In a café in Carrum Downs in 2016, a frustrated 39 year father angrily shook his 5 month old baby. Concerned onlookers called police and the man was charged and convicted for assault. Thankfully, his daughter was not injured.[1] At Lasseters Casino in the Northern Territory on new years day, 2013, a security staff member witnessed a mother “shake the baby like a rag doll, hard enough for the baby’s head to flop backwards and forwards. She did this three or four times”. Police were called. Subsequently, “medical staff thoroughly examined ‘Baby C’ at Alice Springs Hospital” but “this examination revealed that she had sustained no physical injuries.”[2]
There are multiple documented shaking episodes that have been witnessed, some caught on video [3]. This is appalling behaviour by the caregivers. People should not shake babies. However, none of these witnessed cases of shaking a baby resulted in the brain injuries that are associated with Shaken Baby Syndrome, i.e. Subdural and Retinal Haemorrhages, and brain swelling.
By contrast, every case of Shaken Baby Syndrome (SBS), where an infant does have this ‘triad’ of brain injuries, the infant was allegedly shaken by a perpetrator without being seen. There are no documented cases of Shaken Baby Syndrome that were witnessed.[4]
Shaken Baby Syndrome advocates claim that this is because “child abuse almost inevitably occurs in the absence of independent adult witnesses”[5].
There are obvious problems with this claim. Firstly, as shown above, people have been witnessed shaking infants. It is just that when the shaking was independently witnessed, the SBS associated brain injuries did not occur.
Secondly, every other type of assault on infants has been witnessed. In one case, a woman was caught in the act of trying to suffocate her infant with a pillow. In another case a man was witnessed picking up an infant by the back of the neck and throwing it to the floor. Some are even caught on video camera. In this instore video [Warning: video contains graphic content] you see a woman punch an infant.
Yet shaking that results in the SBS associated brain injuries are never witnessed nor caught on video. This is despite claims that it is “the leading cause of physical child abuse deaths in the U.S.” [6] According to SBS advocates, there are 1300 cases each year in the U.S. alone [7]. The asserted 200 cases over the past decade in the U.K. are supposedly only the “tip of the iceberg” [8], whilst advocates claim that 180-200 cases occur in France each year [9]. In Australia, advocates assert that shaking kills as many infants as car crashes [10,11]. This is not to mention the rest of the world.
I need to say it again: despite these allegedly huge numbers, no incidence of shaking that leads to the SBS associated brain injuries has been independently witnessed.
Further, there is no documented case where a person has arrived at a hospital with their gravely ill infant and informed the doctor that they had shaken the infant, in an attempt to help the doctors identify the best course of treatment. So, in the supposedly tens of thousands of cases of shaking over the past decades, not once did a parent take responsibility and own up, in the hope of helping their infant. Ok, I get it, people generally are not going to want to own up to that type of thing. But never in tens of thousands of cases has someone put the health of their infant first and said “I was frustrated and I must have shaken her too hard. Please help her.” Not once?
All documented “confessions” to shaking, which are explored in other blog posts on this website, were made during interrogation. I explain in my peer reviewed article why Shaken Baby Syndrome is the perfect storm for eliciting false confessions, and why the documented confessions are not reliable enough to provide an evidentiary basis for the fact that shaking causes the SBS related brain injuries, let alone the notion that doctors can determine that an infant was shaken merely by analysing those brain injuries [12].
The fact that no shaken baby case has been witnessed seems pretty hard for shaken baby advocates to digest and then continue to maintain that the Shaken Baby Syndrome hypothesis is valid (oh.. added to the fact that it is not supported by any science [13]). How do shaken baby advocates deal with this?
Well at least one advocate, U.K. Paediatric neuroradiologist Dr Neil Stoodley, tries to claim that the lack of independently witnessed cases helps prove that Shaken Baby Syndrome is real. According to Stoodley “Virtually all these injuries occur when the child is with a single carer. It’s not witnessed by anyone else. The holy grail of lawyers is to find a naturally occurring medical condition we’ve been missing all this time that causes it. Let’s assume there is one. Most diseases tend to occur at different times of day. This one would have to be somehow sentient and know the child it’s about to cause trouble with, is in the care of a single carer.” [14]
Well, I guess that could have some logic as an argument. If it were true. But it simply is not true. Many examples exist where the infant was not alone when it collapsed. A study in Australia found that the majority of suspected cases of shaking are not prosecuted because investigators were not able to determine who did the shaking [15]. The author of the study, Dr Amanda Stephens, put this down to one parent lying to protect the other: “families generally close ranks after incidents of what doctors call non-accidental head injuries" [15]. As though it is the norm for parents to protect a person who has just violently killed their infant.
A coronial inquest into a case of the supposed shaking death of an infant in Sydney[16], where the coroner could not determine which parent had done the assault, led to a NSW parliamentary review [17] that recommended that the law be changed to allow both parents to be charged in such circumstances. This followed a U.K. law that was introduced in 2003, following a Law Commission report [18] that was inspired by the work of a U.K. Shaken Baby advocacy group[19]. The report was set up to address the following situation:
A child is cared for by two people (both parents, or a parent and another person). The child dies and medical evidence suggests that the death occurred as a result of ill-treatment. It is not clear which of the two carers is directly responsible for the ill-treatment which caused death. It is clear that at least one of the carers is guilty of a very serious criminal offence but it is possible that the ill-treatment occurred while one carer was asleep, or out of the room. [18]
The report described this as a “widespread problem”. I am not really sure what Stoodley is referring to when he claims that infants only show symptoms when with a single carer.
Medical doctors are aware of the importance of witnesses for understanding the causes of these brain injuries. Prof. Colin Smith, another U.K. SBS believer and advocate, uses the lack of witnesses for other proposed causes of the “triad” of brain injuries to claim that those causes lack supporting evidence. “Take the argument that short falls can cause the triad. That’s a nice theory but, in real life, ‘you only get the triad from such a fall when no one else is watching’. When there are witnesses to a fall, you typically find a very different pattern of bleeding as well as fractures. ‘And that is not the triad,’ he says. The same goes for sepsis, heart complaints and the theory that oxygen starvation caused by choking can lead to the triad. “There isn’t a single witnessed choking case that looks anything like this,” he says.”[13]
So, according one SBS advocate, the lack of witnessed SBS cases that results in the ‘triad’ of brain injuries helps prove that shaking is the cause of the triad, and according to his colleague, the lack of witnessed short fall cases that result in the ‘triad’ proves that short falls cannot be the cause of such injuries. This certainly is high level confirmation bias. The pièce de résistance in this is that there are documented cases of witnessed short falls that resulted in SBS related brain injuries [20]. Which, along with the large number of times people have claimed infants with such injuries have had short falls (but were not believed), puts shorts falls above shaking on the evidence scale.
Due to the fact that no one has witnessed a shaking event that leads to these brain injuries, or reported shaking when presenting their sick infant at hospital, SBS advocates assume that the carers are lying, and tell others to do likewise, advising that “pediatricians and emergency physicians have to rely heavily on the histories given by adult caregivers, and they are often false” and that SBS is “a crime in which false histories and denial are common.” [21] Indeed, SBS advocates go further. This is from the U.S. Department of Justice’s Office of Juvenile Justice and Delinquency Prevention:
In most cases of shaken baby syndrome, there are no skull fractures and no external signs of trauma. The typical explanation given by the caretakers is that the baby was “fine” and then suddenly went into respiratory arrest or began having seizures. Both of these conditions are common symptoms of shaken baby syndrome. [22]
So the advice here is that when a history is given that excludes shaking, this should taken as a symptom that the infant was shaken.
The message seems to be: do not believe anyone who describes anything other than shaking; do believe those who confesses to shaking [23], no matter what type of suggestive interrogation techniques were used to gain that “confession”; and if carers describe that the infant was fine prior to collapse, then not only are they lying, their statement can be taken as symptomatic of shaking. No wonder all evidence based reviews of Shaken Baby Syndrome have found that it is fundamentally based on ‘circular reasoning’ [24,25,26,27].
Without independently witnessed cases, one cannot safely say that shaking causes the SBS related brain injuries. To establish this would require a series of independently verified cases, in order to be certain that the infants’ injuries can be attributed to the assault, and was not caused by some vulnerability in the infant due to an underlying, perhaps undetected, medical condition and the shaking was simply incidental.
Studies have attempted to demonstrate that shaking can cause these brain injuries by referring to cases where people have confessed to shaking. However, these studies “were made in the absence of an appropriate level of consideration of research into interrogation methods and false confessions”[12]. They fall well short of the evidence that would come from a sample of independently witnessed shaking events. Nevertheless, the comprehensive Swedish review [28] of the evidence base of SBS credits such studies with providing “low quality evidence” that shaking can cause these SBS associated brain injuries.
But the claims of SBS believers are much stronger than simply asserting that shaking can cause these brain injuries, given that there is a long list of medical conditions that can also cause such brain injuries. [28] The doctors claim that they are able to infer that shaking occurred by looking at the type of brain injuries suffered. To support such a claim, what is needed is a significant sample of cases where there can be confidence that shaking has been the cause of the SBS related brain injuries, such as witnessed cases of shaking. Then a comparison could be made with cases where these brain injuries were known to have some other causes, such as cases where more than one witness saw an infant collapse without having been shaken.
Ideally, “blind” comparisons could also be done. The medical files could be sent to doctors, without labelling which were shaking and which had other causes. One could then determine if the experts truly can distinguish which were shaken by reference to the medical files. One could perhaps even determine the error rates, how many times they got it wrong, to see how reliable these determinations are.
It is a common refrain by SBS advocates that you cannot do scientific experiments to confirm the shaking baby hypothesis because you cannot do experiments that involve shaking babies. Prof. Smith argues that “you’re never going to see such proof in a scientific study because the only way to scientifically prove shaking causes the triad is to actually shake a baby. And, of course, that’s not allowed.”[14] Stoodley agrees that “we cant do the relevant experiments” [14]. In the 2018 trial of Joby Rowe in Victoria, Dr. Linda Iles said that you “can’t conduct . . . controlled experiments . . . with actual human children”, whilst Dr. Lin Joon opined that there is no “irrefutable evidence because we can never produce that evidence”[29].
But this limitation applies to a large range of medical conditions. You cannot infect someone with a rare virus to test how it progresses. It is common for doctors to rely on independent witness accounts when trying to get a better understanding of illnesses, or when making diagnoses. In my upcoming book, The Road to Damnation, a major question in the case centered on whether the accused man, Robert Farquharson, had a condition known as cough syncope. The doctor testifying in the case observed that “Ideally, we like to see a collateral history, in other words, someone having witnessed what went on… If someone, more than one person perhaps, provides a history that they witnessed someone coughing and then black out, that's very powerful evidence…’[30]
The unethical implications of shaking a baby in the name of science is not the issue that is preventing scientific research being done into shaken baby syndrome. What is needed is a sample of cases that we are confident were the result of shaking, such as independently witnessed cases of shaking baby syndrome.
It has been almost 50 years since the shaken baby hypothesis was proposed, and so far the sample size of such witnessed cases is zero. Until such a sample emerges, then there is simply no evidence that doctors are able to diagnose shaking by reference to certain brain injuries. Indeed, there is only low quality evidence that shaking can even cause these injuries.
If all this is seems crazy to you, there is a simple explanation for that. It is crazy.
Well, it is certainly not scientific. Shaken Baby Syndrome is an unsubstantiated belief on the same level as anti-vaxxers’ belief that vaccines cause autism, another hypothesis that lacks any evidence base. Yet these medical doctors believe in the shaken baby hypothesis so strongly that they give testimony that often results in people receiving very long prison sentences, usually people who have just lost an infant. In other cases, the unsubstantiated assertions of doctors lead to the removal of children from their parents.
These medical doctors who believe in the SBS hypothesis have a lot of authority. With that comes a lot of responsibility.
References
[1] Allison Harding, Dad placed on bond after shaking and shouting at five-month-old daughter during cafe outing, Frankston Standard Leader December 1, 2016
[2] Inquest into the death of Baby C [2014] NTMC 017
[3] see e.g. Luttner, Sue, Witnessed Shaking: Reports and Reflections
[4] see e.g. Papetti, R. 2018 The Forensic Unreliability Of The Shaken Baby Syndrome § 4.1 (Christopher Milroy ed.) at p152
[5] Biron D, Shelton D. Perpetrator accounts in infant abusive head trauma brought about by a shaking event. Child Abuse Negl. 2005;29:1347–1358.
[6] According to the National Centre for Shaken Baby Syndrome
[7] Again according to the National Centre for Shaken Baby Syndrome
[8] According to data from the National Society for the Prevention of Cruelty to Children
[9] Mireau E. Hématome sous-dural du nourrisson et maltraitance. À propos d’une série de 404 cas. Thèse de médecine. 2005. Université Paris V.
[10] Kaltner M. Abusive head trauma: incidence and associated factors in Queensland [PhD thesis]. Brisbane: University of Queensland, 2010.
[11] Natasha Bita, Baby Shaking deaths on a par with road toll, the Australian, Sept 10, 2015
[12] Brook, C. Is there an evidentiary basis for shaken baby syndrome? The conviction of Joby Rowe, 2019, Australian Journal of Forensic Sciences
[13] Lynøe N, Elinder G, Hallberg B, Roseen M, Sundgren P, Eriksson A. 2017 Insufficient evidence for ‘shaken baby syndrome’–a systematic review. Acta Paedia; 106:1021–1027.
[14] Will Storr, ‘We believe you harmed your child’: the war over shaken baby convictions,
TheGuardian Dec 8, 2017
[15] Anne Guest 'Shaken baby' cases rarely prosecuted, ABC, 17 Sep 2009.
[16] Inquest into the death of Cooper Scifleet, Findings of Deputy State Coroner MacMahon, 30 October 2013
[17] Roth, L. Criminal liability of carers in cases of non-accidental death or serious injury of children 23 Sept 2014, Parliamentary Research Service (NSW)
[18] UK Law Commission, Children: Their Non-Accidental Death or Serious Injury (Criminal Trials), Report, September 2003
[19] National Society for the Prevention of Cruelty to Children, Which of you did it? Problems of achieving criminal convictions when a child dies or is seriously injured by parents or carers, November 2003
[20] e.g. Norrell Atkinson et al., Childhood Falls with Occipital Impacts, 34 PEDIATRIC EMERGENCY CARE 837 (2018)
[21] Showers J., Never Shake a Baby: The Challenges of Shaken Baby Syndrome
[22] U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention 2002 Battered Child Syndrome: Investigating Physical Abuse and Homicide
[23] Mark S. Dias 2011, The Case for Shaking, in Child Abuse And Neglect: Diagnosis, Treatment And Evidence “”
[24] Lynøe N, Elinder G, Hallberg B, Roseen M, Sundgren P, Eriksson A. 2017 Insufficient evidence for ‘shaken baby syndrome’–a systematic review. Acta Paedia; 106:1021–1027.
[25] Donohoe M. Evidence-based medicine and shaken baby syndrome, part I: literature review 1966–1998. Am J Forensic Med Pathol. 2003;29: 239 –242.
[26] Eva Lai Wah Fung et al. 2002, Unexplained Subdural Hematoma in Young Children: Is It Always Child Abuse?, 44 PEDIATRICS INT’L 37, 40
[27] Högberg, Göran et al. Circularity bias in abusive head trauma studies could be diminished with a new ranking scale. (2016).
[28] see e.g. Appendix A of SBU assessment report 255e/2016 Traumatic shaking The role of the triad in medical investigations of suspected traumatic shaking
[29] The Queen v Rowe, Joby. T Forrest JA. [2018] VSC 490
[30] DPP v Farquharson [2007] VSC 469 at p1611