Dr. Joseph Hagan's first patient of the morning has been running a fever for days. Wren eyes him warily as her mother, Amanda, reports the 6-month-old has been fussy ever since she received a round of vaccines a week earlier. Hagan sits down at the girl's eye level, clucks his tongue and scoots his chair close to her. Wren lets out a high-pitched wail.
"You don't believe I came near you. How rude of me!" Hagan jokes, as he presses on the baby's belly. Wren's cries jump an octave as she flushes beet red. "I know, I know," he says soothingly, examining her ears, mouth and throat.
Upon noticing some red spots in her mouth, Hagan diagnoses Wren with an enterovirus similar to Coxsackie, which can cover a child's hands, feet and mouth in painful sores and leave him or her cranky and miserable.
"She may have a fever tomorrow, but you've probably paid your dues," Hagan reassures the mother. "By Sunday, she'll be ready to party."
After 35 years as a Burlington pediatrician and a University of Vermont medical school professor, Hagan routinely sees patients like Wren, whose issues are relatively simple to resolve. But the 63-year-old physician, a candidate this fall for president of the American Academy of Pediatrics (AAP), is also Vermont's resident expert on abusive head trauma, more commonly known as "shaken baby syndrome." In 2009, the AAP adopted the more inclusive term in recognition that many of the serious injuries that infants and toddlers suffer at the hands of adults aren't caused by shaking alone. Gripping, squeezing, slamming or wrenching their small bodies can also result in permanent injury or death.
In those cases, it's usually too late for Hagan to help the patient.
Hagan, a native of the Washington, D.C. area, first developed an interest in child-abuse prevention back in the mid-1970s, while he was still a resident at the University of Vermont College of Medicine. He joined the faculty there in 1979.
"I realized ... that these cases make me incredibly angry," Hagan recalls. "But I also realized that in order to be an effective pediatrician," that reaction "was not going to serve me well, so I began to study it."
His interest predates the term "shaken baby syndrome," which didn't appear in medical literature until 1984. It wasn't until the late 1980s and early '90s that pediatricians began to fully grasp the effects of abusive head trauma, where the brain sloshes back and forth inside the skull like a bag of water, breaking blood vessels, causing swelling and killing neurons.
For nearly three decades, Hagan has been on the front line of abuse prevention in Vermont. In the mid-1980s, he helped the state develop its regulations governing infant medical neglect. Soon thereafter, he was hired to be the state's medical consultant on large and complex child-abuse cases; these days he fields about four to six such cases each year. For the last 19 years, Hagan has also volunteered to either chair or cochair the citizens' advisory committee of the Department of Children and Families, which reviews all known instances of serious child abuse.
While Hagan acknowledges a cluster of "horrendous cases" in Vermont this year — so far, physical abuse has allegedly claimed the lives of three young children in Chittenden County, and a fourth death is under investigation — he points out that the problem of AHT isn't a new one. In general, it often happens to children before age 1; infants between three and four months are at the highest risk. That's when babies tend to cry the most, he says, which can trigger a sudden, violent outburst on the part of a parent or caregiver.
Are there "typical" perpetrators of abusive head trauma? Interestingly, Hagan said that in his experience, the problem cuts across all socioeconomic lines, just like alcoholism and opiate abuse. And, contrary to popular opinion, he adds, most offenders aren't mentally ill, alcoholics or drug addicts, though such problems can further predispose a parent to abusing a child. As he puts it, "There's no 'we' and 'them.' It's 'us.' We're all vulnerable to this."
Usually, there are three factors that coalesce into a "perfect storm" for abusive behavior. First, parents may be predisposed to abuse because they, too, were raised in abusive households or are managing chronic stress in their lives such as a bad marriage, a substance problem or employment difficulties.
Second, Hagan says there's usually some "provocative" behavior on the part of the child, such as a tantrum, an uninterrupted bout of crying or defiant behavior by an older child.
Finally, Hagan says, there's usually an "inciting event" such as a lost paycheck or a job dismissal that pushes the parent over the edge.
Why does it seem as though Vermont is experiencing a spike in both the frequency and seriousness of these cases? Hagan suggests that one underlying cause may be "toxic stress" — that is, strong, frequent and prolonged adversity caused by persistent poverty, substance abuse, food insecurity and violence in the home, which can actually alter the functioning of the brain by causing neurons to not divide or grow. Researchers now believe that this effect can last not just for one lifetime, but even change the way people's DNA functions over multiple generations in a process called epigenetics.
"It's very difficult to change the epigenetics once it happens," Hagan says. "So now we have this multigenerational experience that's very hard to break."
Addressing the problem will take more than just hiring a few more DCF investigators and social workers. It'll take more "inputs upstream to prevent those needs down the road," he says. Hagan isn't sure whether Vermont can muster the "enormous political will and heavy investment" that would require, especially for gains that may not be seen for a generation.
But he's not giving up. Hagan likens the campaign against child abuse to that of childhood nutrition, then mass immunization, which helped launch the field of pediatrics more than a century ago. Nowadays, he says, pediatricians have begun asking parents not just about their children's health but also about what else is happening in the household.
Years ago, the doctor's question, "How are you all doing?" was merely a conversational icebreaker. Today, it could save a life.
A version of this article appeared in the August 6, 2014 issue of Seven Days.
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