Abusive Head Trauma: - PowerPoint Presentation

Slide1

Abusive Head Trauma:Mechanisms, Triggers and THE Case for prevention

Dr Suzanne Smith PhD

Assistant Director of Nursing (Safeguarding)

The Pennine Acute Hospitals NHS Trust

January 2017Slide2

COPING WITH CRYING: APPROACHES TO PREVENT ABUSIVE HEAD TRAUMA

Suzanne Smith and Robin

Balbernie

09.15 - 09.30 Registration and refreshments

09.30 – 09.45 Welcome and introduction

09.45 – 10.15 Describing Abusive Head Trauma (AHT) and triggers.

0.15 – 11.15 Breaking Point: Why We Snap.

11.15 – 11.30 BREAK

11.30- 12.00 Impact on children, families and society: the case for prevention

12.00 – 12.15 Designing a prevention campaign

12.15 – 13.00 Bringing over there over here: findings from across the pond.

13.00 – 13.20 A Multi Agency Public Health Approach to Prevention.

13.20 – 13.30 Questions and Close. Slide3

What is AHT?

AKA Shaken Baby Syndrome

Child Abuse

Catastrophic injuries:

intracranial injuries

Retinal haemorrhages

Bony

injuries

Causal mechanism rarely confirmed

Acceleration/deceleration

Impact

1 in 14 cases – fatal before hospital discharge

Half of severely injured survivors die before aged 21.

VIDEOSlide4

Incidence

2000 24.6 per 100,000 in first year

2008 26 per 100,000 in first year

2011 20 – 24 per 100,000 in first year

DGH – paediatrician can expect to see a case every 1 or 2 years.

PAT –

approx

2+ cases in one year (5 in 2 years)

2.6% of American parents admitted to shaking a child under 2 years

9% felt like shaking.

Cases seen by paediatricians – only a proportion of cases of AHT.

It’s the leading cause of death and long-term disability for babies who are

harmedSlide5

WHO SHAKES?

70% perpetrators are males.

Can occur in every socio-economic group.

Kesler

(2008) Both mothers and fathers were often Africa American and fathers more often Hispanic. Mothers more often smoked in pregnancy, sought ante-natal care late and how birth weight babies.

CAUTION: these families are more likely to be reported for AHT (or conversely, families conforming to other demographics are less likely to be reported).

Jenny et al (1999) found that ‘missed’ cases of AHT more frequently involved ‘intact’ and ‘Caucasian’ families Slide6

The effects of Stress

Infant crying

Poor sleeping patterns

Includes reduction in coping ability

Poor parent/child interaction

Reduction in self-esteem

Exhaustion

Frustration and anger Slide7

triggersStress is seen as an especially prominent antecedent in violence towards children.

Background or environmental stressors such as noisy environments and in particular, uncontrollable noise.

A crying baby can be described as uncontrollable and its effects on parents and caregivers can be powerful.

Crossing the line between legitimate and non-legitimate punishment seems to stem from a battle to cope beneath a constellation of stressors leading to frustration and anger.Slide8

Triggers70% of babies shaken are shaken by men

Coping with crying: Living on the edge.

Caregivers lose control and shake – baby stops crying.

Demonstrable relationship between the normal peak of crying and babies subject to AHT.

Increase in cases of 1

st

month of life, a peak at 6 weeks during 2

nd

month and a decrease during the 3

rd

to 5

th

months of life.Slide9

Normal Crying curveSlide10

Cases of AHTSlide11

Coping strategiesSuccess depends on controllability

Problem solving where the stressor cannot be controlled can lead to frustration and distress.

support

through

the problem rather than

solving

the problem

The need for a careful approach towards a responsive professional intervention that is rooted in evidence is, therefore, crucial.Slide12

It’s normal

The literature on the subject of parental coping draws attention to the need for parenting education and support about what

is 'normal’

and the professional response to which should be ‘universal’. The stress of a crying baby, which every parent/caregiver will experience as the increase in infant crying is normal, can impact on parenting ability and can have a potentially negative impact on child welfare.Slide13

Breaking Point: Why We Snap.

Robin

BalbernieSlide14

Break (15 mins

)Slide15

COST

Survival with significant brain injury or death.

Emotional cost.

Inpatient hospitalisation (PICU)

Long term medical services –

Physio

OT

SALT

Educational needs

Foster care

Family and criminal proceedings

Prison/probation

SCR cost

Loss of societal productivity and occupational revenue.Slide16

cost

Peterson et al (2014) assessed 1209 patients with AHT and 5895 matched controls.

Approximately 48% of patients with AHT received inpatient care within 2 days of initial diagnosis, and 25% were treated in emergency departments.

AHT diagnosis was associated with significantly greater medical service use and higher inpatient, outpatient, drug, and total costs for multiple years after the diagnosis.

The estimated total medical cost attributable to AHT in the 4 years after diagnosis was $47 952 per patient with AHT (2012 US dollars).

Children continue to have substantial excess medical costs for years after AHT. These estimates exclude related nonmedical costs such as special education and disability that also are attributable to AHT.Slide17

Case discussion.Charlie’s Story

Troy’s StorySlide18

Winston Churchill memorial trust travel fellowship

Travel to Learn: Return to Inspire

The aim of this Fellowship was to explore international programmes related to the prevention of child maltreatment with a particular focus on AHT in infants and to gain an understanding about the wider context of the delivery of care and the systems and processes in which they are provided and commissioned.Slide19

Programmes visited

SEEK

(Safe Environment for Every Kid) Baltimore, Maryland

Shaken

Baby Syndrome Prevention Programme Hershey, PA

Safe

Babies New York Buffalo, NY

Period

of Purple Crying Vancouver, BC

Period

of Purple Crying and Child Advocacy Centre Helena, MT

Period

of Purple Crying and Family Support Centre Wichita, KSSlide20

100% preventable

No co-ordinated prevention campaign.

NSPCC coping with crying

:

https

://www.nspcc.org.uk/services-and-resources/services-for-children-and-families/coping-with-crying

/

The film is shown to parents by professionals or volunteers who work with babies such as midwives, maternity support workers, health visitors and children’s centre workers.

After

watching the film, parents receive a leaflet with more information

.

Results

from our research show the Coping with Crying programme is helping to keep babies safe. Parents who have seen the film are more likely to react positively towards their baby’s crying and feel confident seeking help and support when needed

.

However, message is ‘Babies cry for a reason – you just have to find it’.Slide21

Public health & prevention

Child abuse is a public health issue.

AHT prevention messages clearly aligned to PH levels of prevention.

Primary

Secondary

Tertiary

Add ‘supportive’ as a level.Slide22

WHERE ARE YOU?Slide23

DESIGN A PREVENTION CAMPAIGN

GROUP WORKSlide24

Some Tools: SEEK (Safe Environment for Every Kid)

A practical evidence-based tool to briefly and systematically screen parents for prevalent psychosocial problems that are risk factors for child maltreatment, and that generally jeopardize children's health, development and safety.

Parental Depression

Parental Substance Abuse

Harsh Punishment

Major Parental Stress

Intimate Partner Violence

Food Insecurity

The SEEK PQ is also:

 Designed to screen for, not diagnose, risk factors for child maltreatment. It is Validated for use in primary care practice and is intended for parents to complete, voluntarily, in advance of their child's regular

checkup

. Slide25

Website

http://theinstitute.umaryland.edu/frames/seek.cfm

http://media.wix.com/ugd/77e10d_7deaa9c956404e16b3a094b19977c657.pdfSlide26

 Dear Parent or Caregiver:

Being a parent is not always easy. We want to help families have a safe environment for kids. So, we’re asking everyone these questions. They are about problems that affect many families. If there’s a problem, we’ll try to help.

Please answer the questions about your child being seen today. If there’s more than one child, please answer “yes” if it applies to any one of them. This is voluntary. You don’t have to answer any question you prefer not to.

 Slide27

PLEASE CHECK□ Yes □ No Do you need the phone number for Poison Control?

□ Yes □ No Do you need a smoke detector for your home?

□ Yes □ No Does anyone smoke tobacco at home?

□ Yes □ No In the last year, did you worry that your food would run out before you got money or Food Stamps to buy more?

□ Yes □ No In the last year, did the food you bought just not last and you didn’t have money to get more?

□ Yes □ No Do you often feel your child is difficult to take care of?

□ Yes □ No Do you sometimes find you need to hit/spank our child? Slide28

□ Yes □ No Do you wish you had more help with your child?

□ Yes □ No Do you often feel under extreme stress?

□ Yes □ No In the past month, have you often felt down, depressed, or hopeless?

□ Yes □ No In the past month, have you felt very little interest or pleasure in things you used to enjoy?

□ Yes □ No In the past year, have you been afraid of your partner?

□ Yes □ No In the past year, have you had a problem with drugs or alcohol?

□ Yes □ No In the past year, have you felt the need to cut back on drinking or drug use?

□ Yes □ No Are there any other problems you’d like help with today?

Please give this form to the doctor or nurse you’re seeing today. Thank you!Slide29

SEEK EVALUATION

SEEK

resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer Child Protective Services reports, fewer instances of possible medical neglect documented as treatment

non-adherence

, fewer children with delayed immunizations, and less harsh punishment reported by parents. Families with prior child welfare involvement were not excluded from the study sample, blending results for primary, secondary, and tertiary prevention (intervention) samples. Slide30
Slide31

PURPLE 3 dosesDose 1: hospitals and birthing centres

Dose 2: strategic reinforcement of the PURPLE message outside of the hospital

Dose 3: increase the opportunity for public awareness of AHT through a ‘positive community norms’ campaign on AHT.

VideoSlide32

Pennsylvania Shaken Baby Syndrome Prevention Program

Hospital Based Prevention Programmes

http://childrens.pennstatehealth.org/documents/11396217/11476368/2016+3rd+Quarter+Newsletter/db2cccdb-90ff-45c0-a917-7169cbf9362f

Safe Babies New York (same model)

http://www.safebabiesny.com/wp-content/uploads/2016/06/20160615053919_Safe-Babies-NY-Brochure-ENGLISH-FINAL-2016-01.pdfSlide33
Slide34

Does prevention work?

A co-ordinated, hospital based parent education programme targeting parents of all newborn infants can significantly reduce the incidence of abusive head trauma in children less that 36 months.

Dias et al (2005) Preventing Abusive Head Trauma Infants and Young Children: a hospital based prevention program

Pediatrics

115: 470 – 477

16 infants who were born in the 8 year study period were treated at the children’s hospital for shaking injuries sustained during their 1

st

year of life. Of those infants 14 were born during the 5 year control period and 2 during the 3 year post implementation period. The decrease from 2.8 injuries/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.Slide35

Does prevention work?

Although the frequency of SBS cases decreased, it is not possible to be absolutely certain that the educational programme was the cause of the decrease. Uncertainty about the cause and effect relationship is an inherent limitation of before/after study design, but the absence of changes over time in 3 nearby states without similar prevention programmes lends support to a cause/effect interpretation.

Fathers and male surrogates are nearly 5 times as likely as mothers to shake an infant. From the parents surveyed only 40.4% of fathers watched the educational video. Finding better ways to reach male caretakers should be a priority.

Altman et al (2010) Parent Education by Maternity Nurses and Prevention of AHT.Slide36

Does prevention work?

The primary aim of this study was to determine whether there was any change in visits of 0- to 5-month old infants to the medical emergency room (known as the Emergency Department in the UK) of a metropolitan paediatric hospital after province-wide implementation of a public health prevention program that teaches new parents about the properties of early crying in normal infants. After program implementation, crying cases were reduced by 29.5% (p < .001). The most significant reductions were for crying visits in the first to third months of life. The authors concluded that the findings imply that improved parental knowledge of the characteristics of normal crying secondary to a public health program may reduce MER use for crying complaints 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 in

Pediatric

Emergency Room Visits for Crying Complaints J Dev

Behav

Pediatr

36:252–257, 2015Slide37

materialsSlide38
Slide39
Slide40
Slide41

Effective intervention and prevention

Recommend a multi agency co-ordinated programme that touches on all the different levels of prevention.

Each ‘touch point’ is brief & can combine ‘safe sleep’ whilst reinforcing simple messages:

Infant

crying is normal

Comfort

methods will sometimes be able to sooth the baby and the crying will stop.

If

the crying is getting to you, it’s OK to walk away when you have checked your baby is safe.

Never

ever shake or hurt a baby.Slide42

How professionals feel about the message

Fears that parents will become angry and feel accused

Fears of upsetting parents just after birth

Evidence – parents welcome education, small number of parents do not.

My research: the subject position that the message will offend is a professional construct.Slide43

Recommended programme

Primary Prevention aligned with GM’s ‘Starting Well’.

School based education.

Hospital based intervention.

Postnatally

by midwife message reminder.

HV birth visit message reminder.

HV team planned visit at 3-4 weeks – Safe Sleep and Coping with Crying focused visit.

GP 6 week check: SEEK questionnaire.

Public health campaign.

Community Educators.

Fatherhood summits/cafes/parent cafes. Slide44

Secondary prevention

Reiteration of messages :

Identified stressors with families who have babies.

Opportunistic intervention by reactive agencies and ensuring messages are passed to caregivers.

Crying baby is already an established problem and families are sending out ‘coping alerts’ (HVs, GPs, EDs, Paediatric staff etc..)

Development of OOH crying baby helpline.

Volunteer/charity based parenting programmes

Contact sessions with babiesSlide45

Tertiary prevention

Improved recognition and referral

Piloting of ‘clinical rules’ to indicate investigations at an earlier stage for babies attending with head injury/neuro symptoms.

Child Advocacy Centre/Family Support Centre provisionSlide46

supportiveHelp for affected families – support groups, advocacy groups, bereavement services.

Peer educators.Slide47

Wrap around Education

All professionals, volunteers, parent groups, peer educators who have contact with families with babies.

Access to brief e-learning and materials.Slide48

Measuring impactImpact on numbers of AHT victims – not completely reliable as an indicator of success.

Impact on numbers of parents/carers attending EDs with ‘crying baby’ – and no signs of illness.

Qualitative measures – parental reports, do they remember the message, have they recalled it/used the materials when they needed to etc..

Look at the evidence base – there is a lot about!Slide49

Next steps

Endorsement/support from LSCBs/Children’s Trusts/partnerships, CCGs, Health and Well-being Boards.

Agree staged roll out of agreed elements of programme.

Identify change makers from each agency and key stakeholder organisations.

Establish a GM, multi agency including parents to co-design the detail of the campaign.

Consider the purchase of PURPLE to lift and shift to UK/consider alternative.

Approach Universities

Produce strategic plan including evaluation strategy and cost benefit analysisSlide50

Role of the social worker?

Infant crying is normal

Comfort methods will sometimes be able to sooth the baby and the crying will stop.

If the crying is getting to you, it’s OK to walk away when you have checked your baby is safe.

Never ever shake or hurt a baby.Slide51