- AHT —
- abusive head trauma
The first descriptions of the injuries associated with child abuse are commonly attributed to the French pathologist Auguste Ambroise Tardieu.1,2 His “Étude médico-légale sur les sévices et mauvais traitements exercés sur des enfants” (Forensic Study on Cruelty and the Ill Treatment of Children) in 18603 described findings of child fatalities from “acts of cruelty and ill treatment, of which young children fall victim from their parents, their schoolmasters, and all who exert over these children some degree of authority.”2 John Caffey reintroduced the study of child abuse in 19464 when he described 6 infants with chronic subdural hematomas in whom he identified long bone fractures from an “obscure” traumatic origin. Fredrick Silverman, a junior associate of Caffey’s,5 collaborated with C. Henry Kempe and colleagues in 1962 to frame “The Battered Child Syndrome.”6 They proposed a constellation of findings from the trivial to the fatal. They noted these injuries were historically noted to be from “unrecognized trauma” but were in reality from “serious physical abuse.”6
From these early investigators, the body of medical literature on child abuse now numbers >25 000 citations.7 After decades of increased academic study, clinicians and researchers can now begin to reap some of the benefits of earlier researchers and clinicians. Piteau et al,8 in this issue of Pediatrics, ask a clearly defined question, use a comprehensive search strategy, and lucidly assess the quality of the studies retrieved. Their meta-analysis confirms the systematic review findings recently described by Maguire and colleagues.9 Both of these reports, using different search protocols and analyzing different data from the same body of literature, independently confirm the diagnostic precision of retinal hemorrhages, subdural hemorrhages, and rib fractures for abusive head trauma (AHT). By independently using different strategies on the same body of literature and demonstrating similar results, we see clear support for these clinical findings, which are often used in diagnosing AHT.
The modern study of child maltreatment continues to evolve. It has grown from the case reports and case series into large reports of institutional experiences, database surveys, and sophisticated literature syntheses. Sophisticated observational cohort10 and case-control11 studies have provided important outcomes and prevention data. Despite the absence of a coordinating national research body and being underresourced,12 some promising multisite prospective networks13,14 have emerged. Two challenges exist: the absence of a definitive gold standard test for abuse and the heterogeneity of the data. Abusive injuries can occur in various locations, have a variety of appearances, and may result from many mechanisms. Research in the diagnosis or prevention of child maltreatment requires consideration of epidemiology, radiology, ophthalmology, neurology and neurosurgery, biostatistics, psychiatry and psychology, biomechanics, and pathology. The literature from each of these clinical perspectives consistently supports of the diagnostic features associated with AHT.
When considering the vast child maltreatment literature base, the evidence has become clear. As the research methodology evolves, literature base increases, and analyses become more sophisticated, we will be able to delineate more clearly the certainty of our diagnoses. The more we know about abuse when it has occurs, the more informed we will be in our efforts to study, ensure safety, provide services, and ultimately prevent, it.
- Accepted May 15, 2012.
- Address correspondence to Christopher Greeley, MD, MSB 2.104, 6431 Fannin St, University of Texas Health Science Center at Houston, Houston, TX 77030. E-mail:
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health and Human Development or the National Institutes of Health.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: The work was supported by award number K23HD065872 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Funded by the National Institutes of Health (NIH).
COMPANION PAPER: A companion to this article can be found on page 315, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2011-1545.
- Tardieu A
- 7.↵Institute of Medicine and National Research Council. 2012. Child Maltreatment Research, Policy, and Practice for the Next Decade: Workshop Summary. Washington, DC: The National Academies Press
- Piteau SJ,
- Ward MGK,
- Barrowman NJ,
- Plint AC
- Maguire SA,
- Kemp AM,
- Lumb RC,
- et al
- Giardino AP,
- Hanson N,
- Hill KS,
- Leventhal JM
- Hymel KP,
- Stoiko MA,
- Herman BE,
- et al
- Copyright © 2012 by the American Academy of Pediatrics