Joint Statement on Traumatic Head Injury due to Child Maltreatment (THI-CM): An update to the Joint Statement on Shaken Baby Syndrome

On this page

• Background
• Foundation statements
• Recommendations
• Key references and resources
• Appendix A: Acknowledgements
• Appendix B: Expert reviewers

The Joint Statement on Shaken Baby Syndrome (SBS), originally published in 2001, was a national collaboration to recognize and provide guidance on this important public health issue. The Joint Statement on SBS required revisions to reflect developments in knowledge, understanding and practice within and between sectors. The purpose of this revised joint statement is to outline the key principles underpinning professional practice in traumatic head injury due to child maltreatment (THI-CM) in Canada. To achieve this goal, this Joint Statement on THI-CM includes:

1. Multi-sectoral foundation statements on the medical and public health issues related to traumatic head injuries in children when child maltreatment is a possible cause;
2. Updated terminology and approach to communication about THI-CM; and
3. Recommendations to assist in implementing the updated terminology and approach to THI-CM.

Specific guidance for professionals on the approach to, or management of, individual cases is beyond the scope of this document. It is anticipated that relevant sectors will develop, update, and/or revise their guidance documents based on these foundation statements. 

Background

Traumatic head injuries comprise a small proportion of child maltreatment (abuse, neglect and exposure to intimate partner violence) cases in Canada. However, THI-CM may result in permanent disability or death, and represents a significant and preventable burden to families and society. 

Revision process

To inform the revision of the joint statement, the Public Health Agency of Canada, in partnership with the Canadian Paediatric Society, conducted an environmental scan and literature review in 2012. A facilitated expert roundtable and the establishment of a multi-sectoral advisory group followed. This advisory group reviewed the content and structure of the original Joint Statement on SBS to determine its relevance and the requirements for updating.

The literature review was updated and a revision of the joint statement began in 2015. An Expert Advisory Committee, spanning multiple sectors, provided feedback and advice on the process and content of the revision. This Committee was comprised of members of the medical, legal, law enforcement, judicial, child welfare, public health and health promotion sectors, with representatives from across Canada. (A list of experts can be found in Appendix A.) Consultations were held in both English and French with particular attention given to terminology issues between languages.

It was recommended that the terminology of shaken baby syndrome be changed as outlined in this document. The terminology was chosen through an iterative process with attention to the meanings of various terms that have been used in the literature to date and how these terms are interpreted within different disciplines and sectors. The term, THI-CM, is believed to reflect the current language used by health professionals (traumatic head injury) and aids to separate the diagnosis (traumatic head injury) from opinion on the cause of injury (child maltreatment). This issue will be addressed more thoroughly in a companion document. 

THI-CM may result in permanent disability or death, and represents a significant and preventable burden to families and society.

The Expert Advisory Committee developed a series of foundation statements. These statements are intended to summarize areas of content agreement and to serve as the underpinnings for professionals working with children and families affected by THI-CM. A series of recommendations was also developed to encourage future work and implementation of the Joint Statement on THI-CM. 

Foundation statements

i. Terms and definitions

• THI-CM is defined broadly to include traumatic injury to the head (skull and/or brain and/or intracranial structures), which may also be accompanied by injury to the face, scalp, eye, neck or spine, as a result of the external application of force from child maltreatment.
• THI-CM is the preferred term in Canada for research, public health, policy and prevention initiatives. 
• For clinicians recording a diagnosis in the health record, Traumatic Head Injury (THI) can be used along with a list of key medical findings (e.g.: scalp hematoma, skull fracture, subdural hemorrhage). 
• The diagnosis of THI can be followed by a statement of concern for THI-CM as a possible cause alongside other relevant differential diagnoses (traumatic and/or medical). THI-CM should not be communicated as a definitive diagnosis based solely on initial medical information.
• The determination of and use of the term, THI-CM, as a final opinion in an individual case should be made based on consideration of the combined information from the medical, child welfare and/or legal sectors.

ii. Epidemiology

• THI-CM is relatively uncommon in Canada and is present in a small proportion of cases of child maltreatment. However, it accounts for significant morbidity and mortality.
• The recognition of THI-CM is often challenging. These cases are frequently not recognized or are misdiagnosed as conditions other than head injury. Statistics on the frequency of THI-CM likely underestimate the scope of the problem.
• THI-CM is most commonly diagnosed in infants less than 1 year of age, but can also be seen in older children.

iii. Causes, injuries, and outcomes

• THI-CM can result from blunt force impact, compression or crushing force, penetrating force and/or inertial forces, such as those that occur with shaking or whiplash.
• A variety of head, eye, neck and spine injuries can occur with THI-CM. While some types of injuries have a higher likelihood of being the result of maltreatment, no one medical finding or constellation of findings is exclusively caused by THI-CM. 
• Brain and eye injuries can result from both the traumatic event (primary effect) and the body’s response to the traumatic event (secondary effect). Health outcomes, including death, can also be related to both primary and secondary effects of THI-CM.
• The outcomes of THI-CM may be severe and often include death or long-term disability. Children who survive THI-CM may require long-term rehabilitation, medical, educational, social, child welfare and legal supports. Their families may also require services and supports.

iv. Prevention

• It is essential that all involved sectors recognize the importance of the prevention of THI-CM. The development and evaluation of current and future prevention efforts should be evidence-based and should consider prevention of maltreatment in the context of optimal health and well-being of children and families.
• There is insufficient evidence for the recommendation of specific programs and strategies for the prevention of child maltreatment at this time. While the evidence base continues to develop, programs that recognize risk and protective factors, promote early intervention, provide additional supports to families and reduce stressors for families may be useful.
• THI-CM can be associated with caregivers’ responses to infant crying. Education programs for new parents on infant crying and ways to soothe a crying infant can be effective at increasing parents’ knowledge, yet the evidence is conflicting about whether such knowledge reduces the incidence of THI-CM.

v. Role of professionals

• It is the responsibility of all people in Canada, including professionals, to report suspected harm or risk of harm to children from child maltreatment to child welfare authorities according to legislative requirements.   
• Professionals in all sectors have important and complementary roles in cases of THI-CM. Professionals from each sector should respect the breadth and limits of their areas of expertise.  In addition, they should work collaboratively with colleagues in other sectors, recognizing the child’s health and well-being as central to their work. 
• While research has answered many important scientific questions about THI-CM, some questions remain where the research findings are less certain or where the area has not been adequately studied. It is important that professionals involved in the investigation, assessment and management of THI-CM consider and communicate the strengths, limitations and areas of uncertainty within the evolving scientific knowledge base about THI-CM.
• When the opinion of a medical professional leads to considering THI-CM as a cause for a child’s head injury, the opinion is to be informed by current scientific evidence. Physicians providing expert opinions on THI-CM as a cause of injury require adequate training, knowledge and experience. They must also be familiar with their role in relation to the child welfare and the legal system and engage in peer review and/or quality assurance practices. 

Recommendations

1. Adopt standardized terminology and definitions of THI-CM and its associated injuries to facilitate clear communication across sectors, which will allow for consistent identification of THI-CM for research and quality assurance purposes.
2. Professionals and professional organizations in relevant sectors recognize the child’s health and well-being as central to the process, and activities of their work in THI-CM, and they use practices that minimize harm to the child. 
3. Continue to develop, rigorously evaluate and prioritize THI-CM prevention programs. 
4. Encourage further research in THI-CM and maltreatment. This could include scientific research, program evaluation and/or legal analysis, within or across sectors.   
5. Adequately educate and train professionals working in the field of THI-CM and child maltreatment in order for them to fulfill their professional roles and responsibilities.
6. Professionals working in the field of THI-CM develop collaborations and participate in multi-sectoral training to ensure adequate understanding of the roles and responsibilities of professionals in other relevant sectors.  
7. Use and adapt the content of this joint statement on THI-CM across sectors to inform the practices and activities in clinical services, research, legal practice, policy development, public education, prevention and health promotion on the topic of THI-CM.

Key references and resources

The following selected references and resources include clinical guidance, narrative reviews, evaluation studies, international perspectives and other topics for readers’ interest and do not reflect the full scope of the relevant literature.

1. Canadian Child Welfare Research Portal: http://cwrp.ca/overview
2. Christian CW, Block R. Committee on Child Abuse and Neglect, American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics 2009; 123(5): 1409-11
3. Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD Jr, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol. 2018; 48(8):1048-1065.
4. Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics 2015; 135(5): e1336-1354
5. Euser S, Alink LRA, Stoltenborgh M, Bakermans-Kranenburg MJ, van IJzendoorn MH.  A gloomy picture: a meta-analysis of randomized controlled trials reveals disappointing effectiveness of programs aiming at preventing child maltreatment. BMC Public Health. 2015; 15:1068
6. Frasier LD, Kelly P, Al-Eissa M, Otterman GJ. International issues in abusive head trauma. Pediatr Radiol 2014; 44 (S4):S647-S653
7. Greeley CS. Abusive head trauma: a review of the evidence base. Am J Roentgen 2015; 204(5): 967-973
8. Iacobucci F, Hamilton G. The Goudge Inquiry and the role of medical expert witnesses. Canadian Medical Association Journal 2010; 182(1): 53-56
9. Laurent-Vannier A, Nathanson M, Quiriau F, Briand-Huchet E, Cook J, Billette de Villemeur T, et al. A public hearing “Shaken baby syndrome: guidelines on establishing a robust diagnosis and the procedures to be adoped by healthcare and social service staff”. Guidelines issued by the Hearing Commission. Ann Phys Rehab Med 2011; 54: 600-625
10. Leventhal JM, Ashes AG, Pavlovic L, Moles RL. Diagnosing abusive head trauma: the challenges faced by clinicians. Pediatr Radiol 2014; 44(Supp 4): S537-S542
11. Lopes NR, Williams LC. Pediatric abusive head trauma prevention initiatives: A literature review. Trauma Violence Abuse. 2018; 19(5):555-566
12. MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. Lancet 2009; 373(9659): 250-66.
13. Maguire S, Pickerd N, Farewell D, Mann M, Tempest V, Kemp AM. Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review. Arch Dis Child 2009; 94: 860-867
14. Mikton C, Butchart A.  Child maltreatment prevention: a systematic review of reviews. Bull World Health Organ. 2009; 87(5): 353-61
15. New South Wales Department of Health, Government, Australia. Policy Directive: Children and Infants – Acute Management of head injury. 2011. https://www1.health.nsw.gov.au/PDS/pages/doc.aspx?dn=PD2011_024#
16. Parks SE, Annest JL, Hill HA, Karch DL. Pediatric Abusive Head Trauma: Recommended Definitions for Public Health Surveillance and Research.Atlanta (GA): Centers for Disease Control and Prevention; 2012. https://www.cdc.gov/violenceprevention/pdf/pedheadtrauma-a.pdf
17. Piteau SJ, Ward MGK, Barowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: A systematic review. Pediatrics 2012; 130(2): 315-323
18. Public Health Agency of Canada. Canadian Incidence Study of Reported Child Abuse and Neglect – 2008: Major findings. Ottawa, 2010. https://www.canada.ca/en/public-health/services/health-promotion/injury-child-maltreatment-section/child-maltreatment/canadian-incidence-study-reported-child-abuse-neglect-major-findings-2003/canadian-incidence-study-reported-child-abuse-neglect-2008.html
19. Royal College of Paediatrics and Child Health: Child Protection Evidence http://rcpch.ac.uk
20. Watts P and Child maltreatment guideline working party of the Royal College of Ophthalmologists UK. Abusive head trauma and the eye in infancy. Eye (Lond) 2013; 27(10): 1227–1229.

Appendix A: Acknowledgements

This joint statement on THI-CM was a collaboration between the Public Health Agency of Canada and the Canadian Paediatric Society.  Members of the Expert Advisory Committee included:

Dr. Michelle Ward (Medical Co-Lead / Author)
Vice President, Child and Youth Maltreatment Section, Canadian Paediatric Society
Head, Division of Child and Youth Protection, Children’s Hospital of Eastern Ontario
Associate Professor, Department of Pediatrics, Faculty of Medicine, University of Ottawa

Dr. Michelle Shouldice (Medical Co-Lead / Author)
Past President, Child and Youth Maltreatment Section, Canadian Paediatric Society
Head, Division of Paediatric Medicine, The Hospital for Sick Children
Associate Professor, Department of Pediatrics, Faculty of Medicine, University of Toronto

Noreen Agrey
Executive Director, Saskatchewan Prevention Institute

Dr. Thambirajah Balachandra
Chief Medical Examiner, Department of Justice, Province of Manitoba

Dr. Matthew Bowes
Chief Medical Examiner, Nova Scotia Medical Examiner Service

Mike Darling
Detective/Constable, Vancouver Island Integrated Major Crime Unit

Dr. Lionel Dibden
Child Adolescent Protection, Alberta Stollery Children’s Hospital

Hon. Stephen Goudge
Court of Appeal of Ontario, Paliare Roland Barristers

Dr. Dirk Huyer
Chief Coroner, Office of the Chief Coroner for Ontario

Dr. Harriet MacMillan
Psychiatry & Behavioural Neurosciences, McMaster University

Dr. Amy Ornstein
Child Protection Team, Department of Paediatrics, IWK Health Centre

Dr. Michael Pollanen
Chief Forensic Pathologist, Centre for Forensic Science & Medicine, University of Toronto

Over several years, the Expert Advisory Committee received guidance from international, national and regional experts through two expert roundtables, a multi-sectoral review committee and a working group on language and terminology. These expert contributors represented a variety of sectors, including; the medical (pediatrics, family practice, ophthalmology, forensic pathology, northern medicine, coroner and medical examiner systems, psychiatry, nursing, medical research and prevention), legal, law enforcement, judicial, child welfare, public health and health promotion sectors.

Appendix B: Expert reviewers

Dr. Claire Allard-Dansereau
Pediatrician, Child Maltreatment
Centre hospitalier universitaire (CHU) mère-enfant Sainte-Justine

Nicholas C. Bala
Professor, Child Protection/ Family Law
Queen’s University

Dr. Anne-Claude Bernard-Bonin
Pediatrician, Child Maltreatment
Centre hospitalier universitaire (CHU) mère-enfant Sainte-Justine

Dr. Laurel Chauvin-Kimoff
Paediatrician, Child Protection Program
Montreal Children’s Hospital

Sylvie Fortin
Projet prévention SBS et maltraitance infantile
Centre hospitalier universitaire (CHU) mère-enfant Sainte-Justine

Mary-Ellen Hurman
Crown Attorney
Ministry of the Attorney General of Ontario

Christa Laforce
Training and Partnership Development Sergeant
Child Protection Section, Edmonton Police Service

Dr. Amber Miners
Pediatrician
Government of Nunavut

Dr. Kamiar Mireskandari  
Paediatric Ophthalmologist
The Hospital for Sick Children/Canadian Ophthalmological Society and Strabismus

Dr. Karine Pepin
Pediatrician, Child Maltreatment
Centre hospitalier universitaire (CHU) mère-enfant Sainte-Justine

Nancy Poole
Director of Research and Knowledge Translation
BC Centre of Excellence for Women’s Health

Marie-Noël Thériault
Ministère de la santé et des services sociaux du Quebec
Direction des jeunes et des familles

Dr. Marlene Thibault
Pediatrician
Centre Mère-Enfant Soleil du CHU de Québec-Université Laval

Provincial/Territorial Directors of Child Welfare Committee