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Babies Cry, You Can CopeThe background to ICONDr Suzanne Smith PhD, MA, BA, RGN, RHV:ICON FounderandChief Programme Advisor

AKA Shaken Baby Syndrome Child Abuse Catastrophic injuries: Brain injuries Bleeding behind the eyes Bony injuries Causal mechanism rarely confirmedAcceleration/deceleration Impact 1 in 14 cases – fatal before hospital discharge Half of severely injured survivors die before aged 21.

2011 20– 24 per 100,000 in first year District General Hospital – paediatrician canexpect to see a case every 1 or 2 years 2.6% of American parents admitted to shaking achild under 2 years; 9% felt like shaking Cases seen by paediatricians – only a proportionof cases of AHT It’s the leading cause of death and long-termdisability for babies who are abused

Survival with significant brain injury or death Emotional cost Inpatient hospitalisation (Paediatric Intensive Care) Long term medical services – PhysiotherapyOccupational TherapySpeech and Language TherapyEducational needs Foster care Family and criminal proceedings Prison/probation Serious Case Review cost (circa 75,000) Loss of societal productivity and occupational revenue.

70%perpetrators are males – fathers/malesurrogates (Kesler et a 2008; Altman et al 2010) Can occur in every socio-economic group Coping with crying: Living on the edge Caregivers lose control and shake – baby stops crying Demonstrable relationship between the normal peakof crying and babies subject to AHT. (Barr et al 2006) Increase in cases in the 1st month of life, a peak at 6weeks during the 2nd month and a decrease duringthe 3rd to 5th months of life

Success depends on controllability Problem solvingwhere the stressor cannot becontrolled can lead to frustration and distress support through the problem rather than solvingthe problem The need for a careful approach towards aresponsive professional intervention that is rootedin evidence is, therefore, crucial

Travel toLearn: Return to Inspire The aim of this Fellowship was to exploreinternational programmes related to theprevention of child maltreatment with a particularfocus on AHT in infants and to gain anunderstanding about the wider context of thedelivery of care and the systems and processes inwhich they are provided and commissioned.

SEEK (Safe Environment for Every Kid)Baltimore, Maryland Shaken Baby Syndrome Prevention ProgrammeHershey, PA Safe Babies New YorkBuffalo, NY Period of Purple CryingVancouver, BC Period of Purple Crying and Child Advocacy CentreHelena, MT Period of Purple Crying and Family Support CentreWichita, KS

A practical evidence-based tool to briefly and systematically screen parents for prevalentpsychosocial problems that are risk factors for child maltreatment, and that generallyjeopardize children's health, development and safety. Parental Depression Parental Substance Abuse Harsh Punishment Major Parental Stress Intimate Partner Violence Food InsecurityThe SEEK PQ is also:Designed to screen for, not diagnose, risk factors for child maltreatment. It is Validated for usein primary care practice and is intended for parents to complete, voluntarily, in advance oftheir child's regular check-up.

SEEK resulted in significantly lower rates of childmaltreatment in all the outcome measures: fewerChild Protective Services reports, fewer instances ofpossible medical neglect documented as treatmentnon-adherence, fewer children with delayedimmunizations, and less harsh punishmentreported by parents. Families with prior childwelfare involvement were not excluded from thestudy sample, blending results for primary,secondary, and tertiary prevention (intervention)samples.

Dose1: hospitals and birthing centres Dose 2: strategic reinforcement of the PURPLEmessage outside of the hospital Dose 3: increase the opportunity for publicawareness of AHT through a ‘positive communitynorms’ campaign on AHT. Video

Hospital Based Prevention Programmes 96217/11476368/2016 3rd Quarter Newsletter/db2cccdb-90ff-45c0-a917-7169cbf9362f Safe Babies New York (same s/2016/06/20160615053919 SafeBabies-NY-Brochure-ENGLISH-FINAL-2016-01.pdf

A co-ordinated, hospital based parent educationprogramme targeting parents of all newborn infantscan significantly reduce the incidence of abusive headtrauma in children less that 36 months.Dias et al (2005) Preventing Abusive Head Trauma Infants and Young Children: a hospital based prevention programPediatrics 115: 470 – 477 16 infants who were born in the 8 year study period weretreated at the children’s hospital for shaking injuriessustained during their 1st year of life. Of those infants 14were born during the 5 year control period and 2 during the3 year post implementation period. The decrease from 2.8injuries/year to 0.7 injuries/year represents a 75%reduction (P 03).Altman et al (2010) Parent Education by Maternity Nurses and Prevention of AHT.

Although the frequency of AHT cases decreased, it is notpossible to be absolutely certain that the educationalprogramme was the cause of the decrease. Uncertaintyabout the cause and effect relationship is an inherentlimitation of before/after study design, but the absence ofchanges over time in 3 nearby states without similarprevention programmes lends support to a cause/effectinterpretation Fathers and male surrogates are nearly 5 times as likely asmothers to shake an infant. From the parents surveyedonly 40.4% of fathers watched the educational video.Finding better ways to reach male caretakers should be apriorityAltman et al (2010) Parent Education by Maternity Nurses and Prevention of AHT.

The primary aim of this study was to determine whetherthere was any change in visits of 0 to 5 month old infants tothe Medical Emergency Room (known as the EmergencyDepartment in the UK). After program implementation, crying cases were reducedby 29.5% (p .001). The most significant reductions werefor crying visits in the first to third months of life. The authors concluded that the findings imply thatimproved parental knowledge of the characteristics ofnormal crying secondary to a public health program mayreduce Medical Emergency Room use for cryingcomplaints in the early months of life.Barr R G, Rajabali F, Aragon M; Colbourne M., Brant R., Education About Crying in Normal Infants Is Associated with a Reduction inPediatric Emergency Room Visits for Crying Complaints J Dev Behav Pediatr 36:252–257, 2015

My WCMT report recommends a multi agency co-ordinatedprogramme that touches on all the different levels ofprevention.Each ‘touch point’ is brief & can combine ‘safe sleep’ whilstreinforcing simple messages: Infant crying is normal Comfort methods will sometimes be able to sooth the babyand the crying will stop. it’s OK to walk away when you have checked your baby issafe and if the crying is getting to you. Never ever shake or hurt a baby.

Charlee’sAngels: funded travel for familiesaffected by AHT to an initial consultation event.Hosted private group on social media forconsultation. Families have all commented on allparts of the process and materials. Dynamic partnership with Kim Jones. Established a national steering group initially inRochdale, now transferred to Hampshire. Engaged with Royal College of Paediatrics andChild Health and The University of Birmingham. Presented ICON at a Winston Churchill MemorialTrust conference in March 18.

Impacton numbers of AHT victims – notcompletely reliable as an indicator ofsuccess. Impact on numbers of parents/carersattending Emergency Departments with‘crying baby’ – and no signs of illness. Qualitative measures – parental reports, dothey remember the message, have theyrecalled it/used the materials when theyneeded to etc. FUNDING.

Pause for thought .

ICON – Hampshire’s ExperienceKim Jones: Designated Nurse forSafeguarding ChildrenWest Hampshire Clinical CommissioningGroup

Development of ICONFollowing a recommendation from Child U’s Serious Case Review for a localpreventative campaign, contact was made with Dr Sue SmithA presentation was made to the Hampshire Safeguarding Children Board’s Learningand Inquiry GroupA proposal and presentation for a campaign was made to the HampshireSafeguarding Children Board’s Board meeting in June 2017, which was fullyendorsedA task and finish group was formed

Hampshire’s task and finish group joined the national steeringgroup hosted by Rochdale Clinical Commissioning Group: Hampshire led on the development of ICON materials andcollaborated with parents via Dr Smith and Mae Hampshire’s group sought feedback from children, youngpeople, parents/carers and professionals on the materialsand the messages Hampshire led on a pilot across children’s services, healthand inclusion to gain feedback from parents/carers andprofessionals about the ICON messages and materials.ICON Journey

ICON Journey – PreventionSpecialist – improvedrecognition andreferralTargeted – Socialworkers/paediatriciansPublic HealthMessage to allparents31

Universal Stages of ildrenincludingFixers FilmGP 6 WeekCheckRed BookPre-birthvisits fromHV/FNPandMidwifeHV contactSupported by ICON training, parent leaflet with script forprofessionals, fridge magnets, posters, films, social media campaignsand DadPad App for parents (targeted at males)

Targeted Stages of PreventionChildren’sServices – FamilySupport (EarlyHelp)ParentingSupportInclusion TeamEarly Yearssettings –nurseries andday-careFamily NursePartnership foryoung parents (incertain areas)

Tertiary Stage of ecutionJudiciaryEducation

Next Steps for ICON?Hampshire are the newly appointed national lead for ICONLaunch and promote ICON amongst professionalsWork with Fixers to develop a film for children and young peopleLaunch to the general public utilising ‘Daisy the Bus’Evaluate and publish evidenceEngage with other areas to nationally grow ICON

Teaching Children and Young People aboutAbusive Head TraumaSteve Morton: Teaching and LearningAdviser for Personal DevelopmentLearning

Should ICON be taught in Schools?Teaching children and young people about Abusive HeadTrauma (AHT) raises issues regarding how this sensitivesubject (and, indeed, the whole concept of abuse) ispackaged and delivered so that pupils have a real depth ofunderstanding and an increased knowledge of thepotential harm caused by AHT.

Good schools will have robust policies and programmes for Personal Development.A reflection and perhaps an extension of a school’s commitment to all aspects ofSafeguarding.Preparing children and young people for all aspects of life through a Personal,Social and Health Education programme (PSHE).Taught overtly and is fundamental to whole school ethos.Teaching about AHT: Thewider context

AHT fits in to the category “teaching sensitive subjects” however that coversvirtually all of the PSHE curriculum.It’s a scary subject, so teacher competence and confidence is of paramountimportance.Must not be taught in isolation from the rest of the curriculum.Teaching about AHT

Not taught in isolation .So, how best to approach this subject?The “Fixers” film as an initial stimulus for discussionTeaching about AHT:Joined up thinking

Any teaching about AHT needs to be given in a clear and relevant context. Thisis important life skills information that can sit in several areas of personaldevelopment learning. These could include:Child care skills (looking after infants, parenting and baby sitting)

Rights Respecting Education (UNICEF articles on the rights of the child)Discussions based around factual and fictional narratives about AHT (in the contextof an English lesson)Role play and drama with a focus on AHT

Engagement with Young People – How do wedeliver the ICON message