Frequently Asked Questions about Inflicted Brain Injury

Traumatic Brain Injury is the leading cause of death and disability in children who have been abused. Infants are at the greatest risk. The New South Wales Child Death Review Team's 10-year survey of 136 fatal assaults found that children less than 1-year old were sixteen times more likely to die than those aged between 5 and 15.

More than 50 children with inflicted Traumatic Brain Injury were admitted to just New South Wales’ two statewide children’s hospitals - The Children's Hospital at Westmead and Sydney Children’s Hospital - during the last 5 years alone, and their numbers are increasing. Their average age was 10 months. The international research evidence indicates that around 1 in 3 die as a result of the injuries to their brain. And of those who survive, as many as 2 in every 3 will live with profound and permanent disability.

Yet the incidence of inflicted Traumatic Brain Injury may be dramatically higher than the numbers of children admitted to hospital. During 2007-08, over 12,000 notifications of physical abuse made to Australia's child protection agencies were substantiated - there was reason to believe that the child had been, was being, or was likely to be abused. In the same year, less than 200 infants were hospitalised due to assault. For every child admitted with inflicted Traumatic Brain Injury, international surveys suggest as many as 150 other children in the community may suffer head trauma from caregivers. 1 in every 3 cases of inflicted Traumatic Brain Injury may be missed even if they reach hospital. And nearly 1 in 3 of those children will go on to be re-injured, and 1 in 10 die.

Q1. How many Australian children experience inflicted Traumatic Brain Injury as a result of abuse?

• Brain Injury Australia believes that there are no reliable numbers on national incidence - that is, the number of new "cases" in a given year - for inflicted Traumatic Brain Injury in children. There are, however, some guides.

• Information obtained by Brain Injury Australia shows 52 children with inflicted Traumatic Brain Injury have been admitted to New South Wales’ two statewide children’s hospitals - The Children's Hospital at Westmead and Sydney Children’s Hospital - over the last 5 years, and their numbers are increasing. Their average age was 10 months.

• A review of admissions to the pediatric brain surgery unit at The Children’s Hospital at Westmead between 1995 and 2002 found 65 cases of inflicted Traumatic Brain Injury.

• The most common cause of what’s called subdural haematoma (the collection of blood in the space between the outer and middle layers of the covering of the brain, caused by force applied to the head sufficient to rupture veins) in infants and effusion (the resulting leakage of cerebrospinal fluid) is abuse. From international surveys, a group of Australian paediatricians, paediatric neurosurgeons, and researchers have estimated that 65 cases of subdural haematoma/ effusion occur each year nationwide the result of inflicted Traumatic Brain Injury.

• A review of admissions to The Royal Alexandra Hospital for Children/ The Children's Hospital at Westmead between 1987 and 1996 found 38 children with subdural haematoma/ effusion, the commonest cause for which (in 55% of cases) was inflicted Traumatic Brain Injury.

• Evidence from a survey conducted in the United States suggests that, for every child admitted with inflicted Traumatic Brain Injury, as many as 150 other children in the community suffer head trauma from caregivers.

• The NSW Department of Community Services responded to 327 “reports of baby shaking” between 2004 and 2006. 284 of the cases “required investigation”.

• Between 10-18% of cases of Cerebral Palsy in Australia occur after birth - the result of brain infection or haemorrhage (bleeding), poisoning or head trauma. Of these 60-100 new cases each year, around 10% are the result of inflicted Traumatic Brain Injury. Information obtained from the Cerebral Palsy Institute by Brain Injury Australia indicates that their numbers are increasing.



Q2. How common is physical abuse of children in Australia?

• During 2007-08, over 12,000 notifications of physical abuse made to Australia's child protection agencies were substantiated - there was reason to believe that the child had been, was being, or was likely to be abused.
• During 2007-08, there were 194 hospital separations for infants (less than 12 months old) and 218 for children aged 1- 4 years due to assault.

 

Q3. Which children are at the greatest risk?

Infants


•  Infants are at the greatest risk of inflicted Traumatic Brain Injury. The New South Wales Child Death Review Team's 10-year survey of 136 fatal assaults found that children less than 1 year old were 16 times more likely to die than those aged between 5 and 15.
• A review of all admissions over a 2-year period of children with head injuries aged less than 1 year to hospitals in large city in the United States found that 95% of serious Traumatic Brain Injuries were the result of child abuse.
• Part of the reason for the high rates of inflicted Traumatic Brain Injury in infants is due to the unique features of their brain. They have proportionately large heads supported by weak neck muscles. Their brains are soft. Any excessive acceleration, deceleration, or rotation of the head – from being shaken, for example – can result in intracranial bleeding and damage to developing neural pathways. Most intracranial injuries in young children are not associated with skull fractures.


Indigenous children


• During 2007-08, Indigenous children were more than 6 times as likely to be the subject of a substantiation of a notification of child abuse or neglect than non-Indigenous children.

 

Q4. What happens to these children – how many die?

• The New South Wales Child Death Review Team's 10-year survey of 136 fatal assaults found the risk of death by assault for Aboriginal children is four times greater than that of non-Aboriginal children.

•  25 children were killed by their parents, on average, every year in Australia between 1989 and 2002. Just under half of all victims were killed with the use of “assaultive force”. The most common cause of death would be inflicted Traumatic Brain Injury.

• In 2003, the leading cause of death among children aged 0–14 years was injury. Assault was the third most common type of injury causing death.

• Fatal child abuse is the most common reason for child homicide, accounting for more than 1 in 3 of the 437 homicides of children aged less than 15 years recorded in NSW between 1991 and 2005. The most common cause of child abuse resulting in death is inflicted Traumatic Brain Injury.

• In the United States, there were an estimated 1,760 child deaths due to child abuse or neglect in 2006-07. The US’ Advisory Board on Child Abuse and Neglect argues that this is a significant underestimation and reported that a more realistic estimate of child deaths was around 2,000 per year. This would approximate to five children per day.

• The World Health Organization estimates 57,000 children were victims of homicide in the year 2000. The highest rates of fatal child abuse are found among children aged 0-4 years. The most common cause of death was inflicted Traumatic Brain Injury, followed by abdominal injuries and intentional suffocation.




Q5. What happens to the children who survive inflicted Traumatic Brain Injury?

 As many as 1 in every 3 children the victims of inflicted Traumatic Brain Injury will die as a result of their injuries. Of those who survive, as many as 2 in every 3 will live with profound and permanent disability.



Q6. Is inflicted Traumatic Brain Injury always picked up in hospital?

• As many as 1 in every 3 cases of inflicted Traumatic Brain Injury may be missed even if they reach hospital.

• Where inflicted Traumatic Brain Injury is detected, more than 2 in 5 of those children will show signs of previous head trauma. Where inflicted Traumatic Brain Injury is undetected, nearly 1 in 3 children will go on to be re-injured, and 1 in 10 die. As many as 4 out of 5 subsequent deaths from inflicted Traumatic Brain Injury could have been prevented with earlier diagnosis.

 

Q7. Who commits this kind of abuse?

• New South Wales’ Child Death Review Team found that parents, spouses, domestic partners or other family members were responsible for the “overwhelming majority” (95.8%) of the 136 fatal assaults of children that occurred between 1996 and 2005.

• Of the perpetrators identified in 65 cases of inflicted Traumatic Brain Injury admitted to The Children’s Hospital at Westmead, 37% were fathers, 31% maternal male partners, 15% mothers, 10% other relatives and 7% were babysitters.

• A study of 52 cases of inflicted Traumatic Brain Injury in infants investigated by the Queensland Police Service found “victims were shaken, thrown, punched, head-butted, and attacked with objects such as lumps of wood.”
  
  

  Q8. Is inflicted Traumatic Brain Injury the same thing as Shaken Baby Syndrome?

  • They are different names for same thing but inflicted Traumatic Brain Injury can occur to a child of any age. Other names you might hear are “abusive head trauma” or “non-accidental head injury”.

  • The expression "Shaken Baby Syndrome" derives from the work of Dr John Caffey, an American radiologist. His 1974 paper on the “Whiplash Shaken Infant Syndrome” offers this description: “the most characteristic pattern is that of massive traumatic intracranial [within the skull] and intraocular [inside the eye] bleeding in the absence of external signs of trauma to the head and neck. The clinical presentation is often nonspecific with symptoms of irritability, excessive crying, vomiting, drowsiness and seizures. The lack of history of trauma makes the diagnosis of intracranial haemorrhage [bleeding] difficult, and other diagnoses such as systemic infection, or meningitis [infection of the tissues around the brain] may be considered. Subdural hematomas [the collection of blood in the space between the outer and middle layers of the covering of the brain, caused by force applied to the head sufficient to rupture veins] associated with child abuse are often bilateral [on both sides of the brain] and this may aid in the diagnosis of non-accidental injuries.”

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