potentials in 15 patients with plagiocephaly, including 10 withpositional plagiocephaly, two with lambdoid synostosis, andthree with anterior plagiocephaly. Irrespective of the cause ofplagiocephaly, these infants had smaller amplitude P150 andN250 responses than normal controls. The ﬁndings support acommon etiology of cognitive impairment in craniosynostosisand deformational plagiocephaly.The causal relationship between head deformation andadverse cognitive sequelae is, however, difficult to establish because many comorbid conditions may predispose a child todevelop deformational plagiocephaly. Hypotonic children,such as those with mental retardation, chromosomal abnor-malities, and cerebral palsy, or children with torticollis, are atrisk for deformational plagiocephaly because they develop apreference for one head position over the other. Still, a strongcircumstantial argument can be made against the likelihood ofdeformational plagiocephaly, per se, having a significanteffect on children’s cognitive development, namely that headdeformation, whether unintentional or by design, is a wide-spread cultural phenomenon among prehistoric and indige-nous peoples.
Anthropological and Historical Contextsof Deformational Plagiocephaly
Cranial deformation practices, whether intentional or unin-tentional, have been a common feature in many ancient soci-eties. Indeed, in many parts of the world such practices con-tinue today.
Unintentional Cranial Deformation
Unintentional shaping of an infant’s cranium is the conse-quence of habitual positioning. Many historic and prehistoricNative American groups, particularly in the Southwest andPlains, used cradleboards to contain an infant while it was car-ried or sleeping, or while the mother was engaged in otheractivities. The use of cradleboards ﬂattens the occiput, muchlike the deformation seen in contemporary American infantswho are habitually placed on their backs to sleep (
). Asin contemporary infants, the deformation was often asymmet-rical as a result of an infant’s preference for looking toward oneside or another (
).Positional plagiocephaly is common in prehistoric South-western skeletal samples and extends across a considerablelength of time. Cradleboards have been found from the Basket-maker II period (c. 100 BC–AD 400). Occipital deformation wasalso common in the Adena and Hopewell people and at someMississippian and protohistoric sites in the Southeast andMidwest (40). These people, however, did not use a writtenlanguage. Thus, the learning disorders thought by some (4, 28,50) to be associated with deformational plagiocephaly mayhave been too subtle to be recognized by people in societies inwhich cranial deformation was common.
Intentional Cranial Deformation: “Headshaping”
Intentional shaping of infants’ heads, resulting in moreextreme deformation of the cranium than cradleboarding, wasalso widely practiced in the past and continues today.Dingwall’s (16) 1931 book,
Artificial Cranial Deformation: AContribution to the Study of Ethnic Mutilations,
remainsunequaled for its breadth and detail of the topic, surveyingthe history of the practice around the world. Gerszten andGerszten (20) and Goodrich and Tutino (21) reviewed infor-mation on intentional cranial deformation as it relates to thehistory of neurosurgery and to the development of craniofa-cial surgery from various parts of the world. Anatomists andothers (17, 27, 29, 34, 47)have been fascinated with artificialcranial deformation even before the birth of physical anthro-pology as a formal discipline, as exemplified by works likeSamuel Morton’s (37)
Crania Americana; or a Comparative Viewof the Skulls of Various Aboriginal Nations of North and South America
, published in 1839. This volume contains 72plates,principally of skulls from North and South America and theCaribbean. Extreme examples are best known from theNorthwest Coast, Peruvian cultures, and the ancient Olmec,Toltec and Maya in Mesoamerica. Intentional deformationwas also common in the southwestern and southeasternUnited States (12, 40, 48). Known European cases date fromthe Neolithic period, and have been found in Britain (7),among the Huns of eastern and central Europe (49), and inancient Cyprus (33). In antiquity, head shaping was practicedon every inhabited continent, with evidence from Iraq as earlyas 45,000 BC (42) and in fossilized remains of early
from Australia (2).Devices used to shape heads include cloth bindingswrapped around the infant’s head, anteroposterior compres-sion via boards or stones bound together and placed aroundthe head, and cradleboard attachments that compress the fore-head. In some cultures, mothers molded and squeezed theheads of their infants between their hands while nursing,changing them from breast to breast so that a desired symmet-rical appearance could be obtained (16). Most cultures usedcranial modiﬁcation as a marker of ethnic identity or social sta-tus. It was also done to appear ferocious in battle and for cul-tural or racial imitation. Deformation and sex also correlate,
VOLUME 60|NUMBER 6|JUNE2007|
Example of unintentional cranial deformation among theSouthwest Native Americans. Lateral (
) and basilar (
) views withoccipital ﬂattening caused by cradleboarding showing plagiocephaly sim-ilar to the positional plagiocephaly that results from positioning infantssupine. Photographs courtesy of Charles Merbs, Ph.D., with permission.