Preventing abusive head trauma resulting from a failure of normal interaction between infants and their caregivers

Abstract

Head trauma from abuse, including shaken baby syndrome, is a devastating and potentially lethal form of infant physical abuse first recognized in the early 1970s. What has been less recognized is the role of the early increase in crying in otherwise normal infants in the first few months of life as a trigger for the abuse. In part, this is because infant crying, especially prolonged unsoothable crying, has been interpreted clinically as something wrong with the infant, the infant's caregiver, or the interactions between them. Here, we review an alternative developmental interpretation, namely, that the early increase in crying is a typical behavioral development in normal infants and usually does not reflect anything wrong or abnormal. We also review evidence indicating that this normal crying pattern is the most common trigger for abusive head trauma (AHT). Together, these findings point to a conceptualization of AHT as the consequence of a failure in an otherwise common, iterative, and developmentally normal infant-caregiver interaction. They also imply that there is a window of opportunity for prevention of AHT, and potentially other forms of infant abuse, through a public health primary universal prevention strategy aimed at changing knowledge and behaviors of caregivers and society in general concerning normal development of infants and the significance of early increased infant crying. If effective, there may be important implications for prevention of infant abuse nationally and internationally.

Fig. 1.

Age-specific number of reported cases of SBS in infants from 0 to 18 mo of age from the NCSBS Victim Database entered between January 1, 2003 and August 31, 2004. Diamonds and the solid line represent all cases irrespective of stimulus (n = 591), and squares and the broken line represent the subgroup of cases with crying reported as the stimulus (n = 166). (Reproduced with permission from ref. . Copyright 2007 Lippincott Williams & Wilkins, Inc.)

Fig. 2.

Crying amounts and patterns from three North American studies illustrating the age-related crying curve and absence of a secular trend. Triangles represent data from Brazelton (69), circles represent data from Hunziker and Barr (70), and diamonds represent data from Kramer et al. (77). (Reproduced from ref. . Copyright 2005 Elsevier Ltd.)