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PARENT EDUCATION PROGRAMME

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29 ‘Coping with Crying’: An innovative new programme to support positive parenting and prevent child abuse
Peter Richards, NSPCC ‘Coping with Crying’ Implementation Manager
With colleagues: Camilla Sanger, Carlos De Sousa and Sally Hogg
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‘Coping with Crying’: An innovative new programme to support positive parenting and prevent child abuse

Peter Richards NSPCC ‘Coping with Crying’ Implementation Manager, and  colleagues Camilla Sanger, Carlos De Sousa, Sally Hogg

Infant crying can be difficult for parents, and in extreme cases, given a combination of other factors, can lead to a parent harming their baby and the baby suffering from a non-accidental head injury (NAHI). There are currently no evidence-based services in the UK for supporting parents in managing infant crying and preventing NAHI. The NSPCC (National Society for the Prevention of Cruelty to Children) has developed a service to fill this gap called ‘Coping with Crying’. ‘Coping with Crying’ is a psycho-educational film that raises awareness about the risks of shaking babies, improves parental understanding about crying and promotes the use of positive coping strategies. The initial evaluation results are promising and the NSPCC is developing an approach for national scale up of the service to ensure that it is available to parents of all new babies.

Research indicates that normal infant development predicts a crying peak between one and two months of age (St James-Roberts, 2012). It is known that up to one in five infants cry for long periods without apparent reason, but that such crying behaviour is linked to normal development and has been found to resolve in the majority of infants by five months of age (Barr et al., 2005; St James-Roberts & Halil, 1991).
The sound of infant crying affects each parent to a different degree, with research suggesting that in some cases, it can have an adverse impact on a parent’s mental state or the quality of their partner relationship (Patrick et al., 2010). A recent evidence synthesis demonstrated that infant crying can also have an effect on the parent-infant relationship (Oldbury & Adams, 2015). This review identified difficulties and delays in parent-infant bonding related to perceived levels of infant crying. Parents expressed feelings of anger, frustration, guilt and shame, often reporting feeling unprepared and that the experience of being a parent had not met their expectations.
Other research outlines parents’ aggressive thoughts and fantasies related to crying, and in extreme circumstances, their aggressive physical behaviour towards the infant such as smothering, smacking or shaking (Patrick et al., 2010). This in turn can induce a non-accidental head injury (NAHI). The relationship between crying and NAHI is further supported when exploring age-specific incidence curves for NAHI, which are found to closely follow that for crying levels in infancy (Lee et al., 2007).
It is estimated that NAHI occurs with an annual incidence in the UK of 24.6 per 100,000 children younger than one year, although these findings are likely to be a significant under-estimate due to the difficulties associated with reporting (Minns & Barlow, 2000).

Age-specific incidence curves for NAHI follow crying levels in infancy

There are a number of risk factors associated with NAHI. One study (Kemp & Coles, 2003) found that in a sample of 62 families with a child who had experienced NAHI, the following factors were present: a history of reported child abuse in a third of families; domestic or criminal violence in two fifths; mental illness, drug or alcohol abuse in two fifths; lower socio-economic status in the majority; and the mothers’ age being lower than the national average. Fathers represented 70% of those who shook the baby. Nonetheless, 30% of cases in the sample had no known social risk factors.

Non-accidental head injury in infants
NAHI can take a number of forms. An infant may be repeatedly shaken with great force, causing the infant’s head to move very rapidly forwards and backwards. This may be combined with impact of the head, either on to a hard or a yielding surface, again using considerable force. The infant may be gripped around the chest or abdomen and the force of the adult’s hands can cause bruising of the skin as well as internal injuries, such as rib fractures. Some infants may be smothered and some may have other injuries such as abrasions or bites, fractures of the arms or legs and evidence of neglect. It is estimated that 85% of children with NAHI also have some other form of injury (Hobbs et al, 2005).
Most often, the immediate consequence of trauma is a sudden change in the infant’s behaviour and wellbeing. Usually this takes the form of loss of consciousness, sometimes with cessation of breathing. The infant may develop seizures and if consciousness is regained, he will be irritable, crying, limp and disinterested in feeding. Some infants are subjected to repeat episodes of abuse and medical attention may not be sought until the infant is in a dangerously unwell state.
NAHI in the form of shaking, or shaking combined with impact, can cause sub-dural bleeding (between the infant’s brain and the skull), brain swelling and retinal bleeding (into the retina of the eyes). The bleeding and brain swelling can only be detected by specialist tests (examination of the eyes with an ophthalmoscope, CT and MRI brain scans and X-rays) carried out in hospital.

30% of NAHI cases have no known social risk factors

Health professionals may be asked to see an infant who has suffered these injuries because of the infant’s crying, refusal to feed, history of collapse, seizures or an episode of cessation of breathing. Those who shook the baby seldom volunteer exactly how the injuries occurred and sometimes misleading information is given, such as an account of a low-level fall or alleged injury by a sibling in play (Hettler & Greenes, 2003). It is important to obtain a detailed account of the infant’s condition leading up to the illness and to examine carefully, including fully undressing the infant, before carrying out specialist tests.
Many infants require urgent treatment, which may include intensive care and neuro-surgery to drain sub-dural blood and so reduce pressure on the brain. Despite the best treatments, around two-thirds are left with permanent brain injuries (Jayawant & Parr, 2007). Because of the relatively high frequency of this type of injury and the high incidence of late effects, NAHI is a leading cause of neurological disability in children in the UK. Permanent injuries include epilepsy, learning difficulties, visual impairments and cerebral palsy.

Why was ‘Coping with Crying’ developed?
In addition to the terrible impact on a child’s life, NAHI presents a significant economic cost to the public sector. It was estimated in 2001 that the cost to the National Health Service (NHS) of infant crying and sleeping problems was £65 million (Morris et al., 2012). In the US, ongoing medical costs can exceed $300,000 (roughly £195,000 at today’s exchange rate) for each child, without taking into account the loss of social productivity or occupational revenue (Dias et al., 2005). A more recent study from New Zealand suggests that the average cost per child, taking into account costs associated with medical treatment, the criminal justice system, education and care, was over NZD1 million (roughly £466,000 at today’s exchange rate) for each child (Friedman et al., 2012). This presents a compelling moral and economic case to prevent these outcomes and focus attention on reducing the incidence rate of NAHI. In spite of this, however, there are no evidence-based NHS services for supporting parents in managing infant crying and preventing NAHI.
As 30% of cases have been found to have no known social risk factors (Kemp & Coles, 2003), it was thought that a targeted approach to reducing NAHI in babies would not reach all families where a baby was at risk. A primary universal approach, on the other hand, would bring the benefits of not overlooking babies where there was no identifiable risk, reducing the likelihood that parents who receive the service might feel stigmatised, and encourage parents and professionals to talk more generally about crying.

The ‘Coping with Crying’ Programme
The ‘Coping with Crying’ programme was inspired by research in the United States which demonstrated that it is possible to reduce the incidence of NAHI through parent education. The NSPCC used this paradigm to develop a powerful psycho-educational film to help parents care for their crying baby and reduce the risk of their becoming stressed and harming their baby. To develop a high-quality film that was acceptable to parents and elicited behaviour change, the NSPCC worked with Warwick Medical School, Great Ormond Street Hospital and a range of other professionals and service users.

‘Coping with Crying’ programme
The programme aims to help parents cope with crying and reduce the risk of abuse by increasing their knowledge so that they are in a position to make an informed choice about their actions. The ten minute film prepares parents for their baby’s crying and includes:
• Testimony from parents about their experiences of looking after a new baby;
• Practical tips and ideas from parents about how to soothe a crying baby;
• Expert advice about infant crying;
• Expert information about the risks of non-accidental head injuries, including an animation about the impact of shaking on a baby’s brain, and
• A case study of a child who was injured through shaking.

The film, which is available in a wide range of languages, is designed to be shown to parents by a qualified professional. This is to ensure it is presented in the right context and so that parent(s) have the opportunity to discuss any concerns, ask questions or have a broader conversation about crying after watching it. It is shown in pregnancy or the first six weeks of life, which is when the messages are most pertinent to parents and in advance of the period of highest risk for babies. It should be shown to fathers or other male carers as well as mothers, since fathers are more likely to inflict NAHI (Kemp & Coles, 2003). The programme provides health services and those working within children’s services with the resources and training to deliver the approach in the most effective and sensitive way.

What has the evaluation shown?
Since 2011, the NSPCC has undertaken a two-phase pilot to assess the impact of showing the film and to understand the most effective mode of delivery. The first pilot was delivered in 24 hospitals and birthing units around the UK, and involved showing the film to parents before they were discharged after the birth of their baby. The second phase (not yet completed) involves assessing the film’s reach and impact beyond delivery in maternity services by showing it in a variety of community settings at different times during the perinatal period.
The mixed method evaluation carried out to date draws on demographic data collected from more than 30,000 parents who have seen the film, focus group data from parents and a comparative study of the effects on parents’ attitudes, knowledge and behaviour (Coster, 2014; Coster et al., 2014; Hogg & Coster, 2014).

Qualitative data
Ten focus groups were held in four different areas with a random selection of 40 parents (34 mums and 6 dads) who had taken part in the programme and consented to be contacted. The focus groups took place between four and six months after the parents had seen the film and were held in various NSPCC service centres and one hospital. Participants were given a £10 voucher for taking part. They were asked to reflect on their responses to watching the film, their experience of being a new parent and the strategies they used to cope with stress and crying (Coster, 2014).
Analyses of the focus group data indicate that parents remember seeing the film and were able to relate to the practical information it provided. They were particularly moved by the case-study aspect of the film, which tells the story of a baby who dies as a result of being shaken. Parents reported that watching the film was more powerful than receiving a leaflet with the same information. While some parents were upset by the difficult story, they could see its value and felt that it was justified because of the reality of the risk.

 ‘At the time I was thinking, that’ll never be me … but because I’d watched it, I was able to think back to it, to think ‘keep your cool … don’t do anything’. (Mother)
(Hogg & Coster, 2014)

Parents said that their knowledge about their babies’ vulnerability had improved and that they knew more about how to protect them after watching the film. The film also helped parents understand that it is normal for babies to cry and reduced feelings of failure that they might have otherwise felt about their parenting.

‘It [the film] went into the theory about what this [shaking a baby] can do, and this played on my mind, especially when it’s like four or five in the morning, and you’ve got a lack of sleep and the baby’s just screaming in your ear, and I can remember going, ‘Don’t shake him, don’t shake him’. That’s just something that stayed in my mind, anyway.’ (Dad)
(Hogg & Coster, 2014)

They also recalled and talked about a number of the coping strategies that the film suggests, including keeping their voice calm, seeking help from their family or a friend if they needed it, and giving themselves permission to take five minutes out to calm down away from the baby, if they felt stressed. These strategies provided parents with a sense of control and enhanced their sense of responsibility.

 ‘I thought about the DVD a few times. I thought, ‘You know what, every parent goes through this. It’s not just me,’ and that makes a big difference, to know you’re not the only
one.’ (Mother)
(Hogg & Coster, 2014)

The findings suggest that showing the film to parents helps build their confidence to care for their infant, reduces stress and builds their parenting capacity, thereby reducing the risk of NAHI.

‘Any person, no matter how intelligent you are, no matter how stable you are, there can come a time when your baby is just driving you nuts, and it’s about recognising that and maybe when that happens to go, ‘Well, do you know I remember watching that DVD, I’m just going to walk out this room.’
(Practitioner comment -  Unpublished)

Quantitative data
A telephone survey with over 1500 participants provided quantitative data from two groups: parents who had taken part in the programme and a random sample of parents who had not. The survey was designed to measure the impact of the film across a range of outcomes related to parents’ attitudes, knowledge and behaviour associated with their baby’s crying. The results and analysis provide evidence that the programme has a small - as expected in a universal intervention (Burig, 2002) - but significant positive impact on some of
these outcomes:

• 99% of parents who took part in the programme remembered watching the film.
• 82% of parents reported that they used at least one of the tips suggested by the film to calm their baby, which increased for the group of parents identified as ‘vulnerable’.
• Parents who had viewed the film were more likely to agree with the statements, ‘You shouldn’t handle your baby roughly’ and ‘It’s OK to leave your baby for a few minutes when you are stressed and finding it hard to cope’.
• Both groups reported equally low levels of how often they shouted at or were rough with their baby, although the self-reporting of this measure is likely to be low due to the social unacceptability of such behaviour.

The methodology, full set of results and findings have been published (Coster et al., 2014).

What are the future plans for ‘Coping with Crying’?
The NSPCC is nearing the end of the second phase of the ‘Coping with Crying’ pilot, which assesses its reach and impact across a variety of community settings at different times during the perinatal period. In this phase, the programme is being delivered by midwives, health visitors and children’s centre staff to parents in groups at a clinic or community centre or individually at home. The findings from both phases of the pilot will inform plans for the national roll-out of the programme across the UK, which will begin in early 2016.
The service will be made available to relevant health, children’s and social care organisations who wish to deliver the film in their area. All materials required to implement and deliver the service will be made available through an online hub. This will include the film itself, a training package, implementation guidance (including recommendations for best practice delivery models) and access to promotional resources.

Acknowledgement
Thanks to Denise Coster, who leads on the evaluation of ‘Coping with Crying’.


 

REFERENCES
Barr, R.G., Paterson, J., MacMartin, L., Lehtonen I., Young S. (2005) Prolonged and unsoothable crying bouts in infants with and without colic. Developmental & Behavioral Pediatrics, 26, 14-22.
Burig, J.E. (2002) Special issues related to randomized trials of primary prevention. Epidemiologic Reviews, 24, 67-71.
Coster, D. (2014) Evaluation of the Preventing Non-accidental Head Injuries Programme: Focus groups with parents report. London, NSPCC.
Coster, D., Bryson, C., Purdon S. (2014) Evaluation of the Preventing Non-Accidental Head Injuries Programme: Impact report. London, NSPCC.
Dias, M.S., Smith, K., Mazur, P., Li, V. Shaffer, M. L. (2005) Preventing abusive head trauma among infants and young children: A hospital-based, parent education program. Pediatrics, 115(4),470-477.
Friedman, M.S., Reed, P., Sharplin, P., Kelly, P. (2012) Primary prevention of paediatric abusive head trauma: A cost audit and cost-utility analysis. Child Abuse and Neglect, 36, 760-770.
Frasier, L.D., Kelly, P., Al-Eissa, M., Otterman, G.J. (2014) International issues in abusive head trauma. Paediatric Radiology, 44(4),647-53.
Hettler, J., Greenes, D.S. (2003) Can the initial history predict whether a child with a head injury has been abused? Pediatrics, 111(3),602-7.
Hobbs, C., Childs, A.M., Wynne, J., Livingston, J., Seal, A. (2005) Subdural haematoma and effusion in infancy: An epidemiological study. Archives of Disease in Childhood, 90(9), 952-5.
Hogg. S., Coster, D., (2014) Helping Parents Cope With Babies’ Crying: Evidence from a pilot programme to support parents and keep babies safe. London, NSPCC.
Jayawant, S., Parr, J. (2007) Outcome following subdural haemorrhages in infancy. Archive of Diseases in Childhood, 92(4),343-7.
Kemp, A., Coles, L. (2003) The Role of Health Professionals in Preventing Non-Accidental Head Injury. Child Abuse Review, 12,374-383.
Lee. C., Barr. R.G., Catherine. N. (2007) Age-related incidence of publicly-reported shaken baby syndrome cases: Is crying a trigger for shaking? Journal of Developmental and Behavioral Pediatrics, 28,288-93.
Minns., R., Barlow K. (2000) Annual incidence of shaken impact syndrome in young children. The Lancet, 356,1571–1572.
Morris, S., St James-Roberts, I., Sleep, J., Gillham, P. (2001) Economic evaluation of strategies for managing crying and sleeping problems. Archives of Disease in Childhood, 84(1),15-19.
Oldbury, S,. Adams, K. (2015) The impact of infant crying on the parent-infant relationship. Community Practitioner, 88(3),29-34.
Patrick, S., Garcia, A., Griffin L. (2010) The Role of Family Therapy in Mediating Adverse Effects of Excessive and Inconsolable Neonatal Crying on the Family System. Families, Systems, & Health, 28(1),19-29.
St James-Roberts, I., Halil, T. (1991) Infant crying patterns in the first year: Normal community and clinical findings. Journal of Child Psychology & Psychiatry, 32,951-968.
St James-Roberts, I. (2012) The Origins, Prevention and Treatment of Infant Crying and Sleeping Problems: An evidence-based guide for healthcare professionals and the families they support. London, Routledge.

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