Traveling Upstream on Child Protection

The Texas Safe Babies initiative pilots and evaluates population level strategies focused on reducing incidence of maltreatment of infants in Texas.

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By Daniel Oppenheimer
Editor, Texas Health Journal


The sound of an infant crying is one of the most stressful sounds in human existence, particularly for parents. It sets off a cascade of alarm bells in the brain, and triggers an urge to stop the crying—to quiet the alarms—that is immensely powerful. In most cases this leads to soothing and nurturing. Tragically, however, when that soothing repeatedly fails to silence the alarms, some parents become overwhelmed by the stress and act in a way that harms the baby.

Add in all the other stresses of new parenthood, including money stresses, sleep deprivation, shifts in family structure, and the sudden introduction of responsibility for another human’s life, and the result is that infancy is typically one of the most challenging periods in adults’ lives, including those with resources and support.

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Infancy in general can be so difficult for parents, in fact, that in Texas more than two percent of infants become a victim of abuse or neglect before reaching their first birthday. This is a maltreatment rate that is six times higher than for children between the ages of 1 and 4, and even higher relative to older kids. In recent years, rates of infant maltreatment have been increasing, primarily as a result of the infant having prenatal exposure to drugs.

In 2015, the state of Texas launched the Safe Babies initiative, which focuses on piloting and evaluating population level strategies for reducing incidence of maltreatment of infants, with the ultimate goal of scaling up effective strategies to reduce maltreatment statewide.

Among the strategies being evaluated by Safe Babies are Period of Purple Crying® (PoPC), an educational program that teaches parents about patterns of normal infant crying; the Father’s Playbook, an Android-based app designed for expectant fathers; the Parenting Action Plan, which encourages new mothers to make a customized plan for dealing with some of the stresses of new parenthood; and the Father’s toolkit, which give new fathers supportive education after the baby is born.

Researchers are also using hospital discharge data, birth certificate data, and Child Protective Services data on confirmed cases of abuse and neglect to identify trends in child maltreatment, both at the statewide level and in some cases down to the ZIP code level. The hope is that the data analysis and the evaluations of various interventions will build an evidence base that can contribute to the longer term effort to reduce maltreatment statewide.

It’s a challenge that’s as daunting as it is urgent, said Dr. Dorothy Mandell, director of Safe Babies and Assistant Professor of Community Health at The University of Texas Health Science Center at Tyler, which is contracting with the Texas Department of Family and Protective Services (DFPS) to implement the program.

“The hard truth is that there are, at best, one or two programs that have shown some evidence of reducing maltreatment,” said Mandell. “And those are intensive, expensive home visiting programs that would be difficult or impossible to scale to the state level. There’s recent evidence that even those programs may not be reducing maltreatment. To have a real impact on maltreatment rates, over the long term, we’re going to have to pair those intensive programs with more universal but lower intensity programs that helps the entire population.”

Safe Babies is part of just such an arsenal of approaches that DFPS, through its Prevention and Early Intervention (PEI) division, is implementing to reduce the overall incidence of maltreatment of children.

Mandell said that improvement is likely to depend, somewhat counterintuitively, on a shift away from the idea that successful interventions should be aimed directly at reducing maltreatment. Instead, said Mandell, the focus should be on building strength and resilience in families, particularly in those families that may be higher risk for maltreatment.

“Think about how we deal with prevention in other realms,” said Mandell. “We don’t jump into the road to prevent car accidents or tell people to stop getting in accidents. We put structures in place to encourage safer driving, like speed limits and seatbelt laws. We add safety features to cars to improve road awareness. To bring down rates of maltreatment, we don’t need to be saying to parents, ‘Don’t maltreat your baby.’ We need to support parents through education, anticipatory guidance about typical infant development, mental health counseling, substance abuse treatment, support for their bonding with their babies through play, and other means.”

What a successful strategy will look like, said Mandell, is not yet clear. One of the key findings from Safe Babies, in fact, is a negative one. The Period of Purple Crying® (PoPC) intervention has shown no effect on infant physical abuse in Texas. Mandell and her colleagues used birth certificate data and CPS data to study outcomes among the more than 70,000 babies that have been born, since 2012, in the 45 hospitals that have adopted the program.

They found that implementation of PoPC was not associated with a decrease in physical abuse in early infancy. This is consistent with other studies of PoPC, which has been implemented in multiple states with similar (lack of) results.

“This doesn’t mean that Period of PURPLE Crying is having no positive effects,” said Mandell. “It may be improving family dynamics or parental functioning in ways that aren’t captured in the abuse data. But it does mean that we need to keep working on expanding the means of education and support for parents. The heart of a public health approach is to assess the risk factors associated with maltreatment and address them at an individual, community, and societal level. It may turn out that PoPC is an important part of a suite of efforts that collectively will improve resilience and impact maltreatment rates.”

In order to test that proposition, Safe Babies is now evaluating two distinct courses of interventions that combine aspects of PoPC with other supports and education.

One, aimed at new mothers, is focused on the 2 week, 2 month, and 5 month well-baby visits. At the child’s two-week well-baby visit, moms are given a first “dose” of PoPC material (or the second dose if the first was given at the hospital). She will also meet with  a trained staff member to collaboratively develop a “Parenting Action Plan,” which focuses on sleep hygiene, soothing a crying baby, what to do when the baby’s crying is overwhelming, identifying safe caregivers in case of emergency, and issues surrounding feeding and bonding with the baby.

At the subsequent 2-month and 5-month visits, staff check in on whether the parenting action plan is working or needs to be revised.

“It’s a public health approach,” said Mandell. “We want to focus on the upstream drivers of maltreatment and move the needle on those. Move them away from unrealistic expectations of their children, and having negative attributions about them when things don’t go as expected. We want to focus on maternal sleep, which is a neglected topic, and have her develop strategies for getting enough sleep. Address the drivers, and move the parents out of the danger zones.”

The code to  download the pilot version  of the Father’s Playbook app is PIP2018.

The code to download the pilot version of the Father’s Playbook app is PIP2018.

The other intervention provides expectant or new fathers (defined as the primary male caregivers) with a series of educational tools. These include:

●     Informational materials on the mental health challenges of new parenthood that have been adapted to include male specific symptoms of depression and anxiety.

The cover of  Parenting in Pictures , which is given to fathers as part of a suite of materials provided to prepare them for new parenthood.

The cover of Parenting in Pictures, which is given to fathers as part of a suite of materials provided to prepare them for new parenthood.

●     A picture book, Parenting in Pictures: A Handy Guide to Bonding with your Baby, that the father can read to the baby that doubles as a guide to playing with and understanding babies.

●     Baby cards from Vroom® that provide the father with safe play activities that have been designed by child development researchers to nourish brain development.

●     The Father’s Playbook app, which is a “pregnancy” app for men that will extend into the postnatal period.

The assumption, said Mandell, is not that each element of each intervention will be effective. Rather, the evaluations are designed so that the effect of each aspect can be evaluated along with the collective effects of the full regimes. As more information comes in, the programs can be altered to emphasize what’s working, eliminate or reduce what’s not, and better integrate the kinds of low-intensity efforts that Safe Babies is evaluating with more intensive programs aimed at high risk parents or those already involved with the child protection system.

“It’s important that we develop universal prevention mechanisms,” said Mandell. “Not just because we can’t predict who will or will not abuse or neglect their children, but because all parents need help, and the work of making all of our families stronger and providing them support is what may, ultimately, reduce maltreatment.”