Introduction to Special Section: Pediatric Psychology and Child Unintentional Injury Prevention: Current State and Future Directions for the Field

Unintentional injuries are the leading cause of death for children 1–19 years of age, not only in the United States but also in most other developed nations (CDC, 2017; Haagsma et al., 2016; WHO, 2008). Statistics for emergency department visits are equally shocking. In the United States in 2014, for example, almost 25,000 children <20 years of age visited an emergency department because of an injury every day (CDC, 2017). This child health issue is pervasive and touches the lives of families in all income levels and all racial, ethnic, socioeconomic, and cultural groups.

The Society of Pediatric Psychology has long incorporated child injury prevention into its mission, training goals, and scholarship. Early research in the area was published in Volumes 5 (Matheny, 1980) and 8 (Langley, McGee, Silva, & Williams, 1983) of this journal, and this special section represents at least the fifth special section/issue in the journal devoted partly or entirely to unintentional child injury prevention (DiLillo & Tremblay, 2005; Roberts, 1986, 1993; Routh, 1997). In fact, in an effort to identify ways to address child unintentional injury as a child health priority, a society task force was formed in the early 1990s to review the current state of the field and make recommendations for future research to enhance prevention efforts (Finney et al., 1993).

One noteworthy insight that emerges when applying an historic lens is that remarkably similar themes appear across the special issues, the 1993 task force report, and the publications in the current special section. These themes include the need for greater attention to children’s developmental status in planning research and interventions; the need to focus on developing, evaluating, and disseminating empirically supported prevention programs; and the need to draw on established behavioral and developmental theories and use these to inform research on childhood injury risk and prevention. More recently, an additional theme in the broader field of pediatric psychology has emerged and also applies to the childhood injury area: the need to address disparities in risk and extend prevention programs to vulnerable populations, including low-income, ethnic minority, and global at-risk populations (Lescano, Koinis-Mitchell, & McQuaid, 2016). Below, we elaborate on each of these four themes and discuss how they are reflected in the contributions to this special issue. We conclude with suggestions for future prevention-focused research in the field.

Development

Developmental considerations play an important role in understanding and preventing childhood injuries (Morrongiello & Schwebel, 2008). Although it is clear from epidemiological data that unintentional injuries are the leading cause of death across all stages of development throughout childhood (i.e., infancy through adolescence and young adulthood), the type and location of injury varies considerably with developmental stage (CDC, 2017), and these differences have important implications for identifying risk factors and developing prevention strategies.

For young children, most injuries occur in the home. Caregiver’s supervision practices and hazards in the environment, therefore, are key determinants of injury risk. In fact, caregiver supervision (defined by attention, proximity, continuity; Gitanjali et al., 2004; Morrongiello, 2005) predicts both the frequency and severity of injury for young children (Kuhn & Damashek, 2015; Morrongiello, Corbett, & Brison, 2009; Schnitzer, Kruse, Dowd, & Morrongiello, 2015). In the current special section, Damashek & Corlis (2017) studied relations between caregiver supervision and injury in lower-income families. Slemaker, Espeleta, Heidari, Bohora, & Silovsky (2017) also report research with caregivers that addresses the fact that hazards in the home elevate injury risk for young children in Latino families. What is evident across these studies is that at early stages of development (infancy, toddlers, preschool), children’s injury risk depends on caregivers’ safety practices: active supervision and removing home hazards are strategies that prevent injuries.

With increasing development, there is a shift and children experience most injuries when playing away from home, often in the company of peers (Morrongiello, Corbett, & Sandomierski, 2013; Shannon, Bradshaw, Lewis, & Feldman, 1992). Because the opinions of peers gain in importance with development, risk factors for injury during middle childhood and adolescence often relate to peers, with influences operating via processes that include modeling risk behaviors and/or verbalizing encouragements of risk taking (Christensen & Morrongiello, 1997; Morrongiello & Marks, 2008). The research reported in this special issue by Morrongiello et al. (2017) demonstrates the protective (risk reducing) and positive influences that peers can have on youths’ risk behaviors. They found that exposing children to peer-communicated social norms encouraging cautiousness reduced injury-risk behaviors in recreational settings.

In sum, attending to developmentally relevant factors in research on childhood injury is critical because it can suggest risk and protective factors that are meaningful at that stage in children’s lives and that are likely to influence injury risk and prevention strategies.

Theory

Surprisingly, theory-driven research in the area of childhood injury is uncommon. Hence, it is noteworthy that a few of the current articles assimilate theoretical constructs to some extent. In the article by Miller, Azar, Stevenson, and Johnson (2017), they test a social-information processing model to determine what factors increase the risk that caregivers will provide inadequate supervision. Comparing mothers of preschoolers who had neglect histories (poor supervision) with those who did not, they found that having unreasonable expectations and maladaptive beliefs about injuries (e.g., attributions to fate, injuries are beneficial because they toughen children up) were more common in the neglect than the nonneglect group. Moreover, social-information processing factors predicted having maladaptive beliefs. Integrating individual risk factors to create models that elucidate processes that operate to predict risk outcomes can greatly advance the field, and more of this type of research is sorely needed.

Morrongiello, Seasons, et al. (2017) test an aspect of the Theory of Planned Behavior (i.e., subjective norms), which is an intrapersonal theory shown to predict health-related behavioral intentions and behaviors (Armitage & Connor, 2001). Consistent with the theory, the research demonstrates that exposing children to peer-communicated behavioral norms predicts behavioral intentions and reductions in risk behaviors during childhood. When placed in the context of past research, which demonstrates similar social norm influences in adolescence and adulthood (e.g., Borsari & Carey, 2003; DeJong et al., 2006), these findings illustrate the utility of applying theoretical constructs in injury-focused research and how such constructs can guide the formulation of prevention strategies that can then be applied broadly across developmental life stages.

Prevention

Whether approached from a behavioral (Peterson, Farmer, & Mori, 1987), ecological (Gielen & Sleet, 2003), or biopsychosocial (Irwin, Cataldo, Matheny, & Peterson, 1992) perspective, the current body of scientific literature offers a reasonable understanding of the individual, interpersonal, and environmental factors that place children at higher or lower risk of unintentional injury. Now the challenging task for the field is to determine how to translate this knowledge and create effective prevention programs and strategies. Importantly, we see this increasingly being done (in this special issue: Morrongiello, Hou, et al., 2017; Morrongiello, Seasons, et al., 2017; Shen et al., 2017; Slemaker et al., 2017) and the increasing demand by public health and other community organizations for “empirically supported” prevention programs will no doubt serve to recruit more researchers to focus their efforts in this area. In fact, we would argue that psychologists have a moral and ethical responsibility to apply their knowledge about the etiology of childhood injury to develop and then disseminate evidence-based prevention programming that reduces injuries and improves children’s health.

In addition to drawing on empirical studies elucidating risk factors, effective prevention strategies also often capitalize on basic scientific theory concerning child development and health behavior change. Interventions might be focused on changing child behavior (Morrongiello, Seasons, et al., 2017), or the behavior of their adult supervisors (Morrongiello, Hou, et al., 2017), or even behavior-based modification of a child’s contextual environment (Slemaker et al., 2017), but in all cases, the theoretical mechanisms behind behavior change is important to consider. The manuscript by Morrongiello, Seasons, et al. (2017) in this special section offers an example. Recognizing increased risk for injury among children with poor impulse control and high sensation-seeking, especially when they are in a state with an elevated positive mood, Morrongiello, Seasons, et al. (2017) developed an intervention to capitalize on behavioral-change theory (e.g., Theory of Planned Behavior) and social-ecological models of development that emphasize peer contexts (Albert, Chein, & Steinberg, 2013). Consistent with these theories, she found that exposing children to messaging aimed at creating the perception of a social norm against risk taking was effective to reduce their recreational risk taking, especially when children were in an aroused positive mood state.

Vulnerable Populations

As in many areas of pediatric psychology, there are substantial health disparities in child injury risk. A large portion of the data in the child injury research literature has been collected from Caucasian participants in North America, Australia, and Western Europe (Lescano et al., 2016). However, ample epidemiological evidence documents the fact that culture, race and ethnicity, and income all influence risk for child unintentional injury, both within countries (Faelker, Pickett, & Brison, 2000; Pressley, Barlow, Kendig, & Paneth-Pollak, 2007) and globally (Haagsma et al., 2016).

Attention to diverse and vulnerable populations is slowly emerging in the field, as evidenced by the fact that three papers in this special issue focused their analysis on vulnerable populations in the United States (Damashek & Corlis, 2017; Miller et al., 2017; Slemaker et al., 2017). Damashek and Corlis (2017), for example, offer results from a case-crossover design that demonstrates the importance of maternal supervision for reducing child injury risk among a sample of low-income families, 53% of whom were non-White. This is an important contribution because child injury rates show a significant income gradient, whereby lower income families constitute the highest risk injury group. Consistent with research on supervision in middle- and upper-income families, Damashek and Corlis (2017) found that reduced proximal supervision increased the frequency and severity of injuries in children 1–5 years of age. Also in this special issue, Slemaker and colleagues (2017) describe the results of a study supporting the use of home safety intervention to reduce hazards in the homes of Spanish-speaking Latino families. Both papers highlight the commonalities between vulnerable North American populations and previous results, but also illustrate the need for culturally and socioeconomically specific considerations.

Also represented in this special issue is emerging scholarly interest in global child injury prevention. Over 90% of child injury deaths in the world occur in low- and middle-income countries (Causes of Death Visualization, 2017), a highly disproportionate amount given just 62% of the world’s population of children live in those countries (World Bank, 2017). It seems imperative that we extend effective prevention strategies from high-income countries to the rest of the world, and that we explore culturally and geographically specific injury risks and mechanisms to identify behavioral strategies to reduce injury incidents globally. Shen and colleagues (2017) broach this topic in this special issue, conducting a systematic review of behavioral interventions to reduce child dog bites and then highlighting the fact that pediatric dog bites are more common in low- and middle-income countries of the world, but that 11 of the 12 intervention studies included in the systematic review were conducted in four high-income countries (Australia, Canada, United States, and United Kingdom). Shen and colleagues (2017) discuss the need for culturally relevant interventions that consider risks such as the prevalence of stray dogs in local communities, the presence of rabies in dog populations and the accessibility of rabies vaccines for children, and cultural habits regarding adult supervision of children. They also discuss a topic that spans all child injury prevention domains: consideration of how intervention programs developed in high-income countries might be applied to lower-income countries. Some psychological aspects transcend cultures—consider the roles of child development, behavioral modeling, and information processing. Other psychological aspects vary widely owing to cultural and environmental context, and must be modified to suit locally specific implementation.

Future Research Directions for Injury Prevention

Developing prevention initiatives based on research evidence and theory increases the likelihood these will be effective, but this approach does not eliminate the need to conduct rigorous evaluations of these initiatives. Moreover, as prevention programs are being developed, it is important to consider how these might be disseminated broadly in the future if they prove successful. The economic and personnel resources to deliver the intervention should be considered, and practical constraints addressed. Demonstrating efficacy in a highly controlled situation is necessary but should be conducted with awareness that ultimately—to improve child health—the program must function with effectiveness in real-world contexts. For informed decision-making about injury prevention programs, therefore, it is desirable to have data from feasibility trials, as well as cost-effectiveness analyses. Moreover, extending these trials to include vulnerable populations who are most at risk for injury is essential. The Supervising for Home Safety program, for example, yielded positive results in both an efficacy and effectiveness trial with middle-upper-income caregivers (Morrongiello et al., 2017). In future research, it would be informative to determine whether the program is comparably effective for caregivers in lower-income families who constitute a high-risk group.

There is a strong emphasis in the field now on using technology for injury prevention, and innovations in technology are not only creating opportunities for prevention but are enhancing cost-effectiveness in the dissemination of safety information and implementation of prevention strategies. Theories about behavior change, however, also need to be considered. For example, safety information that was previously delivered by medical personnel during well-child checkups can now more cost-effectively be delivered by a computer-based kiosk in the waiting room (Gielen et al., 2007). Extending this to capitalize on the popularization of smartphone technology, it is possible to use apps to deliver developmentally tailored home safety tips directly to parents who register for the service when they give birth (McKenzie & Roberts, 2016). Given how ubiquitous cell phone ownership is, this approach could create the opportunity to deliver targeted safety messaging to many parents at any time and regardless of their geographic location. While the appeal of such an approach is obvious, research to determine how to assimilate behavior-change principles into this delivery format also is essential because increasing knowledge is typically not sufficiently motivating to evoke behavioral changes that prevent injuries.

Technological advancements also have had an impact on research concerning children’s pedestrian safety, but a greater focus on developmental considerations would be a useful future direction in this research. Virtual reality technology has paved the way for safe and ethical research on the decisions children make when crossing streets in varied traffic conditions (Morrongiello, Corbett, Pyne, & Beer, 2016; Schwebel, Shen, & McClure, 2016). However, further research on the mechanisms that explain why children’s crossing risk declines with age might provide important insights into the type of training that would be most effective to improve younger children’s crossing skills. For example, future research might examine the development of different attention processes and determine how they influence and/or constrain the pedestrian skills that children can be taught at different ages. This type of research is essential to determine the nature of the pedestrian risks that operate at different developmental stages and how behavioral training programs might be tailored to address the specific risks that child pedestrians face at different developmental stages. A similar developmentally focused approach to identifying dog bite risks may provide unique insights for devising more effective prevention approaches (Schwebel, Li, McClure, & Severson, 2016).

Finally, although injury-risk behaviors by children often occur in social contexts, there are numerous gaps in our understanding of peer influences on injury. For teenagers, a primary injury prevention focus is to reduce risky driving. Past research shows that peer influences on risky driving are substantial but additional research is needed to establish the mechanisms that explain these effects. For example, how do emotional factors come into play during driving, do these interact with attention processes, and what are the implications for prevention? For school-age children, now that it has been established that peer-communicated social norms influence children’s risk-taking behaviors (Morrongiello, Seasons, et al., 2017), a next step will be to determine whether these effects are sustained over time. Does exposure to social norms aimed at reducing risky head hits in soccer, for example, produce positive behavioral outcomes that endure throughout the playing season?

The current selection of papers advances our understanding of pediatric injury and prevention, but it is hoped that the papers also serve as a catalyst to inspire further research on this pressing child health issue. Our field has advanced tremendously since the early research published in Journal of Pediatric Psychology, but the rate of preventable child injuries remains unacceptably high. Developmentally focused studies that incorporate relevant theoretical constructs can significantly advance our prevention efforts, and these prevention initiatives must apply to all children, including vulnerable populations most at risk of injury.

Funding

Conflicts of interest: None declared.