Home Program Period of PURPLE Crying

Period of PURPLE Crying

Topic Areas
Scientific Rating
Child Welfare Relevance
Prevention of Child Abuse and Neglect (Primary) Programs
3  — Promising Research Evidence
Medium

About This Program

Target Population: All mothers, fathers, and secondary caregivers of infants up to 2 years of age as well as society in general in their understanding of early increased infant crying and shaken baby syndrome

For parents/caregivers of children ages: 0 – 2

Program Overview

The Period of PURPLE Crying program is the name given to the Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT) prevention program developed by National Center on Shaken Baby Syndrome. The program educates parents and caretakers on normal infant crying, the most common trigger for shaking an infant. It was designed to be used primarily in universal, primary prevention settings, but is applicable to secondary prevention as well.

The letters in PURPLE stand for the common properties of crying, including unsoothable crying, in infants during the first few months:

  • Peak pattern (crying peaks around 2 months, then decreases)
  • Unpredictable (crying for long periods can come and go for no reason)
  • Resistant to soothing (the baby may keep crying for long periods)
  • Pain-like look on face
  • Long bouts of crying (crying can go on for hours)
  • Evening crying (baby cries more in the afternoon and evening)

The other important word in the name is "period," letting parents and caregivers know there is a beginning and ending to the infant crying phase. The program includes a full color 10-page booklet, parent reminder card, a 16-minute PURPLE Crying video and a 17-minute Crying, Soothing, Coping: Doing What Comes Naturally video intended to be given to parents of new infants. The program materials are available in an App+Booklet package which grants them access to a web and/or mobile application. The program materials are available in two formats: DVD with booklet package or web and mobile application with booklet package. The program also contains a public media component aimed at changing cultural attitudes about crying, especially inconsolable crying.

Program Goals

The goals of the Period of PURPLE Crying program are:

  • Increase understanding of early increased infant crying
  • Reduce the incidence of shaken baby syndrome/abusive head trauma

Logic Model

View the Logic Model for Period of PURPLE Crying.

Essential Components

The essential components of the Period of PURPLE Crying program include:

  • Approaches prevention through thoughtfully designed positive messages about normal infant development, specifically, crying in normal infants with an emphasis on the dangers of shaking, rather than just being limited to warnings of the negative consequences of shaking
  • Aims to be educational, attractive and relevant to all caregivers
  • Aims to bring about a cultural change in understanding of infant crying both for caregivers and the general public
  • Aims to increase program "penetration rates" to new parents and be widely acceptable to health care professionals and groups disseminating the intervention
  • Provides program materials that are presented at a grade 3 language level, translated into eleven languages and includes closed captioning for the hearing impaired on the English version, to take home to review and share with others

Program Delivery

Parent/Caregiver Services

Period of PURPLE Crying directly provides services to parents/caregivers and addresses the following:

  • Parents and caregivers of a newborn

Recommended Intensity:

Three 3–10-minute contacts: The first contact is the delivery of the intervention materials to parents of all newly born infants via a demonstration of the materials by a trained educator or provider. This first contact needs to take place within the first weeks of the baby's life before the baby's crying increases. The second contact reinforces important messages of the program to parents at public and state department of health programs, home visits, and/or pediatric well baby visits. This contact is a little more flexible in terms of timing, generally occurring throughout the first three months following the baby's birth when crying has reached its peak. The third contact is designed to come from exposure to a public education campaign. This campaign is important to make sure that all other members of society hear about and understand the Period of PURPLE Crying. The timing for this contact is not set to the timing of a baby's birth. It is dependent upon a jurisdiction or an organization's capacity to educate the community where Dose One, and ideally Dose Two, is occurring.

Recommended Duration:

At least 3 months, can be longer depending on the public education campaign.

Delivery Settings

This program is typically conducted in a(n):

  • Birth Family Home
  • Hospital
  • Outpatient Clinic

Homework

Period of PURPLE Crying includes a homework component:

All families are encouraged to review and share the program materials with other family members and caregivers of their baby.

Languages

Period of PURPLE Crying has materials available in languages other than English:

Arabic, Cantonese, French, Somali, Spanish

Close captioning for the hearing impaired is available on the English version.

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Materials provided by the National Center on Shaken Baby Syndrome and Internet access.

Manuals and Training

Prerequisite/Minimum Provider Qualifications

There are no educational requirements, but the provider must take the training online or in person and be in a position where they have authority to give programs to new parents. The provider should protect the fidelity of the program by complying with the protocol required.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual details:

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Period of PURPLE Crying Training for Implementation is available at http://training.dontshake.org. Nursing and Social Work Continued Education (CEU) Contact Hours available.

Number of days/hours:

1 Hour

Implementation Information

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Period of PURPLE Crying.

Formal Support for Implementation

There is formal support available for implementation of Period of PURPLE Crying as listed below:

The National Center on Shaken Baby Syndrome (NCSBS) has a designated PURPLE team to provide ongoing technical assistance to all partners implementing as well as leadership teams with jurisdiction-wide initiative and programs. The NCSBS provides support for program marketing, public education campaigns, unlimited access to online training modules, research, outreach, and customizations of design assets.

Fidelity Measures

There are fidelity measures for Period of PURPLE Crying as listed below:

The evaluation tools are available upon request and consist of an implementation checklist, Public Health evaluation form, maternity nurse interview questions, public health nurse interview questions, and parent interview questions. A Fidelity Agreement is signed by both parties before program can be implemented.

Fidelity Measure Requirements:

Fidelity measures are required to be used as part of program implementation.

Implementation Guides or Manuals

There are implementation guides or manuals for Period of PURPLE Crying as listed below:

There is an implementation protocol, and a management guidebook as well as an implementation checklist that are available through the PURPLE team via email or phone. In addition, the complimentary Period of PURPLE Crying Program Implementation online training discusses in details implementation processes.

Implementation Cost

There have been studies of the costs of implementing Period of PURPLE Crying which are listed below:

Beaulieu, E., Rajabali, F., Zheng, A., & Pike, I. (2019). The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia, Canada. Child Abuse & Neglect, 97, Article 104133. https://doi.org/10.1016/j.chiabu.2019.104133

Research on How to Implement the Program

Research has been conducted on how to implement Period of PURPLE Crying as listed below:

Nocera, M., Shanahan, M., Murphy, R. A., Sullivan, K. M., Barr, M., Price, J., & Zolotor, A. (2016). A statewide nurse training program for a hospital based infant abusive head trauma prevention program. Nurse Education in Practice, 16(1), e1–e6. https://doi.org/10.1016/j.nepr.2015.07.013

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

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 newborns: A randomized controlled trial. Pediatrics, 123(3), 972–980. https://doi.org/10.1542/peds.2008-0908 

Type of Study: Randomized controlled trial
Number of Participants: 2,738

Population:

  • Age — 18–55 years
  • Race/Ethnicity — Not specified
  • Gender — 100% Female
  • Status — Participants were mothers recruited from prenatal classes, maternity wards and pediatric offices.

Location/Institution: Washington State

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to investigate the effect of providing mothers with the Period of PURPLE Crying materials on their knowledge and behavior related to the prevention of shaken baby syndrome. Participants were randomly assigned to receive either the Period of PURPLE Crying intervention or information on infant safety and safe sleep. Measures utilized include a questionnaire about the mother’s knowledge about crying and shaking. Results indicate that mothers receiving the Period of PURPLE Crying intervention showed higher knowledge scores about crying and shaking the baby, more positive reported behavioral responses to crying, and more likelihood of sharing information with other caregivers about walking away and the dangers of shaking. They also reported more minutes of contact during crying. However, rates of picking up the baby, walking away when distressed, and daily frustration scores were not different across groups. The Period of PURPLE Crying group reported longer periods of distress in their babies than the control group. The authors speculate that increased reports of distress may be a result of the focus on crying in the Period of PURPLE Crying materials, but suggest that this result needs to be followed up. Limitations include concerns about lack of generalizability due to gender, reliability of self-reported measures, missing data, and length of follow-up.

Length of controlled postintervention follow-up: 2 months.

Barr, R. G., 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. Canadian Medical Association Journal, 180(7), 727–733. https://doi.org/10.1503/cmaj.081419

Type of Study: Randomized controlled trial
Number of Participants: 1,279 mothers

Population:

  • Age — At least 25 years
  • Race/Ethnicity — Not specified
  • Gender — 100% Female
  • Status — Participants were new mothers who had had an uneventful pregnancy and a healthy singleton infant.

Location/Institution: Greater Vancouver Area, British Columbia, Canada

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine whether the use of the educational materials from the Period of PURPLE Crying program would change maternal knowledge and behavior related to shaking. Participants were assigned to receive either the Period of PURPLE Crying program or control materials during a home visit by a nurse within 2 weeks after the birth of their child. Measures utilized include a questionnaire about the mother’s knowledge about crying and shaking. Results indicate that the mean score for knowledge about infant crying was greater among mothers who received the Period of PURPLE Crying materials than among mothers who received the control materials. The mean scores were similar for both groups for shaking know-ledge and reported maternal responses to crying, inconsolable crying, and self-talk responses. Compared with mothers who received control materials, mothers who received the Period of PURPLE Crying materials reported sharing information about walking away if frustrated more often, the dangers of shaking, and infant crying. Walking away during inconsolable crying was significantly higher among mothers who received the Period of PURPLE Crying materials than among those who received control materials. Limitations include concerns about lack of generalizability due to gender, reliability of self-reported measures, missing data, and length of follow-up.

Length of controlled postintervention follow-up: 6 weeks.

Fujiwara, T., Yamada, F., Okuyama, M., Kamimaki, I., Shikoro, N., & Barr, R. G. (2012). Effectiveness of educational materials designed to change knowledge and behavior about crying and shaken baby syndrome: A replication of a randomized controlled trial in Japan. Child Abuse & Neglect, 36(9), 613–620. https://doi.org/10.1016/j.chiabu.2012.07.003

Type of Study: Randomized controlled trial
Number of Participants: 201

Population:

  • Age — 25–35 years
  • Race/Ethnicity — 100% Japanese
  • Gender — 100% Female
  • Status — Participants were new mothers who received the Period of PURPLE Crying intervention.

Location/Institution: Japan

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess the effectiveness of Period of PURPLE Crying on mothers of newborns in Japan. Participants were randomized to receive either Period of PURPLE Crying materials or analogous control materials on infant safety via mail within 2 weeks of birth. Measures utilized include a telephone questionnaire and the Baby’s Day Diary. Results indicate that scores on crying knowledge scales, percentage of sharing of advice to walk away if frustrated by crying, and walking away during unsoothable crying were significantly higher in the Period of PURPLE Crying group than the control group. Self-talk behavior scale tended to significance in the Period of PURPLE Crying group. Limitations include knowledge and behavior changes were assessed only for mothers whereas fathers have been reported to be the most likely perpetrators of shaking, the use of self-report data only, lack of generalizability to other ethnic populations; and lack of follow-up.

Length of controlled postintervention follow-up: None.

Barr, R. G., Rajabali, F., Aragon, M., Colbourne, M., & Brant, R. (2015). Education about crying in normal infants is associated with a reduction in pediatric emergency room visits for crying complaints. Journal of Developmental & Behavioral Pediatrics, 36(4), 252–257. https://doi.org/10.1097/DBP.0000000000000156

Type of Study: Other quasi-experimental
Number of Participants: 30,790 (visits)

Population:

  • Age — 0-5 months
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Participants were infants in the medical emergency room due to crying.

Location/Institution: BC Children’s Hospital (BCCH) – Vancouver, British Columbia, Canada

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to determine whether there was any change in visits of 0- to 5-month-old infants to the medical emergency room (MER) of a metropolitan pediatric hospital after province-wide implementation of a Period of Purple Crying. Participants were all 0–5-month-old infants who visited the MER during the study period. Measures utilized include administrative records of Presenting Complaint, Final Diagnosis, and Disposition for each MER visit. Results indicate that there was an associated reduction of almost 30% in MER visits for cases of crying and colic in the 3 years after implementation of the program in maternity wards and public health units across the province of British Columbia. Furthermore, the most significant reductions were for crying complaints during the first 3 months of life. Limitations include the quasi-experimental study design and that the decrease in MER visits may have been caused by some other factor, or that infants were seen by other health care providers instead.

Length of controlled postintervention follow-up: Varies.

Zolotor, A. J., Runyan, D. K., Shanahan, M., Durrance, C. P., Nocera, M., Sullivan, K., ... Barr, R. G. (2015). Effectiveness of a statewide abusive head trauma prevention program in North Carolina. JAMA Pediatrics, 169(12), 1126–1131. https://doi.org/10.1001/jamapediatrics.2015.2690

Type of Study: Pretest-posttest with comparison states
Number of Participants: 405,060

Population:

  • Age — Not Specified
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Participants were new mothers who received the Period of PURPLE Crying intervention and the nurses who delivered the program.

Location/Institution: North Carolina

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to assess the impact of a statewide implementation of the Period of PURPLE Crying on preventing abusive head trauma (AHT) in infants. Participants were all mothers of newborns in the state. Measures utilized include administrative data on abusive head trauma rates and purpose of calls to nurse advice line. Results indicate that after implementation of the Period of PURPLE Crying intervention, the number of telephone calls to a nurse advice line, especially those regarding infants younger than 3 months, significantly declined. However, no reduction in state-level AHT rates was identified using a difference-in-difference analysis to compare AHT rates in North Carolina with AHT rates in 5 selected comparison states over time, controlling for economic indicators. Limitations include nonrandomization of participants; the primary outcome, AHT rates, is based on administrative claims data, which may be subject to regional and temporal variation; and lack of follow-up.

Length of controlled postintervention follow-up: Varies.

Barr, R. G., Barr, M., Rajabali, F., Humphreys, C., Pike, I., Brant, R., Hlady, J. Colbourne, M., Fujiwara, T. & Singhal, A. (2018). Eight-year outcome of implementation of abusive head trauma prevention. Child Abuse & Neglect, 84, 106–114. https://doi.org/10.1016/j.chiabu.2018.07.004

Type of Study: Other quasi-experimental
Number of Participants: 354,477

Population:

  • Age — Not Specified
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Participants were all parents of newborn infants born between January 2009 and December 2016.

Location/Institution: British Columbia, Canada

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to determine whether the British Columbia experience implementing a province-wide prevention program (Period of PURPLE Crying) reduced abusive head trauma (AHT) hospitalization rates. Participants were the parents of all newborn infants born during the study period. Measures utilized include administrative data on AHT hospitalizations and tracking data on whether families received the intervention. Results indicate that 90% of mothers received the Period of PURPLE Crying intervention, with fathers present 74.4% of the time. By 2–4 months, 70.9% of mothers and 50.5% of fathers watched the DVD and/or read the booklet. AHT admissions decreased for < 12-month-olds by 33% and by a statistically significant 35% for < 24-month-olds. Limitations include that other factors may have caused the reduction in rates, a lack of comparison to similar data in other provinces, and that fatal AHT cases were excluded, as they were not admitted to the hospital.

Length of controlled postintervention follow-up: Varies.

Sadler, K., Rajabali, F., Zheng, A., Jain, N. & Pike, I. (2023). Impact of a parent education program delivered by nurses and health care providers in reducing infant physical abuse hospitalization rates in British Columbia, Canada. Canadian Journal of Nursing Research 56(1), 109–116. https://doi.org/10.1177/08445621231222527

Type of Study: Other quasi-experimental
Number of Participants: Not specified

Population:

  • Age — 0–24 months
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Participants were all children, ages 0–24 months, admitted to BC Children’s Hospital during the study period.

Location/Institution: British Columbia, Canada

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to determine if the Period of PURPLE Crying program had an impact on the rate of physical abuse hospitalizations for children less than or equal to 24 months of age in British Columbia since province-wide implementation in 2009. Participants were all children, ages 0–24 months, admitted to BC Children’s Hospital between 1999 and 2019. Measures utilized include administrative hospital admission data. Results indicate that physical abuse hospitalization rates decreased by 30% after Period of PURPLE Crying implementation. Limitations include concerns about the accuracy of the coding for physical abuse in hospital records and that other efforts besides Period of PURPLE Crying may have led to the outcomes.

Length of controlled postintervention follow-up: Varies.

Additional References

Barr, R. G. (2006). Crying behaviour and its importance for psychosocial development in children. In R. E. Tremblay, R. G. Barr, & R. D. Peters (Eds), Encyclopedia on early childhood development. Centre of Excellence for Early Childhood Development. Available at this link.

Barr, R. G. (2012). Preventing abusive head trauma resulting from a failure of normal interaction between infants and their caregivers. Proceedings from the National Academy of Sciences of the United States of America, 109(Suppl. 2), 17294–17301. https://doi.org/10.1073/pnas.1121267109

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 and Behavioral Pediatrics, 28(4), 288–293. https://doi.org/10.1097/DBP.0b013e3180327b55

Contact Information

Danielle Vazquez
Title: Executive Director
Agency/Affiliation: National Center on Shaken Baby Syndrome
Website: www.dontshake.org
Email:
Phone: (801) 447-9360 x111
Shantel Wakley
Title: PURPLE Program Director
Agency/Affiliation: National Center on Shaken Baby Syndrome
Website: www.dontshake.org
Email:
Phone: (801) 447-9360 x102

Date Research Evidence Last Reviewed by CEBC: April 2024

Date Program Content Last Reviewed by Program Staff: August 2024

Date Program Originally Loaded onto CEBC: August 2008