The Science is Clear — Now Let’s Strengthen Our Response to Abusive Head Trauma

Navigating Legal Challenges with Scientific Integrity

6 min readApr 29, 2025

By Allysa Gambarella, former prosecutor and Senior Director of Education & Engagement at the National District Attorneys Association

It starts with a call no one wants to receive — an infant is brought to the ER unresponsive, clinging to life, with no clear explanation provided by caretakers. For prosecutors, child protection workers, and investigators, these are the cases that stay with us forever. Abusive Head Trauma (AHT) is not just medically complex; it is emotionally devastating, legally challenging, and increasingly scrutinized in courtrooms and newsrooms alike.

AHT, previously known as Shaken Baby Syndrome, continues to be one of the most severe and misunderstood forms of child abuse encountered by prosecutors, law enforcement, and child protection professionals. While the medical science surrounding AHT remains sound, courtroom challenges and public skepticism have escalated. The result: cases that are difficult to prosecute and victims whose voices risk being lost amidst confusion, misinformation, and legal maneuvering.

The Medical Reality vs. The Legal Narrative

The diagnosis of Abusive Head Trauma is not new, nor is it fringe. It is supported by decades of peer-reviewed research and clinical experience. The American Academy of Pediatrics (AAP), the most widely respected authority on pediatric health, has long recognized AHT as a legitimate and critical medical diagnosis. Their latest technical report, authored by experts across multiple medical subspecialties, reaffirms AHT as a leading cause of fatal child abuse and a diagnosis rooted in sound science.

Yet, in the courtroom, defense teams are increasingly challenging this diagnosis and introducing alternative theories not grounded in mainstream medicine. These theories can confuse jurors and judges and can cast unwarranted doubt on credible medical findings.

For prosecutors, understanding and articulating the medical foundation of AHT is essential to present clear, evidence-based arguments. The AAP’s report is a vital tool in this effort, offering the scientific consensus and current research needed to push back against misinformation.

Key Takeaway: The medical consensus around the diagnosis of AHT is clear. Prosecutors must be equipped to communicate the overwhelming medical acceptance of the AHT diagnosis and counter defense narratives that distort or misrepresent the science.

The Evolving Legal Landscape: Litigation, Scrutiny, and Strategy

AHT cases are being heavily litigated across the country. Motions to exclude expert testimony, Frye and Daubert challenges, and appellate and post-conviction scrutiny are becoming routine. These legal tactics aim to discredit the medical underpinnings of AHT and introduce doubt, even when the facts and science are clear.

The evolving legal landscape demands more than just strong evidence. It requires strategy. Prosecutors must be prepared not only to present the facts but to educate judges and juries on the reliability of the diagnosis and the qualifications of their medical experts. Pre-trial hearings are no longer procedural hurdles: They are battlegrounds for defending the integrity of the AHT diagnosis.

To navigate this, prosecutors should consult with their experts early, prepare comprehensive motion responses, and consider filing motions of their own to preclude unqualified or unscientific defense testimony. Leveraging the National District Attorneys Association’s Technical Assistance and Training (including trial advocacy and child abuse) can help prosecutors bolster their legal arguments and enhance courtroom performance.

Building Strong Cases from the Start: Investigation Matters

A strong prosecution begins with a solid investigation. In AHT cases, this means a methodical, coordinated effort that integrates medical, investigative, and legal elements from the start. Prosecutors should be involved early in the process, not just after an arrest is made. Early involvement ensures that investigators know what evidence will be needed in court and that interviews and timelines are structured to support a legally sound case.

AHT injuries often result in the rapid onset of symptoms. It’s vital to construct a timeline around when symptoms began and, importantly, who was with the child at that time. Medical records, caretaker accounts, behavioral changes, and symptom presentation collectively establish a comprehensive factual framework for AHT cases.

Additionally, caretaker interviews must be conducted strategically. Initial interviews should focus on gathering objective facts: the child’s behavior, recent routines, and any notable events or injuries. Only after a full medical evaluation is conducted should interrogative interviews occur, informed by the medical findings.

Evidence collection is another critical pillar. Items such as photos of the scene, body-worn camera footage, surveillance video, digital communication between caretakers, and medical records from birth to present should all be gathered and evaluated. Interviewing other children in the home, reviewing child protective history, and obtaining relevant warrants are also essential components of a successful investigation.

The Power of the Multidisciplinary Team: Collaboration Is Not Optional

AHT cases are among the most complex child abuse prosecutions — and successful outcomes cannot be achieved alone. Success requires collaboration between prosecutors, investigators, child protection professionals, and the medical community.

Formalizing this collaboration through multidisciplinary teams (MDTs) is critical. These teams should develop protocols and memorandums of understanding (MOUs) that define roles, responsibilities, and communication pathways. Doing so helps prevent duplicative interviews, ensures timely sharing of medical results, protects the integrity of evidence, and prioritizes the safety and needs of the child.

The role of medical professionals cannot be overstated. Child abuse nurses and pediatricians, radiologists, neurologists, ophthalmologists, and pathologists can help prosecutors understand and communicate complex findings, identify limitations in testimony, and anticipate defense claims. These experts can also aid in deciding which subspecialists should testify at trial and how best to present their findings.

Preparing for Trial: Clarity, Confidence, and Simplicity

AHT trials can be daunting. The medical complexity, emotional gravity, and legal challenges require prosecutors to be skilled litigators and effective educators. Jurors must be guided through the facts in a way that is clear, credible, and compelling.

This starts with preparation. Prosecutors must anticipate common defense tactics — claims of accidental injury, preexisting conditions, birth trauma, or rare medical disorders — and prepare their experts to rebut them confidently. Introducing and addressing these arguments during direct examination can help neutralize the arguments before they are raised as part of the defense case.

Prosecutors should avoid the trap of trying to out-science the defense. Overly technical presentations can confuse jurors and dilute the strength of the prosecution’s case. Keep the narrative simple: a non-mobile child with life-threatening head trauma that is inconsistent with any explanation offered by caretakers.

Key Takeaway: Trial success hinges on clarity and preparation. Simplicity in storytelling, combined with expert guidance, can overcome even the most aggressive defense narratives.

Moving Forward Together: The Path Ahead

While AHT cases may be among the most challenging in our field, they are also among the most important. At stake are the lives, safety, and futures of our most vulnerable victims. The path forward is not to retreat in the face of controversy but to move forward together, grounded in science, strategy, and shared commitment.

To help address these challenges, the National District Attorneys Association (NDAA) has released a new resource, Abusive Head Trauma: Considerations to Strengthen Case Outcomes. This document provides a high-level overview of national AHT case trends, actionable strategies, and considerations for navigating AHT cases with confidence, clarity, and compassion.

Every case matters. Every child matters. And every professional reading this plays a critical role. Let’s stay informed, stay connected, and stand together against child abuse.