Advocacy Day(s)

We have a new administration, of course, but we also have a new Congress, with much to consider.

The economic stimulus legislation is at the top of the list. Eventually, bills which didn't make it through the last Congress will be reintroduced and the process towards passage begins anew.

The Education Begins at Home Act (home visiting support), the MOTHERS Act (postpartum depression) and the SBS Prevention Act will again work their way towards passage.

And there's also legislation for a bi-annual Children's Conference to reconsider (the bill formerly known as S.2771)...

Thoughts of synergy float through my head.

For example, in the last Congress, 45 Senators supported one or more of those bills (S.667-32; S.1375-11; S.1204-9). Although several have left the Senate (not necessarily in a bad way: Senators Obama, Biden, Clinton, Salazar are among the departed), most remain.

First thought: if the legislative sponsors and the advocacy community coordinated a request for cosponsors, perhaps including a briefing for the staff of new members, there's no reason why all three bills shouldn't achieve the same level of support.

Second thought: the Association of Maternal Child Health Programs meets in DC February 21-24, and the CWLA's annual congressional advocacy day is February 24.

Lots of planned activities, to be sure, but perhaps opportunity to squeeze in a breakfast or late afternoon activity that also briefs these constituencies on three very relevant bills.

Third thought: put both together. Talk once to both groups: then instead of individual advocacy visits, staffers can learn more about relevant activities in their states, and children/health staffers from different Senate offices can meet, mingle and enhance working relationships.

S.667: A bill to expand programs of early childhood home visitation that increase school readiness, child abuse and neglect prevention, and early identification of developmental and health delays, including potential mental health concerns, and for other purposes.
Sponsor: Sen Bond, Christopher S. [MO] (introduced 2/16/2007) Cosponsors (32)

Sen Bayh, Evan [IN] - 3/28/2007
Sen Biden, Joseph R., Jr. [DE] - 7/18/2007
Sen Bingaman, Jeff [NM] - 3/20/2007
Sen Brown, Sherrod [OH] - 10/1/2007
Sen Cantwell, Maria [WA] - 5/15/2007
Sen Cardin, Benjamin L. [MD] - 3/20/2007
Sen Casey, Robert P., Jr. [PA] - 5/8/2007
Sen Clinton, Hillary Rodham [NY] - 2/16/2007
Sen Coleman, Norm [MN] - 9/10/2007
Sen Collins, Susan M. [ME] - 3/15/2007
Sen Durbin, Richard [IL] - 4/10/2007
Sen Harkin, Tom [IA] - 4/23/2007
Sen Kerry, John F. [MA] - 3/7/2007
Sen Landrieu, Mary L. [LA] - 11/13/2007
Sen Lautenberg, Frank R. [NJ] - 4/10/2007
Sen Levin, Carl [MI] - 4/21/2008
Sen Lieberman, Joseph I. [CT] - 9/20/2007
Sen Lincoln, Blanche L. [AR] - 5/15/2007
Sen McCaskill, Claire [MO] - 3/14/2007
Sen Menendez, Robert [NJ] - 6/7/2007
Sen Mikulski, Barbara A. [MD] - 10/31/2007
Sen Murray, Patty [WA] - 9/17/2007
Sen Obama, Barack [IL] - 11/1/2007
Sen Reed, Jack [RI] - 10/2/2007
Sen Roberts, Pat [KS] - 3/6/2007
Sen Rockefeller, John D., IV [WV] - 3/14/2007
Sen Salazar, Ken [CO] - 7/19/2007
Sen Smith, Gordon H. [OR] - 3/29/2007
Sen Snowe, Olympia J. [ME] - 4/17/2007
Sen Stabenow, Debbie [MI] - 6/11/2007
Sen Whitehouse, Sheldon [RI] - 6/7/2007
Sen Wyden, Ron [OR] - 6/23/2008

S.1375: A bill to ensure that new mothers and their families are educated about postpartum depression, screened for symptoms, and provided with essential services, and to increase research at the National Institutes of Health on postpartum depression.
Sponsor: Sen Menendez, Robert [NJ] (introduced 5/11/2007) Cosponsors (11)

Sen Boxer, Barbara [CA] - 7/24/2007
Sen Brown, Sherrod [OH] - 5/11/2007
Sen Clinton, Hillary Rodham [NY] - 2/25/2008
Sen Dodd, Christopher J. [CT] - 5/11/2007
Sen Durbin, Richard [IL] - 5/11/2007
Sen Inouye, Daniel K. [HI] - 9/10/2008
Sen Lautenberg, Frank R. [NJ] - 5/11/2007
Sen Obama, Barack [IL] - 10/23/2007
Sen Sanders, Bernard [VT] - 6/13/2007
Sen Snowe, Olympia J. [ME] - 5/11/2007
Sen Whitehouse, Sheldon [RI] - 5/25/2007

S.1204: A bill to enhance Federal efforts focused on public awareness and education about the risks and dangers associated with Shaken Baby Syndrome.
Sponsor: Sen Dodd, Christopher J. [CT] (introduced 4/25/2007) Cosponsors (9)

Sen Bayh, Evan [IN] - 6/3/2008
Sen Boxer, Barbara [CA] - 7/24/2007
Sen Brown, Sherrod [OH] - 5/1/2007
Sen Casey, Robert P., Jr. [PA] - 12/7/2007
Sen Cochran, Thad [MS] - 5/11/2007
Sen Johnson, Tim [SD] - 1/22/2008
Sen Lautenberg, Frank R. [NJ] - 9/10/2007
Sen Lugar, Richard G. [IN] - 7/29/2008
Sen Schumer, Charles E. [NY] - 6/27/2007

S.2771: A bill to require the president to call a White House Conference on Children and Youth in 2010.
Sponsor: Sen Landrieu, Mary L. [LA] (introduced 3/13/2008) Cosponsors (15)

Sen Bayh, Evan [IN] - 3/13/2008
Sen Brown, Sherrod [OH] - 5/19/2008
Sen Burr, Richard [NC] - 7/8/2008
Sen Cardin, Benjamin L. [MD] - 4/7/2008
Sen Casey, Robert P., Jr. [PA] - 3/13/2008
Sen Clinton, Hillary Rodham [NY] - 4/15/2008
Sen Dodd, Christopher J. [CT] - 3/13/2008
Sen Hagel, Chuck [NE] - 3/13/2008
Sen Johnson, Tim [SD] - 3/13/2008
Sen Kerry, John F. [MA] - 3/13/2008
Sen Lugar, Richard G. [IN] - 4/2/2008
Sen Obama, Barack [IL] - 4/15/2008
Sen Smith, Gordon H. [OR] - 6/23/2008
Sen Snowe, Olympia J. [ME] - 3/13/2008
Sen Whitehouse, Sheldon [RI] - 3/13/2008

Good News: Parenting Program Reduces Abuse

A Medscape article (requires free registration) reports encouraging results from a trial of the "Positive Parenting Program" in South Carolina:

January 29, 2009 — When parents have broad access to a widely promoted positive parenting program, key measures of child maltreatment drop significantly, a population-based study shows.

The study is published online January 22 in Prevention Science (article).

The US Triple P (Positive Parenting Program) System Population Trial found lower rates of confirmed child abuse, foster-care placements, and hospital visits for child injuries in 9 counties in South Carolina where a multilevel parenting support system — the Triple P — was implemented compared with 9 counties providing usual services.

The evidence-based parenting program, developed by study coinvestigator Matthew R. Sanders, PhD, from the University of Queensland, in Brisbane, Australia, is designed to provide parents with skills to deal with newborns to 12-year-old children. It offers different levels of parental support to match a family's needs. The current study focused on child-maltreatment outcomes in children younger than 8 years.

Researchers estimate that implementation of the Triple P system would translate into 688 fewer cases of child maltreatment, 240 fewer out-of-home placements, and 60 fewer children with injuries requiring hospitalization or emergency-department treatment for every 100,000 children younger than 8 years on an annual basis.

"This is the first large-scale study to show that by providing all families, not just families in crisis, with access to parenting information and support, we can reduce the rates of child maltreatment in whole communities," lead author Ronald J. Prinz, PhD, from the University of South Carolina, in Columbia, said in a statement.

Resources:

Triple P - http://www.triplep.net/
Triple P America - http://www.triplep-america.com/
South Carolina Triple P - http://tpinfo.sc.edu/
SAMHSA National Registry of Evidence-Based Programs and Practices http://www.nrepp.samhsa.gov/programfulldetails.asp?PROGRAM_ID=218
CWLA (positive parenting tips/resources) - http://www.cwla.org/positiveparenting/

Opportunity 7: Radio PSAs

Simple Public Service Announcements are available (National SBS Coalition here; Kiwanis here; DOD offers a video PSA here)

Ask your local radio station to incorporate some into their public service mix.

If you're really ambitious, work with the stations in your listening area to do a "radio block."

The Shaken Baby Association did one in Wisconsin: this article describes how.

Radio Stations Shake up Listeners with Shaken-baby Spot

For 50 seconds on more than 240 Wisconsin radio stations listeners heard the screams of a crying baby on Tuesday morning, April 7. It was part of a radio road block to raise awareness and raise funds for the Shaken Baby Association, an organization that works to prevent, detect and treat shaken baby syndrome.
Gary Mueller, creative director for Serve Marketing, which specializes in providing advertising, marketing and counsel services to underserved charitable organizations said, “You can’t escape it, much as you can’t escape taking care of a baby that’s inconsolable.” Mueller did the voice-over for the spot: “No matter how much she cries, no matter how tired you are, no matter how frustrated you get – never, ever shake a baby.”

Adding Injury to Insult: the Long Tail of Mild TBI

The Washington Post reports on a study in Brain (January 28) that looked at the long term effects of concussions in athletes (the study evaluated individuals who suffered a concussion in college, not infants, so extrapolate the effect of "mild" pediatric TBI with care - see the study by Anderson, also in Brain, which found that children who sustained early brain insults before age 2 years recorded global and significant cognitive deficits, while children with later EBI performed closer to normal expectations, suggesting a linear association between age at insult and outcome).

It's a long tail.

It is surprising that long term studies haven't been done before: one more indication that there is much to learn about "mild" TBI.

Concussion's Effects May Linger for Decades

WEDNESDAY, Jan. 28 (HealthDay News) -- Athletes who suffer a concussion can experience a decline in their mental and physical processes more than 30 years later, according to a Canadian study that's the first to identify these kinds of long-term effects.

The researchers examined 40 healthy, former university-level athletes between the ages of 50 and 60.  Of those, 19 had suffered a concussion more than 30 years ago, and 21 had no history of concussion.

Compared to those who were concussion-free, the participants who'd been concussed only once or twice in their early adulthood showed declines in attention and memory, as well as a slowing of some types of movement.

Most research focuses on the immediate, post-concussion period and on deciding when it's safe for a concussed athlete to return to play. The long-term effects of concussion tend to be overlooked.

AANS - Facts about concussion.

CDC - Facts for Physicians about Mild TBI

Report to Congress on Mild TBI (2003)

GAO - Report on Mild TBI Screening for Veterans (2008)

Resource: Trustline.Org and Child Care

California has a good tool for parents who want to screen child care providers - Trustline.org

What is TrustLine?

TrustLine is California's registry of in-home child care providers, tutors and in-home counselors who have passed a background screening. It was created by the California Legislature in 1987 and is a powerful resource for parents hiring a nanny or baby-sitter. All caregivers listed with TrustLine have been cleared through a fingerprint check of records at the California Department of Justice. This means they have no disqualifying criminal convictions or substantiated child abuse reports in California. TrustLine is administered by the California Department of Social Services and the non-profit Child Care Resource and Referral Network. It is endorsed by the California Academy of Pediatrics.

However, you still need to ensure that anyone who cares for your child is aware of the vulnerability of young children to shaking and inflicted head injuries, and has a coping plan for those inevitable moments of frustration and anger.

Ask them to make that commitment and let them know it's OK to call you.

Radio Interview: Bonnie Armstrong, Shaken Baby Alliance

An interesting interview with Bonnie Armstrong, executive director of the Shaken Baby Alliance.

An interview with Ms. Bonnie Armstrong, Exec Dir and Co-Founder of The Shaken Baby Alliance. The Shaken Baby Alliance is dedicated to support for victim families and professionals, prevention of Shaken Baby Syndrome, and justice for the innocent victims. (1 hour)

And downloadable onto your MP3 player or iPod...what could be more convenient?

The interview was done about this time last year, but it remains well worth a listen!

Lessons: Issue Marketing and the March of Dimes

The Issue Marketing website has a very interesting article on how March of Dimes has developed a low cost online advocacy/marketing program.

...The March of Dimes' Affiliate Program launched in January 2006. As the affiliate manager in charge of the program, Bair creates and posts banners to the My Affiliate Program website — with occasional suggestions and support from a staff of six at KowaBunga! who are assigned to the March of Dimes account.

Approved Affiliates then download the banners and post them on their own websites. Banners typically focus on upcoming events, such as WalkAmerica or Prematurity Awareness Month, which are refreshed once an event passes or pregnancy issues, encouraging women to seek prenatal care before and during pregnancy.

Internet surfers who click on the banners are taken to a landing page on March of Dimes' website that includes a call-to-action, such as: signing-up for an event, making a donation, signing a petition, or writing to Congress to support legislative change.

As a well-known charity with a popular cause, many Affiliates have been willing to help the March of Dimes, even without compensation. In the first 11 months of the Affiliate Program, 550 website publishers applied to be Affiliates and 70% were approved (sites involving activities not aligned with the mission of the Foundation, like gambling, pornography or smoking, were declined).

KowaBunga! promotes the March of Dimes to its Affiliate Network: Bair also actively recruits websites that cover complementary topic areas, such as pregnancy and parenting...

Results: eleven months into its Affiliate Program, the March of Dimes' 400 Affiliates had already donated more than 40 million banner ad impressions.  Says Jeffery Bair, "Our initial approach has been to use our Affiliate Program to help create awareness of March of Dimes' key issues, including how to prevent birth defects, premature birth and low birthweight."

Good news: SBS Prevention Legislation - IA, CT, NJ, MT

So far, January has brought four legislative initiatives for Shaken Baby Syndrome prevention: bills in Connecticut, New Jersey and Iowa, and a bill drafting request in Montana.

NJ:  Assemblymen Greenwald, Fisher and Munoz have introduced a bill (A725) to require hospitals to offer parents educational materials about SBS and have someone discuss SBS with new parents before they leave the hospital.

CT:  Representative Mushinsky has introduced a bill (HB 5165), cosponsored by Rep. Rojas,  that would require that high school and middle school students have an opportunity to learn about SBS

IA:  A bill (House File 65) has been introduced by Representatives Smith, Heaton and Miller to require hospital based SBS education.   Interestingly, Iowa provides lobbyist declarations: of note, the Iowa Medical Society supports this bill.

MT: A bill is being drafted (LC 2012) at the request of State Senator Laslovich to require SBS education.

Opportunity 6: Talk to a New Parent

Over the last couple of days, there has been discussion on a pediatric listserv about the consuming feelings of frustration, depression and hopelessness experienced by some parents of autistic children. Add to that, the understandable frustration of searching for a cure...

Something very similar happens with new parents.

A 2003 study by Mayo Clinic researchers found that 69 per cent of mothers and 58 per cent of fathers reported having unwanted "obsessional thoughts" about their newborn child, including suffocation or SIDS, accidents, intentional harm, losing the infant, illness, unacceptable sexual thoughts and risk of contamination from other people or objects.

A 2008 study in Canada supports those findings, concluding

High parenting stress and low social support predicted the occurrence of thoughts of intentional harm. Little evidence of an association between these thoughts and aggressive parenting was found. Unwanted intrusive thoughts of harming one’s infant are a relatively normative experience during the early postpartum period, particularly in association with greater parenting stress and low social support.

Of note, the Mayo study reported new fathers were as likely as mothers to worry about their baby dying from sudden infant death syndrome, suffocating, or being hurt in accidents - and as likely to think about intentionally harming their child.

Education is needed: a 2008 study found that nearly one-third of U.S. parents had "a surprisingly low-level knowledge of typical infant development and unrealistic expectations for their child's physical, social and emotional growth." 

And this Australian study concluded that "fathers, at the time of the birth, have needs in regard to their ability to cope with the stresses of new parenthood and the skills and knowledge to care for their new baby."   It also includes some interesting references to research on anxiety and postpartum disorders experienced by fathers.

So, one thing you can do is talk frankly and openly to a new parent.  

Share this information, and if you are a parent, share your experience.  Especially the toughest moments and the "unwanted" thoughts. 

It's important that new parents understand that those feelings of frustration and anger are normal, so they know that it's OK to talk about it.

And don't forget to talk about postpartum depression and mood disorders.   

Postpartum disorders are more common, and advice from healthcare professionals is less common, than you might think.

Good News Friday: New York's Got A New Mom as Senator...

Kirsten Gillibrand (1) is a recent mother; (2) had been our Representative in Congress; and (3) is Governor Paterson's pick to replace Hillary Clinton as New York's junior Senator (she has other qualifications, of course, as the New York Times discusses...)

She cosponsored the SBS Prevention Act (HR 2052) in the last Congress, and we expected that she would do so again when Representative Nita Lowey reintroduces in this Congress.

She and Representative Herseth Sandlin shared the honor of (1) becoming mothers during the 110th Congress and (2) consponsoring HR 2052 in that Congress.

So, we're sad to see her leave the House, but welcome her to the Senate.

She will have an opportunity to join Senator Schumer, New York's senior Senator, as a cosponsor of the SBS Prevention Act when it is reintroduced by Senator Dodd. Senator Schumer has been a longstanding supporter of SBS education...

We hope she'll also join as a cosponsor of two other bills that are good for young children and their families: the MOTHERS Act and the Education Begins at Home Act, both of which were recently introduced in the 111th Congress.

Opportunity 5: SBS Training for social service programs

Typically, county government includes a department of social services (DSS) that is responsible for providing foster care and funding child care for TANF recipients who need it to return to work.

Ask the DSS Commissioner to incorporate an hour of training about the vulnerability of young children, SBS, and coping skills. Equally important, ask that the trainers also teach these caregivers how to educate other caregivers.

If the complaint is that it will cost too much, let them know that it will cost a lot more to treat one SBS case. And remind them that there are savings: the county will be saving its share of the costs Medicaid would have paid to treat one child.

Not to mention lawsuits....it cost NYC's Administration for Children's Services, the agency that manages NYC's foster care program, $1 million to settle a $500 million lawsuit brought by the Cochran Law Firm on behalf of Antonia Phillips, a child who suffered inflicted injuries while in the ACS foster care program. The case continued until 2007, so New York's taxpayers undoubtedly paid some significant legal expenses as well.

Opportunity 4: Shareholder Resolutions and Safer Babies

"Socially responsible investing" is trying to do good for a lot of environmental causes.

For a good example of how business can respond to the challenge, see this article about Baxter Healthcare and its CEO, Harry Kraemer.

It would be a good thing  if the SRI movement was trying to do as much to encourage businesses to support their employees who are parents or caring for young children, and to support child abuse prevention efforts in their communities.

Googling didn't find one counterpart of SRI activitists working to prevent child abuse.  That's surprising, because it's obvious that preventing abuse is not just something that's good for parents and children: it's good for the bottom line.

Each year, the direct consequences of child abuse cost federal and state taxpayers over $110 billion.  That's about 1% of GNP, and it includes federal, state and local government tax dollars being spent on investigating and prosecuting child abuse, incarcerating the prepetrators and treating the survivors for the immediate costs of medical and rehabilitation services.

If that's not enough, add the cost of lost consumers: according to the Council on Economic Development, an average American would earn roughly $600,000 over a lifetime, and pay about $200,000 in taxes to federal, and local governments. 

So, assume that each of the 1400 children who don't survive abuse each year and the tens of thousands who do survive with physical and mental disabilities would have contributed $400,000 from their earnings to the economy and paid $200,000 in taxes to governments.

Divide that sum by a company's share of sales and that's lost sales.

Still not enough?  Add the collateral damage: increased costs of health and education services for survivors of inflicted injuries; reduced productivity and socially constructive behaviors as a consequence of abuse and neglect.  Add the cost of criminal justice and penal services that follow survivors of abuse and neglect.

When a corporation earns $1,000,000, it writes a check for $10,000 in taxes to pay for the direct costs of abuse and neglect.  In that case, the costs to shareholders are obvious.

However, the costs are not nearly as obvious when a corporation doesn't earn those dollars in the first place.  

And they're certainly not obvious or clear when a child doesn't grow up to become a customer, an employee or  an executive.  Or when the folks who make up its work force suffer the social consequences of inflicted injuries or cope with those who do.

So there's plenty of reason for socially responsible investors to insist that corporations do more to support parents and caregivers.

Mac Bledsoe pointed out an important truth: preventing child abuse is not just about telling someone what not to do.  It's necessary, but not sufficient.  

They need the opportunity to learn what to do.

So, anyone in the SRI community willing take up the challenge?

Email your nominations.

Profiles in Education: University Hospital of New Mexico

The University Hospital of New Mexico has not only implemented a hospital based prevention program, but created a simple set of webpages that profiles their prevention program for new parents.

It's interesting to see that (1) they hope to expand it to all 52 NM hospitals and (2) they will be adding materials in Vietnamese and Navajho this year.

Tony Hillerman would be proud...

UNM Hospitals
Shaken Baby Syndrome: Prevention & Awareness Program
Our Program

The University Hospital has a parent educational program to prevent infant head trauma. This program duplicates the educational part of an educational/epidemiological study conduced by Dr. Mark Dias. From 1998 to 2004, Mark Dias, MD, FAAP and colleagues implemented a hospital-based parent educational program in upstate New York to teach new parents about the dangers of infant shaking. This study reduced the incidence of SBS by 47% in New York State.

Our Objectives

Our objectives of this educational program are to:

Establish an Abusive Head Trauma Prevention Program at University Hospital as a "standard of care.
Provide educational materials about SBS to the parents of newborn infants.
Assess parents' comprehension of the dangers of violent infant shaking at 7 months via telephone follow-up
Track effectiveness of the program through the collection of returned commitment statements (CS)
Evaluate the program's affect on the regional incidence of Shaken Baby Syndrome (SBS).
This study introduces the SBS prevention program to the University Hospital and will be administered to all parents of newborn infants prior to discharge from the hospital.

Opportunity 3: Support School Education Projects

3. Education about Shaken Baby Syndrome in schools doesn't only reach future parents.

And it doesn't only reach teen parents who are still in school.

It is also an opportunity to educate babysitters about the vulnerability of young children to shaking injuries and the need to be prepared with a coping plan for the inevitable moments of frustration.

So, contact the Family and Consumer Science or Health educators at your local high school and middle schools. Offer to buy them one of the many educational DVDs available from the National Center on Shaken Baby Syndrome, the Shaken Baby Alliance or the Midwest Children's Resource Center.

Coordinate that effort with the local educators who teach babysitter classes. Ask what they teach their classes about SBS, SIDS and other safety and injury prevention topics (for example, how many teenage babysitters are aware that giving honey to infants puts them at risk for botulism - and that about 1,000 children a year are estimated to suffer a reaction)

There are some good syllabuses for school education on line, and the New York State Education Department should be working on a curriculum as we speak. Similar legislation has been pending in Illinois, and was just introduced in Connecticut last week.

Opportunity 2: Educate a child care provider

It's estimated that more than 8 million children under age 5 are in child care for all or part of the week, and the AAP reminds us that children age 5 and younger are vulnerable to SBS and inflicted injuries.

Ask your child care provider if she or he is aware of the danger of shaking a young child (not just babies and infants).

Ask if they received training on coping skills for infants and toddlers.

Ask them what their coping plan is to deal with moments of frustration.

Ask who they will call in those moments: you, or a trusted friend, to vent that frustration.

Give them permission to call you in those moments. Let them know you think that would be the hallmark of a responsible child care provider.

On Martin Luther King Day, What Better Way...

to celebrate a life, and a call to service, than a challenge to list, in the course of the next year, 365 opportunities for education and awareness that can help parents and caregivers to prevent injury.

I hope to add, on average, one opportunity a day, or seven a week, or thirty a month. Average allows for spurts and stops.

So, let's start with the obvious:

1. Ask your local maternity hospital if they offer new parents an opportunity to learn how they can help protect their child from inflicted head injuries (or ask a new parent). If not, offer the administration and the lead nurse on the maternity service the JCAHO newsletter article that explains how an effective hospital education program can reduce the incidence of inflicted head injury by nearly 50%.

There Are No Words...

...for some things.

When there should be, but aren't, it tells us something.

Jeffrey Zaslow observed that we have words that describe the natural order of things, but not the aberrations that disturb that order. So, in the normal course of life, when death comes upon a family, those who live on become widows, widowers or orphans.

However, he noted, there is no word for one who has lost a child.

Similarly, while abnormal is the absence of normal, no word readily comes to mind as the opposite of abuse, especially when it's used in the context of children.

To be abnormal is not to be normal, to be absent is not to be present, but what is it not to abuse?

Good parenting - or good caregiving - is not defined by the absence of abuse.

Any suggestions?

Big Ideas for Children: the economy of investing in children

First Focus offered Big Ideas for Children: essays by a wide range of policy advocates on ways we can invest in children (to download or request a copy, visit here).

It's a rich stew of proposals, including one by James Heckman, who won the Nobel Prize for economics. It's encouraging that a number of the proposals recognize the difference between just spending money (more money is the means to do more stuff) and investing (creating policies, tools and institutions to identify and exploit new means to achieve goals).

Investing in early childhood is an economy: it hits the "tipping point" early and provides maximum leverage for scarce resources. It's an investment that offers compounded "interest" for children, parents and society.

Big Ideas: highly recommended reading...

Other Resources

Ounce of Prevention: Invest in the Very Young

Partnership for America's Economic Success - especially the Partnership's West Coast Forum (2008) (includes a keynote presentation by Michael Millken)

Committee on Economic Development (2006): Building the Economic Case for Investments in Preschool (links to proceedings of the 2006 Conference)

American Federation of Teachers (2007): The Case for Early Investment in Our Kids

The Birth to Five Alliance

Other Perspectives

PCAA http://preventchildabuseamerica.blogspot.com/2008/09/americas-leading-thinkers-propose.html on Big Ideas.

The Brookings Institute blogged on child care initiatives

The New America Foundation's Early Ed Watch blog has a very interesting post on the economic analysis offered by Heckman and Federal Reserve economists Arthur Rolnick and Rob Grunewald.

Slate (2007): Teach The Children Well

Thanks for First Focus for putting together an illustrious crew of visionaries to look at our national policies on children's health and well-being.

Albany Times Union: Preparing New Fathers

Today's Albany Times Union has served up a pretty good story about new fathers (Google discovered it on the San Antonio Express "Moms" website).

While issue can be taken with the claim that there's no evidence suggesting men are more likely to abuse children than women, I did like the tone of the article and the suggestion that after the standard remedies are tried, it becomes an experiment to find a solution that works (obviously not while the rage motor is running).

(Curiously, it doesn't appear to have run in the Times Union, although it discusses the SBS education program at St. Peters).

By Michael Lisi - Albany Times Union
ALBANY, N.Y. — There are many things that put fear into the hearts of first-time dads.

A crying baby who won't stop crying easily tops that list.

A colicky baby is chaos defined for a new dad, especially young dads with little or no experience with children. And it's hard to know what to do next. Should you rock the baby? Feed the baby? Change him?

When nothing works, what then?

Mix that confusion with a lack of sleep, and it's easy for bleary-eyed dads to start feeling frustrated with their little bundles of joy.

For some dads, that frustration can turn to rage.

While there is no evidence that men are any more likely than women to commit child abuse, a widely cited study from 2006 found that men (as many as 1 in 10), like women, can suffer postpartum depression. This can lead to withdrawal from the family and baby, and even to irritability and aggression.

“One of the problems for men is that often they don't have as much direct child-care experience (as women), and when put in that situation, they don't know how to deal with it,” said Dr. Rudy Nydegger, chief of psychology at a New York hospital. “There's panic, frustration, a whole range of emotions and feelings. Sometimes they get angry and lose control.”

“It's usually a time of frustration when a baby has been crying and the parents can't calm it down,” said Dr. Lisa Kamerling, a pediatrician. “They're exhausted and worried because they don't know why the baby is crying.”

That flash of rage could prove fatal to an infant if he or she is shaken or thrown. The blood vessels attached to a baby's brain and skull can become dislodged when a baby is shaken, potentially causing brain damage and permanent disabilities.

“Even a little bit of shaking can harm a baby,” said Kamerling.

Fortunately, there are many ways for new dads and moms to deflate the frustration and head off the potential of injury to an uncooperative baby.

At St. Peter's and other hospitals across New York, the first step starts before parents and baby leave. New parents are shown a video that details infant abuse and what to expect when they get home. Parents also get parenting pamphlets and are counseled by nurses, said Jon Sorensen, public relations manager for St. Peter's.

Sometimes, that isn't enough to ease a new dad who's at wits' end with a colicky baby. He's thinking of only one thing: stopping the baby from crying.

Taking a step-by-step approach is the best way to deal with the situation, Nydegger and Kamerling recommend.

Some steps are obvious: Check to see if the baby needs a new diaper, is hungry or needs to be burped. Check to see if the baby has hurt him-or herself, is too hot or too cold.

A lot of crying — sometimes up to three hours a day — is normal for some babies, Kamerling said. Of course, if something seems out of the ordinary, it's always best to let a pediatrician make that determination.

Once you've made the initial checks, it's time to get creative....

Quick resources on perpetrator characteristics

Shaken baby syndrome in Canada: clinical characteristics and ...
Shaken baby syndrome is an extremely serious form of abusive head trauma, the extent of which is .... Overall, the perpetrator was male in 72% of the cases;
www.pubmedcentral.nih.gov/articlerender.fcgi?artid=140423

Shaken Baby Syndrome: Diagnosis and Treatment
victim found that male perpetrators outnumbered ...... as a small body size, large head-to-body ratio (ie, the head. is approximately 25% of body weight),
www.radiologictechnology.org/cgi/reprint/80/2/151.pdf

Prevent SBS British Columbia - SBS - Shaken Baby Syndrome
This outnumbers females by a 2.2 to 1 ratio (Starling et al 1995). The four largest groups of SBS perpetrators are: • biological fathers 37% - 47%
www.dontshake.ca/information/information.php?id=38&type=4

[PPT] Nevada Shaken Baby Syndrome Prevention
Feb 15, 2008 Who ARE The Perpetrators? No Social or Economic boundaries
www.snahec.org/pcanv/info/materials/SBS%20presentation%20for%20PCA%20NV.ppt

Sometimes, you just have to ask...

In 2005, the Surgeon-General held a workshop on preventing child maltreatment.

The proceedings are available here, and there was lots of discussion by lots of interesting people about new ways to prevent child abuse.

One of the most compelling points (at least for me) came during a talk by Sharon Ramey, a researcher at Georgetown University. She described the unintentional consequence of a simple research tool on parental behavior:

Dr. Ramey explained how new technologies are allowing researchers to study child maltreatment. For example, in one study, cell phones were used as tools to find out where mothers and babies were and what their interactions were. This observational study found that mothers of all ages and income levels liked to use the cell phones and they relayed information to researchers. A quarter of the participants thought this was an intervention (it was not). It caused mothers to notice things about their children, and mothers said it made them become better mothers.

As with the Hawthorne experiment, a little interest goes a long way.

Not only is it good to talk about the positive things, but sharing bad experiences is probably a good way to reduce stress and frustration about those experiences.

I also wonder if there was a bit of the "guardian" effect that was discussed in research by Julia Wrigley on SBS events in child care centers and home care settings.

Another key observation about prevention education:

The study also detected urgent conditions reflecting the most common cause of neglect-neglect due to ignorance. In four cities, it commonly was found that not everyone knew about health, safety, or cognition.

Television programs are being used to help promote positive parenting. Dr. Ramey commented on a national public television series funded by a foundation and based on books authored by Dr. Ramey and her husband. Often the didactic educational approach is not the best way to provide information. Literacy is an issue, and new ways must be found to disseminate information about evidence-based practices.

It's only four years ago, but I wonder what Dr. Ramey would say today about using social marketing concepts into prevention.

An Enduring Tragedy

Brian Deyo was a SBS "survivor."

He died at age 21. His death was the result of injuries caused when he was shaken by his mother. He was two and a half months old then.

This article from the Argus Times in Vermont provides a window into the enduring tragedy of a child who survived inflicted head trauma.

His grandparents hope that his story will bring greater awareness. We can share that hope.

Parenting: Teaching Manners

An interesting article by Perri Klass, a pediatrician, in today's NY Times. He adds Miss Manners to the list of parenting experts:

But the age-old parental job remains.

And that job is to start with a being who has no thought for the feelings of others, no code of behavior beyond its own needs and comforts — and, guided by love and duty, to do your best to transform that being into what your grandmother (or Socrates) might call a mensch. To use a term that has fallen out of favor, your assignment is to “civilize” the object of your affections.

My favorite child-rearing book is “Miss Manners’ Guide to Rearing Perfect Children,” by Judith Martin, who takes the view that manners are at the heart of the whole parental enterprise. I called her to ask why.

“Every infant is born adorable but selfish and the center of the universe,” she replied. It’s a parent’s job to teach that “there are other people, and other people have feelings.”

Not an easy job under the best of circumstances. For those who are not gifted with teaching skills or a teacher's disposition, it's easily twice the challenge to do well by child and parent when bringing a child into civilization's embrace.

When the job is done well, the fabric of our society grows stronger.

Not to mention that parent-child conflicts are reduced.

One more tools that parents can use - if they think about it...

New Jersey - Good (but not as good as it could be) News about Hospital Education

Newsday reports the New Jersey legislature will consider legislation on Thursday (Jan. 15, 2009) that includes distribution of "literature" to new parents about SBS before they leave the hospital.

Good news that they're taking that step, but as long as New Jersey is going to ask hospitals to deliver information, why not do it effectively and efficiently?

A recent study reported that video education is more effective, overall (and see more resources listed at the bottom of this page).

Moreover, if the legislature is seeking to adddress inequities, it would be ironic to rely upon written literature, which has to overcome the problems of lower rates of general literacy and health literacy, language barriers and culturally competent communications (the proposed NJ legislation would also require that someone at the hospital discuss the information with parents before the baby is discharged: that's good - if it happens).

Hospitals in New York, such as Vassar Brothers Medical Center, have included SBS education as a routine part of patient discharge - after the parents have had the opportunity to watch an educational video. The video provides a standard message and illustrates behavior in ways that a brochure can't do.

Shaken baby education is an opportunity to educate parents about how they can help protect their child. But add those barriers to the overall problem of framing messages to avoid the "child abuse" stigma, and the likelihood is that written education will likely perpetuate those inequities.

NJ Assembly takes up inequities in prenatal care
By ANGELA DELLI SANTI | Associated Press Writer
January 11, 2009

TRENTON, N.J. - Assemblywoman Sheila Oliver wants to see more young, pregnant minority women get the prenatal care they need.

Backed by a state Department of Health and Senior Services study highlighting serious disparities among the quality of care for women with unplanned pregnancies, Oliver, D-East Orange, is planning a Thursday hearing on ways to improve the inequities.

"New Jersey is too good to rank near the bottom when it comes to the state of health care for expectant mothers and their children," said Oliver, who chairs the Assembly Human Services Committee.  Health and Senior Services Commissioner Heather Howard is slated to talk about the state's prenatal care awareness campaign during the hearing.

Also slated to be on tap during Thursday's Assembly session are two bills arming caretakers with information that protects children.

Legislation sponsored by Democrats Nelson Albano and Matthew Milam of Cape May Court House, and Ruben Ramos Jr. of Hoboken protects children from tip-over accidents involving furniture and television sets.

Another bill likely to be up for consideration Thursday requires information on shaken baby syndrome to be delivered to parents of newborns.

That legislation, sponsored by Democrats Lou Greenwald of Voorhees, and Doug Fisher of Bridgeton, requires literature on the topic to be distributed in the resource guide on child abuse that is given to new parents. It also requires someone at the hospital or birthing center to discuss the information before discharge.

Resources

Child Abuse Negl. 2008 Oct;32(10):949-57.
Intervention type matters in primary prevention of abusive head injury: event history analysis results.
Russell BS

MCN Am J Matern Child Nurs. 2008 Nov-Dec;33(6):371-5.
Shaken baby syndrome education program: nurses making a difference
Smith KM

W V Med J. 2008 Nov-Dec;104(6):22-3.
Testing educational strategies for Shaken Baby Syndrome.
Bailey M

J Dev Behav Pediatr. 2008 Dec;29(6):508-11
Getting the word out: advice on crying and colic in popular parenting magazines.
Catherine NL

Child Abuse Negl. 2008 Nov;32(11):1017-25.
Secondary analysis of the "Love Me...Never Shake Me" SBS education program.
Deyo G

A Joint Vision for Home Visiting

Five programs* that have developed nationally-recognized home visiting programs have expressed their shared vision for home visiting services.

It's encouraging to see their shared vision includes collaboration on advocacy:

Prevention services in general are underfunded and a low priority on our nation’s domestic policy agenda. The complexity and volume of need among families and young children in this nation far exceeds the capacity of any one of our programs. Therefore, we will work together to advocate for a greater investment in effective prevention programs for children and families.

Home visitation is a service delivery strategy that is essential to better support our country’s youngest children. We are unified in our view that building relationships with parents and children in their home environments is a uniquely valuable approach to nurturing parental competence and successful early childhood development. Together, we intend to make this type of service delivery practice more broadly accepted and a welcome and trusted approach in family development.

Helping society understand the value - the return on the social investment - created when these opportunities are available to new parents is essential to making the "resource pie" larger for all of these programs. It's even more important in these difficult economic times...

Resources

* Healthy Families America, Home Instruction for Parents of Preschool Youngsters, Nurse-Family Partnership, Parents as Teachers, and The Parent-Child Home Program

RAND - The Economics of Early Childhood Policy: What the Dismal Science Has to Say
The fundamental insight of economics when comparing early childhood policies with other social investments is that a growing body of program evaluations ...
www.rand.org/pubs/occasional_papers/2008/RAND_OP227.pdf

National Home Visiting Services Shared Vision Statement
http://www.parentsasteachers.org/atf/cf/{00812ECA-A71B-4C2C-8FF3-8F16A5742EEA}/HV%20Shared%20Vision%20Statement.pdf

A Curriculum on Social Investment and Human Resources
http://salises.uwimona.edu.jm:1104/sa63f/Course%20Outline_63F.pdf

Heckman (Science, 2006) Skills Formation and the Economics of Investing in Disadvantaged Children
http://www.brainwave.org.nz/wp-content/uploads/2007/03/valuing_prevention.pdf

Minneapolis Federal Reserve Bank (2003)- "The Economics of Early Childhood Development: Lessons for Economic Policy"
http://www.minneapolisfed.org/publications_papers/pub_display.cfm?id=3351

RAND find Parents as Teachers Promising Practice

Courtesy of the MCH Listserv, which publishes a useful weekly alert

RAND'S Promising Practices Network Features Parent Education Program

The Parents as Teachers (PAT) program provides parents with child development information and parenting support.

RAND's Promising Practice Network (PPN) on Children, Families and Communities recently recognized it as a "program that works." PAT is a four-part intervention model in which trained and certified parent educators offer support to children and their families from pregnancy until the child is 5 years old.

Program services include home visits; child health, hearing, vision, anddevelopmental screenings; parent group meetings; and a resource network that links families with needed community resources. Studies have shown that PAT has proven effects on the number of infants born weighing 5.5 lbs or more as well as on young children's cognitive and physical development.

The PPN Web site contains a program overview as well as information on program
participants, evaluation methods, key evaluation findings, probable implementers, funding, implementation detail, and issues to consider.

Example sites, contact information, a list of resources, and a bibliography are also available at http://www.promisingpractices.net/program.asp?programid=88&ref=ppntext.

Resources

Parents as Teachers

Promising Practices Network

MCH Alert Newsletter
a weekly electronic newsletter that provides timely reference to research, findings, policy developments, publications, programs, and initiatives affecting the MCH community

Greater Risk for Multiples?

Some SBS/head trauma cases recently in the news involve twins, reminders that raising multiples brings extra stress...

Elmont NY mother of twins (2008)

North Bay ON trial of father for inflicting injuries on twin boys (2004)

Rapid City IA boyfriend inflicting head injury on a 21 month twin

Raising Twins has a very good blog post about SBS for the parents of twins (indeed, for all parents and caregivers: she emphasizes the importance of educating to all caregivers and being alert for symptoms of PPD)..

Articles about SBS

Thought it might be useful to start work on compiling a list of good articles about SBS:

The Hartford Courant did a story about Teresa Trojanski and her son, TJ, which has since been published in a number of other newspapers in the Northeast

CBS News did a profile about the work of Matt and Char Johnson in Minnesota

The Palm Beach post did an excellent photo essay on Gabbi Poole

Parenting magazine did an excellent story on "The 5-Second Tragedy"

Other nominees?

Intermittent Explosive Disorder

An article in today's Wall St Journal mentioned "intermittent explosive order." It appears to be more common that I recognized. According to the Mayo Clinic:

Intermittent explosive disorder is characterized by repeated episodes of aggressive, violent behavior in which you react grossly out of proportion to the situation. People with intermittent explosive disorder may attack others and their possessions, causing bodily injury and property damage. Later, people with intermittent explosive disorder may feel remorse, regret or embarrassment.

Intermittent explosive disorder occurs most often in young men and may affect as many as one in 14 U.S. adults.

Most people with this disorder grew up in families where explosive behavior and verbal and physical abuse were common. Being exposed to this type of violence at an early age makes it more likely for these children to exhibit these same traits as they mature.

There may also be a genetic component, causing the disorder to be passed down from parents to children.

So, roughly 1 of 14 parents could have this disorder? And 1 in 8 babies could have colic? Not a good mix...

PPD and Abuse - Pediatrics

I may be repeating myself, but it's important to collaborate on initiatives, such as the Melanie Blocker Stokes MOTHERS Act, to increase awareness of postpartum depression and help families cope with the consequences.

Pediatrics. 2006 Jul;118(1):e174-82. Links
The timing of maternal depressive symptoms and mothers' parenting practices with young children: implications for pediatric practice.

McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W.
Columbia University Mailman School of Public Health, New York, New York, USA.
BACKGROUND: The prevalence of maternal depressive symptoms and its associated consequences on parental behaviors, child health, and development are well documented. Researchers have called for additional work to investigate the effects of the timing of maternal depressive symptoms at various stages in the development of the young child on the emergence of developmentally appropriate parenting practices. For clinicians, data are limited about when or how often to screen for maternal depressive symptoms or how to target anticipatory guidance to address parental needs. RESULTS: Of 5565 families, 3412 mothers (61%) completed 2- to 4- and 30- to 33-month interviews and provided Center for Epidemiologic Studies-Depression Scale data at both times. Mothers with depressive symptoms at 2 to 4 months had reduced odds of using car seats, lowering the water heater temperature, and playing with the child at 30 to 33 months. Mothers with concurrent depressive symptoms had reduced odds of using electric outlet covers, using safety latches, talking with the child, limiting television or video watching, following daily routines, and being more nurturing. Mothers with concurrent depressive symptoms had increased odds of using harsh punishment and of slapping the child on the face or spanking with an object. CONCLUSIONS: The study findings suggest that concurrent maternal depressive symptoms have stronger relations than earlier depressive symptoms, with mothers not initiating recommended age-appropriate safety and child development practices and also using harsh discipline practices for toddlers. Our findings, however, also suggest that for parenting practices that are likely to be established early in the life of the child, it may be reasonable that mothers with early depressive symptoms may continue to affect use of those practices by mothers. The results of our study underscore the importance of clinicians screening for maternal depressive symptoms during the toddler period, as well as the early postpartum period, because these symptoms can appear later independent of earlier screening results. Providing periodic depressive symptom screening of the mothers of young patients has the potential to improve clinician capacity to provide timely and tailored anticipatory guidance about important parenting practices, as well as to make appropriate referrals.

Terra Incognita and UNICEF...

Down on the lower right side of this blog, there's an interesting window on the world. You'll see little national flags that generally show whereabouts the visitors to this blog hail from.

There's a lot of unflagged ground out there.

While this blog isn't of general interest, I am quite curious about the kinds of prevention activities that going on in Latin America and Africa.

Not only because the work by Des Runyan suggests that the incidence of shaking is higher in the developing countries of the world, but because many immigrants to the US, Canada and Europe come from those areas.

Not only do they raise their own children, but many raise other children. Education in their country of origin helps insure they have knowledge and coping skills when they are caregivers in their new homes.

The thought occurs that working with child advocates in the developing world to develop educational opportunities for new parents that help them learn ways they can keep their children safe and offer them opportunities to enhance the early development of their children would also be, if handled in a culturally competent way, a useful tool of diplomacy.

Whether educational resources accompany UNICEF and/or USAID funded MCH programs or simply consist of a collection of culturally competent audio and video resources on the Internet that emigrants can link to family and friends at home, it would be a good thing to help folks in Latin America and Africa seeking SBS resources to find them.

So, looking at the FeedJit map, the first question is "is anyone looking?"

If they are, the second question is "how can we reach them?"

Any ideas (in addition to finding a Spanish-speaking writer to co-blog) ?

Not much on SBS in Latin America: this report on Brazil

It's interesting to see that awareness of inflicted injury is growing in Saudi Arabia, Kuwait, the United Arab Emirates and other regions of Arabia.

And USAID reports Egypt is No. 1 in reducing child deaths.

UNICEF statistics on child abuse deaths in the developed world

For Better or For Worse - Micheal's Losing It...

In terms of getting an awareness message across, I thought this series from the "For Better or For Worse" comic strip, by Lynn Johnston, was phenomenal (click on a panel for a better view). You can see the entire sequence in the November, 2004 FBorFW archive

http://www.fborfw.com/strip_fix/archives/2004_11.php

North Carolina Prevention Initiative Expands

Good news: the statewide program in North Carolina continues to expand.

Rex Healthcare Center, located in Raleigh, NC, announced today that it has implemented the NC prevention program, based on the PURPLE campaign.

Profile: San Francisco SBS Prevention Project

The Women's Health Resource Center of the University of California at San Francisco is supporting a SBS prevention project in San Franciso, and has just published a status report on its website.

The SBS Work Group is proposing a three tiered approach:

• SBS prevention education for new parents in hospitals
Education for all parents and caregivers of newborns in basic "child abuse prevention strategies", with prevention messages that remain true regardless of the child’s age.

• SBS prevention training for obstetrical and pediatric providers, governmental and community-based agencies
SBS prevention training for obstetrical and pediatric providers, governmental and community-based agencies on how to reach those who did not have the opportunity to receive education intervention in a SF delivery hospital, so they can provide the prevention message to their clients.

• SBS prevention messages for the general public
A public awareness campaign will be planned, implemented, and evaluated to inform the general public, including those responsible for caring for a newborn or small child, to increase aware of the risks of shaking a baby and prevention techniques. The campaign strategies will include development of public awareness posters and ads for newspapers and buses.

I'm glad to see this effort being undertaken in San Francisco.

Hopefully, the SF SBS Prevention Work Group has been in touch with the existing regional prevention projects in California and elsewhere, such as Linda Loma Hospital and the Sacramento area regional projects in Sacramento, Sutter and Stanislus counties, coordinated by Dr. Angela Rosas, with the support of the Hannah Rose Foundation, as well as the Alberta and Ontario and Upstate New York SBS prevention projects, to name a few, to design collaborative interventions and engage the benefit of their experience.

New York City has a "take good care of your baby" campaign. And as far as buses and billboards (SBS Prevention) or billboards (Reagan's Rescue)

A good strategic, comprehensive plan for a SBS prevention campaign is available from Calgary, Alberta [FN 4], and Richard Volpe and John Lewko, with the support of the Ontario Neurotrauma Foundation, offer an excellent compendium of evidence based prevention practices

There is some contact info available on those California projects:

Joanna Laffey, MPH, Training Coordinator
SF Shaken Baby Syndrome Prevention Project and Manager
Women’s Health Resource Center, UCSF National Center of Excellence in Women’s Health, (415) 885-3796
LaffeyJ@obgyn.ucsf.edu
www.ucsf.edu/whrc

Loma Linda University Children’s Hospital program
Clare Sheridan-Mattney, MBBCh
Medical Director, Child Abuse and Neglect team

Sacramento area programs
Angela Rosas, MD
Director, BEAR Care Center
5301 F Street, Suite 313
Sacramento, CA 95819
916.736.6470
angela.rosas @ ucdmc.ucdavis.edu (remove spaces)
Arosas @ csmgs.com (remove spaces)

Hannah Rose Foundation
http://dontshakeyourbaby.com/contact-us/

The Child Abuse Prevention Council of Sacramento, Inc.
4700 Roseville Road, Suite 102
North Highlands, CA 95660
(916) 244-1900

SBS Prevention Blogs

The folks responsible for the Never Shake a Baby Arizona program are blogging...

If you know about any other blogs with a primary focus on SBS prevention, please let us know by posting a comment with the URL or emailing it to SkipperVigil@yahoo.com

There may indeed be a thousand points of light out there: hopefully, the Internet will help us link together and provide some general illumination...

A To-Do List for the New Year

In no particular order (I was going to call it a wish list, but perhaps "to-do" list better renders the sentiment...)

1. Encourage prevention advocates to enlist the tools of social marketing. Prevention 1.0 involves making brochures and videos about "don'ts." Those tools increase awareness, but only if the intended audiences get them, read/watch them, and act upon them. For new parents, social marketing not only means leveraging the normal paths that people follow to get information, but using the "teachable moment" of birth and parenthood to best advantage. Prevention 2.0 means using tools that parents "pull" to themselves (we got a good checklist to use with babysitters and child care providers), not just brochures and videos that have to be pushed (before we left the hospital, we had to watch...).

2. Continue to reframe prevention. Parents - and caregivers - want to keep babies safe. Parents want to get some sleep. They want to console colicky babies.

3. Advocates need to embrace the social entrepreneurship model. We are making something useful: circumstances in which babies will be safer. If it's useful, why not sell it, and use the "profit" to sustain the product?...

4. Use SBS Awareness Week to increase awareness among legislators and policy makers.

5. Encourage reintroduction of federal legislation that will make a difference: the SBS Prevention Act, the Education Begins at Home Act (home visiting), and the Melanie Blocker Stokes MOTHERS Act (postpartum depression).

6. Develop a National Action Plan for SBS prevention. The NCHIND Strategic Plan for Targeting SIDS is a good model, and there is clearly need for research on the factors that cause inflicted injury, as well as effective and efficient ways to prevent those injuries.

7. Partner with the child care community to promote education and awareness.

On the incidence of inflicted injury: appearance and reality

The article on inflicted injuries in Sweden prompted a couple of thoughts...

Looking up the birth rate, I was surprised to find the crime rate in Sweden is reported to be above average for EU counties.

With 107,400 births, applying the rates of inflicted head injury found by the Barlow/Minns (24/100,00 under age 1) and Dias (41.5/100,000) studies, the expected incidence of inflicted head injury would be somewhere between 26 and 45 cases a year.

Tracking the Barlow and Minns paper, I found several studies of incidence, with some wide variation in rates. There seem to be a number of reasons that contribute to the diversity:

- the criteria used to define SBS/AHT/NAHI cases included in the studies vary;
- sources of case information are generally secondary;
- the upper age range of cases included in the study vary - age limit of one or two years were common, but the 2001 AAP Technical Report states injury can result up to age 5 (and there is a report of injury inflicted by shaking at age 7);
- the quality of diagnosis varies cnsiderably among hospitals
- medical professionals elect not to report cases of suspected abuse; see also Sege and Flaherty, Forty years later: inconsistencies in reporting of child abuse, Arch Dis Child, 2008 93: 822-82; a 2005 study of Pennsylvania pediatricians

Other sources on incidence:

King et al. Shaken Baby Syndrome in Canada:clinical characteristics and outcomes of hospital cases
2003 Can. Med. Assoc. J., 168(2): 155-159
10.6/100,000 (under age 5)
Email: king @ cheo.on.ca

Kessler, Dias et al. Demographics of Abusive Head Trauma in the Commonwealth of Pennsylvania, J. Neurosurgery in Pediatrics, May 2008 Vol 1(5)
14.7/100,000 under age 2
Email: Mdias @ hmc.psu.edu

Keenan et al. A Population-Based Study of Inflicted Traumatic Brain Injury in Young Children, JAMA, August 2003;290:621-626
17.0/100,000 under age 2
Email heather.keenan @ hsc.utah.edu

Talvik et al. Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia, Acta Pædiatrica, 2007 Vol 95(7), 799 - 804 (dissertation)
28.7/100,000 infants
Email: inga.talvik @ kliinikum.ee

Wirtz et al, Passive surveillance of shaken baby syndrome using hospital inpatient data, Am J Prev Med., 2008 34(4 Suppl): S134-9
Using CA inpatient data (1998-2004)
5.1/100,000 "strict SBS definition
14.0/100,000 "broader" SBS definition
Email: steve.wirtz @ cdph.ca.gov

Minns et al., Incidence and demography of non-accidental head injury in southeast Scotland from a national database, Am J Prev Med, 2008 34(4 Suppl):S126-33
33.8/100,000 infants (NAHI)
Email: Robert.Minns @ ed.ac.uk

Alexander et al., Incidence of impact trauma with cranial injuries ascribed to shaking, 1990 Am J Dis Child 144:724-726

Jayawant et al.,  Subdural haemorrhages in infants: population based study. 1998 BMJ 317:1558–61.
12.8/100,000 (SDH, 82% suggestive of abuse, under age 2)
21.0/100,000 (SDH under age 1)
kempam @ cardiff.ac.uk

Kelly, P. Infantile subdural haematoma in Auckland, New Zealand: 1988–1998, 2004 J. NZ Med Assn Vol 117(1204)

Kelly P et al., Shaken baby syndrome in New Zealand, 2000-2002, 2007 J Paediatr Child Health, 12,
14.7/100,000 'minimum' inflicted infantile SDH
19.6 per 100,000 'maximum'
Email: patrickk @ adhb.govt.nz

Barlow KM, Minns RA; Annual incidence of shaken impact syndrome in young children. Lancet 356:1571-1572, 2000 [requires free Lancet registration]
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)03130-5/fulltext

Gessner et al. Incidence of infant physical abuse in Alaska, Child Abuse & Neglect, 2004 28, 9-23
66/100,000 (inflicted head injuries, contrasting incidence reported in Barlow and discussing possible reasons)
Email: Brad_Gessner @ health.state.ak.us

Sun et al. , Non-accidental subdural haemorrhage in Hong Kong: incidence, clinical features, management and outcome, Child's Nervous System, 2006 Vol 22(6) 593-598
1.5/100,000 children under age 5
Email: wpoon @ cuhk.edu.hk

Incidence of reported shaking in response to crying

Reijneveld, Infant Crying and Abuse, Lancet (2004)
5.6% parents of children 6 months reported shaking, slapping, smothering

Theodore et al. Epidemiologic Features of the Physical and Sexual Maltreatment of Children in the Carolinas, Pediatrics, Vol 115(3), March 2005, e331-e337
2.6% of US parents reported shaking of a child under age 2 in their household

Runyan, The Challenges of Assessing the Incidence of Inflicted Traumatic Brain Injury: A World Perspective, Vol 34(4) Supplement, S112-S115 (April 2008)

While 2.6% of parents of children aged under 2 years in the U.S. report shaking their child as an act of “discipline,” survey data from lesser-developed countries on four continents indicate that shaking, as a form of discipline, may be many times more common among infants in their countries and that the consequences, short of hospitalization or death, are inadequately studied.