] say is generally not believed by a vast majority of doctors—and it’s not believed by medical organizations.” Alexander points to a 2001 position paper from the American Academy of Pediatrics stating that SBS “injuries are the result of violent trauma” and not from “short falls, seizures, or as a consequence of vaccination.”
Ronald Uscinski, a clinical assistant professor of neurosurgery at Georgetown Hospital and George Washington University, first entered the SBS arena when a colleague asked him to testify for the defense in the Louise Woodward case. During the quiet summer before the trial, Uscinski read every paper and monograph he could find on the syndrome.
Uscinski traced medical citations in SBS research back to a 1968 study involving rhesus monkeys subjected to collisions and violent accelerations. Uscinski already knew the study—it had been conducted by his mentor, Ayub Ommaya, the very same colleague who had brought him into the Woodward case. Uscinski says the study yields no firm conclusions about the consequences of shaking monkeys or, for that matter, babies.
“When I put all of this together, I said, my God, this is a sham,” Uscinski says. “Somebody made a mistake right at the very beginning, and look at what’s come out of it.”
In 2007 Uscinski took on an SBS case in Washington, D.C., testifying on behalf of two parents, Greg and Julianna Caplan, who were accused of SBS abuse. The Caplans were ultimately exonerated, yet they remained on the city rolls as potential child abusers until earlier this year. Uscinski wrote in an editorial in the Washington Post in March, “This is not to say that child abuse does not exist. I have witnessed such cases and have been deeply and painfully moved by the plight of innocents who have been injured or even killed....And yet I am no less moved by the plight of the wrongfully accused (and even convicted), their families and their loved ones. This is particularly so when such accusations are based on impure science, a flawed legal foundation, and completely inadequate or inappropriate public policy.”
