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

Maternal depression, child behavior, and injury

BACKGROUND

Few data exist on the effect of maternal depression on child injury outcomes and mediators of this relationship.

OBJECTIVE

To examine the relationship between mothers' depressive symptoms and medically attended injuries in their children and the potential mediating role of child behavior.

DESIGN/METHODS

A cohort of mother-child dyads from the National Longitudinal Study of Youth followed from 1992 to 1994. The primary exposure variable was maternal depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale in 1992. Child behavior was assessed by the Behavior Problems Index externalizing subscale. Logistic regression was used to examine the relationship between depressive symptoms, child behavior, and injury reported in the prior year in 1994.

RESULTS

94 medically attended injuries were reported in the 1106 children (8.5%); two-thirds were sustained in the home environment. Maternal depressive symptoms significantly increased the risk of child injury; injury risk increased 4% for every 1-point increase in depressive symptoms (adjusted OR 1.04, 95% CI 1.01 to 1.08, p=0.02). Increasing maternal depressive symptoms also increased the risk of externalizing behavior problems (adjusted OR 1.06, 95% CI 1.03 to 1.09), but externalizing behavior problems did not significantly mediate the relationship between maternal symptoms and child injury.

CONCLUSIONS

Increasing depressive symptoms in mothers was associated with an increased risk of child injury. Child behavior did not significantly mediate the association between maternal depressive symptoms and child injury in this cohort. Greater recognition, referral, and treatment of depressive symptoms in mothers may have effects on child behavior and injury risk.

Chronic maternal depression and children's injury risk

OBJECTIVE

A substantial number of mothers of young children suffer from depression. One understudied consequence of maternal depression is how it affects toddlers' injury risk. This study examined links between chronic maternal depression and child injury.

METHODS

A national sample of 1,364 American children was studied.

RESULTS

Chronic levels of severe maternal depression placed children at increased risk of concurrent injury from birth to age 3. The relation between chronic, severe maternal depression and child injury risk held even after controlling for variance from family SES, child sex, child temperament and externalizing behavior, and parenting. Chronic maternal depression during infancy and toddlerhood did not influence children's subsequent risk for injury, between age 3 and first grade. Less severe symptoms of chronic maternal depression were unrelated to concurrent or future child injury.

CONCLUSIONS

Chronic, severe levels of maternal depression are linked to concurrent child injury risk during infancy and toddlerhood.

Adult supervision and pediatric injuries in the agricultural worksite

Appropriate supervision is recommended as a strategy to prevent pediatric farm injuries, yet virtually nothing is known about the quality of adult supervision on farms. We therefore explored the nature of adult supervision among pediatric farm injury cases using three theoretically relevant dimensions of supervision: (1) attention, (2) proximity, and (3) continuity. We examined a retrospective case series of 334 pediatric farm injury cases from Canada and the United States that resulted in death or required hospitalization. Patterns of supervision were coded according to the three dimensions. Approximately two-thirds of the injured children (231/334; 69%) had an adult supervisor available (attention). The supervisor was in close proximity of the child in only about half the cases (169/334; 51%) and it was even less common for the supervision to be continuous (37%). Thus, many injuries occurred when children were inadequately supervised. However, approximately one-third of the injured children (112/334; 34%) had what in other circumstances would be considered adequate adult supervision at the time of their injury event, defined theoretically as having supervision available, proximal, and continuous. Yet, children on farms were injured even in the presence of adequate adult supervision. These findings, along with a growing body of literature examining pediatric farm injuries, suggest a need to develop a new definition of adequate adult supervision within the context of the agricultural work environment, or to consider restricting the access of children, especially the very young, to this hazardous worksite.

Parenting behaviors and attitudes about supervision among parents of acutely poisoned children

OBJECTIVE

This study describes the supervision beliefs of parents of children with unintentional poisonings and examines the relationship between supervision beliefs, household composition, and parental age.

METHODS

Children aged <60 months presenting with an unintentional poisoning to an emergency department or urgent care of an urban, academic medical center in Kansas City, Missouri, were identified. Parents completed the Beliefs About Supervision Questionnaire (BAS-Q) by phone within 2 weeks of their child's visit. The questionnaire consisted of 14 child activity scenarios, each followed by 2 questions: What age would you permit your child to perform this activity without constant supervision? How often would you check on a child of this age while engaged in the activity? Two scores were derived: mean age across all scenarios (BAS-Age) and mean time until child is checked on across all scenarios (BAS-Time).

RESULTS

One hundred parents completed the BAS-Q. The majority of respondents were mothers (82%), 40% had 2 or more children in the home aged 5 years or younger, and 61% had 2 or more adults living in the home. Pearson correlations revealed associations for BAS-Time with total children within the home (r = .28, P < .005) and number of children aged 6 to 12 years in the home (r = .28, P < .005). BAS-Age was not related to any aspect of household composition.

CONCLUSION

Less vigorous parental supervision was associated with an increased number of children in the home. Parental supervision may be influenced by reliance on other children in the home.

A new approach to understanding pediatric farm injuries

The objective of this study was to apply a new conceptual approach to the study of pediatric farm injuries. A large case series of pediatric farm injuries in North America was evaluated to assess interactions between risk factors for injury. Information about pediatric farm injuries to children in three age groups (<6 years, 6-12 years, 13+ years) was coded with respect to children's behavior (did unexpected child behavior contribute to injury?), predictability of injury risk (based on what the child had been doing, was the nature or occurrence of injury unexpected?), environmental events (did unexpected environmental events contribute to injury?), and level of environmental risk (low, high). The reliability of coding between independent raters was excellent (kappa=.83) for the 330 cases providing complete data. Results revealed that, in high-risk environments, unexpected child behavior was coded more frequently when children under 6 years were injured than for older children, whereas in low-risk environments unexpected child behavior had less impact on injury risk and showed no such age variation. With increasing age, the predictability of injury increased in a high-risk context, suggesting that youth engage in increasingly hazardous activities as they develop. Consistent with this interpretation, unexpected environmental events increasingly contributed to injury in a high-risk context in the oldest age groups. The observed variations in risk factors suggest that interactions between behavioral and environmental factors are important to consider in studies of the etiology of pediatric farm injuries.

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.

Measuring the risk of physical neglect in a population-based sample

Child neglect accounts for the majority of officially substantiated cases of child maltreatment in this country, although population-based data are lacking. This study estimates the number of children at risk for specific subtypes of physical neglect, using results of an anonymous telephone survey administered to 1,435 mothers of children ages 0 to 17 years in North and South Carolina. Children were considered "at risk for neglect" from lack of enough food, lack of access to medical care when needed, and inadequate supervision. Demographic factors were significantly related to the outcomes of interest, including lower family income with lack of enough food and access to medical care. There was little overlap in children at risk for the different subtypes of neglect. Maternal self-report data can be used to improve researchers' understanding of children at risk for neglect and to explore gaps in knowledge that might be amenable to intervention and prevention efforts.

Older siblings as supervisors: does this influence young children's risk of unintentional injury?

Unintentional injury is a leading cause of death and hospitalization of young children. Many of these injuries occur in the home when children presumably are being supervised. This study focused on the under-explored issue of sibling supervision in the home, drawing on data collected from a sample of Canadian mothers. Mothers in this sample completed a structured telephone interview and mailed back questionnaires to provide information about the nature and extent of sibling supervision that occurs in the home, as well as the younger child's injury history. Results indicated that older siblings supervise younger ones about 11% of their mutual wake time, with children typically playing and parents usually doing other chores during this time. Time spent with siblings as supervisors was positively related to the supervisee's history of injuries suggesting that sibling supervision may elevate younger children's risk of injury. However, the behavior of the supervisee contributed to risk more so than that of the supervisor. Specifically, sibling supervisors were reported to utilize the same types of strategies as their mother and father in their efforts to supervise and persuade younger children to stop things that could lead to injury. However, poor compliance by the younger child when the older sibling was supervising predicted injury. Implications for childhood injury and directions for future research are discussed.

Injury prevention in child and adolescent sport: whose responsibility is it?

OBJECTIVE

Sport and recreational injuries are a leading cause of morbidity in youth. There is a significant body of literature on risk factors for sport-related injuries and a growing body of research supporting the effectiveness of sport-specific prevention strategies in youth. Given the predictability and preventability of injuries in youth sport, the purpose of this article is to develop a model that considers societal responsibility for injury prevention in youth sport, and to discuss the evidence that supports this model.

DATA SOURCES/SYNTHESIS

Previously published papers have provided a basis for expert opinion to discuss an approach to examining the shared societal responsibility for implementing countermeasures to reduce the risk of injury to youth during sports.

RESULTS

Based on a historical perspective, broad conceptual framework, and specific evidence for prevention strategies in youth sport, the authors have developed and supported a theoretical model that defines a responsibility hierarchy in preventing injuries in youth sport. An argument has been made for a hierarchy of responsibility, with the lowest level of responsibility assigned to the child, and the highest level to those organizations or groups with the potential to effect the most change. The justification for this approach has been discussed in the context of the desirability of passive prevention strategies, the limited evidence for the effectiveness of strategies relying solely on behavior change in children and parents, and the level of perceptual and cognitive development in children that inadequately prepares them to take primary responsibility for their own safety in sport.

CONCLUSIONS

The development of effective programs to reduce the burden of sport injury among youth necessitates a scientific approach, the identification of key risk factors for injury, a thorough examination of how factors interact to affect risk, and the identification of potential barriers to the effectiveness of injury-prevention programs.

The Parent Supervision Attributes Profile Questionnaire: a measure of supervision relevant to children's risk of unintentional injury

OBJECTIVE

To further establish the psychometric properties of the Parent Supervision Attributes Profile Questionnaire (PSAPQ), a questionnaire measure of parent supervision that is relevant to understanding risk of unintentional injury among children 2 through 5 years of age.

METHODS

To assess test-retest reliability, parents completed the PSAPQ twice, with a one month interval. Internal consistency estimates for the PSAPQ were also computed. Confirmatory factor analyses were applied to the data to assess the four factor structure of the instrument by assessing the convergent and divergent validity of the subscales and their respective items.

RESULTS

Test-retest reliability and internal consistency scores were good, exceeding 0.70 for all subscales. Factor analyses confirmed the hypothesized model--namely that the 29 item questionnaire comprised four unique factors: protectiveness, supervision beliefs, risk tolerance, and fate influences on child safety.

CONCLUSIONS

Previous tests comparing the PSAPQ with indices of actual supervision and children's injury history scores revealed good criterion validity. The present assessment of the PSAPQ revealed good reliability (test-retest reliability, internal consistency) and established the convergent and divergent validity of the four factors. Thus, the PSAPQ has proven to have strong psychometric properties, making it a unique and useful measure for researchers interested in studying links between supervision and young children's risks of unintentional injury.

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.

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.