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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.”
Assumptions Surrounding the Diagnosing of SBS
Despite how straightforward the diagnosis appears to be, there is a great deal of controversy surrounding the triad of symptoms that are considered indicative of SBS. One area of controversy revolves around the nature and course of subdural hematomas, which are believed to be caused by either a disease process or trauma. When an underlying disease has been ruled out, the diagnostician is left with trauma as the causal factor. Yet, minor brain hemorrhages have been found on the MRIs of 26% of “normal” babies, especially in those delivered vaginally (Looney et al., 2007). Debate also exists as to whether all subdural hematomas are immediately symptomatic and resultant in morphological change. It has been shown that relatively mild structural damage can result in comparatively immediate death, while infants with major damage can survive indefinitely (Geddes, Hackshaw, Vowles, Nickols, & Whitwell, 2001; Geddes, Vowles, et al., 2001). Furthermore, shaking victims have shown no evidence of cognitive impairment for varying lengths of time before ultimately succumbing to their injuries (Denton & Mileusnic, 2003). Another area of controversy surrounds retinal hemorrhages, which are typically considered the product of non-accidental trauma and pathognomonic of SBS, especially when seen in conjunction with perimacular retinal folds (Emerson et al., 2001; Office of Juvenile Justice and Delinquency Prevention [OJJDP], 1996). Yet, a review of the objective scientific research conducted between 1966 and 2003 does not support this conclusion (Lantz, Sinal, Stanton, & Weaver, 2004). With few exceptions, the existing research is methodologically flawed and, as a whole, conflicting. While retinal hemorrhages may eventually be proven to be diagnostic of SBS, to date, there is insufficient evidence to support unquestioning acceptance of this claim. There is no agreement as to what presentation of retinal hemorrhages (in terms of number, size, location, etc.) points unequivocally to SBS. Bleeding in the eye is more common than thought and not always non-accidental (Lantz et al., 2004). Research conducted between 2004 and 2006 on approximately 1,500 corpses found retinal hemorrhages in approximately 1 out of every 6 bodies (BBC, 2008). For example, they have been shown to occur at childbirth, with coagulation disorders; in osteogenesis imperfecta, as a result of near or fatal suffocation, straining, repeated, and forceful sneezing; and very occasionally as a byproduct of resuscitation efforts (Goetting & Sowa, 1990). Approximately 6% of children who were abused, but not by shaking, developed ocular findings, including retinal hemorrhages (Levin, 1990, 1998). Because retinal hemorrhages are not always present in confirmed cases of SBS and because their etiology can be other than trauma, they should perhaps not be considered either necessary or sufficient for the diagnosis of SBS. Controversy also surrounds the diagnostic significance and certainty of the presence or absence of external injury. The diagnosis of SBS is based on the premise that shaking alone is sufficient to cause subdural hematomas and retinal hemorrhages in healthy infants. In addition, it assumes that the injuries (which, again, vary widely in severity and type, etc.) are caused by violent, intentional trauma. The prevailing notion is that the injuries “characteristic” of SBS are equivalent to those seen in a 35 mph automobile accident in which the infant victim was unrestrained, or a fall from a two-story building. Yet, research (including biomechanical analysis) has shown that, although fortunately not the norm, infants and toddlers can and do die from falls as short as 1–4 feet (Omaya, Goldsmith, & Thibault, 2002; Plunkett, 2001). It is generally accepted that bouncing an infant or toddler on one’s knees, tossing a toddler into the air (and catching them), and rough play will not cause SBS (CTF, 2004). Yet, there is not uniform consensus as to what force is minimally necessary to cause subdural and retinal bleeding from shaking. Although some believe that shaking alone is sufficient to cause the type of injuries seen in SBS, others contend that there must also be impact (BBC, 2008; Bandak, 2005; Plunkett, 2001). According to some, impact on a hard surface is necessary, while others believe a soft-surface impact is sufficient. Biomechanical research using infant crash test dummies and corpses has cast doubt on several theories associated with SBS (BBC, 2008; Bandak, 2005; Plunkett, 2001). The levels of force and speed necessary to achieve SBS-type trauma by shaking alone would result in significant injury to the cervical spine, which is seldom seen in SBS cases. In addition, biomechanical research has demonstrated that in simulated one-and-a-half month old dummies, the damage caused by aggressive shaking is statistically similar to that caused by a 1-foot fall onto concrete covered by carpet. A fall from 3 feet on the same surface produces a force that is 40 times greater than that produced at 1 foot, and it is far greater than that produced by vigorous shaking by a human. In brief, biomechanical research suggests that basing the diagnosis of SBS only on the presence of the triad of symptoms lacks scientific certainty.The American College of Forensic Examiners International began in 1992; it is still here. Most membership associations rise and fall in less than a decade, but the passion of ACFEI’s founder, Dr. Robert O’Block, and the thousands of reputable people his associations help each year, has fueled continued growth since ACFEI’s inception nearly two decades ago.
As we continually improve our continuing education coursework, Web presence, and printed publications, that growth is bound to continue. The fields in which our members work, study, and fight are not going anywhere anytime soon, and are dynamic and ever evolving. When you join the American Board for Certification in Homeland Security, the American Association for Integrative Medicine, the American Psychotherapy Association, or the tried-and-true American College of Forensic Examiners Institute, you will see that we rise above the competition in offering continuing education excellence. Dr. Robert O’Block has created a unique opportunity for you to meet like-minded professionals to network, learn, and teach one another and the world at large.
To learn more, please visit www.acfei.com.
What is it that draws so many—nurses, physicians, soldiers, investigators, government employees, psychologists, psychiatrists, social workers, and a sheer multitude of other honorable professions—into the American College of Forensic Examiners Institute fold? Let me share with you just a few of the numerous reasons so you can better decide for yourself, as thousands wisely did before you:
Accreditation. The American College of Forensic Examiners Institute is an approved provider of continuing education by the following:
Continuing education alignments. In addition to the several accreditations above, we are also proud to inform you that:
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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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