 My name is Chris Greeley. I'm a pediatrician at the University of Texas Health Science Center in Houston. I research the prevention and recognition of child abuse, mostly physical abuse, and mostly injured babies and brain injuries and babies. And so we have a panel today to discuss some of the ideas and programs around preventing abuse, particularly physical abuse and neglect in babies. And I wanted to start by framing our understanding of prevention and giving you a couple of slides just on prevention in general. And then we have an expert panel of people who are involved with developing and rolling out of programs that helped to, intended to help support families and young children. And so historically prevention of child abuse was targeted towards the child and that the child was broken or bad and children were locked away. And we hear the ideas of street urchins in the 1800s and early 1900s and that the problem with abuse was the kid just was not made properly and it was their fault. And prevention was recognizing the bad seeds and getting rid of them. In the early part of the 1940s and 1950s there was a real change to look at the perpetrator themselves and it was looking at the parent mostly or people and we had the idea of old men and trench coaches in the street corner beating up kids and abusing kids and it was something that they were wrong, that there was some psychopathology, that they were broken in some way. And really how we've come to today is that we've viewed prevention in a very different light and we view it now as a symptom of larger societal either imbalances or illnesses or problems within societies, communities and families. And so most of us are familiar with the idea of primary and secondary tertiary prevention which is, you know, going before something happens, decreasing the effects of something or ameliorating things after it has happened and really I want to reframe this for you in how prevention really is being thought of now, reframing it to a population level approach. And if we think of population level there are certain key features that are really, really important. One is primary prevention, meaning prevention before abuse would have happened or even the risk factors of abuse have started to develop its population focus not on an individual person but on a community or a group of people, lots of disciplines, it's not just a doctor or a psychiatrist or a social worker or a nurse, it's a collaborative efforts, lots of actions and really one of the hallmarks of modern prevention is one of the challenges which is monitoring and assessing whether it works or doesn't work and that really becomes a big challenge and we'll talk about some of that today. All of this stems from the idea that young kids live in a really complicated world, they have issues themselves, their families may have issues, their neighborhoods may have issues, the society they live in may have issues and this is web what has been described in the past as an ecological theory. All of these things either are risks or protective factors for young kids and I want to reframe prevention along a different continuum and not just really primary, secondary and tertiary but it's in quadrant. So if we think of prevention, we think of responses to bad things, we can either be reactive or we can be preventative or proactive, it can be to a lot of people, a collective or it can be to individuals so what we really want to be in prevention is for a lot of people proactive or preventative and the goal is to be in that top quadrant, not what we see most of the time which is reactive in individual is crisis or therapy sessions, reactive but collective are food banks or helping homeless shelters, things like that, preventative individual are individuals counseling and skill sessions and what we really want to be is that top corner, we want to be helping communities, helping infrastructures, developing networks, helping creating safety nets that are proactive and preventative and for a larger group of people and the goal of some of the programs for your consideration is to sort of think through in this network of being proactive and preventative and helpful for larger families, how do they fit and we look at what are the, what we call, what I call the cake of well being, there are child protective factors or things about the child that make it easy, there are things about the family that make things better, there are things about the community that are protective and there are things about society in general that are protective and we have to balance those against some of the risk factors and the risk is there may be child issues, the child may have colic, the child may have birth defects, the child may be medically fragile, the child may have just a bad temperament, there are family issues that can be risk factors to the child, there are community factors such as access to healthcare or childcare and then there are societal issues where there is injustice, inequality and imbalances and so prevention of child abuse, these balances between increasing the protective factors from child family, community or society and decreasing the risk factors and some of these programs are geared towards that or these programs are geared towards some of these areas and there's not one solution, there's not one answer to child abuse, it is a patchwork addressing individual community and family needs and so that's for your consideration. I'm going to start with Sara Dzynski who will tell a little bit about herself while I get her slides together. Let's see, I think I'm actually going to use this. Can you hear me? No? Let's try that one. How about now? Better? Alright. Well thank you so much for having me here today. As Dr. Greeley said, I'm Sara Dzynski, I work at Dell Children's Medical Center in Austin, Texas. I work in trauma services as a research scientist and a child abuse prevention specialist. This is our facility, we are a member of the Seton family of hospitals, we have over 15 hospitals and clinics in the central Texas area, including two level one trauma centers and Dell Children's is one of those trauma centers. As I said, I'm going to talk with you about abuse of head trauma. When those cases come in, they come into our hospital, they come into our trauma service. We treat them and I can tell you in the past 10 years we've treated about 240 cases of abuse of head trauma in our trauma service and that averages about two cases per month and as someone who sees these cases regularly, that's two cases per month, too many. So what is abuse of head trauma? Basically, it can be caused by direct blows to the head, by dropping, throwing or shaking a child. And now let's talk about shaking baby syndrome. Actually just in FYI, the medical community kind of now prefers the term abuse of head trauma as an umbrella term. Shaking baby syndrome is a form of abuse of head trauma and it occurs when a baby is shaken and held by the torso or the shoulders or the arm, most commonly the torso because you see accompanying rib fractures that come with that. But it can also be with impact to the head with or without shaking. So let's talk about shaking as a mechanism of injury. A child, an infant brain is very soft and so when you shake an infant, their brain is actually kind of pounding against the skull itself and in seeing perpetrator reenactments, videotaped perpetrator reenactments, the shaking motion looks something like this. So you can imagine the head whipping back and forth. The neck muscles are not very strong and you see and for that reason with that impact you see the subdural hematomas, you see the retinal hemorrhages that result and so you can see some really serious cognitive impairment, blindness and death. So what is the scope of the problem? Abusive head trauma is the leading cause of child abuse death in Texas and in the US. So Texas is also among states with the very highest rates of child abuse in the country. And this slide, in Texas we have an average of 191 diagnosed cases of abusive head trauma each year but I want to make really clear that everybody sees the giant asterisk up there. These are hospitalized cases only. They exclude kids that are treated and released from the emergency department. It excludes kids that are dead on arrival who never make it to the hospital or who go to the hospital and go straight to the morgue. And so the true estimates of child abuse are probably two and a half times greater than that. Unfortunately our current surveillance systems and our current classification systems do not accurately capture that. So the true numbers probably more like about 500 cases. So what happens to children who have been victimized by abusive head trauma? About a quarter of them die and those that survive experience some really serious cognitive impairment. We see cerebral palsy, we see severe motor dysfunction so kids have a hard time walking, blindness, seizures, mental retardation and really less than one in 10 kids that is shaken or experienced as abusive head trauma resumes normal functioning. So let's talk about the cost. You can imagine these cases can be extremely costly. As I said we see a couple of them per month and oftentimes these kiddos they don't come in and stay for a couple days and then leave. They're in for four, five, six weeks. And so that in itself can be costly but then think about the physical, educational, occupational therapies that are ongoing for their lifetime that they have to access and then you've got oftentimes if they're removed from their family you've got lifelong custodial care and you've got legal costs. So these can easily exceed a million dollars per child. So what do you think the number one trigger for perpetration is? Who here has kids? Yeah, okay. So you can imagine. Who's seen this curve before? Who's seen this diagram before? Just a few of you. Okay, so this is the peak infant crying curve. So you can see that at about two weeks of age an infant begins to cry more at about five, six to eight weeks they hit their crying peak and they can cry up to five or six hours a day. And then it sort of tapers off at four to five months. So who cries the most? Who's at greatest risk for abuse of head trauma? Infants one to three months of age. I think our average that we see is kiddos infants that are about six weeks of age, the average. And you can imagine that new parents, they're just sometimes not prepared for the amount of crying that infants do. Of those of you who raised your hands with kids, how many of your children cried for more than 20 minutes a day when they were in that phase? Yeah, it can be pretty, pretty tiring, huh? So some other risk factors for abuse of head trauma are poverty, financial stress. So there was a study by Rachel Berger that came out a few years ago that showed that during the economic downturn, the recession, the rates of abuse of head trauma and various sites across the country actually almost doubled. Low educational level, young parental age, so parents, infants of children 20, age 20 or below have a five times higher risk of being shaken than older, than children of older parents. Male gender, males comprise about 70% of perpetrators. Maternal depression and lack of impulse control. So if you think that our neocortex didn't really, doesn't really develop fully until we're 25 years old, there's a lot of people walking around out there with kids who are under 25 and who don't have a fully developed sense of impulse control. So what do we do about it? At our hospital, at our network, we decided on a program called the period of purple crying. We like this program for several reasons. It's based on 30 plus years of research on crying and infant development. It is a primary prevention program, so it touches everybody that comes to a birthing center and has a child, has a new baby. It can also be reinforced secondarily in physicians' offices, through home visiting nurses, through parenting classes in emergency rooms. You'd be amazed. I ran the numbers and last year we had 600 visits to our pediatric ED with the chief complain of infant crying. So parents are very concerned about it and they come in. The other thing we like about this program is that it's available in 10 languages and Arabic is coming soon. And that it's affordable. It's $2 per unit when purchased in bulk. So over here you have $1 million and over here you have $2, which makes more sense. So the program itself, who has actually heard or seen the period of purple crying? Just a few of you. Okay, fantastic. Well this program consists of a 27 minute online training for professionals. And it consists also of a DVD and booklet, kind of a packet. And so what the parent experiences, what the family experiences in the hospital stay when they get their primary prevention, they watch a 10 minute film. And then the nurse or other trained professional gives them a 3-4 minute talk using the booklet as a guide. And then they take those materials home with them. That's a very important part of the program. And they're encouraged to share those materials with anyone who will be caring for their child. And on that DVD there's an additional 17 minute film on infant soothing. So what are some of the key messages? Well purple actually is an acronym. And it stands for a peak of crying, which we talked about previously. It talks, the U is for unexpected, that the crying comes and goes. R is for resist soothing. Your baby may not stop crying no matter what you try. P is for pain like face. L is for long lasting, can last up to five or six hours a day. And E is for evening, that it clusters in the evening just when the parent is the most tired and frustrated. And so a couple of the other key messages are that peak infant crying is normal. That it is okay to feel frustrated. And also that if the frustration is too much, put the baby in a safe place and walk away. Never shake or hurt a baby. Some caregivers may be unsafe, so choose wisely and share these messages with everyone who cares for your child. So what are some of the program results? Some of the published results have shown improved knowledge on infant crying, increased sharing of information on infant crying, dangers of shaking and walking away of frustrated. It's also shown some improved behaviors in walking away, putting the baby in a safe place and walking away. And these are some of their pre-publication results. I just got these from the 14th International Conference on Shaken Baby and Abusive Head Trauma earlier this week. That parents report feeling less frustrated about their infant crying. They feel less stressed about their infant's crying. They've seen a reduction in calls to the nurse line on infant crying, a reduction in ER visits due to infant crying, and a reduction in shaken baby and abusive head trauma hospitalization by about 38%. So these, this is a map, I think you saw this map earlier in the plenary session. This is a map of purple states and other countries. It's also been doing, being done in Japan, Australia. The purple, the dark purple are states that are doing it system wide. The light purple have a certain percentage of hospitals doing the program and different community programs. You can see Texas, we're not, we're white. We're not, we're not light purple. We're not dark purple yet. But we're hoping to get there. So I asked the National Center for a list of sites that are currently implementing the program in San Antonio. And they mentioned San Antonio Army Community Services, University Hospital San Antonio. And unfortunately I was floored. I called the Learn CPR and First Aid Safety phone number. And they do the training for home, for foster cares and childcare providers. And they told me that it used to be a requirement to do the, the period of purple crying, but they no longer do it because it's no longer a requirement by the state. And that just about broke my heart. I thought, gosh, what a missed opportunity there. But an opportunity that I'm very excited to be a part of. We are working as part of the Child Protection Roundtable requesting legislative funding for abuse of head trauma prevention services. We're hoping to ask for a little over five million from the Texas legislature so that hospitals and home visiting organizations can apply for funds to implement the period of purple crying in their communities across Texas. So please keep your fingers crossed on that one. So I love this picture. I just want to, you know, take this opportunity since I have the microphone. I really do think that it is incumbent upon us to be leaders on this issue. As one of the states that has superlative rates of child abuse, it's our job. And it's really, it's really our responsibility to advocate prevention of abuse of head trauma. And so let's be leaders. Let's, let's turn Texas purple. Let's, let's, let's really take up the mantle on this one. So with that, yeah, I can take some questions. Does anyone have any questions? Oh, and that's more information. If you want to write down the information on the National Center. And also, if anyone is interested in the period of purple crying, Julie Price is the director of international programs, and she'd probably end up giving you my name anyway as a local implementer. So you can always reach out to me as well. Yeah. Any questions? Okay. Well, then I'm going to turn it over to Rachel Hullbox, who is going to introduce herself. I'm technically challenged. Oh, there we go. All right. I'm Rachel Hullbox. I'm senior manager partner relations with Haven for Hope. I'm actually not going to talk about Haven for Hope today. Cathy Fletcher with Voice for Children asked me to talk about my experience of becoming a new parent in New Zealand. So it's a consumer perspective of it. I was fortunate to have a child, which was nice, and then also to have that child in New Zealand and experience their parenting program that they have available. So I just want to go over that with you guys. So some of the main points I want to cover is their well child, or it's called Tamariki Ora, which is the Maori word for well child services that are available to new parents living in New Zealand. The network of providers available to new parents living in New Zealand, the parenting together, new mother group, overall plunket programs and the plunket of family violence evaluation project that they have. Some of the things I wanted to focus on, first of all, with the well child Tamariki Ora service is that it is available to all individuals. I'm a US citizen. My child was a US citizen when she was born. They actually changed the rules so she doesn't have dual citizenship, unfortunately, and they changed that 24 days before she was born. So they did reach out to us and ask us and provided us with the service that was available. Being a brand new parent, we were halfway around the world from our family. Not a lot of close friends nearby. It's about an 18 hour time difference as well. So to try to call my friends who were new parents as well to get some advice was difficult in navigating those dateline changes. So it is a free service that's available. 90% of the parents in New Zealand participate in this program. It is offered as soon as you identify midwife or you go to a hospital, as soon as you learn that you're pregnant, they loop you into the system right away to let you know that these services are available for you at the time that you give birth. So some of the programs that are available are the health education and health promotion, which is the thriving under five and the well child book, which actually brought samples of them here that they give out. Of course, it changes every year the cover, but and it is written into languages. It's written in Maori and it's written in English as well. And then they have the health protection and clinical assessment, which are the plunket nurses and the well child visits that occur as well. And then the fauna care and support. The WH actually is a F sound. So it's fauna care and support. And that is the parenting together and new mom's groups that they have available. So you're given three different providers for your well child Pomariki order services from birth to four to six weeks of age. You have your midwife or your GP being brand new to the country and learning that I was pregnant. I had no idea how to find a midwife went to our closest hospital, which was the Christ Church Women's Hospital. When they said you need to find a midwife that I don't know how to go about doing that, they noticed my accent. They said you're American. And I said, yes. You just come to the hospital. We'll take care of you. That's what you're used to. So that's why I actually had a team of seven midwives that I worked through during my pregnancy. I was able to meet all of them during that time. So from four to six weeks to four to four and a half years of age, they identify a well child provider in in our neighborhood that we lived in. Okay. And so you not only get your general practitioner or your pediatrician, you get your plunket nurse. If you're of moderate descent, you get a moderate provider. If you're a Pacific Islander, you would get a Pacific provider and or public health service. And then you can see up there that it shows that at one year of age, they're gonna refer you to a dental therapist at three, four and five. You'll have the hearing and vision tests that are available at the educational center or the schools. At five years of age, parent and child, you get your general practitioner, your public health service. At the age of five, every child begins school on their fifth birthday. So they will have all of this in place. And then on their fifth birthday, they learn a brand new system of life. So I just wanted to show to everybody kind of what the timeline looks like. So you can see the pre birth, you get a car seat rental scheme that's available. We didn't have a car at the time. We didn't really need it. We were taking public transportation. So our buggy work just fine for us. But the car car seat rental was $25. And that's for your for your newborn. As your child gets older and you get a toddler car seat, you upgrade they will upgrade that for you free of charge as well. So you turn one in, you get a new one out. So the other things as you can see, how it kind of correlates you have the clinical services and the volunteer services and the parenting supports that are available. So at newborn, you're referred to the plunket system within the first four to six weeks, you have your first home visit. During that purple, right, you know, phase time that Sarah was just talking about. And you're also also introduced to the plunket system. And then it'll work through it. At seven to eight weeks, you're then introduced to a parenting new mother group that is a six week session. And you proceed to work your way down. As you as your child gets older, the visits become less and less. And so you can see that all outlined for you. So the parenting together new mother group, that does happen at four to six weeks. They are six weeks in length and they connect to again to your neighborhood, Plunket Community Center. It is free of charge. It is for anyone of any economic status. So whether you're upper middle class, or lower middle class, whatever it may be, it's all incomes, all ethnic backgrounds, it's open to anyone can attend it. But what it's doing is so it's connecting you to your neighbors, who just recently had a child just like you. So for my kiddo, she had in her little group, there were kids that were maybe a couple of weeks older, and a couple of weeks younger. So you have that whole timeframe there. So we would have weekly meetings where we're meeting the other moms. And all of our kiddos close in age is kind of fun at first because they all just lay down on the floor. And then as you grow, they start to crawl and then you're on, you know, parent watch duty and everything. One of the great things that I learned time there was that they didn't have Cheerios and you know, every toddler loves Cheerios here in the US. Their version of Cheerios are little sausages. So that was a little hard to explain to them that no, they're actually round cereals that have families ship it over. And we have a photo of all the little Kiwi kids learning to eat Cheerios, the cereal for the first time. And it was pretty cute. So in this weekly meeting that we would have, we'd have a speaker come and you can see some of the sessions and the third bullet point that they provide there during that time. That session's about an hour. And then you're welcome to stay afterwards for tea. So they have just basically it's community center, you're sitting there, you can hang out. You just shut when you're ready to leave, you just turn off the lights, clean up your dishes, and walk on out. And it's like, for hours is at the end of a little cul-de-sac and you just head on out. It's like it was a neighborhood home for folks. So it was a great opportunity. And we did various people would stay for various lengths of time, depending upon if you're catching buses or you're driving home or you just really need to talk to another parent who's going through the same experience you were. So after the parenting together new mother group, the Plunkett nurse actually provides everyone with a contact list. Here are all the other moms that you've been hanging out with. Here's their kids. Here's their birth dates. Here's where you guys live in the neighborhood to each other in case you want to get together. And then it's the responsibility of the parents to carry on the group if they want to. They don't have to meet there. They can if they want to, if they want to, but they have to schedule a particular time. So in my program, there were 16 of us. 13 of them continued with the program. Some of them dropped out a couple of weeks into it. They weren't interested. Six moms continued into weekly and monthly programs. So we would meet at the park. We would meet at the library, at each other's homes. And then the fathers started getting involved, which was really cool because then you had all of these families that were meeting together on a regular basis. We actually celebrated our first birthday party all together and we were able to use the original Plunkett center where we all met. So it was a nice little celebration for us to have. As of today, I am still in contact with five of the other families via social media. We, together, we all were sending photos back and forth to see how we're doing. Someone just had their first communion, so you get to see that. You get to see another kid learn sailing from their first time. All those new experiences, you get to see them from when they were very little to present day. So I just wanted to list what the Plunkett services are available. So they do a home visit right after you have your child. For me, I was very fortunate for a healthy delivery to stay in the hospital for a week. I was like, stay as long as you want. So I stayed for about five days and then I left. But they also had breastfeeding nurses that came in to make sure everything was going okay. Every time that I opted on breastfeeding. But the option was if you did not want to breastfeed, you had to sign a waiver every time to say that it was okay for my child to have formula. So that was a big thing. They really are big in promoting breastfeeding. But once you get home, they have about four to six visits after that time of being home where they're bringing, they're coming to you. You do not have to go out to the hospital. They're all going to come and visit with you. And then after that six visit, they will then start connecting you to the community and to their clinic as well. And the clinic is in the same location as the community center. So it's pretty much a one stop shop. And then you see the clinic or what I visits. So in the first year, they're pretty regular. And here are some of the services that they provide. The family center is what I was talking about with the community facility. So you can go there. They will have a nurse that's on duty to just be there in case you need immediate assistant. You need I need help from someone. Can you can you help me for the moment? They'll take your kid. If you even need to just nap, you know, your kid's been crying and now they're they won't stop crying. Let me just take a nap for a few moments to regenerate myself or rejuvenate myself. They continue with parenting education and support. The plunket line. It says 24 seven line that anybody can call. And I love how they say regardless of how silly your questions may be. I know we called one time when our kid had Ecto green poo and we're like what happened to her. She ate too many peas. So but then also the child safety and car seat car seat scheme, which I talked about a little bit earlier. They continue with the health promotion and information. Again, that's the thriving under five book and the well child Tamariki order book that's available. Let me just pick this up for a second. The great thing about this is that I don't have multiple hands. I can't do this off. But it breaks down. Thanks for you. One to two years old. What you're going to be experiencing. They have a whole section of safety in here. How to do CPR if you need it. One of the most important things I found was at birth right away. This is right there across the top birth. Spontaneously gave me all my measurements for my kid and then proceeded every appointment after that are listed in here. And it's all throughout the very back. All my immunization records for my kiddo are listed. So you take this with you every time you visit or they come to visit you in those first five years. Some of the other things were the parents as first teachers really continuing if there were any of their additional classes that you wanted to be a part of. They had those available as well. The antenatal classes, the mobile units for those who may have been in more remote areas of New Zealand. They will come out to you. And then lastly I just wanted to focus on the Plunkett Family Violence Evaluation Project. My time out in New Zealand my husband was there for a post doctoral research fellowship and I was fortunate to be a part of a research program as well as the family violence news or sorry it was a New Zealand family violence Clearing House where we were able to collect research on violence occurring in New Zealand for a population of three million individuals. There is actually quite a high percentage of violence that goes on there. So with the Plunkett system what they were trying to do was really have someone who is in the home able to ask screening questions on a regular basis to see what's going on to kind of reduce it as quick as they could. Some of their research summaries I won't read them all but some of those that I thought were interesting were the so they interviewed the Plunkett staff and the individuals the moms who get visits from the Plunkett nurses but they talked about their initial anxiety and apprehension the Plunkett staff did first about asking about family violence early on. They realized that the relationship changes as you and your Plunkett nurse get to know one another. I know at times I had a couple of disputes with my own Plunkett nurse in regards to her method that she thought I should do in my own thoughts about it as well but we were very open to disagreeing at times. So but you do have to build that relationship before before someone would be willing to disclose that there's violence in the home which I think was important. They do have particular screening questions and I believe those questions are in the the evaluation report which the sources on the next page as well. Sixty four percent had documentation of family violence screening that was occurring and six percent had evidence of a positive screen response. So they are able to identify it out and while they're visiting books in their home. And then there's a significant variation in the screening across locations. If you're more in a remote area versus in a more urban area they would have that information too. And then lastly at the very bottom there is the website. This is also I believe available electronically for everybody who's here as well if you want to investigate it further. But I just wanted to let you guys know about that. Do you guys have any questions at this point. Yes ma'am. It's the government. Yeah there's actually the royal. What do they call it. What's their official title that they have. The Royal New Zealand Plunket Society is government funded and then you have the Ministry of Social Development that also helps in funding those resources. Yeah anything else. It's been it's mainly offered to first time moms but I can they can't offer it to second and third time moms as well. I know within our group there was one mother who this was her second child. She requested to be a part of it because she had such such a horrible postpartum depression the first time. And it took she told us this probably about eight weeks into us all knowing one another that she the reason why she signed up to continue with the Plunket program was because in her first pregnancy she was living in London at the time and she was standing on the balcony of her flat about ready to throw her in herself or herself and her child off the balcony due to postpartum depression. So she was like this is why I'm here and this is why I have the connection the network to continue with that. So yeah any other questions. OK I'm going to introduce you to Colonel Karen Weiss now. I am Colonel Karen Weiss I am an active duty Air Force nurse and I I'm not in my uniform because I'm really not here to speak on behalf of the military. I'm here to tell you about a program that we offer within the military. So I didn't come in uniform. I am currently the Dean of the Medical Education Training Campus but I am a registered nurse and I've spent most of my career working in obstetrics as a labor and delivery nurse and I'm also a nurse scientist in this project that I'm going to talk about is it developed through about almost 20 years of research. I have to disclose that there I have no financial disclosures and that the information I'm going to provide is my thoughts not those of the military. So you've heard a little bit about I'm not going to speak really about child abuse but I'm going to speak about the preventive program that is meant to decrease maternal anxiety and stress and depression and you've heard the what can happen when mothers have depression postpartum depression in particular but even prenatal depression. And the other aspect of this program is hopefully will the reason it was developed is we know and I'll speak to it that we want to decrease low birth weight and preterm labor and those are other predictors of child abuse. So prenatal maternal anxiety is predictive of early gestational age low birth weight higher rates of childhood illness and also physical and cognitive developmental delays which also are predictive of child abuse. And again prenatal depression is linked to low birth weight it's linked to preterm birth and poor maternal attachment which again anytime there's poor maternal infant attachment we run into problems as mothers late in postpartum. So the following a lot of people do research I know not a lot of for say I guess but those of us that do research in maternal anxiety and stress a lot of people do generalized evaluation of stress but when you do generalized evaluation of stress you can't intervene because you don't know what the stress is that you now have to intervene on. The work that I've done in the past 15 to 20 years looks specifically at anxiety and stress that a woman has relative to being pregnant. And the factors that women feel relative to being a mother we have predicted these things. So that the fears and the anxiety that a woman experiences relative to her acceptance of pregnancy and I can go into all the different components that make up these that would take a while but I will foot stomp that when you talk about acceptance to pregnancy it's body images it's discomfort it's the pain it's all of the things that go into into early pregnancy and it is predictive of preterm birth. Also a woman's ability to identify with their motherhood role how they're going to be as a mother what is that and did they have a role model and who is that role model. It's predictive of preterm birth and then their feelings and their in their preparation for labor. Their concerns and their fears with relative to their preparation for labor that was also predictive of preterm birth. And then this component this feeling of well being of themselves in their own unborn child to their fears relative to that to themselves and what might happen to themselves in labor or even as they carry their unborn child so maybe fears of physical harm to themselves and their unborn child were predictive of preterm birth. So these two components relative to maternal anxiety were predictive of low birth weight and the low birth weight is very much. There's a less in the literature related to anxiety and stress and fear relative to low birth weight but preparation for labor so again their fears relative to how they're going to work through the labor process and how that's going to be for them and I'm going to tell you after being in this area for almost 20 years I mean when I started in labor and delivery most women came in a natural childbirth and now we've transitioned to a to a generation that if probably about 93 percent of all women they expect to have an epidural and they are almost frantic if they think there's any way that they're not going to have an epidural and so if that's the way that they're going to handle that it's very, very concerning to them and they don't have a plan so it's predictive of low birth weight and then their helplessness and loss of control and this was kind of a complicated factor but it kind of plays into the preparation for labor. It's very unusual nowadays in this generation of how of their feelings about helplessness and loss of control but those fears and anxieties relative to their ability to deal with that were predictive of low birth weight. So another really important component about being a mother and being pregnant and dealing with the fears and anxiety relative to that is your self esteem and those of us that are mothers know that while you're pregnant you feel guilty about everything. You know did I eat the right food or did I have a drink and I was pregnant and I didn't know it and then once you have the child a lot of times it can be the father or the baby, your husband no matter how much he cares but they make you feel guilty, your mother makes you feel guilty, your aunts and uncles make you feel guilty. So it's important to build a strong self esteem and that if when they have poor self esteem it is predicted there's a problem with depression and anxiety as well. So it's important that we build a strong self esteem with the father and the baby and that I'm going to footstomp the relationship to the father of the baby and the relationship to the maternal mother are critical to the woman's progressing through pregnancy and when that mother does not have a strong relationship with her mother there has to be somebody to fill that role and when her husband or father, the baby, is not around there has to be somebody to fill that role and I'll talk a little bit about that relative to the military and the things that we face with the absence of the fathers due to deployments, etc. So unique to the military population women with deployed husbands and this is actually research that I did. Initially I followed 95 women who were all deployed had deployed husbands and it was in Florida where the special ops community is and these men in the special ops community are deployed without any notice and they're deployed to locations where there's no communication with their families and so these women a lot of them had no communication with their husbands and those women that could not communicate with their husbands had lower self esteem because again when you're pregnant that husband or that father, the baby they're building up that woman to be the mother that she needs to be and that role that is played by that person they're the people that tell that mother you're going to be a wonderful mother you're beautiful you're taking great care of yourself that's a great plan that you have but when nobody is telling them that it can be a problem. So women that had deployed husbands and those same women we discovered that they actually had lower acceptance of their pregnancy as well which is a pretty amazing finding and even more importantly those women that had low acceptance of their pregnancy you would expect it to gradually go away as they went through pregnancy we had cases where these men were back before the women delivered and even when those men returned before the delivery those women had lower satisfaction in their maternal role than anybody else. So and that's that last line and that's important to know because we also know that these women so acceptance to pregnancy in the first trimester despite the fact that their husbands return affected their satisfaction in the maternal role and satisfaction in the maternal role is predictive of child abuse. So esteem building community support we looked at that and this is actually exactly what we measured. Again a lot of people that do research measured a lot of different components of support they measure tangible support we're really good about giving books and giving blankets and giving all these things when you're expecting a baby that's tangible support. We are really good about giving information support but the important support is the esteem building support that you get from the community a little bit of what she was talking about in New Zealand in that that community of support that peer group it's extremely important. So we did find that when the women said that they had a strong community of support they had they did decrease their fears relative to acceptance to pregnancy relative to identification in the motherhood role preparation for labor well-being of self and baby relationship with their mother and relationship with husband and more importantly and I'll footstomp this that in the military we asked them do you believe your community of support is the military component or is your community of reference the civilian community and when they said their community of reference was their military community they did better. So in other words we need to be surrounded by those that we know and we believe understand us. So we also discovered timing when you build interventions is important and we discovered the support had the greatest effect in the first and second trimesters of pregnancy because again women walk around they're pregnant they don't in the first trimester nobody knows they're they may be pretty quiet about it but they need support. And then this formed the basis for building the moms program. So all of these findings I just described we'll form the basis for the mentors offering maternal support program of which I'm going to talk about. So we designed a mentor support intervention program and when I talk about the mentors they are other women mothers they go through a training program that I built and designed based on these findings. So for every one of these aspects of anxiety they they learn all about that aspect so that when the women come to the class they can help them with that. The timing of the intervention is specific to the type of anxiety and it starts in the first trimester and it goes for eight weeks every other week which will take them to the end of their to the beginning of their third trimester which if you know if you think about pregnancy at the beginning of the third trimester we're really good about offering interventions. At that point in time you go to birthing classes you go to lactation classes you go to epidural classes you go to all kinds of things at the beginning of the third trimester these women need something in the first and second trimester of pregnancy and so now we've met that by the time they're to their third trimester they don't it's not as important now there's other avenues. I'll tell you this one continues though. So we train the mentors and we have a manual and this is actually the old manual. It's gone through revision and based on the input from the women we built we added a postpartum chapter I added a multi-gravity chapter so every every aspect we cover each week so each week is a focused discussion on one of those anxieties on one of those dimensions and we that that guides the discussion and keeps it focused so we don't go off on tangents and that focused discussion is focused also around family connectedness and resilience because we want to build the self-esteem we want to build coping and we want to build resilience. So these are some of the findings and APDS for those of you that work in the depression who work you know that that's a measure of depression it's been validated for postpartum as well as prenatal measure and the women in the treatment group did have a significant change in their level in their depression and the control group actually would appear that they went up slightly. You can see that there's a difference they were randomized this they were totally randomized to the control of a treatment group what happened that and that you see up there cohort with no history history of no deliveries so this would be like the quartiles or when you break the higher risk group so the women that had never had a delivery did have a higher instance of depression and we affected that depression with that group the greatest. The brief is a measure of resilience and so again it would appear as if there was a significant change in the treatment group for them for their feelings of resilience a greater self-esteem and coping after the treatment after being a part of the moms. So I just put these themes up here from the women because in addition to meeting with them every week these things these statements come out from them and and the pressure and the and they share this is what they are able to share together and they talk through and then it helps them but they women in the military wives and I and people are fighting well there's women there's active duty women and I probably should I took all the demographic information out because I didn't want to make it a research presentation but so obviously in the military to be a dependent to get care as for your pregnancy you either have to be a wife of an active duty military member or you'd have to be an active duty pregnant woman we have both of those so the only women that might not be married are the active duty pregnant women because they you know it's the way it works in the military so the women that that are married to a military member as their spouse have a profound fear or any need I mean they feel like they have to totally support their husband in the mission and if they don't do a good job of that then it will impact their husband's career they there's a lot of unwanted moves and it puts additional stress on the women and then they're pregnant and they're moving maybe while they're pregnant and as she mentioned you know she's in New Zealand and she didn't have know anybody she had no family or friends around well this happens every day we're in the military and then they in the military you know it's 24-7 the spouses aren't around the women feel like their husbands are gone at any point in time they're not home for a lot of hours and they feel very isolated and lonely and then they have fears that if their pregnancy doesn't go well or if they you know need his help in the pregnancy they will have ramifications oh no this is actually that happened but this statement is from the active duty women we had more than a few active duty women and it's not actually ongoing as we speak but I'm speaking of women that have been in it they actually are active duty pregnant women and they don't want their commanders to know because they feel like it have ramifications on their career if their commander knows that they're going to be a mother and not just an active duty member so we actually have had several women and we had one with severe depression that we helped a great deal we've had several women that one woman in particular who was pregnant when her husband deployed and she didn't want to have the baby and she actually I think she very much disliked her husband and she didn't want him to have the child either we helped her and to the point that she was very happy that she carried on with her pregnancy and that she loves that child very very much and she's glad that she made the decision she did I could tell you about endless stories in which we've helped these women resolve a lot of conflict they were having over their pregnancies we have decreased their depression and as I indicated we've increased their resilience the mentoring program just like that kind of that peer mentoring program that was already mentioned it creates friendships and bonds among the military wives and mothers we do have a Facebook page they love it and they post pictures of their babies they stay in contact we have women that come after they deliver ironically you know you wonder how it happens but maybe by God's grace or something that these women I've had classes where every single woman in the class is they may have been IVF women and it's like they just seem to find the right class for each other it is just an odd thing but and they're so happy because collectively together they have the same stresses very high satisfaction with the program and it is while we designed this program for the military population it's easily transferable to the civilian population as well again the hope is the original hope I mean I'm talking about child abuse but my work is about decreasing the incidence of preterm birth and low birth weight and so the idea is that we can decrease anxiety and stress and pregnancy then we can decrease the incidence of preterm birth and low birth weight and obviously it provides the mothers with a supportive network before and after pregnancy and it is a funded project by Tri-Service Nursing Research Program are there any questions? Thank you oh I'm sorry yes is this just the Army, Air Force? well right now because it's sort of a it's a program that we've designed and we're gathering data relative to it so it isn't that it's not for any service so it's collectively wherever you live in your community we all get care in the same area so at least here in the San Antonio Military Community which we're doing the project right now all of our care is together so if you're a Marine or you're a sailor everybody's getting it everybody, it's open to everybody well it's we have the project in Florida and we have it here but you know we have to how it works of course is you have to show that it's effective and then hopefully we'll be able to roll it out across the military and even potentially civilian I will say I didn't want to talk about the programs that we have available but I think we had you know she listed the purple project and that it's at Army but we actually have it from all of our family advocacy centers across the military offer that and we have home health nurses that go out and visit our high-risk families etc. so there are a lot of programs this is just one of the prenatal programs that we have right now that we're working on thank you, great question good afternoon good afternoon, my name is Cheryl Wyzee I'm the nurse supervisor for the Nurse Family Partnership program our implementing agency is the Children's Shelter here in San Antonio the Children's Shelter is a nationally accredited nonprofit soon to be certified as a trauma informed care agency and we have a family of services and our particular program belongs to the Family Strengthening Department at the Children's Shelter and Nurse Family Partnership I should say is a program that's been across the country if you may already know I know many in here already know about Nurse Family Partnership it is a program that has over 35 years of research across the nation in some other countries it is a program where you pair a first-time mom a low-income first-time mom with a BSN-prepared RN and that nurse works with that mom from pregnancy up until the time her baby is two years old so it's a pretty long intense program and it provides a lot of services here in San Antonio I should tell you that the Children's Shelter as our implementing agency site began, chose to launch this program in 2008 they were one of the first agencies across the state to take on a Nurse Family Partnership program in Texas today there are 21 sites there were 18 at the time they were originally funded by the Texas Legislator we are paid from the Health and Human Services Commission with matching funds from our implementing agency there are currently two other sites in San Antonio University Health System has a Nurse Family Partnership program and a brand new site, Catholic Charities well Catholic Charities isn't new but their site is a brand new a Nurse Family Partnership site and they are beginning to serve so all together we had the capacity to serve 525 families across Bear County and maybe a little bit outside of Bear County but that is something we wish could be more because as you know there are more than 525 families who could use a home visiting nurse to come and offer services these ladies talked about family support and the importance in the prevention system and the idea of preventing child abuse and once you pair that nurse with a first time mom and they develop that therapeutic relationship it is successful I can tell you and I can give you plenty of outcomes to say that we are a massive as some of the nurses who are here a massive data gathering machine and we can tell you that since implementation our particular site has served over 700 families over 500 babies and we've provided a lot of support and so the philosophy behind Nurse Family Partnership which like I said has over 35 years of research in history actually our national service office is in Denver, Colorado with the University of Colorado Dr. David Oles this is a community health and a client centered philosophy we're a strength based program we find those things our moms do well yes when we walk into a home and we make a relationship with our mom and they voluntarily join an enroll you know we're asking them what's important to them we're asking them what kind of goals that they want to make and these nurses that work at our program work very hard to empower first time moms and I can tell you just the other day talking to one of our nurses she said to me this is called empowerment and that is actually a fact that is very, very much a fact so we empower first time moms living in poverty to successfully change their lives and the lives of their children so they need to be a first time mom they have to be at or below 185th of the federal poverty level all of these items that are started by self declaration basically if a mom qualifies for WIC she can qualify for our program she does not have to be Medicaid eligible essentially they need to reside in our service area which is Bear County although we have a few that are just and a little bit outlying the county we need to enroll them before their 28th week of pregnancy because that one of our goals is to improve pregnancy outcomes and so when you match that nurse with that mom and you get them early enough you can certainly do that and of course they need to be it's voluntary so what do we offer? when I get a referral in and we assign it to a nurse we get you get the client gets an experience BSN RN and I can tell you that our group of nurses I have to say I do preach the program it's really a good program but I can tell you within our particular group of nurses we have so much experience we have labor and delivery nurses we have pediatric specialty nurses we have nurses who are experienced in psychiatric nursing and nurses who have done a lot of community health and some NICU nurses so they have a lot of experience and so I push that as much as I push the program so they deliver our nurse family partnership model of care they start visiting with the mom and they about visit with them about every other week during the pregnancy and up until the time the child is two years old in the beginning they meet with them generally about once a week in their home kind of to get to know them and then they meet with them every other week but once they have that baby during that six week time postpartum where it's so crucial that you have a nurse so you have someone who's trained looking at are they bonding, are they interacting is that baby feeding well is the baby growing does she have problems with breastfeeding how are, what's her support system in her family when you can assess that in the home so you're there once a week you're the eyes and ears of the pediatrician some of our moms are very young we're the eyes and ears of the schools you know it's and of course we're reporting if we see a situation that needs to be reported to child protective services but we're right there in a very intimate setting so mothers and child and children receive their ongoing assessments because you know what first of all we're nurses so we're weighing, we're measuring we're looking at those kinds of things but we also will if we if we assess a situation where a child isn't developing like they should or the mom needs some other kind of medical assistance then we're of course we're referring and we're catching them early so we offer case management we refer to other age services we do have, we contract with our lady of the lake in their counseling center who will provide in-home counseling as well and we do with a because where our implementing agency is the children's shelter we are able to offer some basic needs support as well sometimes we find a mom who doesn't have a safe place for her baby to sleep well we'll work to find a crib, a pack and player something for they can sleep maybe they don't have a car seat maybe the car seat they had was used maybe it was in a car wreck before and so we're gonna work to find some of those basic needs that they need so the goals of nurse family partnership and this is through our national service office of course is to improve pregnancy outcomes and to improve the health and the development of the child we're also working to improve the self-sufficiency of the mom we're asking them what's important to you what do you wanna do in your life where do you see yourself in five years and so we use motivational interviewing and a lot of other those kinds of things to help them see is it time for another baby is it do they need to wait is it how do they see themselves what would another baby look like in their life maybe they wanna go to college let's look at that and then last but certainly not least what the support that we provide prevents child abuse and neglect and it strengthens fragile families and that's what we're there for and that is one of our highlighting goals whoops back up one of it back up well I can tell you that that last slide gives you some of the outcomes of our of our particular program at the Children's Shelter thank you so much Dr. Grayley he's overqualified okay should I hit it forward okay thank you so much okay so at our particular agency these are the most recent outcomes we have and these are some of them are cumulative and some of them are with active clients so we have some really good outcomes about I can tell you some of the quality improvement projects we're working on to increase our breastfeeding rates at six months and to increase our to decrease our preterm birth rate you can see that our our babies are current with immunizations and this is above the NFP state percentage and that's because our nurses are there in the home helping them get requalified for Medicare Medicaid and helping them get those doctor visits are on the phone with the doctors sometimes our babies are developmentally on target because we're working with them on some very important parent interactions things that they can do because most of the moms I can tell you looking at their goals what they want to do is they want to be the best parent that they can be so where they're showing them some parenting things and some some ways that they can do that and and so by teaching them and by showing them and asking them what's important to them you're gonna find that a lot of the moms are gonna wait until their baby is about two years old to have that next baby because they're envisioning their life and and our babies and our moms don't have substantiated case of child abuse and neglect because part of the reason is we're providing support in the home and that is that is really the key that I think that sounds like the same thing we've been hearing with all with all the other presentations in this panel is support is a really key issue to keeping babies from being abused and neglected and that is me thank you so much so um I have to go leave and catch a flight but just for the good part uh first of all are there any questions for Cheryl about the nurse family partnership the program how it's run here in San Antonio yes sir ah well we get referrals from lots of places we of course it is a free program we get referrals we make we do outreach to a lot of different areas we do outreach to pregnancy testing centers we get referrals from them from OB clinics we get referrals from the schools and that may be why a lot of our moms our median age is 17 we also get referrals from the juvenile detention center and from the we've made outreach to the San Antonio police department and to some of their varying agencies to their probation officers so we get referrals from probation officers we also get referrals from the child protective services system not from not because a mom has abused or done anything because this is for first time moms but there we also get some of our moms have been victims of and their minors and so we get referrals from child protective services workers as well each other at the end was much bigger what's the total median well you know what every WIC eligible family in the community and right now we're that's an initiative we're working on getting referrals and actually partnering with WIC to do some referrals with them it would be enormous because there are probably 20 WIC clinics across the county the majority of them along to the city of San Antonio but there's a lot of them yeah I don't know that number yes ma'am the initiative on behalf of the nurse family partnership the information on quantitative data was very good but I'd like to know if you gather or consider gathering information to share on the quality of data go out and speak back on your population as far as whether or not they like the program whether they recommend it to others and overall have they tied into kind of wise wise yes wise yeah well we we do collect client surveys and part of it is part of the survey is just to check off you know agree strongly agree disagree but part of it is actually asking for information about how they feel about the program and what we could do better and so we have at this point we have 100% satisfaction I can tell you that the moms the comments that they say speak to the therapeutic relationship with the nurse you believed in me you taught me that I could do things myself other people didn't believe in me I appreciate the education that you brought I wish this program lasted longer what can I link with to another type of family services program and so those are the kind of comments that we get but thank you very much for that question I should probably include that because I think that yes I think we need and why they need to speak together because there is a lot about I agree there's a lot about anxiety and pregnant moms and one of our particular QI projects is working on preterm decreasing the rate of preterm birth a lot of our moms suffer from toxic shock and environment toxic stress I mean in their environment and I really think that leads a lot to and stress is just such a big issue thank you okay so Dr. Greeley asked me to step in and be the moderator for a moment so I'm going to wear two hats he left us with two questions for the panel and thinking that we could just kind of pass the microphone the first question for each of you is what is the biggest obstacle to your success in the work that you do so this is asking you to wear even more than two hats but if you want we can start here it's a hard question to answer I guess probably what we're talking about is getting programs implemented and you mentioned it that it's hard to show that the program is beneficial and how did it improve outcomes and then once you do that then you've got to have funding to support it that takes time it takes a while and that's why we're here and that's why we hopefully we can get the right program get the right fit but it's hard work one of the challenges is collaboration and that's a good challenge because once you do networking kinds of things then there's a lot of things that you can learn from each other and I think that that's a good challenge one of the biggest challenges really that we struggle with at our site is community resources and that our moms struggle with having good affordable childcare they don't have to leave their vulnerable child with somebody who's less than able to take care of them and they're not always a bad guy they're not always the bad boyfriend who's out of work sometimes they are just an elderly grandparent who is too infirmed or too elderly to you know safely take care of a child so childcare is a big issue housing is a big issue in Bear County and mental health services a significant number of our moms do struggle with emotional disturbance and part of it may be environmental it certainly speaks to anxiety even after they have their baby let me just speak on behalf of being a consumer and the comparison between being overseas and then being here as well and then talking with other moms that are friends as well while there are great services there is a restriction though someone such as myself whose middle class is not going to be able to access the awesome program that you have available and I think that those resources need to be available a challenge is having them available across the board because just in comparison talking to another fellow mom whose same economic status as myself to find out letting her know what resources were available to me while I was overseas she felt that she had no way of even beginning to understand how do I access those resources she had to search to find her own community of other moms kids close in age that she could talk to and relate to so I think to make it a global initiative is one of the challenges that's out there and I would actually probably piggyback on several things that others have said because in implementing the period of purple crying we have two birthing centers within the Seton family of hospitals and in the US we're not Canada we're not New Zealand we don't have a lot of constant contact with all mothers we have this little window of time when they're in the hospital giving birth maybe three days maybe four days so we try to do the period of purple crying in the second day but we're competing there's so many competing interests there's so many other needs that those mothers have in that tiny window of time and it's really it's a challenge it's a challenge for the nurses who have so many requirements and so many things on their plate and it's also funding has been a big challenge because in Canada and New Zealand the need for primary prevention is recognized so fully that the government supports it completely we don't have that we have grant funded organizations where they're funded fairly piecemeal so it's a big challenge okay now I'm gonna put my moderator hat back on and the second question that we're left with is if you could write one piece of legislation that would maybe support the work that you do what would it be and if if you don't have thoughts or if you need to think for a moment I can start on that one okay okay so actually there's two pieces of legislation there's one that we're actually working on at the moment that I spoke about in my talk you know trying to get primary prevention services for prevention of child abuse available the other thing that we're promoting in that piece of legislation is increased funding for nurse family partnership and other home visiting nursing organizations which are just critical in the prevention of child abuse they've been absolutely phenomenal I just want to do cartwheels for the nurse family partnership we've actually been partnering with them in Austin and they've been yeah at any baby can and we love them but the other piece of legislation that just occurred to me yesterday when I spoke with the CPR and first aid organization here in San Antonio that that primary they were doing the primary prevention the abuse of head trauma the period of purple crying education for foster families and and child care providers and then they stopped I don't know why they stopped I personally need to look into that further but I think that would be a critical piece of legislation because it is a huge missed opportunity and I think the more because child care providers comprise a significant number of perpetrators and that cannot be overlooked so those would be my bits of legislation I think for me for legislation is really being able to expand services like what you guys provide to all economic levels and for a longer term to up to age 5 if possible I think that would be fantastic to have well of course my passion is preterm birth and low birth weight and the surgeon general a few years ago there was a task force and they had mandated that we were going to make that a primary issue across the United States that we were going to address the preterm birth issue and it was going to be one of the number one focused areas but yet we need funding so when we decide that we're going to make something the emphasis and in what area related to that are we going to focus on the funding whether it's for research or whether it's for preventive programs or whether it's whatever it is is going to have to be an aspect of that that comes behind that decision that's important the children's shelter family strengthening department has programs umbrella programs called the I parent program and they have no income requirements there are so they pair parent educators and those who provide support to work as case managers to help families and they don't have to be first time moms and so those programs just remind me that there are home visiting programs across the state and some of them don't have income requirements and they aren't perhaps as large as nurse family partnership but they are many of them evidence based curriculum evidence based programs and promising practices programs that could help moms families in need fragile families there is no income base for fragile families sometimes fragile families are not low income and so to pair up and to get more information out that would be good but also to fund those other programs if you're talking about piece of legislation to make that something where you can take if you look across the state of Texas and you see that map and you see dots where there are there are big gaps big gaps in rural areas for example the area between San Antonio and Austin you know the programs can't serve all of those east towards Seguin there are a lot of areas that aren't there aren't programs to serve those people and those people are isolated and need support so getting that map and opening it up in the state of Texas purple but also to connect those dots so that you could get some kind of support for families across I think that would be a really important thing okay so does anybody have any other questions for the panel any commentary anything at all that they would like to ask or share okay oh yeah increase public awareness without crisis such as our football players they're being they're being so horrible to their family violence is being shown or even child abuse as covered up by well that's my right to that's a good word discipline my child awareness higher as they would be willing to fund more with awareness rather than just a group like this with people who deal with it all the time in their awareness of time they ain't paid enough to fund what is public care mm-hmm does anyone want to tackle that question I mean maybe just even from a state standpoint or even a city standpoint you focus on that and make it something that you just blanket the city or you know blanket the state but you know that and that goes back to like legislation that it's determined that there's a week or a month that you blanket the state with information related to that so you increase awareness I mean that I guess could be one way