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Arch Dis Child. 2007 August; 92(8): 734.
PMCID: PMC2083891

Non‐accidental head injury in young children, medical, legal and social responses

Reviewed by Calum Macleod

Edited by Cathy Cobley, Tom Sanders. Published by Jessica Kingsley Publishers, London, 2006, £19.99 (paperback), pp 192. ISBN 1-84310-360-5

Child abuse remains an all too common social evil with devastating consequences for all concerned. This is particularly true of non‐accidental head injury (NAHI) which carries a significant mortality and where long‐term survivors are frequently handicapped. The child, the family and wider society all pay a price. NAHI presents huge challenges to all professionals – medical, legal, social services and police – and yet our understanding of the causes of head trauma, specifically subdural haematoma (SDH), is far from complete.

This compact, and readable, volume explores the complexities and the contentious issues surrounding shaken baby syndrome (SBS), SDH and NAHI. The book includes the findings of a 2‐year research project on the legal and social consequences which arise when children sustain an SDH. The study was completed in 2002 and the authors combine their findings with a critique of current medical, legal and social responses to NAHI in young children in the light of more recent events, including the role of the expert medical witness.

SBS is classically associated with a “triad” of SDH, retinal haemorrhage and encephalopathy. Hitherto, this has been considered de facto evidence of abuse. The authors contend, however, on the basis of their research and the work of others, that the “triad” alone is insufficient to justify a diagnosis of NAHI: “science alone cannot always provide the answers we seek”. The authors argue that while the starting point in the investigation of NAHI will frequently be the treating physician, it is the quality and quantity of evidence gathered by police and social services which are crucial “if miscarriages of justice are to be avoided, children are to be protected from abuse and abusers are to be punished”. Nevertheless, the authors acknowledge the fact that in most cases the cornerstone on which allegations of NAHI are based is medical evidence and expert testimony. There is a call for more research into the cause of head injury in children. The authors acknowledge that the inevitable consequence of future advances may be that miscarriages of justice will be uncovered. The new evidence of the role played by genetic factors in unexplained infant deaths, such as in the case of Angela Canning, is cited as an example. Crucially, however, the authors note that the new evidence did not cause the miscarriage of justice but merely uncovered it. They contend that while we must not expect science to provide all the answers, further research is vital if miscarriages of justice are to be avoided and children protected. However, the authors note that the recent vilification of previously eminent expert witnesses has led to concerns that researchers will be deterred from studying child abuse and paediatricians will withdraw from child protection work. They voice the concern that in the current climate it may be easier for a busy clinician to “suppress doubts and instincts which, in the child's interests, ought to be encouraged”.

This is a thought provoking and informative book with a comprehensive reference section. It may be uncomfortable for some, not least in highlighting the questions raised about SBS, but all paediatricians will benefit from reading it.it.

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Articles from Archives of Disease in Childhood are provided here courtesy of BMJ Publishing Group