A Feasibility Randomized Trial Evaluating Safe Peds: A Virtual Reality Training Program to Teach Children When to Cross Streets Safely

OBJECTIVE

Injury as pedestrians is a leading contributor to childhood deaths. This study evaluated the effectiveness of Safe Peds, a fully immersive virtual reality training program to teach children when to cross street safely, with the focus on a number of foundational skills and practicing these in traffic situations of varying complexity.

METHODS

Children 7-10 years old were randomly assigned to a control (N = 31) or intervention (N = 26) group. Eligibility criteria included English speaking and typically developing. Testing took place on campus. All children completed pre- and post-testing measures, with those in the intervention group receiving training in between. Training comprised 1 session with 3 phases for a total of up to 1.5 hr and was tailored to each child's performance over trials. On each trial, children decided when to cross and fully executed this crossing, with measures automatically taken by the system as they did so.

RESULTS

Negative binomial regression and analysis of covariance tests were applied, predicting post-test scores while controlling for pre-test scores, age, and sex. The intervention was effective in improving children's street crossing skills, including stopping and checking skills (stop at the curb, look left/right/left, check for traffic before crossing the yellow line), and choosing safe inter-vehicle gaps. Children in the control group did not show significant improvements in any crossing skills.

CONCLUSIONS

The Safe Peds program effectively teaches children skills to support their deciding when to safely cross in a variety of traffic situations. Implications for pedestrian injury are discussed.

BASE: Pragmatic Injury Prevention for Practitioners

Unintentional injury remains a leading health problem in developed nations, making injury prevention imperative. Practitioners are primary stakeholders in the injury prevention process but rarely can devote significant time to complicated prevention efforts. Furthermore, theory-based approaches to support injury prevention are less common than atheoretical approaches. We propose a simple method for injury prevention grounded in concepts found in antecedent models. Barriers, attitudes, social context, and environmental factors (or BASE) are suggested as a simple injury prevention model practitioners can follow when working with patients. We present each component of BASE and offer examples of how the approach can be applied to risk factors associated with several types of injury risk behavior.

Mental fatigue delays visual search behaviour in young cyclists when negotiating complex traffic situations: A study in virtual reality

INTRODUCTION

Mental fatigue has been shown to negatively affect motor and sport performance. To date, however, no research focused on assessing the effects of mental fatigue on hazard perception in young cyclists who are highly vulnerable in traffic, especially after school. Therefore, the purpose of this study was to examine the influence of induced mental fatigue on hazard perception and anticipation in young cyclists using a novel Virtual Reality bicycle simulator.

METHODS

In this randomised, counterbalanced, cross-over investigation, forty-eight young cyclists cycled through a Virtual Environment (VE) in which they were confronted with eight simple and six complex traffic situations. Simple traffic situations are considered events including only one other actor can cause a dangerous situation while complex traffic situations include multiple actors than contribute to the dangerous situation. Half of the children were mentally fatigued using the Stroop colour-word task while the other half immediately started the VR hazard perception test. On the second test occasion, one month later, the other half of the group was mentally fatigued.

RESULTS

The results demonstrate that mentally fatigued cyclists fixated the relevant areas of interest (AOIs) in the simple and complex later and showed delayed response times for the complex hazards. Mental fatigue, however, did not alter the speed with which participants cycled through the virtual environment and did not change the hazard perception score.

CONCLUSION

To our knowledge, this was the first study to investigate the effect of mental fatigue in young cyclists with an innovative VR hazard perception simulator. Due to increased mental fatigue, young cyclists might have experienced more episodes of fatigue-related mind-wandering and a deterioration of selective attention for the task at hand. This resulted in a less thorough visual inspection of the scene and delayed braking responses.

Understanding Sex Differences in Children's Injury Risk as Pedestrians

OBJECTIVE

Boys experience more injuries as pedestrians than girls. The aim of this study was to compare how boys and girls cross streets in order to identify factors that differentially influence their injury risk as pedestrians.

METHODS

Using a fully immersive virtual reality (VR) system interfaced with a 3D movement measurement system, various measures of children's street-crossing behaviors were taken.

RESULTS

At the start of the crossing, boys selected smaller (riskier) inter-vehicle gaps to cross into than girls. Subsequently, as they crossed, they showed greater attention to traffic, shorter start delay, and more evasive action than girls, which are strategies that could reduce risk as a pedestrian. Despite these efforts, however, boys experienced more hits and close calls than girls.

CONCLUSION

To enhance their safety as pedestrians, girls adopt a proactive approach and select larger inter-vehicle gaps to cross into, whereas boys apply a reactive approach aimed at managing the risk created by having selected smaller (riskier) gaps. Girls' proactive approach yielded safer outcomes than boys' reactive strategy.

Children's Road-Crossing Behavior: Emotional Decision Making and Emotion-Based Temperamental Fear and Anger

OBJECTIVE

Child pedestrian injuries represent a global public health burden. To date, most research on psychosocial factors affecting children's risk of pedestrian injury focused on cognitive aspects of children's functioning in traffic. Recent evidence suggests, however, that emotional aspects such as temperament-based fear and anger/frustration, as well as executive function-based emotional decision making, may also affect children's safety in traffic. This study examined the role of emotions on children's pedestrian behavior. Three hypotheses were considered: (a) emotion-based temperament factors of fear and anger/frustration will predict children's risky decisions and behaviors; (b) emotional decision making will predict risky pedestrian decisions and behaviors; and (c) children's pedestrian decision making will mediate relations between emotion and risky pedestrian behavior. The role of gender was also considered.

METHODS

In total, 140 6- to 7-year-old children (M = 6.7 years, SD = 0.39; 51% girls) participated. Parent-report subscales of Child Behavior Questionnaire measured temperamental fear and anger/frustration. The Hungry Donkey Task, a modified version of Iowa Gambling Task for children, measured children's emotional decision making, and a mobile virtual reality pedestrian environment measured child pedestrian behavior.

RESULTS

Greater anger/frustration, lesser fear, and more emotional decision making all predicted poorer pedestrian decision making. The mediational model demonstrated that pedestrian decision making, as assessed by delays entering safe traffic gaps, mediated the relation between emotion and risky pedestrian behavior. Analyses stratified by gender showed stronger mediation results for girls than for boys.

CONCLUSIONS

These results support the influence of emotions on child pedestrian behavior and reinforce the need to incorporate emotion regulation training into child pedestrian education programs.

A Model to Predict Children’s Reaction Time at Signalized Intersections

Traffic accident statistics in urban areas, both locally in Croatia and at the European level, identify children as a group of vulnerable road users. The analysis of the parameters that influence the interaction of child pedestrians and other road users requires special attention. This paper presents the results of research about the reaction time of children, measured both in laboratory conditions, via a computer reaction time test, and in actual traffic conditions. The results of the reaction time test in a situation with expected stimuli (a computer test) of children aged 6 to 10 years were compared with the results of the reaction time of adult traffic participants, drivers, who also took part in the computer test. Standard deviations of the reaction times between the control group (drivers, adults) and each subgroup of children were significantly different (p < 0.05). The results suggest that the largest developmental jump occurs between preschool children and first-grade children. In actual traffic conditions, the reaction time of children aged 4 to 16 years at the signalized intersection was measured. The model for predicting the reaction time of children in real traffic conditions was created using a neural network. The model prediction results matched well with the values measured in actual traffic conditions, for the observed intersection (correlation coefficient is 94.56%) and for the validation intersection (correlation coefficient is 92.29%). Parameters influencing children’s reaction times in real traffic conditions were identified by applying both statistical analysis and the neural network model developed. Using both methods, the same key distractors were identified—the movement of children in the group and the use of mobile phones. The case study was conducted at selected signalized intersections in the city of Osijek, Croatia.

Assessing pedestrian safety across modalities via a simulated vehicle time-to-arrival task

Pedestrians must use a variety of visual and auditory cues when determining safe crossing opportunities. Although vision has received a bulk of the attention in research on pedestrian safety, the examination of both vision and audition are important to consider. Environmental, intrapersonal, and cognitive qualities of a pedestrian context may limit the use of one or both perceptual modalities. Across two experiments, we examined the impact of perceptual constraints on pedestrian safety by measuring the accuracy of vehicle time-to-arrival estimates in a virtual environment when vehicles were only visible, only audible, or both visible and audible. In both experiments, participants estimated the time-to-arrival of vehicles moving at one of two speeds (8-kph, 40-kph). In the second experiment, we introduced ambient traffic noises to examine the impact of environmentally relevant traffic noises on pedestrian perception. Results suggest seeing a vehicle is more advantageous than hearing a vehicle when interacting with traffic, especially in the presence of ambient sound. Both experiments resulted in more accurate time-to-arrival estimates in the visual and mixed conditions than in the auditory-only condition. Implications for pedestrian safety and future research are discussed.

Supervision of young children in parking lots: Impact on child pedestrian safety

INTRODUCTION

Pedestrian injuries are a significant pediatric public health concern worldwide. Younger children are at particular risk for pedestrian injuries in parking lots, but there is limited research regarding children's pedestrian behaviors in parking lots.

METHOD

This study examined children's behaviors and safety risks in parking lots through unobtrusive and unannounced observation of 124 children ages 2-10 years and their adult supervisors as they crossed a parking lot from their parked vehicle into a community recreation center.

RESULTS

Adult supervision was inadequate: over 67% of children 10 years of age and younger were unsupervised in the parking lot at some point between the vehicle parking and the child entering into the building. Approximately 90% of all children were outside of arm's length of the accompanying adult at some point while in the parking lot. Additionally, children exited the vehicle prior to the adult in over 50% of observations. Age was associated with safety risk, with older children being unsupervised more often than younger ones.

CONCLUSIONS

Adult supervision of children in a parking lot setting was poor, creating significant safety risks. In addition, many children failed to follow basic pedestrian safety practices themselves, such as looking for moving cars. Injury prevention strategies should be implemented. Practical applications: As researchers gain better understanding about the safety risks for children in parking lots, interventions could target adult and child behaviors through improved supervision, altered perception of risk, and mandated behavioral guidelines for child behavior, such as how and when children exit vehicles in parking lots.

Effect of positive airway pressure therapy in children with obstructive sleep apnea syndrome: does positive airway pressure use reduce pedestrian injury risk?

INTRODUCTION

Treatment with positive airway pressure (PAP) therapy reduces injury risk among adults with obstructive sleep apnea syndrome (OSAS), but the effect of PAP therapy on children's injury risk is unknown. This study investigated whether treatment of OSAS with PAP reduces children's pedestrian injury risk in a virtual reality pedestrian environment.

METHODS

Forty-two children ages 8-16 years with OSAS were enrolled upon diagnosis by polysomnography. Children crossed a simulated street several times upon enrollment, prior to PAP treatment, and again after 3 months of PAP therapy. Children underwent sleep studies at all time points.

RESULTS

Children adherent with PAP had a significant reduction in hits by a virtual vehicle (P < .01) and less time to contact with oncoming vehicles (P < .01) following treatment. Those who were nonadherent did not show improved safety. There was no change in attention to oncoming traffic.

CONCLUSIONS

OSAS may have significant consequences on children's daytime functioning in a critical domain of personal safety: pedestrian skills. In pedestrian simulation, children with OSAS adherent to PAP therapy showed improvement in pedestrian safety and had fewer collisions with a virtual vehicle following treatment. Results highlight need for heightened awareness of the real-world benefits of treatment for pediatric sleep disorders.

LEVEL OF EVIDENCE

Level II Therapeutic Study.

Child pedestrian behaviors: Influence of peer social norms and correspondence between self-reports and crossing behaviors

OBJECTIVE

The aims of this study were to determine if children's perception of peers' behavioral norms for crossing streets relates to their personal norms for doing so and if children's self-reports about crossing relates to their actual crossing in a virtual traffic situation.

METHOD

Children (8-10 years, N = 86) completed questionnaires about peer's norms and their personal norms about crossing streets, and also reported on their recent crossing behaviors. These self-reports about crossing were then related to children's actual crossing behaviors measured using a fully immersive virtual reality (VR) system.

RESULTS

Children's perception of peers' behavioral norms for crossing related to their personal norms for doing so, and their norms related to their reports of how they have crossed in the past few weeks. When crossing virtual streets, children with higher scores on self-reports about risky crossing behaviors selected smaller (riskier) inter-vehicle gap sizes to cross into, showed less start delay (less time appraising traffic before starting), and experienced more hits. Conclusion and practicalapplications: Children's perception of peers' behavioral norms for crossing are relevant to their crossing behaviors and may be one way that peers elevate children's risk of pedestrian injury. Children's self-reports about crossing risk may be useful for identifying at-risk youth and strategically targeting interventions to these children.

Improving safe street-crossing behaviors among primary school students: a randomized controlled trial

Background: Child pedestrian injury is a global public health concern. Our aim in the present study was to investigate the effects of active learning-based educational intervention on street-crossing behavior among male primary school students in Mehriz county, Iran.

Methods: In this randomized controlled trial, 90 first grade elementary school students(experiment = 50, control group = 48) participated. The "ASSURE Model" was applied to design the template of this active learning-based educational program, which was implemented for the experiment group in eight sessions. Behaviors of the students about ‘’looking for vehicles on the street’’, "being cautious of dangers’’ and ‘’crossing from safe places’’ were observed and documented in actual traffic environments before, 1 week, and 6 months after intervention.

Results: One week and 6 months after the intervention, the experiment group’s performance in all 3 behaviors were significantly improved (P < 0.001). Distraction-adjusted differences in the mean scores of behaviors between the experiment (Mean = 2.62) and control (Mean = 3.19)groups before and 6 months after intervention (Mean in experiment groups = 6.3, Mean in control group = 4.24) were also statistically significant (P < 0.001).

Conclusion: Our educational intervention was found to be helpful in promoting the street crossing behaviors of primary school-aged children. School healthcare professionals may apply active learning education as the core category of their interventional programs to promote street-crossing behaviors among primary school students.

Featured Article: Evaluating Smartphone-Based Virtual Reality to Improve Chinese Schoolchildren's Pedestrian Safety: A Nonrandomized Trial

Objective

This nonrandomized trial evaluated whether classroom-based training in a smartphone-based virtual reality (VR) pedestrian environment (a) teaches schoolchildren to cross streets safely, and (b) increases their self-efficacy for street-crossing.

Methods

Fifty-six children, aged 8-10 years, attending primary school in Changsha, China participated. Baseline pedestrian safety assessment occurred in the VR environment and through unobtrusive observation of a subsample crossing a street for 11 days outside school. Self-efficacy was assessed through both self-report and observation. Following baseline, children engaged in the VR for 12 days in their classrooms, honing complex cognitive-perceptual skills required to engage safely in traffic. Follow-up assessment replicated baseline.

Results

Probability of crash in the VR decreased posttraining (0.40 vs. 0.09), and observational data found the odds of looking at oncoming traffic while crossing the first lane of traffic increased (odds ratio [OR] = 2.4). Self-efficacy increases occurred in self-report (proportional OR = 4.7 crossing busy streets) and observation of following crossing-guard signals (OR = 0.2, first lane).

Conclusions

Pedestrian safety training via smartphone-based VR provides children the repeated practice needed to learn the complex skills required to cross streets safely, and also helps them improve self-efficacy to cross streets. Given rapid motorization and global smartphone penetration, plus epidemiological findings that about 75,000 children die annually worldwide in pedestrian crashes, smartphone-based VR could supplement existing policy and prevention efforts to improve global child pedestrian safety.

Developmental Aspects of Unintentional Injury Prevention Among Youth: Implications for Practice

Unintentional injuries, the leading cause of morbidity and mortality among youth in the United States, are burdensome and costly to society. Continued prevention efforts to reduce rates of unintentional injury remain imperative. We emphasized the role of practitioner influence across a linear concept of injury prevention comprising delivery, practice, and application/generalization and within the context of child developmental factors. Specific strategies for injury prevention tailored to the cognitive development stage of the patient are provided. This information may be useful to health care practitioners, who have significant interaction with youth and their families.

Distracted Walking, Bicycling, and Driving: Systematic Review and Meta-Analysis of Mobile Technology and Youth Crash Risk

This article examined the impact of mobile technology on young pedestrians, bicyclists, and drivers. A systematic search yielded 41 articles meeting inclusion criteria: peer-reviewed, published before February 1, 2016, behavioral outcome related to pedestrian, bicycling, or driving in the presence of mobile technology use, youth sample. Eleven studies were meta-analyzed to evaluate increased risk for crash/near-crash while distracted. Risk of bias and quality of research were assessed. Across methodologies, developmental stages, and type of distracting task, mobile technology use impairs youth safety on the road. Quality of evidence was low (pedestrian) to moderate (driving). Findings are discussed from the perspective of cognitive and visual distractions. Policy and behavioral efforts should continue to reduce mobile technology use in transportation settings.

Experiential exposure to texting and walking in virtual reality: A randomized trial to reduce distracted pedestrian behavior

BACKGROUND

Distracted pedestrian behavior is a significant public health concern, as research suggests distracted pedestrians have significantly higher risk of injury compared to fully attentive pedestrians. Despite this, efforts to reduce distracted pedestrian behavior are scant.

OBJECTIVE

Using a repeated measures experimental research design, we implemented a behavioral intervention to reduce distracted pedestrian behavior in the high-risk environment of an urban college campus and simultaneously monitored behavior on a control urban college campus not exposed to the intervention. We had two primary aims: reduce perceived vulnerability to injury among individual pedestrians and reduce distracted pedestrian behavior in the environment through a change in community-based norms.

METHODS

The hallmark of the behavioral intervention was a week-long opportunity for community members to experience personally the risks of distracted pedestrian behavior by attempting to cross a virtual pedestrian environment street while text-messaging. This was supplemented by traditional and social marketing and publicity through various campus partners. A sample of 219 individuals completed self-report surveys about perceived vulnerability to distracted pedestrian injury before experiencing the distracted virtual street-crossing and again after 2 weeks and 5 months. Observational assessment of distracted pedestrian behavior was conducted at a busy intersection on the campus as well as at a control campus not exposed to the intervention at baseline, post-intervention, 10 weeks, and 6 months.

RESULTS

The intervention achieved mixed results. Individuals exposed to texting within a simulated pedestrian environment reported changes in their intentions to cross streets while distracted and in perceived vulnerability to risk while crossing streets, but we did not witness evidence of changed community norms based on observed rates of distracted pedestrian behavior before and after the intervention compared to a control campus not exposed to the intervention.

DISCUSSION

The intervention created some change in self-reported intentions and thoughts but did not create significant behavior change on the campus exposed to it. Further efforts to develop interventions that will yield a reduction in distracted pedestrian behavior are needed.

Effects of secondary tasks on auditory detection and crossing thresholds in relation to approaching vehicle noises

Research suggests an association between distracting environmental sound stimuli and poorer performance in detecting and localizing approaching vehicles using auditory cues. However, no studies have investigated the distractive potential posed by intrapersonal distractors in the context of pedestrian auditory perception. We examined the effects of holding naturalistic vocal and texting cell phone conversations on participants' auditory detection of approaching vehicles and crossing thresholds in a non-visual simulated setting. Ninety-nine adults were randomly assigned to conditions of vocal conversation, texting conversation, or a control group and completed an auditory vehicle detection task. Participants in the vocal cell phone conversation group detected vehicles at significantly shorter distances than participants in the control group. The concurrence of a secondary task did not affect the distances at which participants deemed vehicles noise too close for them to safely cross (i.e., crossing thresholds). Implications for future research and injury prevention are discussed.

Direct observations of active school transportation and stroller use in kindergarten children

Little is known about kindergarten students' active school transportation (AST) and stroller/wagon use as sedentary travel devices. The primary objective of this cross-sectional study was to determine the prevalence of kindergarten children arriving to school by active and sedentary modes, including strollers, in Toronto elementary schools and compare to students in kindergarten to grade 6 (K–6). The secondary objective was to examine factors associated with AST in kindergarten and K–6 students. School travel mode was counted using direct observations at elementary schools in the City of Toronto in 2015. Two samples were observed: 1) Kindergarten sample: a random sample of schools with separate kindergarten entrances (n = 26 schools, 1069 children); 2) Kindergarten to grade 6 sample: observations were conducted at arrival locations at 50% of eligible elementary schools for students of all ages (n = 88 schools, 17,224 children). Proportions arriving by different travel modes were compared using Chi-square analysis. Negative binomial regression was conducted to examine the association between school characteristics and AST. AST was lower in the kindergarten compared to the K–6 sample (60% versus 74%, χ² = 91.37, p < 0.001). The predominant sedentary mode for kindergarten students was by vehicle (38%), with < 2% using strollers/wagons. Recent immigrant status was related to higher AST in kindergarten students; higher social disadvantage, crossing guards, school population and collision rates were related to higher AST in the K–6 sample. Factors influencing AST in young students require further investigation to influence the development of healthy active lifestyles at an early age.

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Observational counts of school transportation mode and stroller use was conducted.

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Active school transportation (AST) was less in kindergarten versus all age students.

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< 2% of kindergarten students use strollers for transportation to school.

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School proportion of recent immigrants was related to AST in kindergarten students.

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Higher social disadvantage was most strongly related to AST in all age students.

How do children learn to cross the street? The process of pedestrian safety training

OBJECTIVE

Pedestrian injuries are a leading cause of child death and may be reduced by training children to cross streets more safely. Such training is most effective when children receive repeated practice at the complex cognitive-perceptual task of judging moving traffic and selecting safe crossing gaps, but there is limited data on how much practice is required for children to reach adult levels of functioning. Using existing data, we examined how children's pedestrian skills changed over the course of 6 pedestrian safety training sessions, each composed of 45 crossings within a virtual pedestrian environment.

METHODS

As part of a randomized controlled trial on pedestrian safety training, 59 children ages 7-8 crossed the street within a semi-immersive virtual pedestrian environment 270 times over a 3-week period (6 sessions of 45 crossings each). Feedback was provided after each crossing, and traffic speed and density were advanced as children's skill improved. Postintervention pedestrian behavior was assessed a week later in the virtual environment and compared to adult behavior with identical traffic patterns.

RESULTS

Over the course of training, children entered traffic gaps more quickly and chose tighter gaps to cross within; their crossing efficiency appeared to increase. By the end of training, some aspects of children's pedestrian behavior was comparable to adult behavior but other aspects were not, indicating that the training was worthwhile but insufficient for most children to achieve adult levels of functioning.

CONCLUSIONS

Repeated practice in a simulated pedestrian environment helps children learn aspects of safe and efficient pedestrian behavior. Six twice-weekly training sessions of 45 crossings each were insufficient for children to reach adult pedestrian functioning, however, and future research should continue to study the trajectory and quantity of child pedestrian safety training needed for children to become competent pedestrians.

Detection and Direction Determination of Approaching Vehicle Noises Among Older Adults

We examined detection and direction determination of auditory cues from a pedestrian environment among a sample of older and younger adults. Review of relevant research suggests normal aging is associated with declines in physical, cognitive, and perceptual abilities. Relatively, few studies have examined the impact of such developmental changes on pedestrian safety among older adults, and none have examined such factors in relation to use of auditory cues. Thirty-five younger and 35 older adults completed cognitive measures and a pedestrian auditory detection task. Some results by speed were similar to past research that examined younger samples. Interactions were discovered between age and speed conditions within the auditory task. Results are discussed in the context of past research and with regard to informing future injury prevention efforts.

Community-based pedestrian safety training in virtual reality: A pragmatic trial

Child pedestrian injuries are a leading cause of mortality and morbidity across the United States and the world. Repeated practice at the cognitive-perceptual task of crossing a street may lead to safer pedestrian behavior. Virtual reality offers a unique opportunity for repeated practice without the risk of actual injury. This study conducted a pre-post within-subjects trial of training children in pedestrian safety using a semi-mobile, semi-immersive virtual pedestrian environment placed at schools and community centers. Pedestrian safety skills among a group of 44 seven- and eight-year-old children were assessed in a laboratory, and then children completed six 15-minute training sessions in the virtual pedestrian environment at their school or community center following pragmatic trial strategies over the course of three weeks. Following training, pedestrian safety skills were re-assessed. Results indicate improvement in delay entering traffic following training. Safe crossings did not demonstrate change. Attention to traffic and time to contact with oncoming vehicles both decreased somewhat, perhaps an indication that training was incomplete and children were in the process of actively learning to be safer pedestrians. The findings suggest virtual reality environments placed in community centers hold promise for teaching children to be safer pedestrians, but future research is needed to determine the optimal training dosage.

Relations between temperamental fear and risky pedestrian behavior

OBJECTIVE

Child pedestrian injury poses a significant global public health challenge. This study examines relations between temperamental fear and children's risky pedestrian behavior, utilizing mediation analytic strategies to study underlying mechanisms of the hypothesized relation.

METHODS

As part of a larger study, 240 seven- and eight-year-old children completed 30 crossings in a virtual reality (VR) pedestrian environment. Three pedestrian behaviors were considered: start gap (lag after a traffic gap appears before child initiates crossing into the gap), time to contact (TTC; gap between avatar and the lead oncoming vehicle), and hits (collisions with vehicles in simulated crossings). Temperamental fear was measured by parent report.

RESULTS

Fearful children were more likely to be struck by virtual vehicles, and the relation between fear and risky pedestrian behaviors was mediated by start gap and TTC. Specifically, children who were temperamentally more fearful were more likely to hesitate before initiating crossing, which led to shorter gaps between themselves and the oncoming vehicle, hence causing them to be more likely to be hit by virtual vehicles. Gender interacted with fear, such that fearful girls were most likely to be hit.

CONCLUSIONS

Both temperamental fear and gender influenced the risk of child pedestrian injuries. Delayed entry into traffic and shorter gaps between children and oncoming vehicles may underlie this relation. Future research should explore how these factors might influence the effectiveness of prevention programs.

Obstructive sleep apnea syndrome increases pedestrian injury risk in children

OBJECTIVES

To evaluate pedestrian behavior, including reaction time, impulsivity, risk-taking, attention, and decision-making, in children with obstructive sleep apnea syndrome (OSAS) compared with healthy controls.

STUDY DESIGN

Using a case control design, 8- to 16-year-olds (n = 60) with newly diagnosed and untreated OSAS engaged in a virtual reality pedestrian environment. Sixty-one healthy children matched using a yoke-control procedure by age, race, sex, and household income served as controls.

RESULTS

Children with OSAS were riskier pedestrians than healthy children of the same age, race, and sex. Children with OSAS waited less time to cross (P < .01). The groups did not differ in looking at oncoming traffic or taking longer to decide to cross.

CONCLUSIONS

Results suggest OSAS may have significant consequences on children's daytime functioning in a critical domain of personal safety, pedestrian skills. Children with OSAS appeared to have greater impulsivity when crossing streets. Results highlight the need for heightened awareness of the consequences of untreated sleep disorders and identify a possible target for pediatric injury prevention.

Training children in pedestrian safety: distinguishing gains in knowledge from gains in safe behavior

Pedestrian injuries contribute greatly to child morbidity and mortality. Recent evidence suggests that training within virtual pedestrian environments may improve children's street crossing skills, but may not convey knowledge about safety in street environments. We hypothesized that (a) children will gain pedestrian safety knowledge via videos/software/internet websites, but not when trained by virtual pedestrian environment or other strategies; (b) pedestrian safety knowledge will be associated with safe pedestrian behavior both before and after training; and (c) increases in knowledge will be associated with increases in safe behavior among children trained individually at streetside locations, but not those trained by means of other strategies. We analyzed data from a randomized controlled trial evaluating pedestrian safety training. We randomly assigned 240 children ages 7-8 to one of four training conditions: videos/software/internet, virtual reality (VR), individualized streetside instruction, or a no-contact control. Both virtual and field simulations of street crossing at 2-lane bi-directional mid-block locations assessed pedestrian behavior at baseline, post-training, and 6-month follow-up. Pedestrian knowledge was assessed orally on all three occasions. Children trained by videos/software/internet, and those trained individually, showed increased knowledge following training relative to children in the other groups (ps < 0.01). Correlations between pedestrian safety knowledge and pedestrian behavior were mostly non-significant. Correlations between change in knowledge and change in behavior from pre- to post-intervention also were non-significant, both for the full sample and within conditions. Children trained using videos/software/internet gained knowledge but did not change their behavior. Children trained individually gained in both knowledge and safer behavior. Children trained virtually gained in safer behavior but not knowledge. If VR is used for training, tools like videos/internet might effectively supplement training. We discovered few associations between knowledge and behavior, and none between changes in knowledge and behavior. Pedestrian safety knowledge and safe pedestrian behavior may be orthogonal constructs that should be considered independently for research and training purposes.

Systematic review and meta-analysis of behavioral interventions to improve child pedestrian safety

OBJECTIVE

Pedestrian injuries represent a pediatric public health challenge. This systematic review/meta-analysis evaluated behavioral interventions to teach children pedestrian safety.

METHODS

Multiple strategies derived eligible manuscripts (published before April 1, 2013, randomized design, evaluated behavioral child pedestrian safety interventions). Screening 1,951 abstracts yielded 125 full-text retrievals. 25 were retained for data extraction, and 6 were later omitted due to insufficient data. In all, 19 articles reporting 25 studies were included. Risk of bias and quality of evidence were assessed.

RESULTS

Behavioral interventions generally improve children's pedestrian safety, both immediately after training and at follow-up several months later. Quality of the evidence was low to moderate. Available evidence suggested interventions targeting dash-out prevention, crossing at parked cars, and selecting safe routes across intersections were effective. Individualized/small-group training for children was the most effective training strategy based on available evidence.

CONCLUSIONS

Behaviorally based interventions improve children's pedestrian safety. Efforts should continue to develop creative, cost-efficient, and effective interventions.

The effects of acute sleep restriction on adolescents' pedestrian safety in a virtual environment

PURPOSE

Over 8,000 American adolescents ages 14-15 years require medical attention owing to pedestrian injury annually. Cognitive factors contributing to pedestrian safety include reaction time, impulsivity, risk taking, attention, and decision making. These characteristics are also influenced by sleep restriction. Experts recommend that adolescents obtain 8.5 hours of uninterrupted sleep each night, but most American adolescents do not. Inadequate sleep may place adolescents at risk for pedestrian injury.

METHODS

Using a within-subjects design, 55 14- and 15-year-olds engaged in a virtual reality pedestrian environment under two conditions, scheduled a week apart: sleep-restricted (4 hours' sleep the previous night) and adequate sleep (8.5 hours). Sleep was assessed using actigraphy and pedestrian behavior via four outcome measures: time to initiate crossing, time before contact with vehicle while crossing, virtual hits or close calls and attention to traffic (looks left and right).

RESULTS

While acutely sleep restricted, adolescents took more time to initiate pedestrian crossings, crossed with less time before contact with vehicles, experienced more virtual hits or close calls, and looked left and right more often compared with when adequately rested. Results were maintained after controlling for age, gender, ethnicity, and average total sleep duration before each condition.

CONCLUSIONS

Adolescent pedestrian behavior in the simulated virtual environment was markedly different, and generally more risky, when acutely sleep restricted compared with adequately rested. Inadequate sleep may influence cognitive functioning to the extent that pedestrian safety is jeopardized among adolescents capable of crossing streets safely when rested. Policy decisions might be educated by these results.

Developmental differences in auditory detection and localization of approaching vehicles

Pedestrian safety is a significant problem in the United States, with thousands being injured each year. Multiple risk factors exist, but one poorly understood factor is pedestrians' ability to attend to vehicles using auditory cues. Auditory information in the pedestrian setting is increasing in importance with the growing number of quieter hybrid and all-electric vehicles on America's roadways that do not emit sound cues pedestrians expect from an approaching vehicle. Our study explored developmental differences in pedestrians' detection and localization of approaching vehicles. Fifty children ages 6-9 years, and 35 adults participated. Participants' performance varied significantly by age, and with increasing speed and direction of the vehicle's approach. Results underscore the importance of understanding children's and adults' use of auditory cues for pedestrian safety and highlight the need for further research.

Auditory detection and localization of approaching vehicles

Pedestrians must use a variety of cues when making safe decisions, many of which require processing of auditory information. We examined detection and localization of approaching vehicles using auditory cues. 50 adults ages 18-49 were presented with actual sounds of vehicles approaching at 5, 12, 25, and 35 mph. Three indices were of interest: the distance at which vehicles were detected, participants' decision regarding the direction from which vehicles were approaching, and their determination of the vehicles' arrival at their location. Participants more easily detected vehicles moving at higher speeds and vehicles approaching from the right. Determination of the direction of approach reached 90% accuracy or better when vehicles were traveling at, or greater than, 12 mph, and were more approaching from the right. Determination of vehicle arrival deteriorated significantly as speeds increased. Implications of the use of auditory cues in pedestrian settings, and future directions, are discussed.

Child Pedestrian Injury: A Review of Behavioral Risks and Preventive Strategies

Pedestrian injury is among the leading causes of pediatric death in the United States and much of the world. This paper is divided into two sections. First, we review the literature on behavioral risk factors for child injury. Cognitive and perceptual development risks are discussed. The roles of distraction, temperament and personality, and social influences from parents and peers are presented. We conclude the first section with brief reviews of environmental risks, pedestrian safety among special populations, and the role of sleep and fatigue on pediatric pedestrian safety. The second section of the review considers child pedestrian injury prevention strategies. Categorized by mode of presentation, we discuss parent instruction strategies, school-based instruction strategies (including crossing guards), and streetside training techniques. Technology-based training strategies using video, internet, and virtual reality are reviewed. We conclude the section on prevention with discussion of community-based interventions.

The relative risk of nearside accidents is high for the youngest and oldest pedestrians

Police road accident data from Great Britain for 1990-2009 were analysed. RR(NF) is the risk of a casualty occurring in the first half of road crossing, the half nearest to the pedestrian's starting position at the roadside, compared to the risk of it occurring in the second half. Children and younger adult pedestrians had a high relative risk of being killed or seriously injured in the nearside of the road (RR(NF)). RR(NF) decreased with age, for men and women, but rose again for people aged over 85 years. It was also substantially lower for children under 10 years old. Three possible explanations for lifespan changes in RR(NF) were evaluated: that change results from slower walking speeds, from a specific failure to attend to the far side before beginning to cross, or from generalised attention control failure. Young people's higher RR(NF) is consistent with evidence that they are prone to generalised attention control failures.

The roles of gender, age and cognitive development in children's pedestrian route selection

OBJECTIVE

Thousands of American children under the age of 10 years are injured annually as pedestrians. Despite the scope of this public health problem, knowledge about behavioural control and developmental factors involved in the aetiology of child pedestrian safety is limited. The present study examined the roles of gender, age and two aspects of cognitive development (visual search and efficiency of processing) in children's safe pedestrian route selection.

METHODS

Measures of cognitive functioning (visual search and efficiency) and selections of risky pedestrian routes were collected from 65 children aged 5-9 years.

RESULTS

Boys, younger children and those with less developed cognitive functioning selected riskier pedestrian routes. Cognitive functioning also subsumed age as a predictor of risky route selections.

CONCLUSIONS

Our findings suggest developmental differences, specifically less developed cognitive functioning, play important roles in children's pedestrian decision making. Directions for future examination are discussed.

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.

Effect of cell phone distraction on pediatric pedestrian injury risk

OBJECTIVE

Early adolescents are using cell phones with increasing frequency. Cell phones are known to distract motor vehicle drivers to the point that their safety is jeopardized, but it is unclear if cell phones might also distract child pedestrians. This study was designed to examine the influence of talking on a cell phone for pediatric pedestrian injury risk.

PARTICIPANTS AND METHODS

Seventy-seven children aged 10 to 11 years old completed simulated road crossings in an immersive, interactive virtual pedestrian environment. In a within-subjects design, children crossed the virtual street 6 times while undistracted and 6 times while distracted by a cell phone conversation with an unfamiliar research assistant. Participants also completed several other experimental tasks hypothesized to predict the impact of distraction while crossing the street and talking on a cell phone.

RESULTS

Children's pedestrian safety was compromised when distracted by a cell phone conversation. While distracted, children were less attentive to traffic; left less safe time between their crossing and the next arriving vehicle; experienced more collisions and close calls with oncoming traffic; and waited longer before beginning to cross the street. Analyses testing experience using a cell phone and experience as a pedestrian yielded few significant results, suggesting that distraction on the cell phone might affect children's pedestrian safety no matter what their experience level. There was some indication that younger children and children who are less attentive and more oppositional may be slightly more susceptible to distraction while talking on the cell phone than older, more attentive, and less oppositional children.

CONCLUSION

Our results suggest that cell phones distract preadolescent children while crossing streets.