An out-of-work young father stays home to care for his infant while his wife is at her job, hoping to make enough money to catch up on their mortgage payments.
The baby's relentless, shrill crying ratchets up Dad's already-strained stress level. Grabbing her from the crib, he gives her a rough shake. The baby falls silent.
Instances of shaken baby syndrome, also known as abusive head trauma, rose markedly across the United States - by 55 percent, according to a recent study - since the recession began in Dec. 2007.
The economic crisis threw millions of people out of work and forced states to curtail social service spending.
Financial stress compounded by harder-to-get help for struggling parents triggered the increase in abuse, the study's authors say.
"An economic recession may be the perfect storm in terms of the risks for abuse head trauma; not only is there increased stress due to job losses etc., but there are also decreased social services and supports," study author Dr. Rachel P. Berger, an assistant professor of pediatrics at the University of Pittsburgh School of Medicine, said in a recent interview with the TIMES NEWS.
"What prompted the study was our sense that the number of cases of physical abuse and particularly abusive head trauma which our Child Protection Team (at Childrens Hospital of Pittsburgh) was involved with had increased markedly beginning near the end of 2007, a time which happened to coincide with the start of the recession," she said.
Berger and her colleagues found that the numbers were not only increasing in the Pittsburgh area, but in Seattle, Washington, and in Columbus and Cincinnati, Ohio.
The finding "was not particularly surprising because of the recognized association between increases stress and increases in violence," Berger said. "The magnitude of the increase, particularly in Pennsylvania - which has a state mandate that every parent of a baby born in this state must be educated about the dangers of shaking - was surprising."
The study was the first to show an increase in a particular type of abuse during an economic recession, she said, and its conclusions were troubling.
"The results should make us very concerned: in these four hospitals there was an average of over three additional cases of abusive head trauma every month during the recession compared to the prerecession period. This translates to perhaps hundreds of additional cases throughout the country during each year of the recession," Berger said. "Given the high morbidity and mortality of abusive head trauma (it is the leading cause of death from child abuse), this is something we should all be worried about."
In her study, Berger compared figures from Jan. 1, 2004 through Nov. 30, 2007 to figures from Dec. 1, 2007 through Dec. 31, 2009. She presented her findings on May 1 at the Pediatric Academic Societies annual meeting in Vancouver, British Columbia, Canada.
Pennsylvania Department of Public Welfare statistics back Berger's findings. Cases of shaken baby syndrome in the state increased sharply from 59 in 2005 to 92 last year.
Three babies died of their head injuries in 2005, and 13 in 2008. Last year, 10 were shaken so violently they died, according to DPW.
However, DPW believes the rise may be due more to increased awareness by doctors than to an actual spike in the numbers of babies being shaken.
"Child abuse overall has been on the decline in Pennsylvania," said DPW spokesman Michael Race. "The number of reported cases of suspected abuse and the number of substantiated cases both went down in 2009 compared to 2008. We attribute that decline in part to increased efforts to address the root causes of child abuse and educate the public on ways to prevent it. The change in the number of shaken baby cases could be due in part to greater awareness by doctors of the signs and symptoms of shaken baby syndrome."
Locally, there were no cases of shaken baby syndrome in Carbon County last year, said county Children and Youth Services Agency director Sallianne Newton.
Carbon County followed the state trend in the drop in substantiated cases of all child abuse from 2008 to 2009.
According to DPW figures, substantiated reports per thousand children in Carbon fell from 1.6 to 1.2 during that time period.
However, they rose slightly in neighboring Monroe and Schuylkill counties. In Monroe, the numbers rose from 1.1 to 1.5 and in Schuylkill, from 2 to 2.5 per thousand.
There were only 16 substantiated cases of abuse in Carbon County in 2009, according to DPW, with 70 in Schuylkill and 59 in Monroe County, according to DPW. The total for all substantiated injuries statewide last year was 5,691.
The conclusions reached by Berger linking increases in abusive head trauma with the recent economic crisis didn't surprise Amy Wicks of the National Center on Shaken Baby Syndrome in Ogden, Utah.
"I think it's kind of interesting. I work with a lot of people who are on front lines - in hospitals or with the police. We've been hearing from them for a while now, but it's hard to pin down solid evidence," she said.
Wicks is also hearing about cuts in social services, including programs that aim to prevent child abuse and teach parenting.
The cuts, she said, "may be selling our parents and families short when they need our help now more than ever."
Wicks' organization estimates there are between 1,200-1,400 cases a year of shaken baby syndrome, but says it's difficult to know exactly.
"There is no central reporting registry for shaken baby syndrome. The numbers are estimates; there is no trackable data. Some hospitals do track, others don't," she said.
Wicks explained that shaken babies may be brought to the hospital with a variety of injuries. It may take time and testing to determine that they were caused by shaking.
For example, babies could be admitted for brain trauma, or because they are not breathing.
But even though there are no absolute numbers, there has been some research done - in North Carolina, the United Kingdom and other places - that have concluded that around 30 per 100,000 children under the age of one will suffer from inflicted brain injuries (most likely is result of being shaken) - about as many as are born each year with cystic fibrosis, Wicks said.
An effective method, the Shaken Baby Syndrome Prevention & Awareness Program, was developed in 1998 by pediatric neurosurgeon Dr. Mark Dias.
The program, which began in upstate New York, nearly halved the incidence of shaken baby cases.
The program uses videos and printed materials to teach new parents about shaken baby syndrome and how to cope with an infant's crying.
Dias brought the program to Penn State Hershey in Pennsylvania in 2002, prompting legislators to adopt the Shaken Baby Syndrome Education Act that same year.
The program partnered with, and is now funded by, the state Department of Health to expand into all birthing and children's hospitals in the state.
In 2007, the U.S. Centers for Disease Control awarded the program a $2.8 million grant to expand.
Under the program, a "booster" of education is given at the time of an infant's two, four and six month immunization visits.
Proposed federal legislation was introduced in 2007 by Sen. Christopher Dodd, D-Connecticut, co-sponsored by Pennsylvania Senator Robert Casey, that would develop a national public health campaign to increase awareness and authorize prevention programs.
The bill, however, continues to languish in committee.