Now, let's talk about the prevention of abusive head trauma and really all forms of child maltreatment. It begins with the basics, strengthening families by reducing risk. The planners, presenters, and content reviewers of this course disclose no conflict of interest. To receive continuing nursing education contact hours for this activity, you will need to attend the entire activity and complete the course evaluation at the end. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. For the next hour or so, we will discuss interventions to prevent child maltreatment and describe strategies that target the prevention of abusive head trauma. Risk factors for abusive head trauma and other forms of child maltreatment have been previously discussed. To prevent abusive head trauma and really all forms of child maltreatment, pediatric health care must intervene to strengthen families and support parents. Universal interventions exist designed for all parents and families, while other interventions are targeted at addressing specific risk factors present in some families. We will discuss both universal and targeted interventions designed to strengthen parents and prevent child maltreatment, including abusive head trauma. Positive parenting is an example of a universal child maltreatment prevention strategy targeted at all parents, regardless of risk. Positive parenting is defined as the continual relationship of a parent and a child that includes caring, teaching, leading, communicating, and providing for the needs of the child. Research has indicated that positive parenting results in long-term positive effects on the cognitive and behavioral development of children. All pediatric health care providers, including pediatric forensic nurses, must be knowledgeable regarding positive parenting. It is crucial that we consistently educate parents about positive parenting techniques, model positive parenting in our interactions with children and parents, and encourage parents to use positive parenting while discouraging the use of harsh discipline. Take a look at the core positive parenting practices. Having a safe and engaging environment, creating a positive learning environment, using effective discipline, which is not harsh physical or verbal discipline, having realistic expectations of the child's behavior, and taking care of oneself as a parent. Forensic nursing and nursing in general offers many opportunities to coach parents regarding positive parenting. Think of the ensuring a safe and engaging environment simply in the course of a sexual assault exam with a young child. It's not unusual for the forensic nurse to remind the parent to stand close to the table to ensure the safety of the child on the exam table. It's also important for parents to have realistic developmental expectations of the behavior of a child. Consider parental frustration with the two-year-old sibling in the exam room during the sexual abuse exam, and the two-year-old just cannot sit still. The parent is maybe yelling at the child or threatening to smack the child, and the forensic nurse intervenes and just points out, this is normal two-year-old behavior. When you're two, you can't sit still for more than two minutes. This is nothing to worry about or be upset about. Pediatric forensic nurses must consistently encourage effective discipline, non-physical methods of discipline. Harsh discipline, both physical and emotional, has been linked to a variety of negative consequences for children. The greatest of which is experiencing physical abuse at the hands of a caregiver. It is not unusual for parents to have developmentally unrealistic expectations of children, even infants. Parents expect a baby to stop crying if fed or held, or giving a pacifier or their diaper changed. When this does not happen, the parent becomes frustrated, and this can become a setup for abusive head trauma. The idea of accepting and using harsh discipline with children can begin in infancy. The majority of physical abuse that I saw in my practice involved a stressed parent with unrealistic developmental expectations of the child and using harsh discipline. Let's take a look at effective discipline. Effective discipline involves developmentally appropriate expectations of the child's behavior. The parent needs to select ground rules for specific situations. The rules need to be discussed with children in words that they can understand. There needs to be consistent reinforcement of the rules. Development of nonphysical methods of discipline should begin in infancy and continue through adolescence. Discourage emotionally abusive discipline. Discourage corporal punishment. Harsh physical and emotional discipline is not effective. While it may result in short-term compliance, no lasting behavioral change develops. Children are not learning the morals and values that parents are attempting to teach. We as forensic nurses need to encourage nonphysical methods of discipline. We've all heard about the Adverse Childhood Experiences Study by Folletti and Company in 1998. The Adverse Childhood Experiences Study is the landmark study that solidified knowledge that childhood experiences such as child maltreatment, household domestic violence, household substance abuse, parental separation and divorce, and criminal household member negatively impacts adult health behaviors and adult health in a dose-related gradient. In 2017, Athe and Company analyzed wave two of the Adverse Childhood Experience Study, which included spanking, which is arguably the most normative form of corporal punishment. What they found was that spanking was associated with similar outcomes to other adverse childhood experiences, especially physical and emotional abuse. Athe and Company concluded that spanking should be considered an adverse childhood experience. The No-Hit Zone is another example of a universal intervention targeted at the prevention of child maltreatment. The No-Hit Zone is a program to address the use of harsh physical discipline in hospitals and other places where children receive care. The No-Hit Zone originated at Rainbow Babies and Children Hospital in Cleveland, Ohio, to address staff concern regarding witnessing parents hit their children or use other harsh discipline at the hospital and staff not feeling empowered to intervene. The No-Hit Zone recognizes that harsh discipline, both physical and verbal, is a source of toxic stress for children and that the staff should intervene when witnessing such harsh punishment. This harsh punishment is also upsetting within a hospital or clinic or other setting to other patients, visitors, and parents. The No-Hit Zone has been implemented by several children's hospitals, clinics, homeless shelters, churches, and other institutions, and they are for the most part willing to share their experiences and material. There's also a website. I have it listed there on the slide. Take a look and you will see that there is assistance in implementing a No-Hit Zone in your institution. This website contains a toolkit for implementing a No-Hit Zone that contains sample policies, training resources such as videos, sample presentations to educate staff, and educational material for both staff and parents, and then also materials and signage to use throughout your institution. So check out that website. No-Hit Zones consist of staff education regarding the negative consequences of harsh discipline, their responsibility to intervene, and how best to intervene. No-Hit Zones also include signage throughout the institution. See an example of digital signage from Nationwide Children's Hospital. The goals of the No-Hit Zone are very straightforward. Reduction in the frequency of harsh discipline in the institution, improving staff comfort, competence, and accountability in intervening when witnessing harsh discipline, elevating the standard of care by promoting positive parenting concepts, and creating a comfort and environment of comfort and safety for all, all patients, family, visitors, and staff. Let's face it. No one wakes up in the morning and says, okay, today I'm going to shake my baby. Almost universally, abusive head trauma and other forms of physical abuse result from a stressed caregiver at wit's end, losing it and shaking, hitting, throwing, or using other forms of physical violence on their infant or child due to their frustration. It is crucial that we as pediatric forensic nurses have an idea of the psychosocial stresses that the families we work with are enduring. It is vital to screen for psychosocial risk factors. Risk factors for abusive head trauma and child maltreatment were discussed earlier. Screening should be universal. You cannot tell by looking at an individual the stressors that they may be enduring. Research indicates that electronic screening may be more effective than face-to-face screening. It's important to only screen for risk factors for which effective community resources are available for you to provide the caregiver. It can take some time to find appropriate community resources. Children's hospitals, child advocacy centers, child protective service, and United Way may be helpful in assisting to identify community resources. The presence of psychosocial risk factors within a family does not necessitate a referral to child protective services unless those risk factors raise concerns for the child's safety. Since the pediatric forensic nurse will not be providing ongoing care to the patient, there may be times when the child's primary care provider may need to be informed of the identified risk factor and intervention provided so that the primary care provider can follow up to ensure that the caregiver follows through and the child is indeed safe. The next three slides are some examples of evidence-based screening tools to screen for familial psychosocial risk factors. The screening tool that I am most familiar with, because we used it in our child advocacy center in our emergency department, is that of SEEK, Safe Environment for Every Child, developed by Dr. Howard Dubowitz, a child abuse pediatrician at the University of Maryland. SEEK has a website, so I would suggest that you check out the website, and you will see that there's a SEEK parent questionnaire. That's a questionnaire that we used in our CAC and emergency department, which consists of 16 yes or no questions that screens for parental depression, parental substance abuse, major parental stress, intimate personal violence, food insecurity, and harsh punishment. The SEEK parent questionnaire is available in English, Spanish, Italian, Chinese, Portuguese, and Nepali. There are also parent handouts on the website, and there is also SEEK training that can be provided, and you can receive continuing medical education credits for completing the training. Here are some additional psychosocial screening tools. These are all evidence-based as well. And finally, another two evidence-based psychosocial screening tools. Another universal intervention for the prevention of abusive head trauma and other forms of child maltreatment is that of anticipatory guidance. Crying is the number one risk factor for abusive head trauma. It is imperative that pediatric forensic nurses and all pediatric health care providers talk to parents about crying and other frustrating developmental stages that can push a stressed frustrated parent over the edge, resulting in abusive head trauma or other forms of physical or emotional abuse. We need to acknowledge crying and talk to parents about crying. It is important that they understand that infant crying is worse in the first few months of life, but that it will get better as the child grows, that they can try calming a crying baby by gently rocking the baby, swaddling them in a blanket, offering a pacifier or holding the baby against their skin, singing or talking softly or taking a walk with a stroller or going for a drive in the car. If the baby won't stop crying, the parent should check for signs of illness and call the doctor if they think the baby is sick. The parent needs to know if they are getting upset. Focus on calming themselves down. Put the baby in a safe place and walk away to calm down. Check on the baby every five to ten minutes. Call a friend, relative or neighbor or your child's health care provider for support. And parents need to be educated to never leave their baby alone with a person who is easily irritated, has a temper or a history of violence. The period of purple crying is an educational effort to prevent abusive head trauma by educating parents about crying. It is a universal intervention. The period of purple crying education consists of a booklet, a ten-minute purple crying video and 17-minute video that shows, that talks about infant crying, ways to soothe the baby, ways for parents to cope with the crying and just talking to parents about what comes naturally when a baby is crying. The purple, the letters in purple stand for P, peak of crying. Parents need to be educated in the period of purple crying educates parents that your baby may cry more each week, the most in month two, than less in months three and five. U, parents are educated that crying can be unexpected. Crying can come and go and you won't know why. R, babies can resist soothing. Your baby may not stop crying no matter what the parent tries. P, a crying baby may look like they are in pain even when they are not. L, crying can be long lasting. Babies can cry as much as five hours a day or more. E, evening, babies may cry more in the late afternoon and evening. And the word period means that the crying has a beginning and an end. And I would urge you to take a look at the website for the National Center on Shaking Baby Syndrome. This is a United States organization. There's a great video by Dr. Ronald Barr who's a developmental pediatrician and has been instrumental in the development of the period of purple crying program and also the study of the program, the effectiveness of the program. And then also I would urge you to check out this website regarding British Columbia in Canada. They have a wonderful program, a very universal program within that providence of educating parents of newborns regarding the period of purple crying. And now let's talk about a couple of studies that have evaluated the effectiveness of the period of purple crying. In the Grossberg study, medical students and pediatric interns rotating through a newborn nursery were taught to give parents of newborns at the maternity hospital education regarding the period of purple crying. And also standard discharge instructions that discussed infant crying. Parents were divided into two groups, either they got the period of purple crying education or the standard discharge instructions education. Parents were contacted at five weeks post birth and queried regarding their knowledge related to the infant's crying and their frustration with it. And what they found, what Grossberg and company found was that the period of purple crying improved caregiver knowledge of crying, however, it did not appear to affect caregiver frustration with crying. I've also included the link to the article there. And then there were two studies done in Canada regarding British Columbia. British Columbia Institute instituted a providence wide robust educational program of the period of purple crying for all parents of newborns delivered in British Columbia hospitals in 2009. A three dose educational program of period of purple crying was administered to parents. The maternity hospital nurse discussed crying and shaking while delivering a booklet and DVD during the maternity admission. And then the second dose involved a public health nurse who reinforced the period of purple crying talking points by phone or an in home visit post discharge. And the third dose of treatment was the annual community education. And now consider the difference in dosages of treatment regarding period of purple crying between the American study and the study by Barr that I'm going to discuss in just a couple of minutes. The American dose was one dose. The Canadian dose involved three doses over a period of a year of education regarding the period of purple crying. So Barr and company in 2018 explored whether the British Columbia experience of implementing a providence wide period of purple crying educational campaign reduced abusive head trauma hospitalization rates. They looked at infants born between 2009 and 2016. There were about 355,000 infants born. The period of purple crying reduced abusive head trauma hospitalizations. Look for children aged less than 12 months. You'll see abusive head trauma hospitalizations reduced from 10.6 to 7.1 per 100,000 to after the educational intervention 6.7 to 4.4 per 100,000 live births. And then look for children less than 24 months. There was a 35% reduction in infant abusive head trauma admissions noted in children less than 24 months. And then Bellew and company in 2019 examined the economic cost of abusive head trauma and the savings to society and healthcare as a result of the period of purple crying educational campaign. So between 2002 and 2014, there were 64 abusive head trauma admissions in British Columbia. The period of purple crying costs about $5 per infant. And look at the cost to society. Look at the cost there to society as a result of the 64 abusive head trauma events. The cost to society was $354 million. The cost of each fatal abusive head trauma was over $7 million. The cost for each severe abusive head trauma was $6 million. And least severe abusive head trauma costs over a million and a half dollars. Significant cost to society. So okay, the period of purple crying costs about $5 per infant. And by decreasing abusive head trauma admissions by 35%, this resulted in an improvement in child safety and health. And also avoided significant costs to society in the tune of $12 million savings to society by implementing the period of purple crying education. Home visitation programs and parenting education programs are more targeted interventions to prevent abusive head trauma and other forms of child maltreatment. Typically families with identified risk factors are linked with home visitation programs and parenting education programs. What are programs with proven efficacy in the prevention of child maltreatment and abusive head trauma? Look at the home visitation programs. The two programs that I am most familiar with are the nurse family partnership where nurses are trained in a it's a national model. They actually went to Denver, Colorado for the training. So they are educated in the standardized model. They're linked with a woman, a pregnant female with some sort of risk factors. A lot of nurse family partnership and help me grow were used in our child advocacy center. The nurses in nurse family partnership at our child advocacy center were linked with a lot of teen moms. They were linked during pregnancy and stayed involved with the family until age two. Help me grow, again, it has proven efficacy. Social workers are linked with a pregnant female and follow the female and her baby to age two. But all of those home visitation programs have proven efficacy in the prevention of child maltreatment. Parenting education programs, there are a couple that have proven efficacy in prevention of child maltreatment. Triple P positive parenting program. See that positive parenting again? It's multi-tiered interventions based on identified needs ranging from universal, which target all parents with positive parenting messages, to tier five, very targeted for children with serious behavioral concerns and parents with their own issues. And then ACTS, parents raising safe kids, which was developed by the American Psychological Association, consists of eight two-hour sessions, again, promoting positive parenting, helping parents understand child behavior and have realistic developmental expectations of behavior, and discipline dealing with anger and resolving family conflicts. Forensic nurses possess the knowledge and skill to be a driving force behind healthcare and societal changes that promote the prevention of abusive head trauma and all forms of child maltreatment. Enrich the implementation of universal period of purple crying education in all maternity hospitals. Consistently screen families for psychosocial risk factors that increase caregiver stress and risk of perpetrating abusive head trauma. Link them with evidence-based community resources to address identified concerns and communicate with primary care providers regarding identified risks. Advocate for improved access to evidence-based home visitation programs, parenting programs, and early childhood education. Be a voice at the practice level as well as the local, state, and national levels, discouraging parental use of corporal punishment and encouraging positive parenting. We as forensic nurses can make a difference for vulnerable infants. Here are a list of references used for this presentation. A complete list is available upon request. If you have any questions, please email me at ghornor at ifn.org. That's G-H-O-R-N-O-R at I-A-F-N dot org.

prevention of abusive head trauma

child maltreatment

strengthening families

continuing education for healthcare providers

positive parenting

universal and targeted interventions

pediatric forensic nurses