Child Abuse Pediatricians (CAPs) are pediatricians with subspecialty training in evaluating suspected child maltreatment, including physical abuse. In cases of abusive head trauma (AHT) – the medical term encompassing what was historically called shaken baby syndrome – CAPs often lead the diagnosis by documenting injuries and concluding whether abuse is the likely causepropublica.orgpropublica.org. Their evaluations and testimony carry significant weight in child protection investigations and criminal trialsamericanbar.org. However, the role of CAPs in independently diagnosing AHT has become increasingly controversial. Critics argue that while CAPs are experts in recognizing patterns of injury suggestive of abuse, they typically lack the specialized training in neurosurgery, neuroradiology, or neuropathology required to definitively diagnose complex head injuries. In recent years, peer-reviewed medical literature, legal case analyses, and expert commentaries have scrutinized CAPs’ conclusions in AHT cases, pointing out limitations in their scope of expertise and calling for greater involvement of relevant medical specialistsamericanbar.orgreadfrontier.org. This report compiles findings from credible sources – including medical journals, expert testimonies, and case studies – that critique CAPs’ role in AHT diagnoses and emphasize the need for multidisciplinary input to ensure accurate and just outcomes.

CAP Training and Scope of Practice vs. Specialized Expertise

Child Abuse Pediatrics is a relatively young subspecialty (established as a board-certified field in 2006) focused on identifying and treating child abuse and neglect americanbar.org. CAP fellowship training lasts about three years and centers on recognizing injury patterns, taking histories, and collaborating with child protection agencies americanbar.orgamericanbar.org. Importantly, CAPs are not trained neurosurgeons, neuroradiologists, or neuropathologists. Their board examinations devote substantial content to detecting physical and sexual abuse (e.g. fractures, bruises, and typical injury patterns), whereas other medical topics receive less emphasis americanbar.org. As the American Bar Association (ABA) notes, CAPs “have special training in child maltreatment but do not always have expertise in a range of possible alternative diagnoses” outside of abuse americanbar.org. In practice, this means that while a CAP might be adept at noting that a baby has subdural bleeding or retinal hemorrhages – findings often associated with AHT – they are not inherently experts in the full spectrum of neurological, radiological, or hematological conditions that could mimic those findings.

Because of these limitations, best practices call for CAPs to work closely with other medical specialists when evaluating suspected AHT. Even the American Academy of Pediatrics (AAP) underscores that AHT is a “complex and challenging clinical diagnosis” requiring input from multiple subspecialties propublica.org. CAPs themselves acknowledge this multidisciplinary necessity. For example, Dr. Nancy Harper, a prominent CAP, testified that her assessments of suspected AHT are made “in concert with specialists like neurosurgeons and radiologists.” propublica.org Likewise, an ABA-endorsed guidance advises that “the optimal practice of child abuse pediatrics relies on collaboration with other subspecialists such as radiologists and hematologists,” and that CAPs should demonstrate how they used outside expertise to inform their conclusions americanbar.orgamericanbar.org. In other words, determining whether intracranial injuries result from abuse should ideally involve a neurosurgeon’s insight into trauma mechanics and required force, a neuroradiologist’s expert interpretation of brain and eye imaging, and a neuropathologist’s examination of brain tissues – with the CAP acting as a coordinator who integrates these findings.

Despite this ideal, in practice CAPs sometimes operate at the edge of their expertise. They may review radiological scans or autopsy reports and render an abuse diagnosis without always deferring to the specialists most qualified to interpret those materials. Courts have taken note of this issue. In a 2022 Louisiana appellate case State v. Galvan-Paz, a child abuse pediatrician, Dr. Paige Culotta, conceded on the stand that she is “not a radiologist,” and that a radiologist would “give the best description” of the X-ray and CT imaging in the case casemine.com. Notwithstanding that admission, Dr. Culotta had diagnosed the infant’s injuries as the result of abuse. This scenario highlights a recurrent theme: CAPs may draw conclusions (e.g. “non-accidental trauma”) from medical findings that really demand specialist analysis, like subtle fracture patterns or chronic vs. acute bleeding in the brain. A board-certified radiologist has years of focused training to identify and date cranial hemorrhages or skull fractures on scans, and a neurosurgeon or neurologist is best positioned to correlate those imaging findings with clinical scenarios. CAP training, while robust in general pediatrics and patterns of injury, cannot match the depth of expertise that these other fields provide in their domains.

A child abuse pediatrician testifying as a medical expert in a case involving alleged abusive head trauma. Critics argue that such physicians should not render definitive conclusions on complex brain injuries without input from specialists in neurosurgery, radiology, and pathology.

The scope of a CAP’s practice also typically does not include performing autopsies or microscopic neuropathology analysis – those are the province of forensic pathologists and neuropathologists. Forensic pathologists have been among the most vocal critics of misdiagnosed AHT cases. They point out that certain telltale signs CAPs rely on (like the so-called triad of subdural hemorrhage, retinal hemorrhage, and brain swelling) are not specific to abusive shaking and can be misinterpreted without careful consideration of pathology. Andrea Miller, Legal Director of the Oklahoma Innocence Project, observes that “there is a divide between pathologists and pediatricians” in these cases – “what emergency room doctors and pediatricians see in imaging looks very different at autopsy.”readfrontier.org In other words, a child abuse pediatrician might interpret diffuse brain swelling on a CT scan as evidence of violent shaking, but a neuropathologist, upon examining the brain, may find no traumatic axonal shearing or neck injuries to support that mechanism, instead finding signs of an underlying medical condition or global hypoxia. This was illustrated in a Florida case involving a CAP named Dr. Sally Smith: prosecutors alleged a toddler’s death was due to shaking based on Dr. Smith’s review, but charges were dropped after a neuropathologist’s second opinion contradicted the abuse diagnosis stories.usatodaynetwork.com. According to internal memos, the neuropathologist identified other explanations for the findings that Dr. Smith had attributed to abuse stories.usatodaynetwork.com. Such cases underscore that specialists like neuropathologists are crucial for an accurate diagnosis, especially in fatal or severe AHT cases where determining the true cause of bleeding or injury is literally a matter of life, death, and justice.

Contested AHT Diagnoses in Court Cases

A number of legal cases highlight the challenges and controversies that arise when CAPs’ AHT diagnoses are subjected to scrutiny by other experts or fact-finders. In many of these cases, the conclusions of child abuse pediatricians have been contested, refuted, or proven incorrect, often after input from neurosurgeons, radiologists, or pathologists.

One high-profile example involves Dr. Nancy Harper, the CAP who leads a child abuse team in Minnesota and frequently testifies in AHT trials. Dr. Harper has stated under oath that she does not believe she has ever misdiagnosed abusive head trauma, asserting “I don’t think I’ve ever had a case where I thought it was abusive head trauma and the other specialist didn’t.”propublica.org Yet judges and juries have disagreed with her conclusions in a number of instances, and her infallibility claim has drawn skepticism. “There is no other specialty in medicine that has zero error rate. None,” noted Kathleen Pakes, a former prosecutor and forensic consultant, regarding Harper’s testimony propublica.org. Indeed, at least four criminal cases in the Midwest have ended in acquittals or dismissals despite Dr. Harper testifying that abuse caused a child’s injuries propublica.orgpropublica.org. In each, the fact-finders were not convinced by the CAP’s abuse diagnosis, suggesting that other evidence or expert opinions raised reasonable doubt. For example, in the 2017 case of a daycare provider accused of shaking an infant (the Gabriel Cooper case), Dr. Harper diagnosed AHT and essentially stated the child was “shaken to death.” However, during legal proceedings it emerged that critical medical evidence had been initially overlooked: an ambulance report, initially provided in illegibly small print, revealed the baby had a documented fall two days prior to collapse propublica.org. Additionally, a defense-hired neurology expert discovered the child carried a gene associated with a bleeding/clotting disorderpropublica.org . These alternative explanations (a recent head impact from a fall, and a possible clotting abnormality) directly undercut the certainty of an abuse diagnosis. Polish courts, reviewing this case as part of an extradition fight (the defendant had left for Poland), refused to honor the U.S. extradition request specifically because the evidence pointed to a dubious abuse diagnosis – the Polish judges criticized Dr. Harper’s assessment, noting that the exculpatory ambulance report was “concealed from the defense” and that the American authorities did not reconsider the case even after this fact came to lightpropublica.org. Furthermore, the Hennepin County Medical Examiner (a forensic pathologist) in that case certified the child’s manner of death as “undetermined” and could not date the injury – a tacit disagreement with the CAP’s conclusion that a recent shaking assault caused the death propublica.org. Ultimately, prosecutors dropped the murder charges after a “final, thorough review” raised concerns about the medical conclusions propublica.org, and the defendant’s family has since filed a federal civil lawsuit accusing Dr. Harper of ignoring and even altering evidence to fit an abuse narrative propublica.org.

Other cases echo a similar pattern: CAPs’ opinions being met with counter-evidence from specialists or subsequent legal reversal. In Wisconsin, Dr. Barbara Knox – another well-known child abuse pediatrician – declared a 4-month-old infant’s injuries “obvious child abuse” in 2017, leading to criminal charges against a daycare provider propublica.org. But before trial, Dr. Knox left her hospital under a cloud of professional misconduct allegations (unrelated to that case), and an investigative series cast doubt on several of her diagnoses propublica.org. At trial, a different CAP (Dr. Harper) stepped in as the state’s expert, but the jury acquitted the defendant. Such outcomes suggest that when CAP conclusions are probed, they do not always hold up – especially if the defense can present alternative medical explanations. Andrea Miller comments that child abuse pediatricians testifying for the prosecution often make bold claims “for which there is no scientific backing,” such as stating that only a car crash at 70 mph or a multi-story fall could produce the kind of head injuries seen – assertions that cannot be empirically validated and serve to downplay any possibility of an accidentreadfrontier.orgreadfrontier.org. In reality, biomechanical research and case studies have documented that relatively short falls can sometimes produce subdural bleeding and retinal hemorrhages in infants readfrontier.org readfrontier.org, and that “lucid intervals” – a delay between an injury and collapse – are medically documented (even if some CAPs deny their possibility)readfrontier.org readfrontier.org. Failure to acknowledge these nuances in court can lead to miscarriages of justice.

Even when CAPs maintain confidence in their conclusions, external review has prompted corrections. The National Registry of Exonerations reports that over 40 people convicted in shaken baby/AHT cases have been exonerated since the 1990spropublica.org. These exonerations often occurred after new expert testimony (from neuropathologists, radiologists, biomechanical engineers, etc.) undermined the original medical evidence of abuse. One landmark example was the case of Audrey Edmunds in Wisconsin, whose shaken baby murder conviction was overturned after a decade in prison when multiple medical experts testified that the triad of injuries could have been caused by other medical conditions and that the timing of the baby’s decline did not definitively point to Edmunds propublica.org  readfrontier.org. Such cases have raised awareness that CAPs, operating without the input of subspecialists, may over-diagnose abuse or too readily attribute findings to shaking. In some instances, hospitals and courts are starting to recalibrate: for example, Dr. Bazak Sharon, a pediatrician (not a CAP) in Minnesota, became concerned that a CAP team was labeling an infant’s chronic subdural fluid as abuse without sufficient evidence. He consulted the child’s neurologist, Dr. Matthias Zinn, who agreed the findings were not definitively abuse-related. Dr. Zinn, who had seen hundreds of such cases, stated he told the CAP team “What evidence do you have, other than the subdural collections?” and that the CAP team “made it clear that they did not respect my opinion.”propublica.org In that case, the neurologist’s dissenting view was essentially disregarded by the hospital’s child abuse team, and Dr. Sharon was even removed from the case and later pressured to resign for challenging the CAP’s assessmentpropublica.org  propublica.org. The incident, reported by ProPublica, showcases the institutional power of CAPs within some hospitals and the friction that can arise when other specialists question an abuse diagnosis. It also exemplifies why many legal and medical experts caution against solely relying on a CAP’s conclusion without a thorough, multidisciplinary evaluation.

Expert Opinions and Calls for Specialist Involvement

A growing chorus of experts – from pediatric subspecialists to legal scholars – argue that diagnosing abusive head trauma requires a team approach and that child abuse pediatricians should not function as lone arbiters of these complex cases. Peer-reviewed literature has emerged that critically examines the CAP model in AHT investigations. For instance, a 2016 review in the journal Legal Medicine bluntly described an ongoing “controversy in child abuse pediatrics” between two camps: on one side, “an established corps of child abuse pediatricians aligned with hospital colleagues and law enforcement,” and on the other, “a multi-specialty challenger group of doctors and other medical professionals working with public interest lawyers.”pubmed.ncbi.nlm.nih.gov The latter group – which includes neurosurgeons, radiologists, pathologists, ophthalmologists, and biomechanical experts – “questions the scientific validity of the core beliefs of child abuse pediatricians” and has raised concerns that a substantial number of false accusations of abuse have occurredpubmed.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov. Dr. Steven Gabaeff, the review’s author (an emergency physician and forensic medicine specialist), traces how a small cadre of pediatricians in the 1970s formulated the shaken baby hypothesis (largely based on untested assumptions about subdural and retinal hemorrhages) and then promoted it as medical gospel in courtspubmed.ncbi.nlm.nih.gov. According to Gabaeff, defense attorneys began seeking out experts from other specialties – e.g. neurosurgery, hematology, biomechanics – who brought in scientific evidence that challenged those assumptionspubmed.ncbi.nlm.nih.gov. Over time, this has made the controversy “more pressing,” with false abuse diagnoses themselves recognized as a serious form of harm that needs addressingpubmed.ncbi.nlm.nih.gov. The clear implication of this peer-reviewed analysis is that no single specialty holds all the answers in AHT cases, and that child abuse pediatricians must integrate knowledge from many domains or risk overdiagnosing abuse based on outdated or incomplete sciencepubmed.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov.

Expert commentary from legal organizations echoes this sentiment. The ABA article “Questions Lawyers Should Ask Child Abuse Pediatricians” advises attorneys to carefully delineate the boundaries of a CAP’s expertise in courtamericanbar.org. It notes that while CAPs have a credential in child abuse, they “depend on other pediatric specialists” in practice, and “the reliability of a CAP’s diagnosis can often be measured in part by how well the CAP collaborated with and synthesized information from other specialists.”americanbar.org. The article recommends probing whether a CAP sought input from (or ruled out the need for) a neurosurgeon, neurologist, radiologist, ophthalmologist, hematologist, geneticist, or metabolic specialist, depending on the case factsamericanbar.orgamericanbar.org. For example, if a baby had unexplained bleeding, did the CAP involve a hematologist to check for clotting disorders? If there were old fractures on X-ray, did a pediatric radiologist date them reliably? If the child had any unusual brain findings, was a pediatric neurosurgeon or neurologist consulted? If the answer is no, the implication is that the CAP may have ventured beyond their core competency. Lawyers are encouraged to find independent experts in those fields to either corroborate or challenge the CAP’s conclusionsamericanbar.org. This approach has a dual benefit: it can prevent wrongful accusations by ensuring alternative causes are fully explored, and it holds CAPs to a higher standard of care in their diagnostic processamericanbar.orgamericanbar.org.

Many medical professionals support this multidisciplinary approach as well. Dr. Patrick Barnes, a pediatric neuroradiologist who once testified for the prosecution in the famous 1997 Louise Woodward shaken baby trial but later became a critic of unfounded SBS diagnoses, has spoken about the evolution in thinking. He helped establish a hospital child abuse review team that explicitly includes multiple specialists and demands a “proper medical workup” for alternative explanations alongside the abuse evaluationpbs.org. Barnes explained that in the past, if a baby presented with the triad of injuries, physicians would “stop there” and assume abuse – “We made that medical diagnosis, and then it carried over into child protection and into the criminal justice system without doing an adequate evaluation of what is going on.”pbs.orgpbs.org Now, he says, enlightened teams work “with multiple specialists in addition to our child abuse pediatrician” and take a “much more careful… comprehensive approach” that might involve reviewing the child’s full medical history, examining for rare diseases, and even re-interviewing caregivers for overlooked accidental trauma eventspbs.orgpbs.org. This shift is aimed at avoiding misdiagnosis of abuse when a medical condition (like a bleeding disorder, metabolic disease, or an old birth injury) is actually to blamepbs.orgpbs.org. Dr. Barnes’ revised approach – essentially, “trust but verify” with respect to abuse findings – aligns with what many others in the field have called for: greater humility and rigor in AHT diagnoses, and recognition that “nothing in imaging can tell you whether it’s accidental or inflicted” without contextreadfrontier.orgreadfrontier.org.

Even some child abuse pediatricians agree on the need for specialist input. As noted, Dr. Harper and others state they do work in concert with subspecialistspropublica.org, and another experienced CAP, Dr. Mark Hudson, wrote in a 2020 commentary that consultation with pediatric neurosurgery and neuroradiology is essential when managing head trauma cases (to guide both diagnosis and treatment)publications.aap.orgpublications.aap.org. A recent survey of pediatric neurosurgeons worldwide reported that neurosurgeons view themselves as “at the forefront of the clinical management of abusive head injuries (AHI) all over the world.”pubmed.ncbi.nlm.nih.gov This indicates that neurosurgeons expect to be intimately involved in AHT cases – not only for surgical treatment but likely in evaluating the injury patterns and causation. When neurosurgeons were asked about medicolegal aspects, many expressed willingness to participate in court proceedings and emphasized the importance of distinguishing accidental trauma from abuse with careful scientific analysisresearchgate.netdontshake.org. Their perspective reinforces that determining how an infant’s brain was injured (shaking, impact, medical illness, etc.) is a complex question that benefits from their expertise in pediatric head injury mechanics.

Professional organizations in related fields have also contributed opinions. The National Association of Medical Examiners (NAME), for instance, has cautioned that diagnosing the cause of infant head injuries requires clinicopathologic correlation – integration of clinical findings with autopsy results – and that labels like SBS/AHT should not be applied without thorough investigation (including ruling out natural diseases). And while the AAP has strongly affirmed that AHT is a valid diagnosis and urged pediatricians to be vigilantreadfrontier.orgreadfrontier.org, even its official statements have evolved to encourage more rigorous workups. The AAP’s 2009 statement on AHT explicitly reminded physicians to “consider alternative hypotheses… A medical diagnosis of AHT is made only after consideration of all the clinical data.”readfrontier.org This was a departure from earlier guidance that treated the diagnosis as presumptive when certain signs were presentreadfrontier.orgreadfrontier.org. The inclusion of that language implicitly recognizes that misdiagnosis was a concern and that pediatricians should involve appropriate tests and consults to exclude other causes before concluding abusereadfrontier.org. The 2020 AAP practice update continued this emphasis, acknowledging (for the first time) that short falls can rarely produce severe injuries similar to AHT, and that the terminology change from “SBS” to “AHT” was sometimes misinterpreted as doubt – prompting the AAP to clarify that while AHT is real, each case requires careful differential diagnosisreadfrontier.orgreadfrontier.org. These nuanced positions, taken together, support the idea that CAPs should not be making the call in isolation. Instead, they should act as part of a multidisciplinary team: identifying possible abuse, but also engaging neurosurgeons for surgical findings, neuroradiologists for imaging expertise, ophthalmologists for detailed retinal exams, and forensic pathologists for autopsy evidence in fatalities.

Conclusion

The critique of child abuse pediatricians’ role in diagnosing abusive head trauma centers on a fundamental point: no single medical specialty encompasses all the knowledge needed to definitively diagnose or rule out AHT. Child Abuse Pediatricians bring invaluable skills to the table – they are trained to spot patterns of injury and psychosocial factors that may signal abuse, and they are adept at coordinating care with child protective services. However, their training in pediatrics and child maltreatment, while broad, does not confer the highly specialized expertise in neurotrauma, imaging interpretation, or pathology that AHT cases often demand. The peer-reviewed literature and case studies reviewed here highlight multiple instances of CAPs reaching firm abuse conclusions that were later challenged or overturned when neurosurgeons, neuroradiologists, neuropathologists, or other specialists re-examined the evidencepropublica.orgpropublica.org. These challenges do not imply that CAPs act in bad faith; rather, they illustrate the limits of one clinician’s perspective in a medically complex scenario. As one legal expert put it, when a doctor claims never to have erred in their abuse diagnoses, it “strains credulity” – medicine is rarely absolute, especially in a field as intricate as pediatric head traumapropublica.org.

Moving forward, the consensus among many experts is that multidisciplinary collaboration is the key to accuracy. Diagnoses of abusive head trauma should ideally be the product of joint deliberation by pediatricians, neurosurgeons, radiologists, ophthalmologists, and pathologists, among others. CAPs can and should continue to play a central role in these evaluations – synthesizing the various findings and providing context about abuse patterns – but they should not operate in a silo. The legal system has begun to adjust to this reality: courts are increasingly receptive to alternative expert opinions and wary of conclusory statements that certain injuries must be abuse without robust scientific backingreadfrontier.orgreadfrontier.org. Likewise, hospital protocols in some places have been updated to ensure that suspected AHT cases trigger automatic consults to relevant specialties, preventing cognitive “tunnel vision.” The ultimate goal of these critiques is not to diminish the importance of child abuse pediatricians, but to prevent tragic outcomes – both for children who might be misdiagnosed and for innocent caregivers who might be wrongfully accused. As Dr. A. Norman Guthkelch, the neurosurgeon who first hypothesized shaken baby syndrome in 1971, lamented decades later upon seeing the theory’s overreach: he was “disturbed that what I intended as a friendly suggestion for avoiding injury to children has become an excuse for imprisoning innocent parents.”propublica.org By embracing the input of subspecialists and acknowledging the limits of their own expertise, CAPs and the broader medicolegal community can better ensure that true abuse is identified and prosecuted – while children suffering from medical conditions are not caught in the net of misdiagnosis, and their families not torn apart. In sum, the diagnosis of abusive head trauma is too critical to be made in isolation – it demands the fullest possible understanding that multiple medical disciplines, working together, can provideamericanbar.orgcasemine.com.

Sources:

• American Bar Association – Gupta-Kagan J., Raz M., & Asnes A. “Questions Lawyers Should Ask Child Abuse Pediatricians.” (Dec 2024)americanbar.orgamericanbar.org

• ProPublica / APM Reports – Lussenhop J. “This Doctor Specializes in Diagnosing Child Abuse. Some of Her Conclusions Have Been Called Into Question.” (July 2025)propublica.orgpropublica.org

• ProPublica – Lussenhop J. “A Doctor Challenged the Opinion of a Powerful Child Abuse Specialist. Then He Lost His Job.” (June 2025)propublica.orgpropublica.org

• Legal Medicine (Tokyo) – Gabaeff S.C. “Exploring the controversy in child abuse pediatrics and false accusations of abuse.” 18:90-97 (2016)pubmed.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov

• Wisconsin Watch / ProPublica – Dukehart C. (photography) – Harper N. testifying in court (2021 trial)

   

• Read Frontier (Oklahoma) – Pierce T. “Diagnosis of Abuse: Some question the legitimacy of certain Shaken Baby Syndrome convictions.” (2021)readfrontier.orgreadfrontier.org

• State v. Galvan-Paz, 321 So.3d 986 (La. App. 2022) – Trial testimony of Dr. Paige Culottacasemine.com

• Developments in Pediatrics – Vinchon M. & Di Rocco F. “The role of the pediatric neurosurgeon in abusive head injuries: a survey…” Child’s Nervous System 38(12):2289-94 (2022)pubmed.ncbi.nlm.nih.gov

• Frontline PBS – The Child Cases – Interview with Dr. Patrick Barnes, Pediatric Neuroradiologist (2011)pbs.orgpbs.org

• ProPublica – Lussenhop J. “MN Child Abuse Pediatrician Nancy Harper’s Diagnoses Have Sometimes Been Called Into Question.” (July 2025)propublica.orgpropublica.org