Pediatric Abusive Head Trauma: Recognition, Prevention, and Long-term Impact

Editor's note: This text-based course is an edited transcript of the webinar Pediatric Abusive Head Trauma: Recognition, Prevention, and Long-term Impact, presented by Alison D. Peak, LCSW, IMH-E.
Learning OutcomesAfter this course, participants will be able to:
Examine the legislation requiring PAHT continuing education, its origins, and its intentions.Identify the prevalence of PAHT, warning signs, and long-term outcomes.Analyze effective prevention programs and their role in preventing and mitigating PAHT in communities.IntroductionWe will talk about some heavy stuff today, and I want to ensure you know I will share stories as I share content. I encourage you to slow down, recognize your thoughts and emotions, and take care of yourself as we walk through this together. My great passion is working on behalf of children from birth through age five and their caregivers, working clinically, programmatically, and systemically on behalf of little ones and those who care for them. I also want you to know that I'm a social worker. I identify deeply as a social worker and love my work. It is part of who I am and all the things that come with me. It'll be a big part of my perspective and the stories I tell today.
I also want you to know that in the process of becoming a social worker, I spent four years as a floater in an early childcare center, so I have also been in early childhood classrooms. I remember working with 15 two-year-olds simultaneously and all the pieces that come with that. I remember those kiddos who were the first ones in the door, the last ones to leave, and who often spent more time with us than they did with caregivers at home. Even in that place of having children in your physical presence for long periods, there are still questions about what happens when they leave and what the rest of their day looks like.
This course is for both social workers and early childhood educators. I'll do my best to wear both hats and keep in mind all the different stories and perspectives you bring. Before we jump in, I want you to take a moment. I'm going to guide you through a grounding activity. As I said, we're going to deal with some pretty heavy content today, so I always like to make sure that we're deeply connected to our space and place and are present as we dive into these things.
I invite you to find a comfortable space. Make sure as you sit that your bones are deeply connected to your chair and that your feet are firmly grounded. After you read the instructions, close your eyes or stare softly about six feet in front of you, whichever is best for you. You're going to take three deep breaths. As you breathe in, count to four, then hold the breath for a count of seven, then breathe out for a count of eight. Do this three times, then come back to the course.
Pediatric Abusive Head Trauma (PAHT) in KentuckyIn 2010, the Kentucky General Assembly passed a bipartisan bill requiring many disciplines to receive consistent training in pediatric abusive head trauma. That original piece of legislation is tagged as Kentucky House Bill 285. That legislation has now been morphed into state policy and can be found in various locations throughout the state code. The original legislation is tagged as Kentucky House Bill 285. At that time, the goal was to increase recognition of signs and symptoms of pediatric abusive head trauma, increase prevention efforts for pediatric abusive head trauma, and ensure that professionals who interact with young children are aware of the potential outcomes of pediatric abusive head trauma given its considerable relationship to child well-being and child abuse.
In the state of Kentucky, the following people must be trained in pediatric abusive head trauma.
Law enforcementHigh school studentsInmates in state penitentiariesGuardian ad litems (attorneys specifically for the child welfare sector)Prospective adoptive parentsChildcare providersPediatricians, radiologists, family practitioners, trauma physicians, and family medicine physiciansPhysician assistants and nurse practitionersParamedics, medical technicians, and first respondersNursesSocial workersI think it's intriguing to think about how, as individuals get closer to years in which they are no longer children but are becoming parents, we are preparing them to know what it means to take care of littles and show up on behalf of them.
What is Pediatric Abusive Head Trauma (PAHT)?First and foremost, what is it? Pediatric abusive head trauma describes a constellation of signs and symptoms resulting from violent shaking and impacting an infant's or small child's head. In mainstream media, this more often gets referred to as Shaken Baby Syndrome, but the medical terminology is pediatric abusive head trauma. This definition clearly states that this does not occur and is not caused by general play, falls from a couch, or other things of that nature. Pediatric abusive head trauma is one of the primary physical child abuse incidents that occur in early childhood.
PAHT in the News and MediaWe first saw pediatric abusive head trauma come into the news and media in 1962. At that time, a physician named Dr. C. Henry Kempe was beginning to identify a connection between aggressive and neglectful parenting and long-term behavioral and mental health symptomology within children who were the recipients of that aggressive and neglectful parenting. Sometimes in the literature, it gets referred to as scary parenting, based on the idea that the caregiver is the source that the child is afraid of. We think about those consistent moments when caregivers are large and out of control. 
As I mentioned, we don't see this constellation of pediatric abusive head trauma with somebody who fell off the couch. Also, we know that all parents get upset sometimes, and kids get yelled at. However, at the other end of the spectrum, the parent may be the person children are afraid of and cannot seek comfort from. Think about really exaggerated, aggressive behavior, including physical abuse, intense emotional abuse, and neglect. Also, keep in mind the intense interpretations of a parent about a child's intentions.
Dr. Kempe's study in 1962 began to categorize these symptoms as battered child syndrome. It was revolutionary for the early '60s to think that child abuse occurred in all types of homes and all types of environments. This was not just seen in families experiencing extreme poverty or only in families with single-caregiver homes. They saw this show up in lots of places regardless of socioeconomic status or kind of caregiving dynamics. This laid the initial foundation for child abuse laws and mandated reporting. When this study came out, the recognition of battered child syndrome prompted legislation to realize that something had to be done. They couldn't just leave things where they were. There needed to be a response to this aggressive and neglectful parenting that deeply impacted these children.
A paper published in 1972 proposed the idea that the brain, as an organ, could sustain injury from being thrown about. They categorized it as whiplash-shaken infant syndrome. It also identified a triad of symptoms observable by X-ray that may or may not accompany other signs and symptoms of abuse, including cerebral swelling and hemorrhaging. Imagine being in a car accident, busting your head open, and needing stitches. There may not be an external manifestation of what is clearly an internal injury.
In 1997, a British nanny was charged with the murder of an eight-month-old baby in relation to a series of symptoms that physicians and police called shaken baby syndrome. This case sparked a series of concerns and awareness from the greater US public about shaken baby syndrome and its potential impacts on children and child well-being. We see this evolution of language from battered child syndrome to whiplash shaken infant syndrome, to the concept of shaken baby syndrome, and, currently, pediatric abusive head trauma.
I was a child when this occurred and remember it fairly clearly because I had an infant cousin at that time. I remember my family being really cautious, more so than they had been in prior years, about who got to hold the baby and where they were standing or sitting when holding the baby. There was an increased awareness that something terrible might happen because of the increased conversations around shaken baby syndrome.
Within broader news media, there is increasing conversation about the role of investigation in child abuse reports. People are slowing down to ask, what is happening, and what is it that occurs in families when there is the experience of pediatric abusive head trauma? Current media is also highlighting that in previous years, people were quick to identify a "victim" and a "culprit" without allowing for the due diligence of an investigation that holds multiple outcomes as a possibility. It is rare to have clear evidence without proof of pediatric head trauma. It's unlikely we're going to catch it on camera. One of the things we are increasingly aware of is that some of the symptoms we begin to see in early pediatric abusive head trauma may be related to an event that occurred weeks or days prior...