A cause of infant injury or death that is hard to diagnose is easier to prevent by educating parents and carers, as Lena Engel reports
Shaken baby syndrome is a crime that usually has no witnesses and whose victims are obviously too young to identify their assailants. The syndrome refers to the violent shaking of infants perpetrated by parents or carers. Severe brain and physical damage to a baby can result from just one fierce episode of shaking.
The European Conference on Shaken Baby Syndrome, staged in Edinburgh at the end of May, highlighted that this form of child abuse is difficult to diagnose and therefore often remains undetected.
Defensive stories
Research carried out in New York state reveals that 75 per cent of perpetrators are parents. Of these, 60 per cent are fathers or father figures, namely stepfathers or boyfriends. The average age of the victims is five months. Only since the early 1960s has this form of child abuse been officially recognised.
It was first called 'battered child syndrome' and was noted for the fact that there was usually a discrepancy between the clinical evidence seen by doctors, and the stories that parents gave for their child's injury or demeanour.
Studies indicate that perpetrators of non-accidental injury come from a variety of social, cultural and economic backgrounds, so it is not just a crime of poverty or social exclusion. In most incidents, it appears that caregivers are unaware of the specific injuries that they can inflict by shaking a baby, and that they misjudge the strength they can exert.
Research into the causes of this form of abuse suggests that repeated injuries to infants are related to poor levels of bonding, stressed parenting and insecure attachments within the family. Common defences for the behaviour advanced by parents are that:
- the damage was caused accidentally by a fall or other injury
- the baby was shaken to resuscitate it
- the diagnosis by clinicians must be wrong.
Parents and carers often refute the clinical evidence and contest criminal charges brought against them. Convictions are not often obtained in these cases, as clinical experts have difficulty in agreeing about the cause of brain damage or death.
Medical professionals have become more knowledgeable about shaken baby syndrome over the past ten to 15 years because of the scientific advances in technical equipment used for brain scans and neuroscientists' increased understanding of the consistency of brain tissue.
The incidence of shaken baby syndrome cases in England and Wales is difficult to quantify because statistics are not available. However, in Somerset and Avon, where efforts have been made to calculate its incidence, records indicate that between September 1999 and September 2002, there were 23 cases of infant abuse described as resulting in excessive head trauma. Of these cases, six babies died and the rest suffered varying degrees of brain damage.
Controversy rages among professionals working in the medical, criminal and child protection fields because injuries to infants' brains can vary in type and severity, so a large number of offences go undetected. Also, evidence is difficult to collect for criminal cases unless the baby has died, when an autopsy can then be conducted. An autopsy will reveal the varying degrees of neurological impairment and different levels of internal brain haemorrhaging.
Certain types of evidence may alert clinicians to the fact that babies have been shaken, if they are brought to accident and emergency wards. These babies may display extreme irritability, breathing difficulties, gaze disturbance, vomiting, poor sucking or swallowing, bulging or spongy forehead, unequal size of pupils and bloodshot eyes, seizures, rigidity, lethargy or coma.
In some cases, infants are subjected to repeated abuse at the hands of parents or carers. It is the responsibility of the medical and community services to recognise some of these initial signs when babies are admitted to hospital, or when the infant's condition is reported by concerned family or neighbours.
The police representatives from Somerset and Avon at the European conference expressed growing concern for this area of criminal behaviour. They explained that their increased awareness of this form of child abuse was having an impact on the way they handled suspected cases and that new protocols had been developed to meet the challenge of these crimes. It is hard for police to doubt the words of perpetrators who present themselves as being loving and caring parents, especially as there are generally no witnesses to babies being shaken.
The Somerset and Avon police also admit that they need to confront their own prejudices regarding this form of abuse. They recognise that, while they collect evidence, parents should be shown understanding and sympathy, as well as the right to confidentiality. In consequence, police in this region are working very closely with other agencies to promote positive support for both children and their parents. It is acknowledged that, for the most part, perpetrators of this type of crime were suffering from physical, mental and emotional conditions, which led them to shake their baby. Therefore the response from neither the police nor society could be the same as that accorded to other types of crime.
Parent education
Much research has been undertaken into shaken baby syndrome over the past ten years in the US, where efforts have been made to initiate programmes to deter parents and carers from harming babies.
In New York state, Dr Mark Dias, a paediatric neurosurgeon, and his colleagues devised an education programme that tried to remind all parents of newborn infants at 16 hospitals about the dangers of violent infant shaking.
They based the programme on the premise that:
- most people know that infant shaking is bad
- shaken baby syndrome represents a momentary lapse of control by a carer, likely to occur as a result of extreme frustration
- 75 per cent of perpetrators are parents (with 60 per cent being fathers, stepfathers or boyfriends)
- the educational programme needed to target parents, and especially father figures.
Their prevention programme began in 1998. The package included training senior and other nurses in each of the maternity wards of 16 hospitals to spend half an hour with each parent, informing them about the effects of shaken baby syndrome. The parents were asked to read particular leaflets and view a video before they went home with their new baby. Parents were then encouraged to sign a statement promising not to shake their newborn baby.
After four years, the programme has achieved outstanding results. There has been a 50 per cent reduction in the incidence of shaken baby syndrome in the state. It is assumed that helping parents to understand the outcomes of shaking babies has enabled them to develop greater self-control and encouraged them to use alternative coping strategies when they were feeling stressed.
Similarly, a prevention programme introduced in the state of Utah in 1997 has been successful. This project also based its impetus on a set of premises that derived from studies of perpetrators carried out over several years.
These were that:
- with other forms of abuse there is often intent while, with shaken baby syndrome, there is no intent to harm the child
- the incidence of this form of abuse could well be 100 per cent preventable
- there were astronomical costs in caring for a victim of shaken baby syndrome and cutting them would represent a significant saving to the state.
The prevention programme included training for staff in hospitals so that they disseminated essential information about the dangers of shaking babies, and offered parents guidance about handling babies.
The programme targeted parents who were expecting babies, and particularly fathers, who were known to be the most likely perpetrators. Special emphasis was placed on training fathers how to look after their new babies. Intensive all-male sessions encouraged fathers to learn practical skills, such as nappy changing and preparing feeding formula, and this intervention helped them develop self-esteem and confidence in caring for their babies. As a result the incidence of shaken baby syndrome has been considerably reduced, repeating the success of the programme in New York State.
Speakers at the European Conference on Shaken Baby Syndrome expressed optimisim that similar prevention programmes introduced across Europe and the US would continue to reduce the incidence of this type of abuse.
However, to achieve this, a great deal of energy and funding would need to be committed to research and prevention programmes.