Study: In Times of Recession, Abusive Head Trauma Increases

The impacts of a recession are profound.

In a study appearing today in Pediatrics, Dr. Rachel Berger reports on the rise in the number of cases during the recent recession, which suggests that the rising tide of economic stress is causing a rise in the number of cases of Abusive Head Trauma/Shaken Baby Syndrome. Link to article

The story is receiving a lot of media attention, so it would be a good time to contact your elected officials and let them know that there are opportunities to help parents keep their children safe.

CBS; TIME; USA Today

As the coverage points out, if the rate reported in the study applies nationwide, it's now more likely that a child will be the victim of abuse head injury than pediatric diabetes.

CBS News includes a couple of tips from Dr. Peter Sherman at Montefiore Medical Center.

Sherman noted that most children studied were publicly insured even before the recession, suggesting that their families were already struggling financially.

Still, the recession affected many lower-income families, and Sherman said the study highlights "a very important issue."

He said pediatricians could help with prevention by asking families about difficulties paying for food or shelter and referring those in need to social service agencies. Just asking parents about stress and acknowledging their struggles can sometimes help, he said.

Most parents who abuse young children aren't "ill-intentioned," he said. "Most of it is kind of just snapping...maybe being sleep-deprived and just losing it. It's something that can happen to anyone."

On the incidence of inflicted injury: appearance and reality

The article on inflicted injuries in Sweden prompted a couple of thoughts...

Looking up the birth rate, I was surprised to find the crime rate in Sweden is reported to be above average for EU counties.

With 107,400 births, applying the rates of inflicted head injury found by the Barlow/Minns (24/100,00 under age 1) and Dias (41.5/100,000) studies, the expected incidence of inflicted head injury would be somewhere between 26 and 45 cases a year.

Tracking the Barlow and Minns paper, I found several studies of incidence, with some wide variation in rates. There seem to be a number of reasons that contribute to the diversity:

- the criteria used to define SBS/AHT/NAHI cases included in the studies vary;
- sources of case information are generally secondary;
- the upper age range of cases included in the study vary - age limit of one or two years were common, but the 2001 AAP Technical Report states injury can result up to age 5 (and there is a report of injury inflicted by shaking at age 7);
- the quality of diagnosis varies cnsiderably among hospitals
- medical professionals elect not to report cases of suspected abuse; see also Sege and Flaherty, Forty years later: inconsistencies in reporting of child abuse, Arch Dis Child, 2008 93: 822-82; a 2005 study of Pennsylvania pediatricians

Other sources on incidence:

King et al. Shaken Baby Syndrome in Canada:clinical characteristics and outcomes of hospital cases
2003 Can. Med. Assoc. J., 168(2): 155-159
10.6/100,000 (under age 5)
Email: king @ cheo.on.ca

Kessler, Dias et al. Demographics of Abusive Head Trauma in the Commonwealth of Pennsylvania, J. Neurosurgery in Pediatrics, May 2008 Vol 1(5)
14.7/100,000 under age 2
Email: Mdias @ hmc.psu.edu

Keenan et al. A Population-Based Study of Inflicted Traumatic Brain Injury in Young Children, JAMA, August 2003;290:621-626
17.0/100,000 under age 2
Email heather.keenan @ hsc.utah.edu

Talvik et al. Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia, Acta Pædiatrica, 2007 Vol 95(7), 799 - 804 (dissertation)
28.7/100,000 infants
Email: inga.talvik @ kliinikum.ee

Wirtz et al, Passive surveillance of shaken baby syndrome using hospital inpatient data, Am J Prev Med., 2008 34(4 Suppl): S134-9
Using CA inpatient data (1998-2004)
5.1/100,000 "strict SBS definition
14.0/100,000 "broader" SBS definition
Email: steve.wirtz @ cdph.ca.gov

Minns et al., Incidence and demography of non-accidental head injury in southeast Scotland from a national database, Am J Prev Med, 2008 34(4 Suppl):S126-33
33.8/100,000 infants (NAHI)
Email: Robert.Minns @ ed.ac.uk

Alexander et al., Incidence of impact trauma with cranial injuries ascribed to shaking, 1990 Am J Dis Child 144:724-726

Jayawant et al.,  Subdural haemorrhages in infants: population based study. 1998 BMJ 317:1558–61.
12.8/100,000 (SDH, 82% suggestive of abuse, under age 2)
21.0/100,000 (SDH under age 1)
kempam @ cardiff.ac.uk

Kelly, P. Infantile subdural haematoma in Auckland, New Zealand: 1988–1998, 2004 J. NZ Med Assn Vol 117(1204)

Kelly P et al., Shaken baby syndrome in New Zealand, 2000-2002, 2007 J Paediatr Child Health, 12,
14.7/100,000 'minimum' inflicted infantile SDH
19.6 per 100,000 'maximum'
Email: patrickk @ adhb.govt.nz

Barlow KM, Minns RA; Annual incidence of shaken impact syndrome in young children. Lancet 356:1571-1572, 2000 [requires free Lancet registration]
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)03130-5/fulltext

Gessner et al. Incidence of infant physical abuse in Alaska, Child Abuse & Neglect, 2004 28, 9-23
66/100,000 (inflicted head injuries, contrasting incidence reported in Barlow and discussing possible reasons)
Email: Brad_Gessner @ health.state.ak.us

Sun et al. , Non-accidental subdural haemorrhage in Hong Kong: incidence, clinical features, management and outcome, Child's Nervous System, 2006 Vol 22(6) 593-598
1.5/100,000 children under age 5
Email: wpoon @ cuhk.edu.hk

Incidence of reported shaking in response to crying

Reijneveld, Infant Crying and Abuse, Lancet (2004)
5.6% parents of children 6 months reported shaking, slapping, smothering

Theodore et al. Epidemiologic Features of the Physical and Sexual Maltreatment of Children in the Carolinas, Pediatrics, Vol 115(3), March 2005, e331-e337
2.6% of US parents reported shaking of a child under age 2 in their household

Runyan, The Challenges of Assessing the Incidence of Inflicted Traumatic Brain Injury: A World Perspective, Vol 34(4) Supplement, S112-S115 (April 2008)

While 2.6% of parents of children aged under 2 years in the U.S. report shaking their child as an act of “discipline,” survey data from lesser-developed countries on four continents indicate that shaking, as a form of discipline, may be many times more common among infants in their countries and that the consequences, short of hospitalization or death, are inadequately studied.