The crime no one wants to believe in

Some parents shake their babies because they were never taught parenting skills that are handed down in larger, extended families. Picture / Reuters

To demonstrate how hard he shook his baby son, Koloa Aholelei picked up a doll. What followed left police in no doubt the shaking was beyond an impulsive lapse. He gripped the doll under the arms and shook it rapidly, backwards and forwards and from side to side, just as he'd done to Randwick several times in the weeks since his wife went back to work.

The fourth night it happened, on November 25, 2003, he shook Randwick for longer. When he stopped, the boy was not breathing and his lips had turned blue. In a panic, Aholelei administered CPR and revived his son. But he did not seek medical help or tell his wife, Alisia, when she came home from nightshift.

Two days later, Randwick, suffering uncontrollable seizures, was taken to a Panmure medical centre, then by ambulance to the Starship children's hospital. At the emergency department, he was assessed at level 3 on a scale of consciousness between 1 and 15. At level 2, a person is considered clinically dead.

Violent shaking, four times in the past month by Aholelei's account, had torn blood vessels in Randwick's brain and retina. Two subdural haematomas were pressuring both sides of his brain. There was extensive fluid build-up between his brain lining and skull and his fontanelle (the soft spot on top of a newborn's head) was bulging.

He was whisked to the neurology ward so neuro-surgeons could ease the pressure on his brain, inserting a needle into his fontanelle to drain the haemorrhages. They would need to repeat the procedure before his condition stabilised.

Randwick was 3 months old. He'd come within a heartbeat of becoming one of the babies who die at their parents' hands before their first birthday.

About a dozen deaths in the first year of life are linked to parental assault each year, although physical abuse of the very young is thought to be under-reported. Scores more babies are hospitalised at their most vulnerable age, before they can tell tales or run away.

Despite years of messages and an expansion in agencies working with new parents, New Zealand continues to produce parents and caregivers whose self-control goes out with the bathwater. We lag in efforts to reduce child abuse overall, with a rate still four times worse than the leading OECD countries.

Up to half of under-ones admitted with non-accidental injuries are suffering what's called shaken-baby syndrome. But the threat posed to our most defenceless citizens by those who are supposed to protect them remains a Cinderella issue. Assumptions and misconceptions cloud the effort to reduce the incidence of a form of abuse that experts say belongs in the same violent spectrum as hitting, throttling or breaking a limb.

Newborns are particularly vulnerable to shaking because their neck muscles are not yet able to support their proportionately large heads. Often, their injuries become apparent only after an MRI scan. Sometimes they are missed altogether.

Auckland child-abuse specialist Patrick Kelly says doctors at the Starship detect 20 to 25 cases a year. He believes many victims are never seen at hospital. "They become unconscious or vomit or become lethargic for a day or two then recover and we never know they've been shaken."

Between a quarter and a third of shaken babies will die, which Kelly says represents six to eight babies a year. At least half will end up with serious or permanent brain damage, apparent only when the child reaches school and affecting behaviour in adulthood. This self-perpetuating cycle of violence represents a huge cost to society.

"It occurs at an absolutely critical stage of life and can be closely related to [later] abuse," says children's advocate Lesley Max, a committee member of the Brainwave Trust.

That anyone would deliberately hurt a baby is, of course, difficult to accept. Ian Hassall, a member of the Child and Youth Mortality Review Committee, says doctors are reluctant to make a diagnosis of death from abuse. "You can probably double the incidence of abuse if you look at the case notes."

Shaken-baby cases may not be outwardly obvious. Symptoms such as vomiting, fever and lethargy are associated with all sorts of illnesses as well as head injury.

Debate continues internationally about the extent of shaken baby syndrome. Several convictions have been overturned after expert witnesses questioned the reliability of prosecution evidence. Clots in the lining between skull and brain can also be caused by a lack of oxygen in the blood due to illness. Some claim such injuries can be caused simply by a baby flopping its head back.

In New Zealand, Flaxmere father Arthur Charles Niania spent 15 months in jail after the death of his 4-month-old son before being found not guilty in April of manslaughter, after a pathologist's determination of non-accidental brain injury was questioned.

But police and health officials are undeterred, arguing that the shaken baby cases that do get to court are the tip of the iceberg.

It's one thing for GPs, visiting midwives and Plunket nurses to suspect abuse, quite another to tackle caregivers about it and get something done. College of Midwives chief executive Karen Guilliland says options can be limited, with wide district variation in support services.

"We are talking about violent families and you have to get them referred to a system which often they don't want to go into. It's a very complex communication - it's very hard to get it out of the woman without scaring her off."

Guilliland says some parents cannot be taught. "There is a component who don't understand that it's not discipline. They think what they are doing is disciplining the baby."

The perpetrator may not be the obvious suspect. A Colorado study of 151 infants found fathers were the abusers in 37 per cent of cases, mothers' boyfriends 20.5 per cent, female childcare providers 17.3 per cent, and mothers 12.6 per cent.

In the light of "never-shake" campaigns, it's a struggle to believe anyone could shake a baby without knowing the potential impact. But in court, defence lawyers routinely argue that their clients "didn't know" or "lacked parenting skills".

Hassall, a former Children's Commissioner and now senior researcher at AUT's institute of public policy, says there's really no defence. While a newborn's brain is extremely fragile, he says it still requires a fair degree of force to cause haemorrhaging. He says the common assumption - that parents snap after days of lost sleep and high stress - is false.

"Nobody wants to believe there are people out there who don't care about injuring babies. But babies injured to the point of being killed are usually subjected to ill-treatment over a period of time. Loss of control on just a single occasion is not a common scenario."

Still, authorities are loath to lay too much blame with caregivers. Financial stress, unemployment, housing, cultural and ethnic factors can all play a part in child abuse. So can alcohol and drugs, particularly P.

Lesley Max says many violent parents are replicating their own upbringing and experiences. "In short we are talking about people with very short fuses and very few skills. They may be chronologically adult but emotionally and developmentally they may be far from the maturity that being a parent demands."

Those demands include feeding, changing, nurturing and coping with irregular sleep patterns and crying babies for the first time. Many mothers return to work early and have dwindling extended family support, so often the male partner is left with baby - and some are way out of their depth.

Take Koloa Aholelei, for example. While he had fathered two children with wife Alisia, both were raised by her mother. At 31, Tongan-born Aholelei wanted a more direct role in bringing up their third child, Leopota Randwick Aholelei, born on September 1, 2003. A month later, he ensured he would be home from work in time to look after the boy so Alisia could return to evening shiftwork as a production assistant at Montana Wines in Glen Innes.

But, he would tell police, he lacked experience in caring for a child. He had not attended antenatal classes and was without family support which, his lawyer argued, he would have experienced as a child in the Tongan community.

His evening routine involved watching TV in bed, often falling asleep, with Randwick either beside him in bed or in his cot. When Randwick cried, his father would feed him milk formula. Incapable of digesting all the formula, the boy sometimes threw up on the bedsheets.

This angered Aholelei, he told police. He would tell the baby, "I've had enough", and "don't do this to me again". He would shake Randwick for several seconds until the boy became quiet and he cleaned him up and put him down. What stilled Randwick was the movement of his brain against the side of his skull - he was semiconscious.

The shaking happened four times between October 20 and November 20, according to Aholelei, increasing in intensity and duration. In a video interview he described the shaking as "pretty hard". The fourth episode was the longest and he shook him "really hard". When the officer in charge suggested he must have been aware the shaking could injure Randwick, Aholelei replied: "I think it's fair to say that."

Yet Aholelei hardly presented as an "at-risk" parent. The court was told he'd led an exemplary life after coming to New Zealand for secondary education in 1988. He attended Penrose High and spent the seventh form at Onehunga High, leaving school with qualifications. He built a good employment history as an air-conditioning installer and married his sweetheart, Alisia. As a preacher in the Tongan church, he was respected in the community.

His barrister Paul Gruar argued that the incidents were isolated and without high intent. Aholelei played a limited role in the upbringing of his earlier children and was unaware that gastric reflux was normal in babies.

Aholelei maintained he never intended to harm his son, expressing regret to police and showing remorse. Yet the evidence included not just hidden haemorrhages. He admitted causing a lip injury to Randwick at eight weeks. A fractured hand also raised suspicions.

In April, Randwick's father was jailed for three years and nine months.

Patrick Kelly says child abuse happens across all sectors of society "from millionaires to the poorest of the poor". A Dutch survey suggests that by six months, nearly 6 per cent of parents have shaken or hit their baby. "All babies are very stressful to care for - they can seem completely unreasonable - pooing all hours, picking up everything they can get their hands on and generally making life a misery."

What differs, he says, is people's ability to cope. "Being able to pull back when you reach the threshold, when you know you are going to hurt somebody."

No one has been able to define precisely what distinguishes the person who crosses the line from someone who doesn't. "Put six parents in a room, all on the bones of their bums, all unemployed, maybe smoking marijuana: five out of six won't be abusing their children and one will be."

Which raises questions about not only the triggers but the kind of programmes needed to reduce shaking and other forms of violence towards babies.

Karen Guilliland says a high proportion of male partners attend antenatal classes where parenting skills are promoted, including explanations of why babies cry, recognising parental fatigue and behaviour management. But the focus is very much on getting mothers through childbirth.

"Anger in our society is not the responsibility of the antenatal-education system. Personally, I would have thought you don't need anybody telling you shaking a baby is not a good thing."

Northland paediatrician Roger Tuck says parenting is a job for which we get no formal training.

"Many parents don't have any idea what they are in for or what their role is. Some have not had ideal role models."

Lesley Max believes an inability to bond plays a part. In traditional (and larger) families, parenting skills were handed down. "Everybody had the opportunity to see how to handle the baby." Today, shorter stays in maternity wards, pressure on women to return to the workforce, dwindling extended family support and financial pressures on partners all raise the potential for problems. Max suspects many vulnerable infants slip through the cracks in state support. "It seems not to be anybody's job to ensure each of the parents has truly bonded with the baby.

"If people are seen once or twice and then left to their own devices, unless something goes horribly wrong they are not likely to receive any help at all. Shaken and dead babies are a system failure, in my opinion."

Ian Hassall agrees isolation increases the risk. "We really need to reorganise our society so we don't have people stuck on their own with babies. It's important to share the responsibility."

Hassall raises red flags around the policies of the main political parties to encourage women back to work. "The fact our political leaders can get away with that kind of thing may be one reason why we perform so badly in statistics relating to children."

Pat Tuohy, the Ministry of Health's child health chief adviser, says health workers know to look for the danger signs, such as unexplained injuries or babies who are frightened of their caregivers. But he concedes there's room for improvement. The Family Violence Prevention Strategy, Te Rito, asks GPs and others to notify Child, Youth and Family if they have suspicions. But Tuohy says referral rates from GPs are still quite low.

"Hospital and community staff are talking to mothers about violence in the family - we are starting to break down the barriers, but it's quite early days."

Tuohy also acknowledges the shortage of referral agencies dealing with abuse and neglect issues in some districts. "We can't prevent [violence] by monitoring individuals. We can prevent it by doing more for families who run into difficulties for a whole lot of reasons - they need more support."

As for Randwick, the future is uncertain. On discharge from hospital, he was weak down one side of his body but improved with physiotherapy. By 15 months, he had a normal examination and was doing well developmentally.

But a Starship paediatrician warned the court he may still have difficulties at school. "Young infants who have sustained a head injury ... may appear in the short term to have fully recovered but could then, at a later stage, have learning problems."

FIRST THREE YEARS ARE CRUCIAL

Bruises, even broken limbs, will heal but a baby's shaken brain can be a lifelong sentence, according to the Brainwave Trust.

The trust's website (see link below) cites research that childhood experiences in the first three years have a huge impact on adult lives.

Basic experiences of love, security and trust help children to become competent, intelligent adults. But neglect, violence and abuse can damage normal brain development, leading to social, emotional and learning difficulties. In situations of danger, a stress response in the brain stem releases "fight or flight" hormones - some of which can, in high concentrations, damage brain development.

When babies are shaken repeatedly, or subjected to other abuse, the stress response becomes overstimulated and becomes a template for brain development. The future is marked by impulsivity, easy arousal and the unthinking release of aggression. In boys, the trauma may lead to hyper-arousal; girls are more likely to retreat into a dissociative state. These conditions are often misinterpreted when noticed at preschool or school.