Research in Child Abuse and Neglect: Nonaccidental head trauma as a cause of childhood death (2006)

Part of our ongoing survey of what the child abuse and neglect literature says about perpetrators. Perpetrator data is highlighted in bold.

http://thejns.org/doi/full/10.3171/ped.2006.104.4.245?cookieSet=1

Journal of Neurosurgery
April 2006 Volume 104, Number 4

Nonaccidental head trauma as a cause of childhood death

Patrick Graupman, M.D.1, and Ken R. Winston, M.D.1
Division of Neurosurgery and Department of Pediatrics, The University of Vermont School of Medicine, Burlington, Vermont; and Departments of Neurosurgery, The University of Colorado Health Sciences Center and The Children’s Hospital, Denver, Colorado

Object
The authors present the demographic and clinical information in 36 children who died as a result of abusive head trauma at a Level 1 pediatric trauma center between January 1, 1997, and January 1, 2004.

Methods
Abusive head trauma was defined as radiographic evidence of intracranial injury and documentation from a multidisciplinary child protection team that the injury was nonaccidental. There was no sex bias for the children in the 1st year of life (nine girls, nine boys). In children older than 1 year of age, boys were much more likely to be victims (14 boys, four girls). At the time of admission, every child exhibited a seriously impaired level of consciousness and 81% had retinal hemorrhages. Injuries to other organ systems were rare (17%). The most common abnormality found on neuroimaging studies was subdural hematoma. Six children underwent craniotomy for extraaxial hematomas. Death occurred within 24 hours after hospital admission in one half of the cases.

Conclusions
Abusive head trauma was the cause of death in 36 (86%) of the 42 children whose deaths were classified as nonaccidental at the Children’s Hospital in Denver between 1997 and 2003. The authors were unable to identify anything that could have been done from a medical or neurosurgical viewpoint to prevent the deaths of these children after they came to medical attention.

Introduction
Child abuse is a broad category that contains emotional, sexual, and physical maltreatment. A population within the physically abused category includes children with an inflicted brain injury. A subset of children in this group ultimately die as a result of their brain injuries, and little has been published about them. Authors of a 2005 study compared the initial GCS scores of children who died of both inflicted and unintentional fatal head injuries, but this study was limited to discussion of GCS scores only.1 The purpose of this paper is to provide patient and guardian demographics, presenting complaints, injuries observed, radiographic results, operations performed, timing of death, and cause of death in children with fatal abusive head trauma admitted to a Level 1 pediatric trauma center.

Clinical Material and Methods

Data concerning all children (age range 0–18 years) who died as a result of abusive head trauma at The Children’s Hospital in Denver between January 1, 1997, and January 1, 2004 form the basis of this report. Abusive head trauma was defined as clear neuroimaging evidence of intracranial injury (on CT scans and/or magnetic resonance images) as well as documentation from a multidisciplinary child protection team that the injury was inflicted. Although clearly brain injured, children with nonaccidental death due to hypoxia (that is, smothering) were excluded from this study unless there was also evidence of significant mechanical trauma to the cranium. Thirty-six of the 42 nonaccidental deaths that occurred at this institution within the designated time span met our criteria for inclusion. The available medical records, neuroimages, and trauma databases were reviewed. In some cases, newspaper articles were used to identify perpetrators who were arrested or convicted of the abuse. The perpetrator is defined as a person who confessed or was convicted of the crime. Also included in this study were two perpetrators who were arrested and awaiting trial with significant evidence against them. Our child protection team consists of social workers, nurse clinicians, and a physician who specializes in child abuse. Cases in which an alleged perpetrator was charged, tried, and found innocent were classified as “perpetrator unknown.” This is not a population-based study, and it was done with the approval of the Colorado Multiple Institutional Review Board (Protocol No. 4-0143).

Patient Demographics
Thirty-six patients met the criteria established for inclusion in this study. The mean age of the children in this study was 11.5 months for girls and 23 months for boys (Table 1). Half of the children were younger than 1 year of age. There was no sex predilection for abuse in children in the 1st year of life (nine girls, nine boys). Boys older than 1 year of age were much more likely to be victims (14 boys, four girls). For the entire group, there was an approximate 2:1 male predominance (13 females, 23 males). Two children in this study had been removed from their homes for previous issues of abuse and were subsequently returned.

Demographics of Perpetrators and Reporters of Abuse
Women were slightly more likely (20:17) to bring the injured child to medical attention (call for help or bring the child to a healthcare facility) than were men. Most frequently, the person bringing a child to medical attention was a biological parent or parent figure, and this person was almost equally likely to be male or female (15:17). Fourteen of the 22 biological parents who brought a child to medical attention were biological mothers. Twenty-seven of the inflictors were male and three were female; therefore women were much more likely to report the event, even though they were much less often the perpetrators. Biological fathers and other father figures accounted for 24 (80%) of the 30 perpetrators. Of the 30 identified perpetrators 13 (43%) were also the reporters of the event.