Abusive head trauma in Maine infants: medical, child protective, and law enforcement analysis.

OBJECTIVE: To collect and compare the results of medical, child protective, and law enforcement evaluation of a sample of Maine children who were victims of abusive head trauma (AHT) in order to describe the clinical and evaluative characteristics as they relate to victims, families and perpetrators of such trauma and to improve the professional response to AHT in Maine.

METHOD: Retrospective chart review of medical, child protective, and law enforcement records of all AHT victims admitted to two tertiary care hospitals in Maine or seen by the state medical examiner from 1991 to 1994.

RESULTS: Nineteen children (age range 2 weeks to 17 months) were identified as victims of AHT (out of a total of 94 head trauma admissions) accounting for 20 hospitalizations during the study period. There was a history of prior injury in 30%, history of prior medical evaluations for possibly abuse related problems in 65%, while, on presentation, 75% had evidence or history of prior injury. The hospitals notified child protective services (CPS) in all 20 cases and correctly identified abuse in 18 (90%). Parental risk factors for abuse identified in CPS records included substance abuse (53%), domestic violence (42%), criminal history (32%), unrealistic expectations (42%), and attachment problems (32%). However, risk factors were inadequately assessed in 53% of homes. Law enforcement identified a likely perpetrator in 79% of cases and in the majority the identified suspect was the father. In the 15 cases where a perpetrator was identified by law enforcement, that person was alone with the child at symptom onset in 14 (93%).

CONCLUSIONS: The medical response, at least at the inpatient level, was generally well done with regard to suspicion and reporting. Cases are possibly being missed at the outpatient level. Child protective risk assessment was limited overall yet in a third of the homes where AHT occurred, few if any risk factors were present to aid in identification and prevention. Law enforcement results suggest that a primary suspect for AHT is the caretaker alone with the child at the time of symptom onset.