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According to the United Nations, 80% of children who die from violence are under age 6, and of those, 40% are infants (Child Welfare Information Gateway [CWIG], 2006; Pinheiro, 2006). The most common cause of violent death for this age group is head injury, followed by blunt force trauma to the child’s body. Although there are many possible sources of traumatic head injury, in 1971 it was suggested that shaking could cause subdural hematomas (and associated cerebral edema), one of the most common types of intracranial injuries seen in deceased infants (Guthkelch, 1971). It was purported that shaking was the mechanism responsible for shearing or tearing the cortical bridging or connecting veins in the brain, which, in turn, caused hematomas. One year later, in 1972, pediatric radiologist John Caffey coined the term “whiplash shaken baby syndrome” to describe a cluster of physical symptoms found in severely traumatized infants. These signs or symptoms included brain injury (i.e., subdural and/or subarachnoid hemorrhages), retinal hemorrhages, and little to no external evidence of head trauma (Caffey, 1972a). Caffey concluded that this type of traumatic intracranial bleeding, similar to that seen in “whiplash” victims, was inflicted by shaking (Caffey, 1972a, 1972b, 1974). Eventually this cluster, or triad, of clinical findings in infants and children came to be known as either “shaken baby triad” or “shaken baby syndrome” (SBS). When additional symptoms consistent with the infant’s head striking a solid or semi-solid surface (such as cranial fractures) were present, the condition was referred to as “shaken-impact” or “shaken-slam.”
The Context of SBS
In those cases in which victims of shaking do present with external trauma, the injuries most typically include bruising to the face, arms, stomach, and/ or back, and are highly indicative of other forms of physical abuse. Shaken baby syndrome seldom occurs in isolation and has been long known to occur in the context of repeated physical abuse, with evidence of prior abuse and shaking often found upon examination (Ewing-Cobbs et al., 1998; Alexander et al., 1990; Caffey, 1972a, 1972b). Shaking tends to escalate over time, becoming increasingly violent, prolonged, and frequent. It has been estimated that in approximately 33–40% of all cases of SBS, there is evidence of previous head trauma due to shaking, such as old or resolving intracranial hemorrhages (Alexander et al.). Among physically abused infants and children, head trauma is not only the leading cause of death, but also of long-term disability (Pinheiro, 2006; Reece & Sege, 2000; Duhaime et al., 1992; Billmire & Myers, 1985). In turn, the most common cause of head trauma among abused infants is believed to be shaking. Between 50–80% of the murders of children aged 10 and under are perpetrated by family members (CWIG, 2006; Pinheiro, 2006). Consistent with this, early researchers noted that SBS was typically inflicted by exceptionally stressed parents or caretakers (Ewing-Cobbs et al., 1998; Alexander et al., 1990; Caffey, 1972a, 1972b). Fathers or fatherfigures, most in their early 20s with low socio-economic status, are the most frequent perpetrators of shaken baby syndrome, responsible for anywhere between 65–90% of all cases (Pinheiro; Children’s Trust Fund [CTF], 2004). A female caretaker or babysitter is the next most common offender, followed by the victim’s mother. In general, infant shaking is associated with the parent or caretaker suffering from biological, social, environmental, and/or financial stress, which increases the risk of impulsive and violent behavior. Adults with past or present problems with substance abuse or domestic violence may be at even greater risk of perpetrating this type of child abuse. The most frequent reason given by offenders for shaking an infant is the frustration that results from caring for an inconsolably crying or incessantly fussy child (Barr, 2007; Pinheiro, 2006; Caffey, 1972). However, shaking may also be triggered by the infant’s excessive coughing or toileting problems, as well as by caretaker sleep deprivation or jealousy of the child by the abusing adult. Although SBS has been reported in cases of children up to age 5, it is most commonly seen in children under the age of 2 years (Keenan et al., 2003; United States Advisory Board on Child Abuse and Neglect [USABCAN], 1995). In the majority of cases, the infant is between 3–8 months. For a number of reasons, including mis- or under-diagnosis, there are no reliable figures regarding the incidence of SBS (Wirtz & Trent, 2008). One difficulty in gathering reliable statistics is the notable variation in the symptom constellation used to define SBS between hospitals. Despite this, the National Center on Shaken Baby Syndrome has reported there are between 600 and 1,400 cases of SBS seen in U.S. hospitals every year (For more information, see: www.dontshake.org/sbs.) Using research conducted by the British Broadcasting Corporation (BBC), the figure rises to between 1,200 and 1,600 in the United States per year (BBC, 2008).
Diagnosing SBS
As identified in the early 1970s, SBS is caused by violent shaking of an infant or young child, causing the brain to rebound against the skull. It is the force of this rebounding that results in the characteristic tearing, bruising, bleeding, and swelling of the brain. Although significant symptoms may develop immediately, while still in the care of the perpetrator, the offender may not seek immediate medical intervention, convincing him or herself the child is “sleeping” (when actually unconscious or comatose) or “needing a nap” (when lethargic and irritable) or suffering from a minor ailment (when vomiting). Many of the clinical signs of SBS are sufficiently problematic to prompt a parent or caretaker to seek medical attention. Unfortunately, that may not occur until days (or even weeks) after the precipitating trauma. By the mid-1970s, computed tomography (CT) was being used in the diagnosis of SBS, and by the mid-1980s, magnetic resonance imaging (MRI) was added adjunctively in order to better refine the diagnosis (Alexander, Schor & Smith, 1986). Although MRI is better able to detect certain brain lesions, it cannot be used if the child is on life support (Sato et al., 1989). When combined, CT and MRI are extremely useful for determining the age of identified injuries, as well as any history of repeated trauma or victimization. Imaging should be repeated in 1–2 weeks as it takes approximately 7–10 days for the healing process to become radiologically visible in new fractures (American Academy of Pediatrics, Section on Radiology [AAPSR], 2000). Since the early 1970s, after Caffey identified “whiplash shaken baby syndrome,” SBS has been diagnosed based on the co-occurrence of subdural hematomas, retinal hemorrhages, and the absence of external injury consistent with a trauma sufficient to induce the first two symptoms (such as a motor vehicle accident or a fall from an appreciable height). However, the diagnosis has been made based solely on the presence of subarachnoid hemorrhages with associated cerebral edema (American Academy of Pediatrics, Committee on Child Abuse and Neglect [AAPCCAN], 2001). Shaking-induced intracranial bleeding is typically most prominent in the inter-hemispheric fissure, although it can be found virtually anywhere in the brain. When retinal hemorrhages are present, they may be easily missed. Accurate diagnosis requires dilation of the pupils, the use of specialized equipment, and examination by a pediatric ophthalmologist (Levin, 1990). Retinal hemorrhages may involve multiple layers of the retina and vary widely between cases in terms of nature, size, severity, number, and location. Those seen in infants who were known to have been shaken resolved anywhere from 1 week to several months, and in some persisted for years (Emerson et al., 2001). In diagnosing SBS, the infant or toddler’s history must be absent any underlying condition(s) known to produce subdural hematomas and retinal hemorrhages. Conditions or illnesses that must be ruled out include hydrocephalus, coagulopathies, or metabolic, inflammatory, thrombotic, or seizure disorders, amongst others (Barnes, 2002; Rutty, Smith & Malia, 1999). Not only do these conditions result in the symptoms characteristic of SBS, they also increase the child’s vulnerability to damage from whiplash-type motion. Similarly, antibiotics, Tylenol, and vaccines have been implicated in infant vulnerability to the effects of shaking.
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By Randy Noblitt, PhD, FACFEI, and Pamela Perskin Noblitt
The Social Security Administration (SSA) has established procedures whereby disabled
claimants can apply for Social Security Disability (SSD) and Supplemental Security
Income (SSI) benefits. This article addresses the criteria by which this agency makes
determinations and why helping professionals are duty-bound to provide advocacy and
support for their legitimately disabled patients. Furthermore, it provides guidance regarding definitions and processes involved in disability determination. Finally, this article challenges helping professionals to rise to the defense of their disabled clients and patients to provide the support and advocacy consistent with professional ethics.
By Randy Noblitt, PhD, FACFEI, and Pamela Perskin Noblitt
The Social Security Administration (SSA) has established procedures whereby disabled
claimants can apply for Social Security Disability (SSD) and Supplemental Security
Income (SSI) benefits. This article addresses the criteria by which this agency makes
determinations and why helping professionals are duty-bound to provide advocacy and
support for their legitimately disabled patients. Furthermore, it provides guidance regarding definitions and processes involved in disability determination. Finally, this article challenges helping professionals to rise to the defense of their disabled clients and
patients to provide the support and advocacy consistent with professional ethics.
By Randy Noblitt, PhD, FACFEI, and Pamela Perskin Noblitt
The Social Security Administration (SSA) has established procedures whereby disabled
claimants can apply for Social Security Disability (SSD) and Supplemental Security
Income (SSI) benefits. This article addresses the criteria by which this agency makes
determinations and why helping professionals are duty-bound to provide advocacy and
support for their legitimately disabled patients. Furthermore, it provides guidance regarding definitions and processes involved in disability determination. Finally, this article challenges helping professionals to rise to the defense of their disabled clients and
patients to provide the support and advocacy consistent with professional ethics.
By Randy Noblitt, PhD, FACFEI, and Pamela Perskin Noblitt
The Social Security Administration (SSA) has established procedures whereby disabled
claimants can apply for Social Security Disability (SSD) and Supplemental Security
Income (SSI) benefits. This article addresses the criteria by which this agency makes
determinations and why helping professionals are duty-bound to provide advocacy and
support for their legitimately disabled patients. Furthermore, it provides guidance regarding definitions and processes involved in disability determination. Finally, this article challenges helping professionals to rise to the defense of their disabled clients and
patients to provide the support and advocacy consistent with professional ethics.
By Randy Noblitt, PhD, FACFEI, and Pamela Perskin Noblitt
The Social Security Administration (SSA) has established procedures whereby disabled
claimants can apply for Social Security Disability (SSD) and Supplemental Security
Income (SSI) benefits. This article addresses the criteria by which this agency makes
determinations and why helping professionals are duty-bound to provide advocacy and
support for their legitimately disabled patients. Furthermore, it provides guidance regarding definitions and processes involved in disability determination. Finally, this article challenges helping professionals to rise to the defense of their disabled clients and patients to provide the support and advocacy consistent with professional ethics.
According to the United Nations, 80% of children who die from violence are under age 6, and of those, 40% are infants (Child Welfare Information Gateway [CWIG], 2006; Pinheiro, 2006). The most common cause of violent death for this age group is head injury, followed by blunt force trauma to the child’s body. Although there are many possible sources of traumatic head injury, in 1971 it was suggested that shaking could cause subdural hematomas (and associated cerebral edema), one of the most common types of intracranial injuries seen in deceased infants (Guthkelch, 1971). It was purported that shaking was the mechanism responsible for shearing or tearing the cortical bridging or connecting veins in the brain, which, in turn, caused hematomas. One year later, in 1972, pediatric radiologist John Caffey coined the term “whiplash shaken baby syndrome” to describe a cluster of physical symptoms found in severely traumatized infants. These signs or symptoms included brain injury (i.e., subdural and/or subarachnoid hemorrhages), retinal hemorrhages, and little to no external evidence of head trauma (Caffey, 1972a). Caffey concluded that this type of traumatic intracranial bleeding, similar to that seen in “whiplash” victims, was inflicted by shaking (Caffey, 1972a, 1972b, 1974). Eventually this cluster, or triad, of clinical findings in infants and children came to be known as either “shaken baby triad” or “shaken baby syndrome” (SBS). When additional symptoms consistent with the infant’s head striking a solid or semi-solid surface (such as cranial fractures) were present, the condition was referred to as “shaken-impact” or “shaken-slam.”
According to the United Nations, 80% of children who die from violence are under age 6, and of those, 40% are infants (Child Welfare Information Gateway [CWIG], 2006; Pinheiro, 2006). The most common cause of violent death for this age group is head injury, followed by blunt force trauma to the child’s body. Although there are many possible sources of traumatic head injury, in 1971 it was suggested that shaking could cause subdural hematomas (and associated cerebral edema), one of the most common types of intracranial injuries seen in deceased infants (Guthkelch, 1971). It was purported that shaking was the mechanism responsible for shearing or tearing the cortical bridging or connecting veins in the brain, which, in turn, caused hematomas. One year later, in 1972, pediatric radiologist John Caffey coined the term “whiplash shaken baby syndrome” to describe a cluster of physical symptoms found in severely traumatized infants. These signs or symptoms included brain injury (i.e., subdural and/or subarachnoid hemorrhages), retinal hemorrhages, and little to no external evidence of head trauma (Caffey, 1972a). Caffey concluded that this type of traumatic intracranial bleeding, similar to that seen in “whiplash” victims, was inflicted by shaking (Caffey, 1972a, 1972b, 1974). Eventually this cluster, or triad, of clinical findings in infants and children came to be known as either “shaken baby triad” or “shaken baby syndrome” (SBS). When additional symptoms consistent with the infant’s head striking a solid or semi-solid surface (such as cranial fractures) were present, the condition was referred to as “shaken-impact” or “shaken-slam.”
According to the United Nations, 80% of children who die from violence are under age 6, and of those, 40% are infants (Child Welfare Information Gateway [CWIG], 2006; Pinheiro, 2006). The most common cause of violent death for this age group is head injury, followed by blunt force trauma to the child’s body. Although there are many possible sources of traumatic head injury, in 1971 it was suggested that shaking could cause subdural hematomas (and associated cerebral edema), one of the most common types of intracranial injuries seen in deceased infants (Guthkelch, 1971). It was purported that shaking was the mechanism responsible for shearing or tearing the cortical bridging or connecting veins in the brain, which, in turn, caused hematomas. One year later, in 1972, pediatric radiologist John Caffey coined the term “whiplash shaken baby syndrome” to describe a cluster of physical symptoms found in severely traumatized infants. These signs or symptoms included brain injury (i.e., subdural and/or subarachnoid hemorrhages), retinal hemorrhages, and little to no external evidence of head trauma (Caffey, 1972a). Caffey concluded that this type of traumatic intracranial bleeding, similar to that seen in “whiplash” victims, was inflicted by shaking (Caffey, 1972a, 1972b, 1974). Eventually this cluster, or triad, of clinical findings in infants and children came to be known as either “shaken baby triad” or “shaken baby syndrome” (SBS). When additional symptoms consistent with the infant’s head striking a solid or semi-solid surface (such as cranial fractures) were present, the condition was referred to as “shaken-impact” or “shaken-slam.”
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