Pediatric unintentional injury: behavioral risk factors and implications for prevention

Unintentional injury is the leading cause of death for children and adolescents between the ages of 1 and 18 in the United States, accounting for more deaths than the next 20 causes of mortality combined. It is estimated that pediatric injury accounts for more than $50 billion in annual losses from medical care costs, future wages, and quality of life. Despite these numbers, much remains to be learned about the behavioral risks for pediatric unintentional injury. This article reviews behavioral risk factors for pediatric unintentional injury risk, with a particular focus on four broad areas. First, we discuss the effects of demographic risk factors, including gender, socioeconomic status, and ethnicity. Second, we present information about child-specific risk factors, including temperament, personality, psychopathology, and cognitive development. Third, we discuss the influence of parents and other primary caregivers on childhood injury risk, with a particular focus on the effects of supervision and parenting quality and style. Finally, we discuss the role of peers on child injury risk. We conclude with a discussion of the ways in which the material reviewed has been translated into injury prevention techniques, with a focus on how pediatricians might use knowledge about etiological risk to prioritize safety counseling topics. We also present thoughts on four priorities for future research: injury risk in diverse nations and cultures; developmental effects of injury; the influence of multiple risk factors together on injury risk; and translation of knowledge about risk for injury into intervention and prevention techniques.

The roles of age, gender, inhibitory control, and parental supervision in children's pedestrian safety

OBJECTIVE

Thousands of American children are injured or killed each year as pedestrians, but behavioral factors in pedestrian injury etiology remain poorly understood. We examined the roles of children's individual differences (age, gender, and inhibitory control) and parental supervision in children's pedestrian behaviors.

METHODS

Using the pretend road method, a sample of 85 children and 26 adults crossed a pretend crosswalk set adjacent to a real road. Safety of crossing the pretend road was determined based on actual traffic on the real road. Adults also crossed the real road.

RESULTS

Adults' behavior on the real road paralleled that on the pretend road, supporting validity of the method. On the pretend road, younger children, boys, and children with less behavioral control engaged in riskier pedestrian behaviors. Children with less behavioral control responded more noticeably to increases in parental supervision.

CONCLUSION

Results are discussed in relation to children's development and injury prevention.

Brief report: a brief intervention to improve lifeguard surveillance at a public swimming pool

OBJECTIVES

Drowning is the second leading cause of unintentional death for American children in middle childhood, but behavioral research designed to prevent pediatric drowning is limited. This study tested the efficacy of a brief intervention to improve lifeguard attention and surveillance at a public swimming pool.

METHOD

Observational data on patron risk-taking and lifeguard attention, distraction, and scanning were collected at a public swimming pool, both before and after a brief intervention. The intervention was designed to increase lifeguards' perception of susceptibility of drowning incidents, educate about potential severity of drowning, and help overcome perceived barriers about scanning the pool.

RESULTS

Postintervention, lifeguards displayed better attention and scanning and patrons displayed less risky behavior. Change was maintained for the remainder of the season.

CONCLUSION

Theoretically driven brief interventions targeting lifeguard attention and surveillance might prove effective in reducing risk of drowning in public swimming pools.

Individual difference factors in risky driving among older adults

INTRODUCTION

Motor-vehicle crashes kill roughly 4,500 American adults over the age of 75 annually. Among younger adults, one behavioral factor consistently linked to risky driving is personality, but this predictor has been overshadowed by research on cognitive, perceptual, and motor processes among older drivers.

METHOD

In this study, a sample of 101 licensed drivers, all age 75 and over, were recruited to complete self-report measures on personality, temperament, and driving history. Participants also completed a virtual environment (VE) course designed to assess risk-taking driving behavior. State records of motor-vehicle crashes were collected.

RESULTS

Results suggest both a sensation-seeking personality and an undercontrolled temperament are related to risky driving among older adults. Sensation-seeking was particularly related to history of violations and tickets, while temperamental control was more broadly related to a number of risky driving measures. Methodological and crash prevention issues are discussed.

Ecology of drowning risk at a public swimming pool

INTRODUCTION

The fourth-leading cause of death in middle childhood is drowning, but there is remarkably little known about swimmer or lifeguard behavior patterns at public swimming pools.

METHOD

This study used non-intrusive observational methodology to examine risk-taking by swimming patrons (predominantly children) and surveillance habits of lifeguards at a public swimming pool. The study also examined whether risk-taking behavior might be associated with density of swimmers, temperature, or lifeguard behaviors.

RESULTS

Results suggested risk-taking behavior was common, with dangerous incidents observed over 90 times per hour. Particularly high were rates of running on the deck, which exceeded 100 incidents per hour near the deepest water of the pool, and jumping into the water dangerously close to other swimmers, which was witnessed about once every two minutes in the shallow water of the pool. Lifeguards tended to scan the pool well, and remain attentive to the areas under their responsibility, but they were distracted about 10 times per hour and warned patrons only about once for every 14 dangerous incidents observed.

CONCLUSIONS

No consistent correlates to risk-taking behavior by swimming pool patrons were identified. Results are discussed with respect to previous findings and implications for intervention.

IMPACT ON INDUSTRY

Findings emphasize the need to increase awareness and adherence to safety rules by swimmers at swimming pools; to educate and remind lifeguards about proper swimming pool surveillance techniques; and to consider environmental changes at public swimming pools that might increase swimmer safety.

Brief Report: Behavioral Risk Factors for Youth Soccer (Football) Injury

OBJECTIVES

By most reports, soccer (football) is among the most played and most popular sports in the world. This study prospectively examined behavioral risk factors for youth soccer injury.

METHOD

Sixty 11- and 12-year-old boys who played on six teams in a suburban recreational soccer league were followed over the course of a season. Six predictors were assessed prior to the start of the season via self-report measures from coaches, parents, and the players themselves: inhibition, aggression, risk-taking, skill, experience playing soccer, and physical size. All games were videotaped, and tapes were reviewed to record players' collisions with other players, fouls, falls during the course of play, and injuries.

RESULTS

Greater skill and less experience playing soccer best predicted injury risk. Inhibition, aggression, and risk-taking did not emerge as predictors.

CONCLUSION

Results are discussed with respect to previous research in youth sport and general pediatric injury risk.

Brief Report: Increasing Children's Safe Pedestrian Behaviors through Simple Skills Training

OBJECTIVES

Hundreds of American children are killed and thousands more injured annually as pedestrians. Simple and effective interventions targeting behavioral changes in children are needed.

METHODS

The present study tested a simple, skill-based training method for increasing safe pedestrian behaviors. Eighty-five children ages 5-8 participated.

RESULTS

Children behaved more safely following training, indicating very brief training can produce at least short-term improvements in pedestrian behaviors.

CONCLUSIONS

Results are discussed with regard to the involvement of parents in the practical application of a simple training procedure and future directions for pedestrian interventions.

Individual difference factors in risky driving: the roles of anger/hostility, conscientiousness, and sensation-seeking

Motor vehicle crashes claim the lives of more Americans than any other cause of injury. One factor long recognized as relevant to predicting dangerous driver behavior is the driver's personality. This study examines the independent and combined roles of three personality traits--sensation-seeking, conscientiousness, and anger/hostility--in predicting risky driving behavior. Seventy-three participants completed personality and driving history questionnaires, and also engaged in a virtual environment (VE) task designed to assess risk-taking driving behavior. Each facet of personality was correlated to risky driving behavior in independent univariate analyses. In multivariate analyses, sensation-seeking emerged as the best predictor of self-reported driving violations. Anger/hostility and the interactive effect of anger/hostility by sensation-seeking also emerged in a multivariate analysis predicting one measure of self-reported driving violations. No personality trait predicted risky driving in the VE in multivariate analyses. Results are discussed with respect to previous work in the field, challenges involved in measuring the constructs of interest, and implications to prevention.

The Influences of Demographics and Individual Differences on Children's Selection of Risky Pedestrian Routes

OBJECTIVE

Thousands of American children under the age of 10 are injured annually as pedestrians. Despite the scope of this public health problem, knowledge about behavioral factors involved in the etiology of child pedestrian injury remains sparse. The present study considered the roles of age, gender, ethnicity, family income, and inhibitory control on children's selection of safe pedestrian routes.

METHODS

Children's selections of risky pedestrian routes were examined in two laboratory analogue tasks. Multiple behavioral and self-report methods were used to measure temperamental inhibitory control.

RESULTS

Children from lower-income families, children of ethnic minority background, younger children, and those with less temperamental control selected riskier pedestrian routes.

CONCLUSIONS

Prevention efforts might be tailored to focus on children at higher risk for pedestrian injury, such as younger, under-controlled children.

Ecology of player-to-player contact in boys' youth soccer play

INTRODUCTION

Youth soccer (football) injuries occur for a wide range of reasons, but the most frequent cause of injury is via player-to-player contact. This study was designed to study the ecology of collisions between players during youth soccer play.

METHOD

Six teams of 11- and 12-year-old male players were followed over the course of a full season. Games were videotaped and reviewed to address three primary questions: how frequently do player-to-player collisions occur; when and where on the field do those collisions occur; and what is the rate of falls and injuries as a result of player-to-player contact.

RESULTS

A total of 1,279 player-to-player collisions was observed, or an average of 65.59 collisions per game. Nearly half of the observed collisions resulted in one or both players falling to the ground, and about one-tenth resulted in the referee calling a foul, but very few of the collisions (less than 1%) resulted in an injury. Collisions occurred relatively consistently throughout the games, no matter what the score was. They occurred most frequently in the midfield area, when the ball was on or near the ground, and when players were attempting to retrieve a loose, uncontrolled ball.

CONCLUSIONS

Results are discussed with respect to implications for injury prevention.

How mothers parent their children with behavior disorders: implications for unintentional injury risk

INTRODUCTION

This study was designed to test the role of parental supervision in explaining why children with behavior disorders have increased risk of unintentional injury.

METHOD

Children referred to a pediatric behavior disorders clinic and their mothers were unknowingly observed in a "hazard room" environment that housed several items that appeared dangerous but actually were altered to be safe.

RESULTS

Mother and child behavior in the hazard room was correlated to parent-, teacher-, and observational-reports of children's externalizing behavior patterns, children's injury history, and mother's parenting styles. Maternal ignoring of children's dangerous behavior in the hazard room was the strongest correlate to children's injury history.

CONCLUSIONS

Poor parental supervision might serve as a mechanism to explain why children with behavior disorders, and those with oppositional behavior patterns in particular, have increased risk of unintentional injury.

Injury risk among children of low-income U.S.-born and immigrant mothers

The number of immigrants in the United States is at an all time high, yet psychologists have largely ignored the domain of immigrant health. This article considers 1 aspect of immigrant health, risk for pediatric injury. A sample of over 5,000 5-year-old children from impoverished families was studied; approximately 13% had immigrant mothers. Children of immigrants had a significantly lower rate of injury in the prior year. This was particularly true of non-White children of immigrants. Three possible mediators for this finding--assistance with parenting, parenting style, and health care accessibility--were considered, but none explained the difference. The need for further research on the topic and implications of results for injury prevention are discussed.

The Stamp-in-Safety Program: A Behavioral Intervention to Reduce Behaviors that Can Lead to Unintentional Playground Injury in a Preschool Setting

OBJECTIVE

To introduce and evaluate the Stamp-in-Safety program, a behavioral intervention designed to increase the quality of supervision by teachers on preschool playgrounds and to reduce the risk of unintentional child playground injury.

METHODS

A quasi-experimental time series design was used, with observational techniques, to evaluate behavior on the playground before, during, and after the intervention as well as during a 6-month post-intervention assessment.

RESULTS

Both applied behavior analysis techniques and inferential statistics suggest that the Stamp-in-Safety program resulted in behavioral changes likely to reduce the risk of child injury on the playgrounds of childcare centers.

CONCLUSION

Results indicate promise for the Stamp-in-Safety program as a low-cost, easily implemented intervention to reduce pediatric playground injury risk at childcare centers. Suggestions for future research are offered.

Does time spent in child care influence risk for unintentional injury?

OBJECTIVE

To investigate the effect of quantity and quality of early child care on children's risk for unintentional injury.

METHODS

A diverse cohort of 1,225 children was recruited from several sites in the United States and followed from birth until first grade. Quantity and quality of child care from birth until entry into kindergarten were used to predict unintentional injuries from age 6 months until first grade. Measures from an evaluation at 6 months of age were tested as covariates.

RESULTS

Children who spent more time in nonparental childcare environments were at slightly reduced risk for unintentional injury after controlling for child (gender, temperament), family [socioeconomic status (SES)], parent (positive parenting), and child care (quality of care) characteristics.

CONCLUSIONS

We discuss possible explanations for the results, including the possibilities that childcare center environments are safer than the homes of most preschoolers or that attendance in child care is nonrandom.

Contributions of multiple risk factors to child injury

OBJECTIVE

Most previous research on etiological factors that predict children's unintentional injuries has focused on single independent risk factors that predict injury, but psychological methods and theory lend themselves to simultaneous consideration of multiple risk factors that might together create an increased or decreased risk for injury.

METHOD

One approach to considering multiple risk factors of child injury, inspired by Lizette Peterson's notion of process analysis, is to consider how risk factors serve in moderated, mediated, and mediated moderation roles to each other. We present two lines of research that exemplify such models. In each, multiple risk factors for child injury are considered within a single theoretical model.

CONCLUSIONS

Implications for understanding the etiology of children's unintentional injuries and developing empirically derived injury prevention techniques are discussed.

The role of impulsivity in children's estimation of physical ability: implications for children's unintentional injury risk

Unintentional injuries are the leading cause of pediatric mortality. One factor that appears to predict injury risk is children's overestimation of physical ability. Fifty-seven 6-year-olds judged their ability to complete basic physical tasks. Half the sample was required to wait 7 s before judging their ability; the other half was permitted to judge immediately. There were no differences in ability estimation accuracy between the 2 groups, suggesting that the institution of a forced decision latency does not increase children's ability estimation accuracy. Replicating previous work, children tended to overestimate their ability, and overestimation of ability was related to history of unintentional injury. Possible explanations for the null finding are offered, and implications to injury prevention and future research are discussed.

The role of fathers in toddlers' unintentional injury risk

OBJECTIVES

Previous work suggests that maternal parenting and supervision reduces risk for children's unintentional injuries, but very little research has examined the role of fathers in children's unintentional injury risk. The role of fathers in protecting children from unintentional injury was considered.

METHODS

A prospective longitudinal design predicted injury risk in 181 toddlers from the ages of 6 to 36 months. Predictor variables included child gender and temperament, individual difference factors of the mother and father, and parenting factors of the mother and father.

RESULTS

Hierarchical regression models suggested that fathers' report of gains to the family from their employment was the strongest predictor of risk of children's unintentional injury. Several other paternal and maternal factors were also modestly related to injury risk.

CONCLUSIONS

Data indicate the need to consider the role of fathers in protecting children from unintentional injuries.

Interactions between child behavior patterns and parenting: implications for children's unintentional injury risk

OBJECTIVES

Two factors were considered as predictors of children's risk for unintentional injury: (a) children's temperamentally difficult behavior patterns and (b) parenting. Along with hypotheses to replicate previous univariate effects, it was hypothesized that active, involved parents with sufficient time resources might reduce injury risk among temperamentally at-risk children.

METHODS

Study 1 used a retrospective design with a diverse sample of over 10,000 5-year-olds. Study 2 replicated Study 1 using a prospective design and behavioral data from a sample of over 1,000 children followed from 6 to 36 months of age.

RESULTS

In Study 1, male gender, child hyperactivity, and family poverty predicted injury in a univariate manner. In Study 2, male gender and lack of positive parenting predicted injury in a univariate manner. Interaction effects also emerged: in Study 1 the interaction between child hyperactivity and parental time resources protected children from injury, and in Study 2 the interaction between child's difficult temperament and positive parenting protected children from injury.

CONCLUSIONS

Children at increased risk for injury, i.e., those with hyperactive and difficult behavior patterns, might be protected in the environment of positive parenting. Theoretically, results suggest that researchers should consider Temperament x Environment interactions along with univariate predictors of outcome behavior. From an applied perspective, results have implications for the design of injury prevention campaigns: Parents who spend positive time with temperamentally difficult children might protect them from injury.

The role of parents and temperament on children's estimation of physical ability: links to unintentional injury prevention

OBJECTIVE

Unintentional injuries, the leading cause of pediatric mortality, are caused by a complex set of intrapersonal and environmental factors. The role of three critical variables--parental supervision, children's temperament, and estimation of children's physical abilities--was examined.

METHODS

Sixty-four 6- and 8-year-old children completed a laboratory experiment with a parent. Both children and parents judged the child's ability to complete reaching, stepping, and crouching tasks. Parents also completed a parent-report measure of children's temperament.

RESULTS

Both children and parents overestimated children's ability, although children did so more than parents. Parents of temperamentally impulsive and undercontrolled children judged that their children could complete tasks that were actually beyond the child's ability. Temperament also affected children's judgments while parents were known to be present or absent: Temperamentally impulsive and undercontrolled children were more accurate in their judgments when parents were standing next to them than when parents were hidden from view behind a one-way mirror.

CONCLUSIONS

The mechanism by which parental supervision might protect children from injury appears to be at least twofold: (a) Parents overestimate children's ability less frequently than children themselves, suggesting supervising parents could intervene to prevent children from attempting dangerous activities; and (b) children judge their physical abilities more cautiously when parents are present. Implications for temperament theory and for injury prevention are discussed.

Is there a link between children's motor abilities and unintentional injuries?

PROBLEM

The common view is that clumsy children experience unintentional injury more frequently. Empirical evidence supporting this position is mixed.

METHOD

One hundred 6- and 8-year-olds completed a battery of nine tasks designed to assess motor ability. Mothers completed a lifetime injury history measure about their children and families completed a 2-week injury diary assessing frequency and severity of daily injuries.

RESULTS

Internal reliability for the motor ability battery was good. Correlations between motor ability measures and injury risk were nonsignificant and near zero.

DISCUSSION

Motor ability does not appear to be directly related to injury risk. Possible explanations include: (a) coordinated and clumsy children engage in hazardous activities with differing frequency; or (b) other individual difference factors may interact with motor ability to explain children's injury risk.

IMPACT ON INDUSTRY

Children's motor abilities do not appear to be directly linked to rate of unintentional injury, but instead may influence risk for injury in conjunction with other factors. Results could have implications to the engineering of children's toys and playground equipment and to the design of appropriate supervision strategies for children engaging in potentially dangerous activities.

Unintentional injury in preschool boys with and without early onset of disruptive behavior

OBJECTIVE

To determine subsequent risk of unintentional injury among preschool boys diagnosed with ODD, boys with comorbid ODD and ADHD, and boys matched demographically to the clinical sample; to test predictive validity of a measure of injury proneness; and to examine factors that might predict injury beyond clinic status.

METHODS

Seventy-nine consecutive clinic-referred preschool-age boys and 76 demographically matched boys without disruptive behavior participated in a 2-year prospective longitudinal design. Time 1 assessment included clinical diagnosis, parent-reported injury proneness, attachment, and verbal abilities. Injury history was measured 1 and 2 years later.

RESULTS

Clinic-referred children had more injuries than the comparison group. Children with comorbid ODD and ADHD had approximately the same injury rate as those with ODD but not ADHD. Parent-reported injury proneness was unrelated to subsequent injuries. Neither attachment nor verbal ability predicted injury significantly beyond clinic status.

CONCLUSIONS

Children with early disruptive behavior are at increased risk of unintentional injury and therefore should be considered prime candidates for injury prevention campaigns.

Using an injury diary to describe the ecology of children's daily injuries

PROBLEM

Two problems were addressed in this study. First, are daily injury diaries an effective means to gather information about children's unintentional injuries? Second, what are the circumstances of children's injuries as recorded through the diary method?

METHOD

Two studies were conducted with a total of 172 children to describe the ecology of children's daily unintentional injuries. Families completed a daily diary for 14 days, describing the circumstances surrounding the injuries children experienced each day.

RESULTS

Descriptive data is provided on the locations, causes, and types of injuries children incurred, as well as who was present when they were injured. Daily injury rate was modestly related to the number of major injuries children had incurred in their lifetimes.

DISCUSSION

The diary methodology was an effective means to study the ecology of children's daily injuries. Children's injuries occur in a wide range of circumstances that can be quantified through diary techniques.

IMPACT ON INDUSTRY

Data obtained from daily injury diaries may be useful in a variety of areas, including study of the etiology of childhood injury, design of interventions to prevent injury, and engineering of toys and playground equipment for children.

Integrating basic and applied developmental research: a new model for the twenty-first century

Until recently, basic and applied research agendas in the field of child development have followed separate paths. One reason the two have not merged is that the objectives of basic and applied research are often seen as incompatible. In this paper, we argue that researchers can simultaneously achieve the objectives of advancing basic knowledge and addressing applied problems within a single research program. We provide a framework for this perspective by first looking back at historical trends of basic and applied developmental research and then looking forward at potential new approaches for integrating basic and applied research. We use our own research on perception of affordances and unintentional childhood injuries to illustrate how researchers might implement these strategies for integrating basic and applied research. We conclude by discussing how we might extend this integration further to include nontraditional classes of application.

Longitudinal and concurrent relations among temperament, ability estimation, and injury proneness

This study examined longitudinal and concurrent relations between temperament, ability estimation, and injury proneness. Longitudinal assessments of Inhibitory Control were collected through a behavioral battery at toddler (33 months) and preschool ages (46 months). Parent-reported measures of Inhibitory Control and Extraversion also were obtained at those ages. At school age (76 months), children participated in a set of tasks to assess overestimation and underestimation of physical abilities. Parents provided reports of children's temperament and injury history at school age. Results showed that children who were high on Extraversion and low on Inhibitory Control as toddlers and preschoolers tended to overestimate their physical abilities and to have more unintentional injuries at age 6. Children low on Extraversion and high on Inhibitory Control tended to underestimate their physical abilities. Implications for injury prevention are discussed.

Cardiovascular reactivity and neuroticism: results from a laboratory and controlled ambulatory stress protocol

A laboratory and controlled ambulatory protocol was used to study whether there are differences in the cardiovascular reactivity of persons varying in neuroticism, the disposition to experience negative subjective emotions. Thirty-six individuals (19 men, 17 women) who scored approximately 1 standard deviation above or below the mean on the NEO PI-R Neuroticism scale (Costa & McCrae, 1992) were recruited from a larger pool of undergraduate students. Participants, who had been outfitted with an ambulatory blood pressure/heart rate monitor, were exposed to 5 laboratory stressors and 7 field stressors during a 6-hour protocol. Results indicated that individuals scoring high in neuroticism showed blood pressure reactivity to laboratory and field stressors that was comparable to that of persons low in neuroticism. Aggregrating responses across stressors, there was evidence of exaggerated heart rate responses. The results suggested that, although neuroticism is related to high levels of negative subjective experience, differences between persons scoring high versus low in neuroticism were not exhibited strongly at the cardiovascular level. The implications for stress, coping, and disease are discussed.

Preschoolers' attributions of mental states in pretense

When young children appear to recognize that someone else is engaging in make-believe play, do they infer what the pretender is thinking? Are they aware that the pretender is thinking about a pretend scenario yet knows what the real situation is? Preschoolers ages 3-5 (N = 45) viewed scenes from the Barney & Friends television series depicting either make-believe or realistic actions. Children were questioned concerning the presence of pretense and the thoughts and beliefs of the TV characters. The children were also presented with false belief and appearance/reality theory of mind tasks. Children who identified when TV characters were engaging in pretend play did not necessarily infer the pretenders' thoughts and beliefs. Inferring pretenders' thoughts was related to performance on false belief and appearance/reality tasks, but simply recognizing pretense was not. These data support the view that children initially learn to recognize pretense from contextual cues and are able to infer pretenders' beliefs only with further development of metarepresentational ability.

Social and temperamental influences on children's overestimation of their physical abilities: links to accidental injuries

This study examined social and temperamental influences on children's judgments about their physical abilities and relations between temperamental characteristics, ability overestimation, and accidental injuries. Six- and 8-year-olds first observed a peer succeed or fail on a set of physical tasks and then made judgments about their ability to perform those same physical tasks. At both ages, children who first watched a peer fail on the tasks made more conservative judgments about their own abilities than did children who watched the peer succeed. The relations between temperamental characteristics and judgment ability differed for the two ages. An aggregated temperament measure of Surgency/Undercontrol was related to judgment accuracy for 6-year-olds and to decision times for 8-year-olds. Likewise, the relations between temperament, ability overestimation, and accidental injuries differed for the two age groups. Ability overestimation was related to accidental injuries for 6-year-old boys whereas temperamental characteristics were related to accidental injuries for 8-year-olds. These findings suggest that both the factors that put children at risk for accidental injuries and the relations between temperamental characteristics and cognitive abilities change with development.