84TH PRIORITY | FEBRUARY 2015
Expanding the Period of PURPLE Crying In Texas
Abstract
Abusive head trauma (AHT) is a leading cause of maltreatment-related death in infants. AHT is
frequently the result of shaken baby syndrome (SBS), which occurs when a parent shakes a baby, often
out of frustration with the baby’s intense crying. The Period of PURPLE Crying is a low-cost program
gaining popularity across the United States and internationally due to its effectiveness in educating
caregivers and improving caregiver responses to crying babies. Due to the vitality of its message and the
cost-effectiveness and efficiency of the program, the PURPLE program should be used on a widespread
level in Texas hospitals and beyond.
Abusive Head Trauma In Infants
Over the last decade, child maltreatment has been on a steady decline across the country with Texas
following a similar trend. However, in 2013, Texas saw 66,398 cases, the highest number of confirmed cases
since 2009. Additionally, although child abuse and neglect fatalities also appear to be on the decline, Texas
still ranks near the top of the list, with the third highest number of fatalities in 2013 at 156 and the seventh
highest rate of maltreatment related fatalities.i The youngest children continue to be the most vulnerable to
abuse, with victims less than one year old to two years old accounting for the largest percentage of victims
across all maltreatment types.ii Abusive head trauma is one of the leading causes of infant maltreatment
fatalities in the United States, with between 1,200 and 1,400 infants sustaining injuries or dying due to the
head trauma annually..iii AHT is frequently the result of someone shaking an infant, a condition commonly
known as shaken baby syndrome.
Triggers Leading to AHT
Excessive infant crying has been cited as the most common trigger for AHT perpetration,iv with infants ages
one to three months at the greatest risk.v,vi,vii,xii For this reason, numerous studies have focused on the cycle
of infant crying and the response of caregivers in order to determine normal infant development behavior
and caregiver reactions. Researchers have identified that there is a “normal crying curve” for infants across
cultures (Figure 1). Despite varying caretaking styles across cultures, a “normal crying curve” is universal: an
infant cries in a strong, unexpected, and unpredictable increasing/decreasing pattern that is unrelated to his
or her needs and/or the environment and that resists consolation. Previously described as “colic,” this
pattern of behavior has been redefined as part of normal infant development.xii However, this behavior still
challenges and distresses caregivers,xii and is a frequent cited cause of SBS during early infancy (Figure 2).
Prevention programs, such as the Period of PURPLE Crying, are targeting these peaks of crying patterns
during the first months of life, as they most closely relate with high rates of AHT.viii
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Figure 1. Normal crying curve of early infancy (from the National Center on Shaken Baby Syndrome).ix
Figure 2.Age-specific incidence of publicly-reported cases of SBS (from the National Center on Shaken Baby
Syndrome).iv
Additionally, retrospective reviews of diagnosed cases of AHT reveal the importance of prevention strategies
that encompass the child(ren)’s entire community, as the alleged perpetrator of AHT is not always the child’s
parent. In fact, non-parental perpetrators tend to cause more severe injuries and account for 77% of the
cases of children over one year of age experiencing AHT.x Yet studies have consistently shown that for the
most vulnerable population, children less than one year of age, biological fathers are overwhelmingly the
most common adult perpetrators, followed by partners of parents, biological mothers, and other adult
caregivers.x,xi,xii For this reason, programs that are universally implemented at birth within a healthcare
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setting and target the child’s entire community of caregivers on educational and coping strategies are most
likely to yield the greatest benefits.
Economic Cost of AHT
Due to the immediate and long-term consequences of SBS/AHT, the children, their families, society, and the
government pay a high price. Approximately 25% of all AHT victims die as a result of their injuries.xii For those
children that survive, 80% incur permanent disability. Disability may require medical or personal care, placing
an additional emotional and financial strain on them and their families.xii,xiii
About half of AHT cases have been shown to require inpatient hospitalization. AHT is correlated with greater
usage of medical care, inpatient and outpatient services, and prescription usage for several years after the
diagnosis, which totals an average of $47,952 per child between the incident and age four.xiv Lifelong
estimated costs are about $1 million per case for treatment, rehabilitation, custodial care, and judicial costs.xv
In Texas, that totals about $191,000,000 each year. In addition, a recent study determined that the lifetime
cost for just a single year of confirmed child maltreatment of all kinds and for all victims in the United States
is around $5.9 trillion.xvi
Key Components of the Period of PURPLE Crying
Due to the identifiable risk behavior (non-accidental shaking) and stimulus (crying) of SBS, most cases of AHT
can be prevented.i,viii,x,xi,xii Specifically developed to reduce the occurrence of AHT, The Period of PURPLE
Crying is a low-cost, evidence-based primary program that was designed using comprehensive empirical
research connecting the crying curve and the triggers and dangers of AHT.xii,Error! Bookmark not defined.,xvii Available
in ten languages that can easily be provided to any birthing facility, the PURPLE program is delivered by
trained professionals to educate new parents, guardians and the community on infant crying and safety
behaviors, in order to reduce AHT.xii,xvii
The program is divided into three “doses.” In Dose 1, the parental portion of the PURPLE program consists of
a ten-minute DVD and 11-page brochure that employs clear, positive, and multicultural messages viewed in
the hospital after giving birth and prior to discharge. Following the viewing, there is a brief three- to fourminute conversation with a trained clinical professional to ensure all questions and concerns are answered
during the parent’s initial stay or visit.xii,xvii In Dose 2, the video is taken home and shared with other
caregivers or used as a reinforcement, such as in home visiting programs or with physicians and public health
practices. Finally, Dose 3 takes the message to the community, through public education and a media
campaign on the dangers of SBS and resulting AHT.
Evaluation & Benefits
The PURPLE program is a relatively low-cost program for prevention of AHT. Ensuring fidelity through specific
professional training, the three doses are administered over the course of two years (Figure 3). The after unit
cost per DVD is $2 plus initial execution and administrative costs; we estimate the total per unit to be
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approximately $4.50 and the total for implementation in 50% of Texas birthing hospitals to be $5 million for
two years. Over 30 years of extensive evaluations – consisting of more than 32 longitudinal parent focus
groups and randomized controlled trials with 4,400 participants from various incomes, racial and cultural
backgrounds – have yielded solid evidence that the PURPLE program can provide much needed education to
help change behavior that can prevent AHT-related injury and death to our most vulnerable Texans.xii,xvii,xviii,xix
Evidence- Based Outcomes
Studies in both the United States and Canada have indicated that:

Mothers understood more about normal infant crying;

Mothers had increased knowledge of the dangers of shaking infants;xx

Mothers increased walk-away behavior when frustrated, especially during periods of
inconsolable crying;xxi

Parents were more willing to share their education;xxii

Knowledge is increased, which suggests preventative modification of harmful behaviors, though
reduction of verified SBS occurrences is unknown;xxiii

The program is effective for both Spanish and English speaking mothers;xxiv

The program may be effective as a secondary prevention program.xxv
At this time, the PURPLE program has been implemented at some level in 49 of 50 U.S. States, including Texas
(currently implemented in 46 sites across Texas), and in eight of ten Canadian Provincesvii,xxvi The PURPLE
program has expanded greatly and currently exists in 800 locations in North America (see Appendix A).xxvii
Concluding Thoughts & Recommendations
Focusing on prevention methods is the most effective way to protect and promote healthy lives and futures
for Texas children. Utilizing The Period of PURPLE Crying can be the first of many prevention programs in a
child’s life that sets a child and his or her family on course of healthy development. The Period of PURPLE
Crying is cost-effective and efficient, requiring minimal resources and achieving vital results. Strategic plans
for reaching families that prefer home births and/or midwives instead of birthing centers or hospitals must
also be developed and implemented so that the program can reach these populations as well.
When employed in a continuum of home visiting and other prevention programs, the Period of PURPLE
Crying can be even more effective. The Nurse-Family Partnership is a home visiting program that has strong
supporting evidence to show its positive effects on prenatal health, birth, maternal health and success, and
child health and achievements. Similarly, the Home Instruction for Parents of Pre-school Youngsters, Parents
as Teachers, Early Head Start, and AVANCE have shown effectiveness for Texas children and families.
Utilizing not one but multiple preventative programs, Texas can further assure a child’s healthy development.
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Appendix A
2-Year Statewide Implementation Proposed Budget
PURPLE Cost Description
Doses 1 & 2: Yr 1 (2016)
Startup cost includes:
planning, training,
shipping, storage,
materials, and hospital
coordinator’s time. Based
on UNC implementation
cost evaluation.
Doses 1 & 2: Yr 2 (2017)
includes maintenance
cost of materials,
shipping, storage, and
reduced hospital
coordinator time. Based
on UNC implementation
cost evaluation.
Dose 3: Statewide public
information campaign
(billboard, radio & TV
PSAs, Click for babies,
printing & publication
across major TX cities)
Projected
Home
Total
Admin
Material Projected Visiting
Participants Total
Cost/Unit Cost/Unit Births
Clients
(50% part.)
Funding
$2.56
$2.00
415,000
23,000
219,000
$998,640
$1.93
$2.00
415,000
23,000
219,000
$860,670
$1,330,000
Project Evaluation and
Statewide
Coordination/Training
$1,840,000
Biennium Total
$5,029,310
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Appendix B
Map of Implementation of Period of PURPLE Cryingxxvi
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References
i
American Academy of Pediatrics. (2014). Statistics. Retrieved from
http://www2.aap.org/sections/childabuseneglect/.
ii
Department of Health & Human Services. (2012). Child Maltreatment (23rd Ed.). Retrieved from
http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012.
iii
National Center for Child Death Review. (2014). Child Abuse and Neglect Fact Sheet. Retrieved from
http://www.childdeathreview.org/causesCAN.htm
iv
Lee, C. Barr, R. G., Catherine, N., & Wicks, A. (2007). Age-related incidence of publicly reported shaken baby
syndrome cases: is crying a trigger for shaking? Journal of Developmental & Behavioral Pediatrics 28(4),
288–293.
v
Parks, S., Sugerman, D., Xu, L., Coronado, V. (2012). Characteristics of non-fatal abusive head trauma among
children in the USA, 2003-2008: application of the CDC operational case definition to national hospital
inpatient data. Injury Prevention, (Feb. 23, 2012).
vi
Parks, S. E., Kegler, S. R., Annest, J. L., Mercy, J. A. (2012). Characteristics of fatal abusive head trauma among
children in the USA, 2003-2007: an application of the CDC operational case definition to national vital
statistics data. Injury Prevention, 18(3), 193–199.
vii
Shanahan, M. E., Nocera, M., Zolotor, A. J., Sellers, C. J., & Runyan, D. K. (2011). Education on Abusive Head
Trauma in North Carolina Hospitals. Child Abuse Review, 20,290–297.
viii
Barr, R. G., Trent, R. B., Cross, J. (2006). Age-related incidence curve of hospitalized Shaken Baby Syndrome
cases: convergent evidence for crying as a trigger to shaking. Child Abuse & Neglect 30(1), 7–16.
ix
Barr, M. (n.d.). The relation of crying to SBS. Retrieved from
http://www.purplecrying.info/sub-pages/protecting/the-relations-of-crying-to-sbs.php
x
Scribano, P. V., Makoroff, K. L., Feldman, K. W., & Berger, R. P. (2013). Association of perpetrator relationship
to abusive head trauma clinical outcomes. Child Abuse & Neglect, 37, 771–777.
xi
Esernio-Jenssen, D., Tai, J. & Kodsi, S. (2011). Abusive Head Trauma in Children: a comparison of male and
female perpetrators. Pediatrics, 127(4), 649–657.
xii
Barr, R.. G. (2012). Preventing abusive head trauma resulting from a failure of normal interaction between infants
and their caregivers. Proceedings of National Academy of Sciences, 109(2), 17294–17301.
xiii
National Center on Shaken Baby Syndrome. (2014). Immediate Consequences. Retrieved from
http://www.dontshake.org/sbs.php?topNavID=3&sbuNavID=23.
xiv
Peterson, C., Xu, L., Florence, C., Parks, S. E., Miller, T. R., Barr, R.G., . . . Steinbeigle, R. (2014). The medical
cost of abusive head trauma in the United States. Pediatrics, 134(1), 91-99.
xv
Showers J. Executive Summary. In: Showers, J. Ed. Proceedings from the Second National Conference on
Shaken Baby Syndrome. Paper presented at: Second National Conference on Shaken Baby Syndrome1998;
Salt Lake City, UT.
xvi
Perryman Group. (2014). Suffer the little children: An assessment of the economic cost of child maltreatment.
Waco, TX: The Perryman Group. Retrieved from http://www.perrymangroup.com/wpcontent/uploads/Perryman_Child_Maltreatment_Report.pdf
xvii
Barr, R. G. (2014). The Period of PUPRLE Crying: Components of the program. Retrieved from
http://www.purplecrying.info/sub-pages/what-is-the-period-of-purple-crying/components-of-theprogram.php.
xviii
Barr, R. G., Rivara, F. P., Barr, M., Cummings, P., Taylor, J., Lengua, L. J., & Meredith-Benitz, E. (2009).
Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and
shaken baby syndrome in mothers of newborn infants: a randomized controlled trial. Pediatrics, July 2009.
Retrieved from http://pediatrics.aappublications.org/content/123/3/972.abstract.
xix
Barr, R. G., Barr, M., Fuiwara, T., Conway, J., Catherine, N., & Brant, R. ( ). Do educational materials change
knowledge and behaviors regarding crying and shaken baby syndrome in mothers of newborns when
delivered by public health home visitor nurses? A randomized controlled trial. Canadian Medical
Association Journal, 180(7), 727–733. Retrieved from
http://www.cmaj.ca/content/180/7/727.full.pdf+html?maxtoshow=&HITS=10&hits=10&RESULTFORMA
T=&fulltext=shaken+baby&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&resour
cetype=HWCIT&eaf.
xx
National Center on Shaken Baby Syndrome. (2009). Randomized controlled trials on the effectiveness of the
PURPLE materials: Parallel studies in the state of Washington (USA) and the province of British Columbia
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(Canada). Retrieved from http://www.dontshake.org/pdf/PURPLE-RandomizedControlledTrials.pdf
Barr, R., Barr, M., Fujiwara, T., Conway, J., Catherine, N., & Brant, R. (2009). Do educational materials change
knowledge and behavior about crying and shaken baby syndrome? A randomized controlled trial. CMAJ,
180(7), 727-733.
xxii
Laskey, A. Evaluation of the Period of PURPLE Crying through word of mouth. Retrieved from
http://dontshake.org/pdf/DrLaskeyEvalPURPLE.pdf
xxiii
Ibid.
xxiv
Bradshaw, J. (2010). Period of PURPLE Crying effective in changing knowledge and behavior in a home
visiting program supporting high risk, first time mothers (Doctoral Dissertation). Retrieved from
http://dontshake.org/pdf/DrBradshawHomeVisitPURPLE.pdf
xxv
Ibid.
xxvi
National Center on Shaken Baby Syndrome. (n.d.) PURPLE Program. Retrieved from
http://www.dontshake.org/sbs.php?topNavID=4&subNavID=32&navID=664
xxvii
Ibid.
xxi
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