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Babies Cry, You Can Cope The background to ICON Dr Suzanne Smith PhD, MA, BA, RGN, RHV: ICON Founder and Chief Programme Advisor

 AKA Shaken Baby Syndrome  Child Abuse  Catastrophic injuries:

 Brain injuries  Bleeding behind the eyes  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.

 2011 20 – 24 per 100,000 in first year  District General Hospital – paediatrician can

expect to see a case every 1 or 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

• f cases of AHT

 It’s the leading cause of death and long-term

disability for babies who are abused

 Survival with significant brain injury or death  Emotional cost  Inpatient hospitalisation (Paediatric Intensive Care)  Long term medical services –

 Physiotherapy  Occupational Therapy  Speech and Language Therapy

 Educational 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/male

surrogates (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 peak

• f crying and babies subject to AHT. (Barr et al 2006)

 Increase in cases in the 1st month of life, a peak at 6

weeks during the 2nd month and a decrease during the 3rd to 5th months of life

 Success 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

 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.

 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, KS

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 check-up.

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.

 Dose 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.

 Video

Hospital Based Prevention Programmes

 http://childrens.pennstatehealth.org/documents/

11396217/11476368/2016+3rd+Quarter+Newslett er/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.pdf

 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 1st 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.

 Although the frequency of AHT 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

• nly 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.

 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).

 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 Medical Emergency Room 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, 2015

 My WCMT report recommends 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.

 it’s OK to walk away when you have checked your baby is

safe and if the crying is getting to you.

 Never ever shake or hurt a baby.

 Charlee’s Angels: funded travel for families

affected by AHT to an initial consultation event. Hosted private group on social media for

• consultation. Families have all commented on all

parts of the process and materials.

 Dynamic partnership with Kim Jones.  Established a national steering group initially in

Rochdale, now transferred to Hampshire.

 Engaged with Royal College of Paediatrics and

Child Health and The University of Birmingham.

 Presented ICON at a Winston Churchill Memorial

Trust conference in March 18.

 Impact on numbers of AHT victims – not

completely reliable as an indicator of success.

 Impact on numbers of parents/carers

attending Emergency Departments 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..

 FUNDING.

Pause for thought……..

ICON – Hampshire’s Experience Kim Jones: Designated Nurse for Safeguarding Children West Hampshire Clinical Commissioning Group

Development of ICON

Following a recommendation from Child U’s Serious Case Review for a local preventative campaign, contact was made with Dr Sue Smith A presentation was made to the Hampshire Safeguarding Children Board’s Learning and Inquiry Group A proposal and presentation for a campaign was made to the Hampshire Safeguarding Children Board’s Board meeting in June 2017, which was fully endorsed A task and finish group was formed

ICON Journey

Hampshire’s task and finish group joined the national steering group hosted by Rochdale Clinical Commissioning Group:

• Hampshire led on the development of ICON materials and

collaborated with parents via Dr Smith and Mae

• Hampshire’s group sought feedback from children, young

people, parents/carers and professionals on the materials and the messages

• Hampshire led on a pilot across children’s services, health

and inclusion to gain feedback from parents/carers and professionals about the ICON messages and materials.

ICON Journey – Prevention

31

Public Health Message to all parents Targeted – Social workers/paediatricians Specialist – improved recognition and referral

Universal Stages of Prevention

Education for children including Fixers Film Pre-birth visits from HV/FNP and Midwife Postnatal contacts by Midwife Red Book HV ‘New Birth’ contact Midwifery Discharge GP 6 Week Check HV Postnatal contact

Supported by ICON training, parent leaflet with script for professionals, fridge magnets, posters, films, social media campaigns and DadPad App for parents (targeted at males)

Targeted Stages of Prevention

Children’s Services – Family Support (Early Help) Parenting Support Early Years settings – nurseries and day-care Inclusion Team Family Nurse Partnership for young parents (in certain areas)

Tertiary Stage of Prevention

4LSCB Bruising Protocol HSCB Unidentified Adults Supervision for professionals Judiciary Education Supporting Police prosecution

Next Steps for ICON?

Hampshire are the newly appointed national lead for ICON Launch and promote ICON amongst professionals Work with Fixers to develop a film for children and young people Launch to the general public utilising ‘Daisy the Bus’ Evaluate and publish evidence Engage with other areas to nationally grow ICON

Teaching Children and Young People about Abusive Head Trauma Steve Morton: Teaching and Learning Adviser for Personal Development Learning

Teaching children and young people about Abusive Head Trauma (AHT) raises issues regarding how this sensitive subject (and, indeed, the whole concept of abuse) is packaged and delivered so that pupils have a real depth of understanding and an increased knowledge of the potential harm caused by AHT.

Should ICON be taught in Schools?

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 of Safeguarding. 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: The wider context

AHT fits in to the category “teaching sensitive subjects” however that covers virtually all of the PSHE curriculum. . It’s a scary subject, so teacher competence and confidence is of paramount importance. 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 discussion

Teaching about AHT: Joined up thinking…

Any teaching about AHT needs to be given in a clear and relevant context. This is important life skills information that can sit in several areas of personal development 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 context

• f an English lesson)

Role play and drama with a focus on AHT

Engagement with Young People – How do we deliver the ICON message

Because the vast majority of AHT cases result from an inability to cope with a crying infant, it is important that the Emotional health and Wellbeing concept is used to underpin deeper understanding (shaking a baby in anger is a dangerous and inappropriate response to a stressful situation

The importance of Emotional Health and Wellbeing

Although young people of school and college age may not consider themselves ready to be taught about any aspect of parenting it’s important that the ICON message is given a wider context. Consideration needs to be given alongside discussions about healthy and unhealthy relationships including; abusive and controlling relationships, anger management, substance misuse, consent, body awareness and personal space, how to stay safe etc.

The new Department for Education draft statutory guidance for Relationships and Sex Education (published July 2018) Consultation period until 7th November 2018 An ideal opportunity to discuss issues about abusive behaviours in the wider context

• f “teaching about healthy relationships”

Opportunity to influence practice…

Primary Prevention Strategy

Dawn Oliver: Named Midwife Safeguarding Children Hampshire Hospitals NHS Foundation Trust Jayne Condie: Area Manager Health Visiting Team Southern Health NHS Foundation Trust Dr Jenny Rattray: Named GP for Child Safeguarding Fareham and Gosport and South East Hampshire CCG

Midwifery

The Associate Director of Maternity Services has committed to delivering the ICON message to parents and carers from 28 weeks gestation. Following the success of the pilot the programme of intervention as per the previous slide will be embedded within the service.

Getting the message out there…

Maternity staff will be trained to deliver the ICON message to parents and carers. A national script has been produced for maternity professionals to support this conversation which reinforces the key points from the ICON leaflet.

From booking

• Referral sent to HV/FNP following booking by Midwife
• HV's to discuss ICON message at Antenatal contact.
• For FNP clients discuss ICON message during a Pregnancy visit agenda matched with client.
• For those not FNP but on Teenage Pregnancy pathway discuss ICON at second antenatal visit

28-36 weeks

• Discuss normal crying, baby states and management strategies
• Check if ICON leaflet and information has been given and any concerns raised.
• If not , give information and leaflet (refer to ICON training) and include any other adults in the house
• Document discussion in parent held child health records and electronic records

New Birth Contact

• Discuss normal crying, baby states and management strategies
• Check if ICON leaflet and information has been given and address any concerns raised.
• If not , give information and leaflet (refer to ICON training) and include any other adults in the house
• Document discussion in parent held child health records and electronic records

Post natal contact

• Discuss normal crying and management strategies
• Re-iterate ICON message and include any other adults in the house.
• Document discussion in parent held child health record.

Health Visiting

In Hampshire there around 12,000-15,000 babies born each year. Each family will be offered an antenatal contact with a Health Visitor All staff will attend training around discussing the ICON message as part of the antenatal contact. This will be alongside Safe sleep and expectations of being a parent as part of the promotional guide. ICON will be embedded within the programme for first time parents groups - part of the transition to parenthood high impact area Audits will take place to ensure message has been heard by families

Getting the message out there…

All new babies and their mothers have a check up by their GP at 6-8 weeks old. Currently no standardised protocol for the maternal part of this check up. Perinatal mental health affects 1 in 5 women and 1 in 10 men and is underdiagnosed in 50% of cases, according to research. Often new parents are scared to disclose mental health issues and domestic abuse to their GP due to fear their children will be taken away, and will instead wait to be asked Some GPs lacked time or understanding that the postnatal check was more than just a physical exam Improving diagnosis and management of perinatal mental illness is a clinical priority for the Royal College of General Practice

General Practice

Holistic template embedded into GP computer system which encompasses:  Mental health assessment  Domestic abuse screening  Social support assessment  Postnatal health education (to include ICON advice and safer sleeping advice)  Physical health assessment Standardising care across Hampshire GPs now receive training in discussing coping with crying and how to use the template in practice as part of their annual safeguarding training Links within the template to RCGP perinatal mental health toolkit, DadPad and the ICON website for additional support for GPs and parents/carers

Template for the 6-8 week postnatal appointment

Universal Services pilot feedback Parents

33% documented that it was OK to walk away if your baby is in a safe place

22% stated that the key message was never shake your baby

Feel more confident I’m doing a good job

Speak to someone if I am struggling

10% noted that some babies cry more than

• thers.

62% noted that crying in babies is normal / OK

Great advice Take a step back if I feel stressed

Universal Services pilot feedback Professionals

Having the ICON message helped me discuss it in a concise way that mum seemed to respond to

It allowed me to give a really clear explanation I found asking ‘is motherhood everything you thought it would be?’ was a great way to get mum to

• pen up

I liked being able to give it to patients to discuss with

• ther care-givers

so I knew the message would be

passed on

Very useful and clear

I really liked it

Helpful prompts to ask the difficult questions

Secondary Prevention Strategy

Fiona Butt Supervisor Family Nurse Partnership Southern Health NHS Foundation Trust Family Support Service Hampshire County Council Marg Dunne Inclusion Team Leader Services for Young Children Hampshire County Council

The Family Nurse Partnership is a licensed, intensive nurse-led prevention and Early intervention programme for young parents. In Hampshire it is delivered in Gosport and Havant, Basingstoke and Rushmoor. Babies of young parents are particularly vulnerable to abusive head trauma because of less emotional regulation due to the developing Adolescent brain. Maximum 64 visits beginning in early pregnancy until child is at least 1 year.

What is Family Nurse Partnership?

Introduce ICON as part of pregnancy visits alongside safe sleeping advice Use of doll to demonstrate effects of shaking Review in initial and subsequent visits after baby’s birth

Getting the message out there…

Family Support Service – Early Help

How the ICON message is incorporated into Early Help:

• Secondary level of intervention so

support is targeted at Level

• The message is delivered in parenting

groups, aimed at Early Years

• Parents of young children who are

asking for help with crying will be invited to SOS clinic

• Build awareness within CS through

meetings, training opportunities, include ICON in work plans

• Target families and build awareness

through Early Help Hub Multi-agency meeting

• Direct 1:1 work with families with

young children

• Build awareness with partner agencies

– workshops and training

• pportunities

Family Support Service – The ICON pilot

What we did

• Trained staff across 3 districts
• Incorporated into all parenting groups
• Direct 1:1 work with parents of babies, young children, expectant parents
• Information stands at Messy Play and District Day
• Identified families at Early Help Hub meetings

What we found out

• Difficulty in blending the message into a parenting programme
• Poor retention for parenting groups means some parents miss the ICON message

What worked

• 1:1 sessions could be adapted easily to meet the learning needs of some parents
• As a talking point, ICON opened conversations and parents passed this onto others
• Parents love the fridge magnet – it’s a help reminder to take a step back
• Parents engaged with information stands – they came to us to learn more

What happens next

• Choose an appropriate session within parenting programme and focus on Early Years
• Promote direct work. 1:1 sessions with parents
• Increase the range of the message to level 4, nurseries, pre-schools, voluntary agencies

Services for Young Children (SfYC) Inclusion Team

We are a team supporting Early Years children (0 to 4 years) with Special Educational Needs in their homes and in their Nurseries, Preschools and childminder settings Team Leaders shared ICON message with individual district Teams to enable them to cascade the ICON message through their work with parents and practitioners

How will the Inclusion Team share this message?

Ensure our preschools/ nurseries/ childminders prominently display the ICON poster for all parents to see - Suggestions have been to put a leaflet in their welcome pack when a child starts their setting, or to hand a leaflet to a pregnant parent. Ensure Inclusion Team/ practitioners make a point of talking to every parent with a young baby to see “how they are” and discuss coping with crying/ crying patterns for support or signpost to appropriate services if required. Ensure that the ICON message is shared widely to parents with leaflets/ fridge magnets as appropriate.

Secondary Services pilot feedback

ICON was shared with other agencies at multi- agency hub meetings

Information stand worked well which parents engaged with

Choosing the right session for the message to be delivered

1:1 sessions adapted the session to meet the need of the family

Parents who attended group, shared their experiences with other parents

Talking point,

• pened

conversat ions

Pause for thought

Promotional Films

The ICON Message ICON – You Can Cope Self Care Tips for New Parents

Available for you to download on the AHT Online Toolkit!

Fridge Magnet/ leaflet

Poster

www.hampshiresafeguardingchildrenboard.org.uk/toolkits/abusive-head-trauma

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