ASSESSMENT AND DIAGNOSIS OF PEDIATRIC ABUSIVE HEAD TRAUMA
Mechanism of Injury
Abusive head trauma encompasses many mechanisms of injury. Children who present with AHT may have been injured in a number of ways, including shaking, blunt impact, suffocation, strangulation, and others. It is important to remember that no single injury is diagnostic of AHT (Choudhary et al., 2018).
Each type of imposed stress produces a characteristic pattern of injury:
- Acceleration and deceleration through an arc (shaking) produce thin subdural hemorrhage and, commonly, retinal hemorrhages.
- Impact is associated with skull fractures, contra-coup bruising, and unilateral subdural hemorrhage.
- Strangulation causes hypoxia and hypoxic ischemic encephalopathy.
These stresses may occur separately or in any combination.

When a baby is shaken, the neck snaps back and forth and the brain rotates, causing shearing stresses on the vessels and membranes between the brain and skull. (Source: Radiologyassistant.nl.)
Clinical Presentations
Healthcare professionals may first encounter young children with AHT in a range of clinical settings, including primary care, urgent care, and emergency departments. Since there are significant variations in the clinical presentation of children with AHT, it is important that professionals are trained to identify potentially life-threatening situations.
While there is an increased awareness now about AHT and how it may present, it is still important to realize that AHT may present with subtle signs and symptoms. A history of trauma is rarely provided in the initial stages, and if it is, it is usually reported as a fall from a distance less than 5 feet (APA, 2020).
Less severely injured infants and young children may present with symptoms that are quite nonspecific and without a history of trauma provided by a caregiver. These symptoms may be transient and improve if the trauma is not repeated. They include irritability, vomiting, and apnea. These and other symptoms of AHT are also seen in other minor medical conditions and can easily lead to a mistaken diagnosis of those conditions instead. Healthcare providers may have difficulty recognizing that such symptoms are the result of abuse, and the infant may return to an abusive environment (see also “Differential Diagnoses” below).
More seriously injured children have symptoms that should lead to rapid diagnosis of intracranial trauma. The caregiver may report a dramatic change in level of consciousness, as in acute collapse, such as unconsciousness, apnea, or seizures. An episode of minor trauma may be given as an explanation for the injury. Examples include falls off beds, being dropped by caregivers, or other minor contact injuries to the head.
Presenting History
Any reported history or statements made by the caregiver regarding the injury should be documented accurately and completely. It is best to include the specific questions asked as well as the responses. Information should be gathered in a nonaccusatory but detailed manner.
There are two general portions of the presenting history that are important to document. The first is the history of the injury event and the second is how the child responded or behaved after the injury.
Questions asked when taking a presenting history should include:
- What happened?
- Who was there when it happened?
- Where did it happen?
- When did it happen?
- What happened afterwards?
- When was the child noticed to be ill or injured? How did the child respond? When did symptoms start? How did you respond?
- What made you bring your child to the doctor (or hospital)?
- When was the last time your child was totally normal or well?
- What has your child been doing and how have they appeared during the last 24–48 hours?
Medical, Developmental, and Social History
Information that may be useful in the medical assessment of suspected physical abuse include:
- Past medical history (trauma, hospitalizations, congenital conditions, chronic illnesses)
- Nutrition history
- Seizure history
- Medications and immunizations
- Family history (especially of bleeding, bone disorders, and metabolic or genetic disorders, which often appear as a history of early deaths)
- Pregnancy history (wanted/unwanted, planned/unplanned, prenatal care, postnatal complications, postpartum depression, delivery in nonhospital settings)
- Familial patterns of discipline
- Child temperament (easy to care for versus fussy)
- History of past abuse to child, siblings, or parents, including history of Child Protective Services or police involvement
- Developmental history of child (language, gross motor, fine motor, psychosocial milestones)
- Substance abuse by any caregivers or people living in the home
- Social and financial stressors and resources (unemployment, divorce/separation, etc.)
- Violent interactions among other family members
(Christian, 2018)
The social history is a critical component of the evaluation. Asking parents about the household composition, other caregivers, siblings, substance abuse, mental illness, and social stressors can provide valuable information. It is preferable to interview caregivers separately; thorough and accurate documentation, including the use of quotes, is critical.
Explanations that are of concern for AHT include:
- Any infant or young child whose history is not plausible or consistent with the presenting signs and symptoms (i.e., explanation that is inconsistent with the pattern, age, or severity of the injury or injuries)
- History of behavior that is inconsistent with the child’s physical and/or developmental capabilities
- Presence of a new adult partner in the home
- History of delay in seeking medical attention
- History or suspicion of previous abuse
- Absence of a primary caregiver at the onset of injury or illness
- Physical evidence of multiple injuries at varying stages of healing
- Unexplained changes in neurologic status, unexplained shock, and/or cardiovascular collapse
(CDC, 2018)
Physical Assessment
There are various signs and symptoms of AHT that can be recognized in a physical assessment of the child. Depending on the severity of the clinical presentation, initial assessment is often focused on identifying and treating life-threatening issues. This initial assessment focuses on the airway, breathing, circulation, and neurologic status.
As noted above, the consequences of less severe cases may not be brought to the attention of healthcare professionals and may never be diagnosed. In the most severe cases, which usually result in death or severe neurological consequences, the child usually becomes immediately unconscious and suffers rapidly escalating, life-threatening central nervous system dysfunction.
Common presenting signs and symptoms of AHT are:
- Lethargy/decreased muscle tone
- Extreme irritability
- Decreased appetite, poor feeding, or vomiting for no apparent reason
- Grab-type bruises on arms or chest (rare)
- No smiling or vocalization
- Poor sucking or swallowing
- Rigidity or posturing
- Difficulty breathing
- Seizures
- Head or forehead appears larger than usual (disproportional growth may be demonstrated on a growth chart if data are available) or soft-spot on head appears to be bulging
- Inability to lift head in an age-appropriate manner
- Inability of eyes to focus or track movement or unequal size of pupils
(NCSBS, 2018)
Complete physical exam for any young child with suspected AHT includes:
- Inspection of all body parts, scalp, ears, and hair
- Inspection of the mouth (lip, tongue, buccal) to look for frenula tears or dental injuries
- Palpation of legs, arms, hands, feet, and ribs to feel for crepitus or deformities
Nursing neurologic assessment of the child with head trauma includes evaluation of:
- Eye opening
- Arousability level or irritability/consolability
- Symmetry of facial expressions
- Movement of upper and lower extremities
- Increased weakness or pitch in cry/vocalizations
- Fontanels
- Each pupil separately for size, shape, equality of reaction to light
- Ability to track objects
- Muscle tone for rigid extension or flexion of extremities, flaccidity, and/or unusual posturing
Research has identified several specific types of injuries as being associated with AHT. These include retinal hemorrhage in 85%, subdural hematoma in over 70%, and hypoxic-ischemic injury and cerebral edema as significantly associated with AHT (O’Meara et al., 2020).
Distinguishing between Accidental and Abusive Head Trauma
There are several challenges to differentiating between accidental (nonabusive/noninflicted) trauma or age-appropriate injuries and child abuse in infants and young children. This is especially true in children who are not yet verbal enough to explain what happened to them (i.e., infants, toddlers, and children with developmental delay and/or altered levels of consciousness).
Because of this, knowledge of typical developmental patterns of injury is helpful. That is, how does the presenting pattern(s) of injury and the child’s age and developmental level match up with the reported mechanism of injury?
DEVELOPMENTAL PATTERNS OF INJURY
Developmental patterns of injury seen in the 0- to 3-year-old range (the age range most frequently seen with AHT) include:
- Trauma from falls from furniture, down stairs, or being dropped by another person
- Traumatic delivery (e.g., forceps, vacuum extraction, and/or breech)
- Motor vehicle accidents
Head injury is frequently involved with these traumas because of several factors, including the larger head-to-body ratio and the inability to shield oneself during a fall.
Developmentally, this age range is at risk for accidental injury because the child’s developmental milestones include increasing motor skills and curiosity, allowing them a greater range and access to potential hazards. The advancing physical abilities of young children often precede their ability to understand the consequences of their actions. Thus, parent/caregiver knowledge of growth and developmental milestones may reduce the likelihood that they will misjudge the ability of the child and utilize an inappropriate supervision strategy. The mechanisms seen in accidental (noninflicted) injuries are generally different in these types of injuries as compared to AHT, as discussed below.
ASSESSMENT QUESTIONS
Because this situation is highly charged for both the family and all the healthcare providers involved, it is a good idea to have a mental checklist in place to both pose questions and evaluate responses in relation to the specific patient in question. Providers should further objectively and clearly document the history as described by the parents and/or caregivers present.
The following are questions a clinician can ask oneself to help separate the unintentional from the inflicted injury:
- What is the age of the child?
- What are the normal behaviors of a child at that age? Developmental stages of childhood determine what kinds of injuries are likely to be seen. The motor skills of the child determine what the child could have done to incur injury.
- Based on the child’s age, is the presenting injury plausible?
- Is the history plausible? Could this injury have been sustained in the manner described? Does the history change with changing information supplied to the caretaker? Adjustments in the account of the injury may be made by caretakers to fit the evolving information, indicating the tailoring of the history to fit new information. Does the history change when related in subsequent accounts by other family members?
- Was the injury witnessed? The lack of information as to how a serious injury has occurred should raise the index of suspicion for an abusive origin.
- Is the social situation in which the injury occurred a high-risk environment? The presence of community or intrafamilial violence, substance abuse, chaotic living arrangements, poverty, social isolation, transient lifestyles, mental health issues, or conflict among family members are red flags.
- Can the described mechanism of injury account for the observed injury? What else could produce the clinical picture?
- Can the history be independently verified (through photographs, scene investigation, etc.)?
Explanations that are concerning for intentional trauma include:
- No explanation or vague explanation for a significant injury
- An important detail of the explanation that changes dramatically
- An explanation that is inconsistent with the pattern, age, or severity of the injury or injuries
- An explanation that is inconsistent with the child’s physical and/or developmental capabilities
- Different witnesses who provide markedly different explanations for the injury or injuries
(Christian, 2015)
(See also “Reporting Child Abuse and Neglect” below for information on when a healthcare provider may be mandated to report suspected AHT.)
Differential Diagnoses
It is also important to rule out underlying conditions that may cause some of the same signs or symptoms associated with AHT or other abuse. Where indicated, medical professionals should inquire about the presence of any of the following conditions or practices:
- Congenital, metabolic, or neoplastic conditions (e.g., aneurysm, arteriovenous malformation, brain tumor, leukemia)
- Connective tissue disease or osteogenesis imperfecta, which may lead to fragile bones that fracture with less force than would be expected
- Acquired causes (e.g., meningitis, obstructive hydrocephalus)
- Undetected bleeding disorders that can lead to abnormal bleeding patterns (e.g., hemophilia, Von Willebrand’s disease, liver disease)
- Traditional or alternative healing practices, which may lead to unusual bruising and scarring patterns (e.g., coin rubbing, cupping, or burning herbs on the skin over acupuncture points)
(Killion, 2017)