By Ryan T. McGuire

In October 2025, a Virginia man, La’Shaun Quintae Holloway, was sentenced to 30 years in prison for killing his two-month-old baby [1]. The facts of the case were horrific. While the baby was in Holloway’s sole care, family members heard him over an Xbox headset yelling obscenities at the infant. Shortly after, the baby stopped crying and was found unresponsive. The child died days later from catastrophic injuries, including a skull fracture, an extensive brain bleed, a fractured clavicle, and 26 rib fractures in various stages of healing. The prosecution’s case relied on a medical conclusion that the injuries were the result of abusive head trauma (AHT).

The Holloway case is a devastating reminder that AHT is a real and tragic event. But are all cases so clearly supported by external evidence? What happens when there is no one who overhears the abuse, no prior history of harm, and no obvious external injuries?

In many such prosecutions, the state’s case rests almost entirely on a specific set of internal findings, commonly known as the “triad.” This triad consists of subdural hemorrhage (bleeding near the brain), retinal hemorrhage (bleeding in the eyes), and encephalopathy (a general term for structural or functional issues in the brain, such as cerebral edema). For decades, courts and investigators have frequently treated the presence of this triad as near-proof of intentional, violent abuse. But is this medical diagnosis, standing alone, such a clear and reliable indicator of abuse that the inquiry can simply stop there?

As the science of pediatric head injuries evolves, the confidence sometimes projected in the courtroom appears to outpace what today’s medicine can actually prove about mechanism, timing, and causation. Overstating this certainty risks turning a complex medical differential diagnosis into a simple—and sometimes incorrect—shortcut to conviction.

The “Triad” and Abusive Head Trauma

Investigators and medical experts often point to a “triad” of medical findings—subdural hemorrhage, retinal hemorrhage, and encephalopathy—to diagnose abusive head trauma (AHT). Courts have frequently relied on this triad as powerful—almost definitive—evidence of intentional harm, particularly in infants. But is this collection of findings such a clear and reliable indicator of abuse that the inquiry can simply stop there? Is the triad “pathognomonic,” meaning a sign whose presence proves a specific disease, or is the reality far more complex?

What is the “Triad”?

To understand the significance of the triad in child abuse investigations, one must first understand its components. In the simplest terms, the triad describes three co-occurring conditions:

• Subdural Hemorrhage: Bleeding in the space between the brain’s surface and its protective outer layer (the dura).
• Retinal Hemorrhage: Bleeding in the light-sensitive tissue at the back of the eye.
• Encephalopathy: A broad term for brain injury, disease, or dysfunction, often presenting as swelling, seizures, difficulty breathing, or a lack of responsiveness.

When these three findings are seen together in an infant, many medical guidelines have historically pointed to AHT, often described as “shaken baby syndrome” (SBS), as the most likely cause [2].

Is the Triad Alone Proof of Abuse?

While the triad is a serious and alarming set of findings, is it, by itself, conclusive proof of abuse? The medical and legal consensus is increasingly cautious. Even organizations that support the AHT diagnosis, like the American Academy of Pediatrics (AAP), stress the need for a comprehensive, multidisciplinary evaluation rather than relying on a single pattern of findings [2]. They promote a holistic, case-by-case synthesis that includes the patient’s history, physical exam, imaging, labs, and social context.

This caution is shared by international bodies. In 2016, Sweden’s national health technology assessment agency (SBU) reviewed the triad and concluded the evidence was “insufficient” to determine its diagnostic accuracy for traumatic shaking [3]. Two decades ago, the UK Court of Appeal, in R v. Harris (2005), warned that the triad, standing alone, should not “automatically and necessarily” lead to a diagnosis of non-accidental head injury (another name for AHT) [4]. These bodies are not saying abuse doesn’t happen; they are saying the triad alone is not a simple equation for it.

What Else Can Cause Triad-Like Findings?

Trauma, underlying medical conditions, and even the process of birth can cause findings that mimic or are identical to parts of the triad. Understanding this full spectrum of potential causes, or “differential diagnoses,” is crucial for both proper diagnosis and legal assessment.

Birth is a significant traumatic event. Large MRI studies have shown that 26–46% of perfectly healthy, asymptomatic term newborns have intracranial bleeding, often subdural [5]. While this typically resolves, residual or evolving collections could theoretically be mistaken for new trauma weeks or months later.

Several conditions can produce subdural collections and even retinal bleeding without abuse. Benign external hydrocephalus (BEH), for example, predisposes infants to chronic subdural collections after even minor, accidental trauma. Metabolic diseases, notably glutaric acidemia type I (GA-1), can present with subdural and retinal hemorrhages and is a well-documented AHT mimic. Infections like meningitis can also lead to subdural fluid collections that look like trauma on a scan. When these alternatives are not rigorously excluded, a confident abuse diagnosis becomes fragile.

The claim that “short falls can’t kill” or cause triad findings has also been overstated. While rare, case studies and reviews have documented fatalities and severe injuries from short-distance falls under specific circumstances [6]. Dismissing an accidental fall a priori is a mistake.

Are There Other Scientific Challenges?

Beyond medical mimics, legal and medical experts grapple with other scientific uncertainties that complicate courtroom testimony.

Prosecutors sometimes use CT or MRI scans to claim they can pinpoint when an injury occurred, locking a specific caregiver into a timeline. However, systematic reviews of this practice have found it to be unreliable. The appearance of blood on scans varies greatly and different “ages” of bleeding can overlap, making precise dating by imaging alone very difficult [7].

The “classic” theory of shaking-only injury is also debated. Some biomechanical studies have found that shaking alone may not generate the force needed for such catastrophic injuries, whereas impact (like a fall) generates far higher accelerations [8]. Other computational models have disagreed. The science of injury thresholds in infants, often scaled from animal or dummy data, is not settled [9].

What is the Legal Value of the Triad?

It is tempting to look for a medical diagnosis or physical observation that is exclusive to abuse because that would make the investigative and legal process universally easier. However, as the science evolves, scrutiny is warranted whenever an expert claims a high degree of certainty based on the triad alone.

The lack of certainty is why legal systems have begun to re-evaluate old convictions based on this evolving science. Appellate courts have recognized the shift. For instance, in State v. Edmunds, a Wisconsin court granted a new trial based on the new medical debate [10]. In Commonwealth v. Millien, the Massachusetts high court found that failing to hire an expert to challenge the SBS theory constituted ineffective assistance of counsel [11].

This debate is not just historical. In October 2025, the Texas Supreme Court stayed the execution of Robert Roberson, sending his case back for review due to concerns about outdated SBS evidence [12].

Ultimately, medical authorities and courts still consider the triad an important indicator of potential abuse, but one that demands a full investigation. It is a starting point for inquiry, not a conclusion. The law requires evidence to satisfy a burden of proof, and as the science shows, the triad by itself may no longer be enough.

Sources:

[1] Press Release, Va. Beach Commonwealth’s Att’y’s Off., Commonwealth v. La’Shaun Quintae Holloway; Brutal Killing of Two-Month-Old Baby Yields 30 Years in Prison (Oct. 6, 2025).

[2] Am. Acad. of Peds., Abusive Head Trauma in Infants and Children, 155 Pediatrics (Supp. 1) e2024070014B (2025) (Technical Report).

[3] Swed. Agency for Health Tech. Assessment & Assessment of Soc. Servs. (SBU), Traumatic Shaking: The Role of the Triad in Medical Investigations of Infants (2016).

[4] R. v. Harris [2005] EWCA Crim 1980, [2006] 1 Cr. App. R. 5.

[5] Rooks et al., Prevalence and Evolution of Intracranial Hemorrhage in Asymptomatic Term Infants, 29 Am. J. Neuroradiology 1082 (2008).

[6] Plunkett, Fatal Pediatric Head Injuries Caused by Short-Distance Falls, 22 Am. J. Forensic Med. & Pathology 1 (2001).

[7] Wittschieber et al., Understanding Subdural Collections in Pediatric Abusive Head Trauma, 40 Am. J. Neuroradiology 1776 (2019).

[8] Duhaime et al., The Shaken Baby Syndrome: A Clinical, Pathological, and Biomechanical Study, 66 J. Neurosurgery 409 (1987).

[9] Schiks et al., Thresholds for the assessment of inflicted head injury by shaking trauma in infants: a systematic review, 306 Forensic Science International (2020).

[10] State v. Edmunds, 746 N.W.2d 590 (Wis. Ct. App. 2008).

[11] Commonwealth v. Millien, 50 N.E.3d 809 (Mass. 2016).

[12] Amanda Lee Myers, Texas Court Stops Robert Roberson’s Execution Over Questions About Shaken Baby Syndrome, USA Today, Oct. 9, 2025.

Author:

Ryan T. McGuire is a law clerk at Woodnick Law PLLC and a second-year student at the Sandra Day O’Connor College of Law. He leverages his master’s degree in philosophy to produce thorough legal research and writing, with a focus on family law matters. Ryan brings a strong foundation in legal analysis and academic interests spanning family and criminal law.