Prevention of Pediatric Abusive Head Trauma – Time to Rethink Interventions and Reframe Messages
Abusive head trauma (AHT) of infants and young children has considerable morbidity and economic costs.1,2Crying is the most often reported trigger for a caregiver to injure an infant.3 To date, most prevention efforts aimed at decreasing the occurrence of AHT have focused on educating parents about how to manage the challenges of infant crying and the dangers of shaking or hurting an infant.
In this issue of JAMA Pediatrics, Dias and colleagues4 evaluate the effectiveness of a statewide educational intervention to reduce rates of AHT in Pennsylvania, bringing to scale a previous similar intervention that was associated with a regional reduction in rates of AHT in New York State.5 The intervention was provided to parents during the postpartum hospital stay and consisted of a brochure, an educational video on the dangers of shaking an infant (“Portrait of a Promise”), and signing of a commitment statement not to shake the infant. Nearly 1 200 000 families of newborns received this intervention from 2003 to 2013.
Despite these efforts, the incidence of AHT during the intervention was higher than before the intervention and not different than the incidence in 5 other states where universal educational programs about AHT were not available. The absence of a control group in Pennsylvania makes it difficult to determine whether the intervention really was not successful. Perhaps confounders, such as the most recent economic recession, affected the rates of AHT in Pennsylvania and thus substantially minimized the effects of the intervention. Previous studies have clearly shown that the recession did increase the incidence of AHT.6
The results of Dias et al4 are similar to those reported by Zolotor et al,7 who evaluated the effectiveness of a statewide AHT prevention program in North Carolina. In the North Carolina study, the intervention was the “Period of PURPLE Crying,” an educational video to educate parents about the challenges of caring for a crying infant and the dangers of shaking an infant. As in the study by Dias et al,4 the intervention did not result in a decrease in the incidence of AHT compared with the incidence before the intervention was universally available, and no difference in the incidence of AHT was noted compared with that of 5 other states.7
In both studies, however, evidence suggested that the intervention helped some families to understand and cope with infant crying. For example, in the present study, interviews of a small subset of parents demonstrated that almost 75% reported that they thought about the video while the infant was crying. Zolotor et al7 found a 20% reduction in calls to a statewide nurse advice line about crying in infants younger than 3 months.
Why were these interventions unsuccessful at reducing the rates of AHT? First, an educational intervention on the postpartum floor may not be the right kind of intervention. Should clinicians really expect that a brief intervention after the birth of a newborn would have a lasting effect on future parental behavior? Can parents who are tired, frustrated, upset, and even angry at their infant’s crying remember the key point of the video that they watched weeks or months before, and then act on it in the heat of the moment? Infant crying may be even more challenging for parents who already struggle with social isolation, economic insecurity or poverty, intimate partner violence, substance use, and mental health problems.
Shaking as an effective but harmful child rearing practice may be more entrenched than clinicians would like to believe. In a survey of 1435 mothers in North and South Carolina by Theodore et al,8 shaking as a means of discipline occurred in 2.6% of children younger than 2 years. The authors surmised that for every child who sustained a serious injury due to shaking, another 150 children likely were shaken and not detected. In addition, perpetrators of AHT state that shaking stopped the child’s crying; this response likely would not have occurred if the child had been slapped or spanked, so a perpetrator’s behavior may be reinforced by the effectiveness of shaking the infant.3 A reexamination of the relationship between the stimulus (infant crying) and response (parental shaking) and ways to disrupt this relationship, other than telling parents of the dangers of shaking or even how difficult infant crying can be, may be needed.
Second, even if the intervention is an effective one, it may have been unsuccessful because it did not reach the intended audience. In the study by Dias et al,4 nearly half the mothers and fathers surveyed did not see the video, and only 20.5% had seen both the brochure and video. Clearly, the intervention in this study did not reach all potential caregivers. In North Carolina, the intervention successfully reached about 90% of mothers of newborns, but rates of AHT still did not decline.9 Although mothers provide most of the infant care, the most common perpetrators of AHT are fathers, stepfathers, and mothers’ boyfriends.10 At a minimum, both parents need to receive the intervention to determine its effectiveness, and male caregivers may need extra attention.
Should postpartum educational interventions to prevent AHT continue? Rather than abandon these strategies altogether, we, like the authors of this study,4 propose modifying and strengthening the intervention by considering the following additional strategies, which will need to be studied to determine whether they are successful:
Parenting behaviors in response to education have been shown to change in direct proportion to the number of sources of that education. Parents taught about safe sleep practices for infants adopted these practices at rates directly associated with the number of people (eg, pediatricians, nurses, and family members) who advised them about safe sleep practices.11 Providing the same educational intervention in a systematic, sustained, consistent manner about the nature of infant crying and the dangers of shaking from multiple, diverse sources whenever the infant presents for medical care during the first 2 years of life may increase its effectiveness and may help to extend the reach of the intervention to all potential caregivers, including parents and others.
In addition to helping parents understand crying behaviors and teaching parents what to do or what not to do when the infant is crying, an alternative approach would be to teach parents how to focus on their own feelings of frustration and anger and how to manage these feelings. Mindfulness training and reflective parenting may be helpful, so parents can modulate their feelings and remain positively connected to their infants in stressful situations.12 Putting the locus of control with parents to control their own feelings rather than trying to control their infant’s behavior, especially because this period of unexpected, intractable, and inconsolable infant crying is brief and circumscribed, may be another step to reduce the frequency of parental shaking behavior.
Educational interventions to prevent AHT can be combined with other approaches to support parents, such as legislation that increases the reach of paid parental leave. Widespread adoption of paid parental leave in California was associated with a reduction in statewide rates of AHT, even during the most recent economic downturn, when compared with neighboring states.13
Population-level approaches to supporting parents that include home visiting may be a potentially effective way of reducing rates of child maltreatment within a community,14 as opposed to using specific interventions to prevent one type of parental behavior, such as shaking a crying infant. Home visitors can be a potent source of information, support, and mentoring that can be delivered in the home when needed, such as to help parents effectively manage their mounting frustrations about a crying infant.
Finally, any approach, whether discreet or at the community level, aimed at preventing AHT should be delivered in a manner that reaches and actively includes male caregivers. Determining how to reach and engage the fathers and boyfriends will certainly be a challenge.
Almost 30 years ago, Ray Helfer, one of the fathers of child abuse prevention, highlighted the perinatal window of opportunity, the period from conception to 18 to 24 months of age, as a time when parents are open to change and new opportunities for growth.15 The challenge of preventing AHT will be to determine how best to use this window of opportunity. Although considerable progress has been made in understanding the relationship between infant crying and AHT, and although this progress has resulted in the development of thoughtful preventive interventions, these interventions as they have been delivered to date have not reduced the rates of AHT. Clearly, mother-focused, antishaking education in the postpartum period alone is not enough. It is time to enhance and expand on these strategies but not to rely on them alone.
Published Online: January 30, 2017. doi:10.1001/jamapediatrics.2016.4512
Conflict of Interest Disclosures: None reported.