PREVENTION STRATEGIES FOR ABUSIVE HEAD TRAUMA

Research has shown that certain protective factors are linked to a lower incidence of child abuse and neglect in general. They are attributes that serve as buffers, helping parents who might otherwise be at risk of abusing their children to find resources, supports, or coping strategies that allow them to parent effectively, even under stress. These protective factors include:

• Nurturing and attachment
• Knowledge of parenting and child development
• Parental resilience
• Social connections
• Concrete supports for parents
• Social and emotional competence of children
  (CWIG, 2021)

Many states have enacted programs aimed at preventing child abuse, including pediatric abusive head trauma in particular, through a public health primary universal prevention strategy aimed at changing knowledge and behaviors of caregivers and society in general concerning normal development of infants and the significance of early increased infant crying. By increasing parental understanding of infant development, with a focus on infant crying and coping strategies to address it, such programs are thought to offer a “window of opportunity” for the prevention of AHT and, potentially, other forms of infant abuse.

Nevertheless, in one comparative study of a statewide abusive head trauma intervention, researchers found no associated significant reduction in the overall hospitalization rates for abusive head trauma among infants, although parents did report significant knowledge gains from the intervention (Dias et al., 2017).

There are several types of prevention education programs and supports currently being utilized and evaluated. These include:

• Hospital-based (inpatient parent training) education programs
• Home visiting programs
• General parenting education classes
• Parent support groups
• Family resource centers
• Crisis intervention services such as hotlines and crisis nurseries

Primary prevention efforts address a broad segment of the population, such as all new parents. Secondary prevention efforts target a specific subset of the population considered to be at higher risk for child maltreatment. Tertiary prevention efforts target perpetrators of child maltreatment and seek primarily to prevent recidivism.

Primary Efforts: General Public and Parent Education

Primary prevention activities are directed at the general population and attempt to stop maltreatment before it occurs. All members of the community have access to and may benefit from these services. Primary prevention activities with a universal focus seek to raise the awareness of the general public, service providers, and decision makers about the scope and problems associated with child maltreatment. Universal approaches to primary prevention might include:

• Public service announcements that encourage positive parenting
• Parent education programs and support groups that focus on child development, age-appropriate expectations, and the roles and responsibilities of parenting
• Family support and family strengthening programs that enhance the ability of families to access existing services and resources to support positive interactions among family members
• Public awareness campaigns that provide information on how and where to report suspected child abuse and neglect

Parent education and support programs typically focus on educating parents on child development and parenting strategies and also have the goal of decreasing parenting practices and behaviors associated with child abuse and neglect. Although parent education programs may serve the general community, many are also directed at populations determined to be at risk for child maltreatment. Parent education about infant crying and the risks of shaking a baby continues to stand out for its empirical evidence (Lopes & Williams, 2016).

Parent education and support programs can address:

• Developing and practicing positive discipline techniques
• Learning age-appropriate child development skills and milestones
• Promoting positive play and interaction between parents and children
• Locating and accessing community services and supports

Healthcare professionals can provide the following messages to parents and caregivers during their everyday encounters:

• Remind parents and caregivers that crying is normal for babies.
• Explain to parents that excessive crying is often a normal phase of infant development.
• Ask parents how they are coping with parenthood and their feelings of stress.
• Assure parents that it is normal to feel frustrated at long bouts of crying and a sudden decrease in sleep, but that things will get better.
• Give parents the number to a local helpline or other resource for help.
• Talk with parents about the steps they can take when feeling frustrated with a crying baby, such as putting the baby safely in a crib on their back, checking on the baby’s safety every 5 to 10 minutes, and calling for help or a friend.
• Let parents know what to check for when their baby is crying: signs of illness, fever, or other behavior that is unusual; discomfort like a dirty diaper, diaper rash, teething, or tight clothing; or whether the baby is hungry or needs to be burped.
  (CDC, 2021)

The Period of PURPLE Crying is an example of a primary-level program specifically geared to the prevention of AHT. The target population is all parents of new infants and society in general, with the goal of increasing their understanding of early infant crying and shaken baby syndrome. The Period of Purple Crying training, when taken by nurses, has also been shown to improve nurses’ short- and long-term understanding of AHT and their confidence in instructing parents and caregivers about its associated dangers and risks (Glennery et al., 2020).

PERIOD OF PURPLE CRYING PROGRAM

(NCSBS, 2018)
P	Peak of crying	Your baby may cry more each week, peaking at 2 months, then less at 3 to 5 months.
U	Unexpected	Crying can come and go and you do not know why.
R	Resists soothing	Your baby may not stop crying no matter what you try.
P	Pain-like face	Your crying baby may look to be in pain even when they are not.
L	Long lasting	Crying can last as much as 5 hours a day or more.
E	Evening	Your baby may cry more in the late afternoon or evening.

The PURPLE program includes a booklet plus either a smart phone “app” that parents can use to track crying and access other developmental and anticipatory guidance information and/or a DVD. The program is designed to help parents of new babies, caregivers, and the public to understand the typical crying curve and the dangers of reacting to an infant’s crying in frustration and shaking a baby. It is based on 30 years of scientific research on the connection between the infant crying curve and the incidence of SBS and is delivered using a specific protocol (Barr, 2021).

(See also “Resources” at the end of this course.)

Secondary Prevention Efforts

Secondary prevention efforts, such as home visitation programs, target a specific subset of the population considered to be at higher risk for child maltreatment, such as poverty, parental substance abuse, young maternal age, parental mental health concerns, and parental or child disabilities. Approaches to prevention programs that focus on high-risk populations might include:

• Parent education programs located in high schools and focusing on teen parents or located within substance abuse treatment programs for mothers and families with young children
• Parent support groups that help parents deal with their everyday stresses and meet the challenges and responsibilities of parenting
• Respite care for families who have children with special needs
• Family resource centers that offer information and referral services to families living in low-income neighborhoods
• Home visiting programs that provide support and assistance to expecting and new mothers in their homes
  (CWIG, 2021b)

Home visiting is a mechanism to provide direct support and coordination of services for families, beginning prenatally or at birth. Visits are conducted by a nurse, social worker, or trained paraprofessional. Programs vary, but components may include:

• Education in effective parenting and childcare techniques
• Education on child development, health, safety, and nutrition
• Assistance in gaining access to social support networks
• Assistance in obtaining education, employment, and access to community services

EXAMPLE PROGRAMS

Two examples of such programs are listed below:

Kentucky’s Health Access Nurturing Development Services (HANDS) program is designed to assist overburdened first-time parents at critical development points. Frequent pre- and postnatal home visits by trained professionals are provided to first-time parents. These appointments assist new parents by sharing important information, problem solving, and helping them to meet basic needs such as housing, food, healthcare, and other required services. All of Kentucky’s 120 counties offer the HANDS program at no cost to families. Enrollment must be during pregnancy or when the infant is less than 3 months old, and referral to HANDS is made through the County Health Department.

Although there is currently no data to support the HANDS program’s effectiveness as it relates to AHT prevention, families who participated in HANDS (compared to families who did not participate) experienced:

• Fewer premature infants
• Fewer low birth weight babies (<5 lbs., 9 oz.)
• Fewer very low birth weight babies (<3 lbs., 5 oz.)
• Fewer developmental delays
• Fewer complications during pregnancy and/or delivery
• Adequate prenatal care
  (HANDS, 2022)

The Nurse-Family Partnership program provides home visits by registered nurses to first-time, low-income mothers, beginning during pregnancy and continuing through the child’s second birthday. It operates nationwide. The program has three primary goals: 1) to improve pregnancy outcomes by promoting health-related behaviors; 2) to improve child health, development, and safety by promoting competent caregiving; and 3) to enhance parent life-course development by promoting pregnancy planning, educational achievement, and employment. The program also has two secondary goals: to enhance families’ material support by providing links with needed health and social services and to promote supportive relationships among family and friends.

(See also “Resources” at the end of this course.)

EFFICACY

The efficacy of home visiting programs continues to be challenging to evaluate, especially as they relate to child abuse prevention. Multiple studies have concluded that the strategy, when well implemented, does produce significant and meaningful reduction in child-abuse risk and improves child and family functioning. Other studies are more limited in their conclusions (CWIG, 2021b).

While there is mixed evidence that home-visiting programs directly prevent child abuse and neglect, it has been found that home visits can impart positive benefits to families by way of influencing maternal parenting practices, the quality of the child’s home environment, and children’s development.

Some studies have linked parenting quality with child maltreatment, as improved parenting skills would likely be associated with improved child well-being and corresponding decreases in maltreatment, even if these effects remain difficult to document. According to the American Academy of Pediatrics, “Vigorous national outcome evaluations substantiate that home-visiting programs are effective in the promotion of healthy family relationships, improvement of overall child development, prevention of child maltreatment, advancement of school readiness, and improvement of maternal physical and mental health” (Duffee et al., 2017).

Tertiary Efforts: Recidivism Prevention

Tertiary prevention activities focus on families where maltreatment has already occurred and seek to reduce the negative consequences of the maltreatment and to prevent its recurrence. These prevention programs may include services such as:

• Intensive family preservation services with trained mental health counselors that are available to families 24 hours per day for a short period of time (e.g., 6 to 8 weeks)
• Parent mentor programs with stable, nonabusive families acting as role models and providing support to families in crisis
• Parent support groups that help parents transform negative practices and beliefs into positive parenting behaviors and attitudes
• Mental health services for children and families affected by maltreatment to improve family communication and functioning
  (CWIG, 2021b)

SafeCare is one example of an evidence-based training curriculum for parents who are at-risk or have been reported for child maltreatment. Parents receive weekly home visits to improve skills in several areas, including home safety, healthcare, and parent-child interaction (CWIG, 2021).