Saving Babies Lives by Preventing Shaken Baby Syndrome
Parkview Health System
By Candace Schuler
Shaken Baby Syndrome is both the most common and most serious form of abuse in children under one year of age. The number one reason an infant is shaken is frustration with the baby’s crying. Studies show that teaching parents and caregivers about the dangers of shaking a baby and how to respond appropriately to an infant’s crying is the most effective way to reduce Shaken Baby Syndrome.
Traumatic brain injury as a result of shaking a baby—aka Shaken Baby Syndrome—is both the most common and most serious form of abuse in children under one year of age. It results in death 25-35% of the time, with 70-80% of survivors suffering life-long physical and developmental problems such as permanent brain damage, speech disabilities, blindness, hearing loss, seizures, behavioral disorders, cerebral palsy, and paralysis.
Although shaking may cause injury to children of any age, infants under the age of one year are the most susceptible to being injured or dying as a result of being shaken. This is because babies’ neck muscles are weak, their heads are heavy in proportion to their body size, and their brains are fragile and undeveloped. Because of this fragility of very young infants, shaking can cause subdural hematoma (tiny veins between the surface of the brain and its outer covering stretch and tear, allowing blood to collect), shearing off or breakage of nerve cells, oxygen deprivation to the brain, retinal hemorrhages, and skull fractures. 
It is important to note that Shaken Baby Syndrome does not happen by accident. It is not a result of bouncing a baby in your arms or on your knee. It does not happen by playfully tossing a baby into the air or driving over bumpy roads with a baby in an infant car seat or on the back of a bicycle. It is highly unlikely to happen as a result of a baby rolling off a bed or being accidentally dropped. As noted above, it is caused by an infant being deliberately and forcefully shaken so hard that its head moves in a rapid, back-and-forth whiplash motion that causes the baby’s fragile, undeveloped brain to repeatedly hit the inside of the skull.
Multiple studies have proven that the number one reason an infant is shaken is frustration; a parent or caregiver becomes so frazzled by a baby's persistent, prolonged crying that they lose control and just shake the baby in an effort to make it stop. Adding to the parents’/caregivers’ level of frustration is the fact that they have never been told that all babies experience prolonged bouts of unsoothable crying in the first few months of life. These crying bouts begin at about two weeks of age, peak in the second month, and generally end by about three or four months. Parents often believe there is something wrong with their baby or with themselves as caregivers when they are unable to soothe and calm their crying infant. This increases the likelihood that they may react in frustration and anger to the crying by shaking or other abuse.
Babies being injured or killed by being shaken in frustration is, unfortunately, not uncommon in the greater Fort Wayne Area. In July 2016, a six-month-old baby boy was fussy and recovering from a respiratory infection. His frazzled mom ran out for a pizza, leaving him with his equally frazzled father. When she returned home 20 minutes later, the baby was unresponsive. His father denies any wrong-doing but the baby’s brain had been slammed so hard against his skull that doctors had to remove bone tissue to accommodate the extensive swelling. He was in a coma for five days and lost an estimated 90% of his brain tissue. Now 15 months old, the baby can breathe on his own but he is still unable to hold his head up, he has diminished eyesight, and he must be fed through a feeding tube. His long-term prognosis is uncertain. In March 2018, a two-month old baby girl was airlifted to Parkview Regional Medical Center, where she died due to injuries caused by being violently shaken. The baby’s father said the infant wouldn’t stop crying and he “lost his temper,” shaking the baby multiple times during the night before finally picking her up out of the crib and throwing her on the bed. These are just two examples of the damage done to infants by shaking them.
Studies show it’s not enough to just teach parents or caregivers what Shaken Baby Syndrome is and why it’s dangerous. They must also be educated about the normal patterns of infant crying and taught how to respond appropriately to an infant’s unsoothable crying. Thus, to prevent Shaken Baby Syndrome, educators must address the root cause—frustration with infant crying—and teach parents and caregivers how to safely deal with it.
In 2007, the National Center on Shaken Baby Syndrome (NCSBS) developed the Period of PURPLE Crying program to teach parents about the dangers of shaking a baby and the normal patterns of infant crying, and then providing proven, evidence-based strategies for parents to try to soothe a crying infant, including putting the infant down in a safe place and walking away when feeling frustrated.
Each of the letters of the word PURPLE refers to one of the six characteristics or “properties” of normal infant crying that parents and caregivers often find frustrating. They are:
P for Peak of Crying – Crying peaks during the second month, decreasing after that;
U for Unexpected – Crying comes and goes unexpectedly, for no apparent reason;
R for Resists Soothing – Crying continues despite all soothing efforts by caregivers;
P for Pain-like Face – Infants look like they are in pain, even when they are not;
L for Long Lasting – Crying can go on for 30-40 minutes or as much as 5 hours or longer;
E for Evening Crying – Crying occurs more often in the late afternoon and evening.
The word “Period” is used to let parents know that this experience of increased frustrating crying is temporary, and eventually does come to an end.
The primary tool used to teach parents and caregivers about the danger of shaking a baby is the Shaken Baby Simulator doll, which is the size of a newborn infant. When the simulator is shaken, LEDs in the head light up to show the areas of the baby’s brain that are damaged by shaking. As one father who participated in the program commented, “The fake baby shaking gadget helped me truly grasp the fragility of an infant.” The program also includes a 10-minute educational DVD and a 10-page full color booklet about the Period of PURPLE Crying and the dangers of shaking an infant, as well as a 17-minute film titled, “Crying, Soothing, and Coping: Doing What Comes Naturally,” to provide parents with proven techniques for coping with a crying infant.
Parkview Health System delivers the Period of PURPLE Crying Program in three “doses” to increase its effectiveness. The first dose is given to all Parkview moms and families after the birth of their baby. This most often occurs in the hospital maternity room but can also occur in prenatal classes, pediatric offices, public health settings, or during home visits. The second dose is delivered via program presentations delivered in conjunction with Parkview’s community partners, i.e., churches, libraries, schools, and non-profit organizations that work with families and children, including “train the trainer” education to staff at Healthier Moms and Babies so they can train their clients/constituency and reinforce the information presented. The third dose is a public education campaign/community awareness to educate grandparents, babysitters, boyfriends, neighbors, and relatives about the PURPLE program so parents will receive support and reinforcement from them and others will have an understanding of what the parents are going through.
The most recent sample of parents (n=101) surveyed found that 100% understood the PERIOD of Purple Crying program content and saw value in it, and 99% intended to share the content with their baby’s other caregivers. A sample of maternity nurses (n=63) who participated in the program showed that 100% modeled appropriate behaviors and techniques.
 American Association of Neurological Surgeons, http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Shaken-Baby-Syndrome , accessed 2018 May 13
 Barr, RG., Preventing abusive head trauma resulting from a failure of normal interaction between infants and their caregivers. Proc Natl Acad Sci USA 2012 Oct 16;109 Suppl 2:17294-301. doi: 10.1073/pnas.1121267109. Epub 2012 Oct 8.
 Spencer, S., Shaken for Life: The survivors of shaken baby syndrome. 2017 May 11. WSBT 22 Anchor/Reporter http://wsbt.com/news/local/shaken-for-life-the-survivors-of-shaken-baby-syndrome
 WANE Staff Reports, Father arrested in baby’s death, 2018 March 29,
 CDC, Preventing Abusive Head Trauma in Children, https://www.cdc.gov/violenceprevention/childmaltreatment/Abusive-Head-Trauma.html , accessed 2018 May 13
SCAN White Paper
Over the past 30 years there have been many studies on the intergenerational patterns of Child Abuse and/or Neglect. These studies have begun to show us the levels of nuance and complexity that exist within the subject. There are several theories that have been cited in order for us to better understand this complexity and how it impacts families within our community. The most prevalent theories are as follows:
- 1)Social learning theory proposes that the behaviors of an individual is shaped through observing and imitating. This theory suggests that adults’ parenting is influenced by their own childhood experiences and their own parents’ behaviors. If the individual experiences abusive or neglectful parenting then they may develop the belief that such behaviors are acceptable and/or effective and replicate them with their own children.
- 2)Attachment theory emphasizes the importance of an early quality attachment with a caregiver. If the caregiver is not caring and sensitive to the infant’s needs, the affected individual struggles to form healthy attachments into adulthood. This is theorized to increase the likelihood of abusive behaviors as an adult.
- 3)Trauma-based models suggest that maltreatment, like any other form of violence, produces trauma symptoms. If untreated and unresolved, these symptoms may increase the likelihood that the individual will engage in violent behavior, including child maltreatment, as an adult.
- 4)Ecological or transactional theories see child maltreatment as the result of multiple influences and systems, including family, community and societal factors. Research grounded in these theories looks for specific risk factors or pathways to better explain intergenerational patterns of maltreatment. (Children’s Bureau)
These theories all factor in to the treatment of families that are involved in substantiated cases of abuse and/or neglect. When the parents have certain experiences or backgrounds the risk of abuse and/or neglect can become even more prevalent and can lead to their children internalizing their experiences and act the same way when they become parents themselves. These factors have been identified through strong studies on Intergenerational Patterns of Child Maltreatment (IGM).
- Mothers’ social isolation and tendency to respond to minor provocations with verbal or physical aggression (Berlin, Appleyard, & Dodge, 2011)
- Maternal substance abuse, or substance abuse while pregnant (Appleyard, Berlin, Rosanbalm, & Dodge, 2011)
- Young parental age, parents’ history of mental illness or depression, and parents living with another violent adult (Dixon, Browne, Hamilton-Giachritsis, 2005)
- Parental age, educational achievement, psychiatric history, and poverty (Sidebotham, Heron & ALSPAC Study Team, 2006)
- Mothers’ marital status, depressive symptoms, and adult experiences of victimization (Thompson, 2006)
- Mothers’ life stress, anxiety, and depression (Egeland, Jacobvitz, & Sroufe, 1988)
- Parents’ experience of intimate partner violence (Renner & Slack, 2006) (DeCraene)
By working with children and their parents, these negative factors can be addressed and worked on to better prepare not just the parents, but teach children that there are other ways to address problems outside of the abuse or neglect that they may have experienced.
Children that learn through their parents that violence or aggression is the primary response to adversity can begin to internalize this attitude and behave in a similar fashion not only while growing up, but when they have children of their own. This is why intervention and preservation services are so vital to addressing abused or neglected children. Through these systems of care they are able to learn that there are other, better alternatives to using violence or aggression through exposure to non-violent adult role models, non-violent problem solving skills, and developmental assistance that can improve the children’s level of self-confidence can break this cycle of abuse or neglect. Most of these lessons can be applied to the parents as well, reducing recidivism rates and keeping the family out of the Department of Child Services system in the future.
By working with these families and children, we help them see that there are other ways to deal with the stresses and struggles that come with being a parent. When they are exposed to non-violent problem-solving techniques and can internalize that there are safer ways to deal with problems, we begin to break the cycle of generational abuse and neglect, protecting the future children of our communities before there is even an opportunity for them to face the trauma of abuse and neglect.
Paper written by Bradley Williams with SCAN Inc.
- “Intergenerational Patterns of Child Maltreatment: What the Evidence Shows.” Child Wellfare Information Gateway, Childrens Bureau, Aug. 2016, www.childwelfare.gov/pubPDFs/i... to explain intergenerational maltreatment.
- DeCraene, Melva. “GENERATIONAL EFFECTS OF VIOLENCE.” Edited by ICDVP Competencies Committee, Community Crisis Center, www.crisiscenter.org/pdfs/Generational_Effects_Of_Violence_doc.pdf.
Abuse is the non accidental situation causing harm to a child at the hands of a parent or guardian. Federal Child Abuse Prevention and Treatment Act, 2003 states child abuse and neglect is an act or failure by parent or caretaker resulting in death, physical, emotional, sexual, neglect or exploitation.
From the 1600-1800’s – children were seen as property of parents. Punishment in every form of abuse including capital punishment.
In 1884 – First case of maltreatment brought to court
In 1899 – First court system to protect a child took place in Illinois
Over 2 million reports of child abuse and neglect are made to state child protective service agencies annually.
More than 1 million children experience demonstrative evidence of abuse and neglect annually.
More than 1,100 children die annually as a consequence of child abuse and neglect.
Of the 872,000 victims of child maltreatment in 2004, 62% were neglect, 18% physical abuse, 10% sexual abuse, 7% emotional abuse, 2% medical neglect nand 15% other maltreatment types such as abandonment, congenital drug addiction, etc.
8% of adolescents report sexual abuse – 74% know their assailant, 34% are under 2 years old and age 14 is the most common age for sexual abuse.
Reports of sexual abuse are up to 30-40% of females or 10-12% of girls under age 14 years old.
Substance abuse is 1/3 to 2/3 of maltreated children
9% of children are in a family with a parent who abuses alcohol or drugs.
Indiana facts on abuse
Deaths in Indiana were 53 in 2003 with 43% under age 5, 54 deaths in 2005. Allen County had 6 of these caused by head blunt force, shaken baby, asphyxiation, and strangulation.
3.4 cases of child abuse per 100,000 children annually in U.S. There were 1490 deaths in 2003 with 81% less than 4 years old.