Caregiver Supervision and Child-Injury Risk: I. Issues in Defining and Measuring Supervision; II. Findings and Directions for Future Research

The influence of parenting on early childhood health and health care utilization

OBJECTIVE

This study examined whether parenting, specifically parental support, structure, and behavioral control, predicted early childhood health care use and moderated the negative effects of socioeconomic disadvantage.

METHODS

A sample of 250 parent-child dyads from a longitudinal intergenerational research program participated.

RESULTS

Greater parental support was associated with increased rates of nonemergency care and a higher ratio of outpatient to emergency room (ER) services, a pattern reflecting better health and service use. Support also moderated the negative effects of disadvantaged family background. Greater behavioral control by parents predicted lower rates of both nonemergency care and ER visits. Structured parenting and behavioral control were associated with lower rates of respiratory illness.

CONCLUSIONS

This study highlights the importance of considering parenting practices when examining variations in early childhood health and health care, and the relevance of parental behavior in designing interventions for high-risk populations.

Maternal perceptions of supervision in pre-school-aged children: a qualitative approach to understanding differences between families living in affluent and disadvantaged areas

AIM

To explore maternal perceptions of supervision and childhood unintentional injury in order to develop understanding and explanation for differences in unintentional injury rates between an advantaged and disadvantaged area.

BACKGROUND

Unintentional injury is the second cause of mortality and a significant cause of morbidity in the zero to four year age group. Children living in socio-economic disadvantage are at a greater risk of unintentional injury than their more affluent counter-parts.

METHODS

Qualitative study using semi-structured interviews; content data analysis was undertaken. Participants included 37 mothers with a child aged less than five years; 16 living in an area of disadvantage (and high rate of childhood unintentional injury) and 21 living in an advantaged area (and low rate of childhood unintentional injury).

FINDINGS

Parents in both areas described the importance of parental supervision in reducing child unintentional injury risks. Parents in both areas used listening as a supervision strategy. Parents in both areas described how 'when the child goes quiet' that is a cue for them to make a visual check on the child. Listening was used more for boys than girls in both areas, but parents in the advantaged area used listening as a supervision strategy more frequently than those in the disadvantaged area. Parents described supervision strategies as being shaped by child character and age rather than child gender. Parents in both areas described similar strategies for managing distractions. An important difference was found with regard to older siblings; parents living in the advantaged area described older siblings as an injury risk to younger children. Parents in the disadvantaged area described older siblings as providing some supervision for younger children. Parents living in disadvantaged circumstances may face greater challenges with regard to supervision than parents living in advantaged circumstances and this may partly explain differences in injury risk.

[Injury prevention in young children]

Epidemiological studies in Germany show that infants and toddlers are at most risk of injury and in need of protection. Of all children under the age of 15 years, they have the highest rates of fatal and severe injuries. Therefore, this article aims to show which injury prevention measures have been proven successful for this age group. International specialist recommendations are described and evidence-based knowledge of interventions is presented from the Cochrane Reviews. For the four most frequent child injury mechanisms (drowning, poisoning, burning, and falling), the World Health Organization recommends a set of measures covering legislation, regulations, changes of environment, education, and emergency medical care. Meta-analyses on the effectiveness of interventions related to safety at home conclude that informing parents personally (face-to-face) and in combination with free safety equipment (e.g., safety gates, smoke alarms) increased parents' safety practices significantly. This included advice on not using baby walkers. Multifaceted education programs for parents (e.g., visiting programs at home or in pediatric clinics) proved to have the highest effect in reducing home accidents to children. The prevention of injuries in young children should be driven by a multifaceted and data-based approach. Postnatal interventions (Frühe Hilfen) at the community level are especially useful to integrate accident prevention at home, because they are connected with family visiting programs.

Supervision and risk of unintentional injury in young children

OBJECTIVE

Assess the association between caregiver supervision and acute unintentional injury in young children; evaluate whether lower levels of supervision result in more severe injury.

METHODS

A case cross-over study was conducted. Parents of children aged ≤4 years whose injuries required emergency department (ED sample) treatment or admission to the hospital (inpatient sample) were interviewed. Information on supervision (3 dimensions: proximity, attention, continuity) at the time of injury and 1 h before the injury (control time) was collected. An overall supervision score was created; a higher score indicates closer supervision. Hospital admission served as a proxy for injury severity. ORs and 95% CIs were calculated.

RESULTS

Interviews were completed by 222 participants; 50 (23%) were in the inpatient sample. For each supervision dimension the inpatient sample had higher odds of injury, indicating effect modification requiring separate analyses for inpatient and ED samples. For both samples, proximity 'beyond reach' was associated with the highest odds of injury; compared with 1 h before injury, children were more likely to be beyond reach of their caregiver at the time of injury (inpatient sample: OR 11.5, 95% CI 2.7 to 48.8; ED sample: OR 2.9, 95% CI 1.8 to 4.9). Children with lower supervision scores had the greatest odds of injury (inpatient sample: OR 8.0, 95% CI 2.4 to 26.6; ED sample: OR 3.3, 95% CI 1.9 to 5.6).

CONCLUSIONS

Lower levels of adult supervision are associated with higher odds of more severe injury in young children. Proximity is the most important supervision dimension for reducing injury risk.

Unintentional poisoning in young children: does developmental stage predict the type of substance accessed and ingested?

BACKGROUND

When children aged 0-4 years are analysed together as a group for poisoning risk, important differences for smaller age intervals by medicinal and non-medicinal substances are masked. These differences have been attributed to child developmental stages but no studies have been conducted that examine the predictive value of child developmental stage for poisoning by substance type, using 3-month age intervals as a proxy for developmental stage and adjusting for the effect of sex, socio-economic status and remoteness of residence.

METHODS

A population-based dataset of unintentional poisoning hospitalizations in children aged 0-4 years was used to predict the type of substance ingested. Associations between the type of substance and age, sex, socio-economic status and remoteness of residence were measured using multivariate logistic regression.

RESULTS

Children aged 12-17 months had significantly higher odds of experiencing a non-medicinal poisoning while children aged 24-41 months had significantly higher odds of experiencing a medicinal poisoning. Males and children from more disadvantaged and outer regional areas had higher odds of experiencing a non-medicinal poisoning.

CONCLUSIONS

Children aged 0-4 years differ in their stage of development and as a consequence, vary significantly in their ability to access their environment. Our results clearly show that odds of poisoning by medicinal substances compared with non-medicinal substances change as children age. This study provides evidence that child development predicts the type of substance accessed and ingested.

Maternal supervision of children during their first 3 years of life: the influence of maternal depression and child gender

OBJECTIVE

The present study examined the effect of child gender and maternal depressive symptoms on routine supervisory practices of mothers longitudinally.

METHOD

Self-report supervision practices were obtained at various time points from 3 months through 3 years of age.

RESULTS

From 3 to 36 months, the quantity of time mothers reported supervising decreased from 7.1 to 6.3 hours, and the proportion of time spent in an intense style decreased from 63 to 46%, whereas that spent in a peripheral style increased from 14 to 32%. Mothers reported more time supervising girls and a greater proportion of this was in an intense style. Mothers with elevated depressive symptoms reported more time supervising but a lower proportion in an intense style.

CONCLUSION

Over the first 36 months of life, routine patterns of supervision change and these vary as a function of maternal depression symptoms and child gender. Implications for child injury risk are discussed.

Cross-cultural adaptation and validation of the Portuguese version of the Parental Supervision Attributes Profile Questionnaire

OBJECTIVES

To cross-culturally adapt and validate the Portuguese version of the Parental Supervision Attributes Profile Questionnaire (PSAPQ). The PSAPQ is a measure of parental supervision, which has not been translated and adapted into any language other than English.

METHODS

The Portuguese version was the result of forward/backward translations, consensus panels and pretesting. Reliability and internal consistency were assessed using Cronbach's α, intraclass correlation coefficient (ICC) and confirmatory factor analysis (CFA) in adults with different educational levels.

RESULTS

Cronbach's α (α=0.70-0.79) and ICC (>0.75) were acceptable in three of four factors. The results of CFA (χ(2)/df=2.243; CFI=0.951; GFI=0.96; RMSEA=0.056; P(RMSEA ≤ 0.05)=0.222) suggest a good adjustment between the factors.

CONCLUSIONS

The Portuguese version of PSAPQ showed acceptable psychometric properties. This study evidenced some vulnerabilities of the fate subscale, emphasising the need for further investigation of the effects of the educational level of the parents.

Risk factors for unintentional poisoning in children aged 1-3 years in NSW Australia: a case-control study

BACKGROUND

Unintentional poisoning in young children is an important public health issue. Age pattern studies have demonstrated that children aged 1-3 years have the highest levels of poisoning risk among children aged 0-4 years, yet little research has been conducted regarding risk factors specific to this three-year age group and the methodologies employed varied greatly. The purpose of the current study is to investigate a broad range of potential risk factors for unintentional poisoning in children aged 1-3 years using appropriate methodologies.

METHODS

Four groups of children, one case group (children who had experienced a poisoning event) and three control groups (children who had been 'injured', 'sick' or who were 'healthy'), and their mothers (mother-child dyads) were enrolled into a case-control study. All mother-child dyads participated in a 1.5-hour child developmental screening and observation, with mothers responding to a series of questionnaires at home. Data were analysed as three case-control pairs with multivariate analyses used to control for age and sex differences between child cases and controls.

RESULTS

Five risk factors were included in the final multivariate models for one or more case-control pairs. All three models found that children whose mothers used more positive control in their interactions during a structured task had higher odds of poisoning. Two models showed that maternal psychiatric distress increased poisoning risk (poisoning-injury and poisoning-healthy). Individual models identified the following variables as risk factors: less proximal maternal supervision during risk taking activities (poisoning-injury), medicinal substances stored in more accessible locations in bathrooms (poisoning-sick) and lower total parenting stress (poisoning-healthy).

CONCLUSIONS

The findings of this study indicate that the nature of the caregiver-child relationship and caregiver attributes play an important role in influencing poisoning risk. Further research is warranted to explore the link between caregiver-child relationships and unintentional poisoning risk. Caregiver education should focus on the benefits of close interaction with their child as a prevention measure.

Examining parents' behaviors and supervision of their children in the presence of an unfamiliar dog: does The Blue Dog intervention improve parent practices?

OBJECTIVES

Young children are at particular risk for dog bite injuries. This study examined parents' supervision of and reactions to their children in the vicinity of an unfamiliar dog.

METHODS

A pre/post intervention/control group randomized design assessed whether exposure to The Blue Dog, a dog bite prevention and education program, positively impacted parent behaviors.

RESULTS

No group differences in pre or post-intervention measures emerged, indicating that The Blue Dog did not evoke improvements in parents' behaviors. Generally, parents showed risky reactions and encouraged children to interact with the dog, even though they knew very little about the dog's safety or disposition. Supervision measures (proximity, watching) remained unchanged (watching) or more lax (proximity) across sessions.

CONCLUSIONS

The results highlight the importance of targeting parent behavior, not just child behavior, in programs that aim to reduce risk of childhood dog bites. The Blue Dog did not effectively change parent behavior.

Smoking and medication during pregnancy predict repeated unintentional injuries in early childhood but not single unintentional injuries

This study investigates prospectively the development of single and repeated unintentional injuries from birth to 42 months in a random population sample of new-born children in Quebec (Canada) (N = 1,770). The outcome measures are single unintentional injuries (SUI) and repeated unintentional injuries (RUI). Results showed that the risk factors for SUI differed from the risk factors for RUI. SUI was predicted by mother's antisocial behavior during high school (OR = 1.72) and mother's age at first birth (OR = 1.82) with children from older mothers at higher likelihood of SUI. Also, boys (OR = 1.36) and hyperactive children (OR = 1.06) were at increased risk of SUI. RUI was predicted by maternal smoking during pregnancy (OR = 1.68), medication on prescription (OR = 1.53) and medication without prescription (OR = 1.54). Boys (OR = 2.01), children with a difficult temperament (OR = 1.13) and those with single mothers had higher rates of RUI (OR = 2.05). Maternal perception of impact (OR = 1.15) and maternal feelings of self-efficacy (OR = 0.87; marginally significant) were also associated with RUI. These results show that maternal and child risk factors identified during pregnancy and just after birth can predict SUI as well as RUI in early childhood. However, the only common risk factor for SUI and RUI is the child's sex, with boys being at higher risk than girls. Implications of these findings and suggestions for prevention are discussed.

"You have to listen to me because I'm in charge": explicit instruction improves the supervision practices of older siblings

OBJECTIVES

Sibling supervision increases young children's risk of unintentional injury. Both noncompliance by the supervisee and insufficient supervision contribute to this risk. The current study examined whether explicitly instructing older siblings to supervise their younger siblings and prevent specific risky behaviors improves their supervision practices.

METHODS

Supervisees and older siblings were placed together in a playroom. One group of older siblings were given explicit instructions not to allow the supervisee to engage in specific risk behaviors, whereas a second group was not.

RESULTS

Informing older siblings that they were "in charge" resulted in a higher frequency of proactive supervision strategies, more forceful reactions to stop supervisee risk taking, and a trend toward improved watchfulness. Supervisees in the no instruction condition also engaged in more hazard interactions compared with those in the instruction condition.

CONCLUSIONS

Explicitly informing older children to supervise younger siblings may reduce younger children's risk of injury when siblings are supervising.

Results of a randomized controlled trial assessing the efficacy of the Supervising for Home Safety program: Impact on mothers' supervision practices

Unintentional injury constitutes a major health risk for young children, with many injuries occurring in the home. Although active supervision by parents has been shown to be effective to prevent injuries, evidence indicates that parents do not consistently apply this strategy. To address this issue, a randomized controlled trial was conducted to evaluate the impact of the Supervising for Home Safety program on parent supervision practices in the home and when unobtrusively observed in a naturalistic laboratory setting. Using a participant-event monitoring procedure, parents of children aged 2 through 5 years completed supervision recording sheets weekly both before and after exposure to the intervention program; Control parents completed the same measures but received a program focusing on child nutrition and active lifestyles. Unobtrusive video recordings of parent supervision of their child in a room containing contrived hazards also were taken pre- and post-intervention. Results indicated that groups did not differ in demographic characteristics. Comparisons of post- with pre-intervention diary reported home supervision practices revealed a significant decrease in time that children were unsupervised, an increase in in-view supervision, and an increase in level of supervision when children were out of view, with all changes found only for the Intervention group. Similarly, only parents in the Intervention group showed a significant increase in attention to the child in the contrived hazards context, with these differences evident immediately after and 3 months after exposure to the intervention. These results provide the first evidence that an intervention program can positively impact caregiver supervision.

Men on Fathering in the Context of Children’s Unintentional Injury Prevention

Injuries are a leading cause of death for children, and parental safety behaviors are fundamental to child injury prevention. Fathers’ perspectives are largely absent. Our novel research connects masculinities, fathering, and childhood injury. Sixteen fathers of children aged 2 to 7 years in two Canadian urban settings participated in photo-elicitation interviews detailing activities they enjoyed with their children and concerns regarding child safety. Participants described how elements of risk, protection, and emotional connection influenced their approach to fathering as it related to injury prevention. Most men considered engaging children in risk as key to facilitating development and described strategies for protecting their children while engaging in risk. Many men identified how the presence of an emotional connection to their children allowed them to gauge optimal levels of risk and protection. There exists a tremendous opportunity to work with fathers to assist in their efforts to keep their children safe.

Marital conflict and fifth-graders' risk for injury

BACKGROUND

Injuries are the leading cause of morbidity and mortality for American children. Marital conflict has been associated with a range of negative health outcomes, but little is known about how marital conflict may influence risk of injury among children. We hypothesized marital conflict would be related to increased youth injury risk after controlling for relevant demographic and parenting covariates.

METHODS

A community sample of 3218 fifth-graders recruited from three US locales was utilized. Ordinal logistic regression models were used to predict the frequency of unintentional injuries from marital conflict while adjusting for demographics, parenting factors (nurturance, communication, involvement with youth), and family cohesion.

RESULTS

Higher levels of marital conflict were associated with higher rates of injury that required professional medical attention (OR=1.20, 95% CI 1.06, 1.35 per standard deviation). The same association held after inclusion of all covariates in a multivariate ordinal logistic regression model.

CONCLUSIONS

Parental marital conflict is associated with higher rates of injuries requiring professional medical attention in preadolescent children.

Supervision to prevent childhood unintentional injury: developmental knowledge and self-efficacy count

Caregiver developmental knowledge was tested as a moderator of the association between caregiver-perceived self-efficacy and perceived supervision to prevent childhood unintentional injury. Caregivers (N = 123; 95 mothers and 28 fathers) of children (M = 3.5 ± 1.2 years, 49.6% female, 80.8% Caucasian) were recruited from pediatric primary care offices and local message boards. All caregivers completed self-report questionnaires on perceived self-efficacy, developmental knowledge, and perceived supervision to prevent injury. Separate hierarchical linear regression models were conducted to test moderation for mothers and fathers. The interaction effect of perceived self-efficacy and developmental knowledge significantly predicted maternal-perceived supervision, R (2) change = .06, F(1, 86) = 6.76, p < .01. No significant findings were detected for fathers. Models of studying injury prevention that consider complex cognitive-behavioral interactions and their potential modifiable role in the development of injury-prevention practices may elucidate upon the attitude-practice gap currently identified in the literature.

Supervisory neglect and risk of harm. Evidence from the Canadian Child Welfare System

OBJECTIVE

This study explores prevalence and characteristics associated with supervisory neglect and physical harm in children in the child welfare system in Canada.

METHODS

The sample included all substantiated primary maltreatment investigations in the 2008 Canadian Incidence Study of Reported Child Abuse and Neglect excluding cases where exposure to intimate partner violence was the sole reason for investigation (n=3,380). Bivariate tests were used to assess differences across types of maltreatments and to compare supervisory neglect cases with and without physical harm on factors related to child injury and supervision.

RESULTS

Supervisory neglect was the primary concern in an estimated 12,793 cases of substantiated maltreatment across Canada in 2008. Compared to other types of maltreatment, cases of supervisory neglect involved more overcrowded housing conditions and children who were younger and less likely to have any functioning issue. Injuries were noted in only 2% of cases supervisory neglect and half of these injuries were not severe enough to require medical treatment. Other physical health conditions were noted in 2% of supervisory neglect cases. Physical harm was noted most often for toddlers (1-2 years old) and adolescents (12-15 years old). Household and caregiver characteristics were not associated with greater rates of physical harm. In contrast, 7% of children with any risk factor suffered physical harm as a result of supervisory neglect mainly related to substance abuse, self-harming behavior, and multiple incidents of running from care.

CONCLUSIONS

Child risk factors are often present in cases of supervisory neglect with physical harm. Nonetheless, 96% of all cases of supervisory neglect substantiated by Canadian child welfare authorities do not involve physical harm. Clearer guidelines are needed for the assessment of supervisory neglect. Alternative response systems may be more suitable for low-risk cases.

Preliminary development of a rapid assessment of supervision scale for young children

OBJECTIVES

Standardized evaluation tools have been shown to reduce variability in care. The objective of this study was to develop a clinically oriented evaluation tool for the rapid assessment of the adequacy of supervision of a young child.

METHODS

The Rapid Assessment of Supervision Scale (RASS) was developed via a 3-step process: (1) a modified Delphi survey of child abuse experts identified the most important characteristics for use in the assessment of adequacy of supervision; (2) the RASS was designed by using standardized definitions and the results of the Delphi survey; and (3) a total of 4 medical professionals evaluated 139 real case scenarios by using the RASS. Reliability and feasibility were assessed.

RESULTS

Sixty-seven child abuse experts participated in round 2 of the Delphi process and 50 participated in round 3. The RASS included 9 supervision characteristics identified from the Delphi process, standardized definitions, and a scoring system. The interclass correlation coefficients for interrater reliability of the mean RASS scores and overall supervision classification were 0.63 (95% confidence interval: 0.56-0.70; P = .000) and 0.59 (95% confidence interval: 0.51-0.67; P = .000), respectively, indicating moderate to strong agreement. For intrarater reliability, correlation coefficients for mean RASS scores indicated moderate to high correlation (0.50-0.83). Correlation for overall classification of supervision ranged from low to high (0.27-0.80).

CONCLUSIONS

The RASS scale has been shown to be efficient and, in a small sample, to have moderate to substantial interrater agreement. Further development could result in a tool that aids clinicians and researchers in the evaluation of supervision.

The mediating role of hyperactivity and inattention on sex differences in paediatric injury risk

BACKGROUND

Extensive research suggests that risk of injury is higher among young boys versus young girls. The present study examined a mediational model to identify mechanisms that may explain differences in injury risk.

METHODS

Reports of child behaviour and two indices of injury risk among 114 children in early childhood were obtained from parents in community-based paediatric medical centres.

RESULTS

Regression analyses and post-hoc examination of indirect effects supported a mediation model in which the relationship between child sex and child injury risk was explained by hyperactivity and inattention.

CONCLUSIONS

Interventions that promote child well-being by targeting constellations of externalizing behaviour problems may simultaneously decrease paediatric injury risk.

The role of child and adolescent development in the occurrence of agricultural injuries: an illustration using tractor-related injuries

Agricultural settings are dangerous, especially for children. This article focuses on child and adolescent development, and how development might influence children's safety in the occurrence of pediatric farm injuries. The authors focus especially on one of the most traumatic causes of pediatric farm injury, those associated with tractor operation. The roles of physical, perceptual, cognitive, and social development are reviewed and discussed, as are relevant sociocultural factors. Following review of developmental risks for child injury in agricultural settings, the authors present a case study of a fatal youth tractor injury and provide illustrations of the child development factors that may have contributed to the death. The authors conclude with a discussion of the implications of developmental aspects of pediatric agricultural injury for behaviorally oriented intervention strategies, including public policy.

The roles of child, parent and environmental factors in pedestrian supervision

Pedestrian injuries are a significant health risk to children, particularly those 5-9 years of age. Surprisingly, few studies have explored parent-related factors that may moderate this risk. We examined parental supervision choices in the context of child pedestrian experience, parent perceptual factors and varying levels of environmental risk. A series of street crossing scenarios were used to examine the roles of child, parent and environmental factors in determining parents' supervision choices. Parents recognised differing levels of risk across environmental conditions and altered their supervision choices accordingly. Child age and parental risk perception were significantly predictive of supervision choices. Our results demonstrate that parents assess multiple factors when determining the intensity of supervision necessary for their children. Notably, parents adjust their supervision in direct relation to changes in the physical environment. Implications of these findings for injury prevention and future research are discussed.

Egocentric or allocentric frameworks for the evaluation of other people's reachability

The adoption of egocentric and allocentric frameworks in the perception of other people's reachability was investigated. In study 1, 24 adults (12 experienced and 12 inexperienced dealing with children) judged vertical reachability for themselves and for two children. In study 2, 37 parents judged vertical reachability for themselves and their children. Absolute errors (|estimate-actual reachability|), absolute percent errors (|1-judgement/actual reachability|×100), and error tendency (underestimations, right judgments, or overestimations) were calculated. Adults were quite accurate in perceiving their own reachability (absolute percent errors ranging from 2.20% in study 1 to 3.12% in study 2) and clearly less precise when estimating children's reachability. Results indicated a tendency for adults to overestimate reachability of the younger child (study 1) and a tendency for parents to overestimate their children's reachability (study 2). No correlation between judgement errors for the self and for the children in any of the studies was observed. Results support the existence of an allocentric and not an egocentric framework when evaluating other people's affordances.

The association of activity level, parent mental distress, and parental involvement and monitoring with unintentional injury risk in fifth graders

OBJECTIVE

Extend findings with young children by examining the strength of association of activity level, parent mental distress, and parental involvement and monitoring with fifth graders' unintentional injuries.

METHODS

Ordinal logistic regression models were used to predict unintentional injury frequency among 4745 fifth-graders. Examined predictors included demographics, parent reports of mental distress, temperamental activity level (tendency to be fidgety, restless, and constantly in motion), and parental involvement and monitoring in adolescents' lives.

RESULTS

Higher levels of both activity level and parent mental distress predicted more frequent injuries.

CONCLUSIONS

As has been found with younger children, unintentional injuries in fifth graders are associated with both parent and child characteristics. The result is discussed in the context of adolescent development. Implications include those for injury prevention (multi-dimensional prevention strategies that incorporate environmental modifications as well as training of youth and parents) and future research (study of potential mechanisms behind injury risk behavior via longitudinal and experimental research; study of injury risk during this phase of child development).

[Circumstances of injury in childhood and adolescence. Data and epidemiology]

The population-related aspects of injuries in children and adolescents in Germany using data from different sources were compiled and analyzed. In contrast to clinical case studies, our focus was on risk groups, injury mechanisms, and context of injury. Sources of information used for this study included the following: Causes of Death Statistics, Hospital Diagnosis Statistics, Child and Adolescent Health Survey, Injury Database. Data for the period 1998 to 2008 on unintentional injuries, violence, and suicide were assessed by age group and gender and study results on sociodemographic risk factors were included. The analysis revealed that injuries display an age-specific dynamic: infants carry a high risk for fatal domestic injuries as well as for injuries due to violence, whereas in adolescents the majority of injuries result from fatal traffic injuries and from suicide. In addition, social factors were found to be related to specific mechanisms of injury (e.g., scalds) and intention (e.g., violence) only. Migration status has an age- and gender-related influence on injury rates.

Adults' perception of children's height and reaching capability

This study investigated the influence of some characteristics of the task, the model, and the observer, in the estimation errors of adults while judging children's affordances. One hundred and eighteen adults, divided in 4 height groups, estimated height and vertical reaching capability of 3 girls (3.55-, 4.74- and 7.06-years old), in the presence and in the absence of the model. Constant errors (CE) (estimation-real value), absolute percent errors (APE) (/1--estimation/real value/ x 100), and error tendency (underestimations, right judgments, or overestimations) were calculated. A model and a condition effect were verified on APE. APE for the younger model were greater than for the other models (p<0.001), and APE in the absence of the model were greater than in her presence (p<0.05). Generally, adults underestimated height (51.8% of underestimations vs. 32.3% of overestimations) and overestimated reachability (51.3% of overestimations vs. 37.7% of underestimations). The overestimation of reachability was more notorious for the younger model, which might reflect adults' difficulty to consider the specificity of younger children's body proportions. Actually, the overestimation bias may suggest that adults perceive young children as on the basis of adult's geometrical proportions.

Validation of a HOME Injury Survey

BACKGROUND

There are no validated observational surveys to assess injury hazards in the home environment.

OBJECTIVE

To evaluate the reproducibility and reliability of a survey quantifying home injury hazards for children.

METHODS

A nested cohort of children in the intervention arm of the Home Observations and Measures of the Environment (HOME) Study trial were analysed. The number and density of hazards were quantified by research assistants in the homes of participants at a baseline visit (BHV) for four high-risk rooms (kitchen, main activity room, child's bathroom and child's bedroom) and stairways and later at an intervention planning visit (IPV) for the four high-risk rooms and entire household. Statistical analysis included Pearson correlation, Bland-Altman analysis of agreement, analysis of variance and kappa statistics.

RESULTS

There were 163 households with measurements at BHV and IPV. The number and density of hazards for the four high-risk rooms correlated significantly between BHV and IPV (r = 0.50 and 0.75, respectively). The number and density of hazards for the four high-risk rooms correlated significantly with that for the whole household at the IPV (r = 0.17 and 0.52, respectively). The number of injury hazards was significantly higher in the kitchen than in the other high-risk rooms, whereas density was highest in the child's bathroom. Inter-rater reliability between research assistants, as measured by the kappa statistic, was excellent with a mean of 0.81.

CONCLUSIONS

The HOME Injury Survey was a reliable and replicable tool for quantifying residential injury hazards. The density of injury hazards was a more stable and valid measure than the number of injury hazards.

"I think he is in his room playing a video game": parental supervision of young elementary-school children at home

OBJECTIVES

Using a prospective design, this research examined supervision of young elementary-school children at home and how this relates to child injury, parent permissiveness, and children's risk-taking propensity.

METHODS

Mothers reported children's history of injuries and recorded home supervision over a 2-month interval on a weekly basis. Children independently completed diaries about daily events, including injuries.

RESULTS

Children spent 24% of time alone, mostly supervised intermittently or not at all. Parent permissiveness was associated with increased time unsupervised, while children's risk-taking propensity was associated with decreased time unsupervised. Greater direct supervision was associated with fewer injuries, while more indirect and non-supervision time emerged as risk factors and were associated with more frequent injury.

CONCLUSIONS

These results extend those from preschool-aged children and suggest that caregiver supervision influences risk of injury across a broad age range throughout childhood. Implications for children's safety are discussed.

Sibling supervision and young children's risk of injury: a comparison of mothers' and older siblings' reactions to risk taking by a younger child in the family

Although parental supervision is associated with reduced risk of injury to young children, supervision by older siblings has been shown to increase this risk. The current study, conducted in Guelph, Canada, explored how this differential risk of injury may arise. It compares the supervision behaviors of mothers to those of their older children when each was the designated supervisor of a young child, shown on a videotape to engage in no risk, risk, and rule violation behaviors in a home situation. The mothers and older child supervisors were told to imagine the toddler on the videotape was the young child in their own family, and to stop the tape and speak to the child whenever they would in real life. Results indicated that supervisees were allowed to engage in more risk behaviors when supervised by older siblings than by mothers. Sibling supervisors reacted to risk behaviors with more prohibitions, whereas mothers adopted a teaching orientation and gave more explanations and directions in response to risk behaviors by the supervisee. Implications for injury prevention and directions for future research are discussed.

Adult pedestrian behavior when accompanying children on the route to school

OBJECTIVE

Pedestrian injuries are a major cause of morbidity and mortality to children, especially boys. Adults serve as pedestrian role models and provide learning opportunities for children when walking to school. The research objectives were to investigate adult pedestrian behavior when accompanying boys and girls.

METHODS

Behavioral observation of 140 adult pedestrians accompanying 4- to 9-year-old children was done in British residential locations. Observations took place at light-controlled crossings, speed-restricted school safety zones, and mid-block unmarked crossing sites. Behaviors observed included stopping at the curb, waiting at the curb, looking left and right before and during road crossing, holding hands, talking, and walking straight across.

RESULTS

In general, adults modeled safe road crossing behaviors. Adult safe behavior scores were higher when accompanying girls than when accompanying boys. No statistically significant differences were found by child age group. The fewest safe pedestrian behaviors were observed at light-controlled crossings.

CONCLUSIONS

Adult pedestrians behave differently when with boys and girls and at different types of road crossing site. Interventions aimed at reducing pedestrian injuries to children may need to take these different everyday experiences into consideration.

Child home injury prevention: understanding the context of unintentional injuries to preschool children

Injury to young children at home is a public health problem. In New Zealand, over half the injury deaths and hospitalisations among 0-4 year olds occur at home. Causes and risk factors for child injury have been identified, but their circumstances are not well described. Understanding the context, however, is important for developing and implementing effective prevention. To obtain the descriptions of injury events, semi-structured interviews were conducted with a convenience sample of 100 caregivers of 0-4 year olds attending an emergency department for a home injury. Analysis from this exploratory study indicated that most events occurred within usual family activity, but had multiple factors interacting. Injury was rarely the expected outcome. Findings concurred with findings from others' research that reported home injury to be complex and multifaceted. Factors related to the environment, the child, the parent, their behaviours and activity interacted, with common patterns preceding injury being evident such as times of day and disrupted routines. Factors were often found to occur regardless of the cause of injury. Complex parental factors were identified, such as not anticipating risk, having unrealistic expectations of children, lacking knowledge of child development and accepting injury as a norm. Directions for further research are identified.

Child Injury: The Role of Supervision in Prevention

As the leading cause of death and major contributor to hospitalization for children, unintentional injury is a significant health problem in the United States. How supervision influences children’s risk of injury has been of interest for some time, and much progress has been made recently to address definitional and measurement issues pertaining to supervision. Increasing evidence supports the notion of a general relationship between increased supervision and decreased injury risk, but also reveals that child behavioral attributes and environmental characteristics can interact with level of supervision to affect injury risk, making it challenging to develop guidelines regarding what constitutes “adequate” supervision. Further research is needed to explore if and how children’s risk of injury varies with different supervisors (eg, mothers vs fathers vs older siblings) and how these relations change as a function of children’s developmental level. Recent research has identified messaging approaches that are effective to invoke a commitment to more closely supervising young children at home. Examining how these messages affect actual supervisory practices is an essential next step in this research and can support the development of evidence-based programs to improve supervision and reduce children’s risk of injuries.

Recognition of home injury risks by novice parents of toddlers

OBJECTIVE

Unintentional injury in the home is a leading cause of death for toddlers. The majority of injuries occur at home; parents play a significant role in injury prevention. Health-related behavior change theory suggests that behavior change is only possible if individuals (a) recognize the problem, and (b) believe they are vulnerable. This study examined these characteristics among novice parents of toddlers by investigating how well parents recognize hazards in the home and whether they believe their toddlers are vulnerable to those hazards.

METHODS

Three types of participants were recruited: novice parents of toddlers ages 12-36 months, daycare employees, and pediatric healthcare workers. All participants were examined three rooms simulating a typical toddler's bedroom, a living room, and a bathroom. Participants marked any hazards they recognized with stickers. Parents completed the hazard identification task twice, once identifying hazards for all toddlers and another time identifying hazards for their child.

RESULTS

Participants identified less than half the hazards present in the simulated rooms; parents identified more hazards than comparison groups. Parents identified significantly fewer hazards for their own child than they identified for other children.

DISCUSSION

Although parents identified more hazards than the professionals, they failed to identify a large portion of hazards and they perceived their own children to have less vulnerability than toddlers more broadly. Results indicate that education about toddler's vulnerability to injury in the home, as well as instructing parents about what situations are hazardous, might be considered during development of toddler home injury prevention programs.

Child pedestrian safety: parental supervision, modeling behaviors, and beliefs about child pedestrian competence

Pedestrian injuries are a significant health risk to children, particularly those 5-9 years of age. Surprisingly, few studies have explored parent-related factors that may moderate this risk. The present study used naturalistic observations of parent-child pairs crossing at uncontrolled intersections and a short interview to examine parental supervision of children during crossings, modeling of safe-crossing behaviors, beliefs about how children come to cross streets safely, and whether child attributes (age, sex) relate to parental practices and beliefs. Results revealed that parents more closely supervised younger than older children, they modeled safer crossing practices for sons more than daughters, particularly younger sons, and although over half the sample believed children need to be explicitly taught how to cross safely, few actually provided any instruction when crossing with their children. Providing parents both with guidelines for how to accurately appraise their child's readiness for crossing independently and with information about best practices for teaching children how to cross safely may facilitate parents' implementing these practices, particularly if this is coupled with public advocacy highlighting the important role they could play to reduce the risk of child pedestrian injury.

Parents' safety beliefs and childhood agricultural injury

BACKGROUND

This study examined potential associations between parental safety beliefs and children's chore assignments or risk of agricultural injury.

METHODS

Analyses were based on nested case-control data collected by the 1999 and 2001 Regional Rural Injury Study-II (RRIS-II) surveillance efforts. Cases (n = 425, reporting injuries) and controls (n = 1,886, no injuries; selected using incidence density sampling) were persons younger than 20 years of age from Midwestern agricultural households. A causal model served as the basis for multivariate data analysis.

RESULTS

Decreased risks of injury (odds ratio [OR] and 95% confidence intervals [CI]) were observed for working-aged children with "moderate," compared to "very strict" parental monitoring (0.60; 0.40-0.90), and with parents believing in the importance of physical (0.80; 0.60-0.95) and cognitive readiness (0.70, 0.50-0.90, all children; 0.30, 0.20-0.50, females) when assigning new tasks. Parents' safety beliefs were not associated with chore assignments.

CONCLUSIONS

Parents' safety beliefs were associated with reduced risk of childhood agricultural injury; the association was not mediated by chore assignments.

Assessing injuries with proxies: implications for understanding concurrent relations and behavioral antecedents of pediatric injuries

OBJECTIVE

To examine the implications of using proxies of medically attended injuries (minor injuries and close calls) for understanding concurrent relations among-and behavioral antecedents of-pediatric injuries.

METHODS

Participants were 812 children from the NICHD Study of Early Child Care. Measures of externalizing behavior, maternal depression, SES, and the home environment were examined as prospective predictors of minor injuries, close calls, and medically attended injuries.

RESULTS

Minor injuries and close calls were associated with medically attended injuries concurrently. Regression equations revealed different prospective predictors across the three outcome variables.

CONCLUSIONS

This study was the first to examine concurrent associations among minor injuries, close calls, and medically attended injuries. Prospective antecedents of each injury assessment were also examined. The present findings signify the importance of distinguishing between these different methods of assessing pediatric injury. The study also illustrated that different analytic strategies were needed to represent observed data of each outcome variable.

An ethnography of low-income mothers' safeguarding efforts

PROBLEM

Children living in lower-income environments are at greater risk for unintentional injuries. However, little is known about the safety practices of mothers living in low-income situations.

METHOD

This ethnographic study explored the child safeguarding experiences of low-income mothers using in-home interviews and observations.

RESULTS

Mothers' safeguarding efforts included cognitive and emotional work, child directed work, and work directed at the physical and social environments. Factors that influenced the women's safeguarding included the quality of the indoor space, availability of safe play space, traffic hazards, sibling interactions, child care supports, relationships with neighbors, and trust in community services.

DISCUSSION

These findings have implications for the conceptualization of safeguarding practices and provide insight about the experiences of mothers living on low-incomes.

IMPACT ON INDUSTRY

When developing safety interventions, program planners should consider the views and practices of mothers as well as contextual factors in the physical and social environments.

Interactions between child behavior patterns and parent supervision: implications for children's risk of unintentional injury

Unintentional injuries are the leading cause of death for children. Prior research has implicated both child behavioral attributes and parent supervisory patterns as risk factors. The present study assessed interactions between these two risk factors and determined whether supervision moderates the relation between child attributes and injury. Mothers completed questionnaire measures of child attributes and supervisory patterns and also recorded how they supervised their young child (2-5 years) at home on each of 10 randomly selected days within a 3-week period. Results provide support for the moderating effect of supervision: Supervision interacted with some child attributes to elevate children's risk of medically attended injury and with other attributes to decrease injury risk. Implications for preventing childhood injuries are discussed.