ADDRESS: (G.M.W.) 1v1adison Avenue, New York 10, New York.
PUBLIC
HEALTH
343
PEDIATRICS, February 1960
SOME
APPROACHES
CHILDHOOD
TO
RESEARCH
IN
ACCIDENTS
George M. Wheatley, M.D., and Stephen A. Richardson, Ph.D.
I
N ALL COUNTRIES for which there arevital statistics, accidents are a major
cause of death and disability among
chib-dren. In countries wllere the food supply is
adequate and infectious diseases have been
brought under control, accidents have
be-come the leading cause of death in the age
group 1 to 19 years. For example, in such countries as Australia, Canada, Sweden,
West Germany, and the United States, more than one-third of all deaths in this
age group are caused by accidents.’
The number of children who are injured
by accidents fan exceeds the number who
are killed. Although no accurate
intenna-tional figures are available, the Morbidity
Survey conducted by the United States
Pub-lic Health Service indicates that in the United States, for every child under 15 killed by accident, 1,100 children are
in-juned severely enough to require medical
at-tention or to be restricted in their activity
for at least a day.
The purpose of this paper is to
charac-tenize briefly the prevalent type of research
on accidents and some of the actions that
have stemmed from its findings. Then some
little-explored areas of research shall be
delineated wilicil seem to hold considerable
promise. Finally, one attempt to encourage
new directions in research and some
im-portant roles the pediatrician may play will
be described.
CURRENT
RESEARCH
The predominant emphasis in research in
the area of accidents has been the collection of quantitative information on the
fne-quency and types of accidents that occur.
Employing the most refined and effective
techniques, such research can tell us not
only how many children have been killed in what sorts of accidents during the past
year but also how many children will be
killed in what types of accidents during, for example, a holiday such as the Labor Day
weekend.
This type of research, by pointing up the magnitude of a certain kind of accident,
can lead to further investigation that is focused directly on its prevention. It can lead also to programs of
action-educa-tional, technologic, and legislative-which reduce either the incidence of a specific kind of accident or the seriousness of its
re-sults.
Some examples will make this clear. Without employing statistical methods, the
Navaho Indians evolved a form of cradle board which gave some protection to the
young children when, with their mother,
they fell from horseback. Contemporary ex-amples are familiar to all of us: In England, Colebrook’s pioneering studies2 showed
that flammable clothing, unguarded fires, and teapots which could be upset easily, were important agents in killing and in-juring children through burns. These led to recommendations for fireproofing of cloth-ing, well-designed fireguards, and
non-tipping teapots. These recommendations led to some self-regulation by industry, some legislation required fire guards, and in one
case the renting of fire guards by the Edin-burgh Public Health Department. In the United States, studies of death from lead poisoning formed a basis for developing
in-ternal regulations and controls by the paint
industry, educational programs, and
legisla-tion aimed at eliminating or minimizing the hazard of toxic paint in homes.3
type of accident seems remote, if not im-possible, the seriousness of its consequences
can be sharply reduced once quantitative studies clearly indicate its magnitude. The
use of safety glass in automobiles is a
dna-matic and successful example. Other famil-iar examples are the provision of life
jack-ets to prevent children from drowning when
boats capsize, or the teaching of swimming at an early age to all children who live near
bodies of water. Examples on a broader
scale include the development of poison control centers which provide immediate
information on the treatment of accidental poisoning and the widespread teaching of first-aid procedures to policemen, firemen, and others who are likely to be at the scene
of an accident.
These illustrations suffice to indicate the
usefulness of the prevalent research, but its
usefulness should not cause us to overlook
some of its inherent limitations. For,
al-though it can tell us how many children will be killed or injured in what kind of accident, it cannot tell us who these chil-dren are likely to be on, more broadly, why
some children are more susceptible to acci-dents than others.
Even such crude sociologic variables as age, sex, ethnic background, and
socioeco-nomic status show us unmistakably that
ac-cidents do not occur by chance alone. We know, for example, that at all ages boys are much more #{149}susceptible than girls to
acci-dental injury and death; that four times as
many Negro children are injured on killed
by burns as white children of the same age and sex; that drownings reach their highest incidence between the ages of 2
and 4 and then show a marked decline. Data such as these, by providing us with clues to such possible causative factors as
patterns of child rearing and subcultural differences, begin to provide some answers to the question of who will be killed on in-juned, but further work with more refined variables is essential if we are to discover
why some children are more susceptible to
accidents than others.
Some of the work done in this direction,
preliminary and limited though it is, is
ex-tremely suggestive. Fuller4 analyzed first-aid records kept of 61 nursery-school chil-dren for the school year. Children hurt
most frequently were rated by independent observers to be: 1) Above average in
strength; 2) courageous ratiler than lacking
in nerve; 3) emotionally excitable rather
than calm; 4) impulsive rather than
cau-tious; 5) rude rather than courteous; and
6) “very masculine” rather than “sissy.” Ful-len and Baune,’ in another paper, present findings related to the question, “Do
chil-dren with a high incidence of injuries
re-veal definable positions in their social struc-tune?” Twenty-one children 7 to 8 years of
age, coming from a school class with an
un-usually large number of injuries, were
studied. Each child was asked sociometric questions about which other children he on she liked in the class. The investigation found that the most popular children
re-ceived fewer injuries than the socially re-jected children, although a few children
contradicted this tendency.
Another study6 of a small group of 6- to 11-year-old children seems to corrobo-rate these findings. It was found that the
child with a history of numerous accidents
seems to be over-active, restless, and
im-pulsive. He tends to want to be olden than
his age and seems to have no feeling of
security at home. He does not retreat from
dangerous situations, and under stress he becomes more impulsive. Children in the
nonaccident group appear to be more timid and submissive and to come from more
closely united family groups. It was found
also that other members of the family of the
child sustaining repeated accidents were fre-quently themselves involved in accidents.
AREAS FOR FUTURE RESEARCH
The results of these studies must be re-garded as tentative. The number and
selec-tion of children studied do not allow gen-eralization, and replication studies would
be valuable. Moreover, it is very difficult to test whether or not the distribution of
CONTRIBUTOR’S SECTION 345
* For a full discussion of this problem see Ref-erence 8.
phenomenon or was attributable to per-sonal factors in the child injured.0 Their major contribution is to indicate new and
promising directions for research and to provide us with some provocative ques-tions : Are childhood accidents associated
with certain patterns of socialization-for example, certain forms of discipline, the
rate and manner in which parents foster in-dependence in their children, the sex roles
which parents prescribe for their children? Are tilene any characteristic chains of events that culminate in an accident-for example,
a quarrel between the parents followed
shortly by harsh and unjustified
punish-ment of tile child? Do some children expose
themselves more frequently to risks? If so,
is risk-taking a decisive factor in accidents
or is it back of judgment or skill in dealing Witll new situations?
If it can be firmly established that there is wide and measurable variation between
children in the frequency with which they
are injured, it will be possible to study
ac-cidents as a symptom of a more general
syndrome of behavior associated with the
child or his family. It is probable that the search will have to be not for single
van-ables but rather for multiple variables with characteristic patterns. For example, are
children who have frequent accidents the same children who have frequent illness or emotional disturbance, who have severe
learning problems in school, who generally conflict with authorities, or who come from
homes in wllich there is severe marital strife?
A different order of question focuses upon
the consequence of early exposure to haz-ands. Specifically, are small children brought up in an environment in which
ex-posure is minimized more or less likely to suffer accidents at a later date? Or,
con-versely, does the hurt of a minor accident
on the experiencing of a near accident serve as a learning device to protect the child
against more serious accident? If a child
ne-ceives a burn at an early age, is he less
likely to suffer a burn or be involved in other accidents at a later age? It is
gener-ally assumed that our goal should be the prevention of all accidents. But if minor
accidents or near accidents prove to have a deterrent effect, we might do well to study how these experiences can be used in a con-tiolled way for educational purposes, or to plan accident-learning experiences, as ad-vocated by Dietnich.7
In outlining this new kind of research, certain assumptions have been made, and now it is necessary to examine some of their
implications.8
1) If we are seeking a relationship be-tween susceptibility to accidents and the
personal and social characteristics of the
victim, we must assume that we can order or classify children according to the
num-ben of accidents they have had. In order to
provide maximum data for each child, we
may need to broaden the definition of
acci-dents so as to include incidents which in-volve only property damage and no
per-sonal injury, or those which involve near
accidents to persons or property. For
ex-ample, aircraft pilots are required to ne-port near collisions so as to provide addi-tional data for a study of the causes of air-craft collisions.
2) In taking a
“number-of-accidents-per-child” approach, we must beware of assum-ing that in every case the child’s behavior
contributes to the accident. The fallacy of such an assumption is obvious when the
child is injured as a passenger in an auto-mobile accident, but it may be equally
fallacious in many less obvious situations.
It seems clear that younger children are
less “responsible” for accidents than olden
ones.
3) In broadening our definition of acci-dent in order to obtain maximum data for
each child, we must beware lest we group together accidents that are causally
un-related.
Thus far the prevalent quantitative
346
the characteristics and problems of an
emerging qualitative research-the kind that will tell us which children are likely to
be killed or injured have been noted. Even if this qualitative research exceeds expectations by enabling us to predict
mon-tality and morbidity for every child, it
would not enable us to prevent accidents.
In order to do this we shall have to know
how accidents occur. What are the human and environmental characteristics necessary for an accidental injury or death to result? To find this out will require careful studies
of all the complex circumstances and condi-tions surrounding an accident.
Obviously research of such complexity
requires the skills and efforts of highly
trained workers from a number of profes-sional disciplines, especially the behavioral
sciences. It also requires the development
of new methods and new research designs. Hitherto, accident prevention has not had
the benefit of this concentrated,
interdis-ciplinary research effort, and one of the major problems is to interest enough corn-petent workers to join forces in such a task.
GROUP
STUDY OF CURRENT
RESEARCH
One attempt to develop this kind of
ap-proach has been made during the past year
by the Association for the Aid of Crippled
Children, a foundation whose mandate is
the prevention of disability among children.
Last year the Association initiated a num-ben of study groups in both university and nonuniversity settings “to critically assess research in accidents related to children.” In order to bring to bear the creative think-ing and research skills of a number of
pro-fessional disciplines, the organizers of the
study groups included persons with a
variety of backgrounds in research, some of whom had not previously studied accidents,
as well as some practitioners with expe-rience in the area of accidents. Among the groups are representatives of anthropology,
architecture, law, pediatrics, psychiatry, psychology, public health, sociology and surgery. On the basis of a review of current
research, the groups will consider strategic
areas for future work. By doing this it is hoped to interest some members of the
study groups in developing and executing
some needed research. The groups keep in
touch by circulating minutes and papers
under study. A bibliography and a listing of
research in progress has been prepared for
all groups, and periodically representatives of all groups meet to exchange ideas and
experiences.
ROLE OF THE PEDIATRICIAN
In this kind of research, the roles that the pediatrician can play become apparent. In clinical practice the pediatrician can, by
obtaining careful case histories of accidents
that come to his attention, develop both
hypotheses and insights into factors of
causation wllich might provide some keys to prevention. The pediatrician in a
univen-sity setting can interest his academic
col-leagues from other departments in the problem of accidents, a problem that no
one traditional academic discipline can
solve.
Accidents may well be a prototype of the kind of problems which will become in-creasingly important in pediatric practice. The complex interrelationship of social,
be-havioral, and biologic factors which may underlie many childhood accidents may also be operative in producing emotional disturbances and other behavioral
prob-lems, including juvenile delinquency and drug addiction. The patterns of co-opera-tive research that pediatricians can develop with colleagues from other disciplines may
give direction for tackling some of these
other problems in child rearing.
REFERENCES
1. Accidents in Childhood, Facts as a Basis for Prevention. World Health
Organiza-tion Technical Report Series No. 118. Geneva, W.H.O., 1958.
2. Colebrook, L. : The prevention of burning
accidents. Brit. M.
J.,
1:1379, 1956.3. Proceedings of Lead Hygiene Conference,
CONTRIBUTOR’S SECTION 347
Nov. 6-7, 1958. New York, Lead Indus-tries Association, 1959.
4. Fuller, E. M. : Injury-prone children. Am.
J.
Orthopsychiat., 18:208, 1948.5. Fuller, E. M., and Baune, H. B. : Injury proneness and adjustment in second grade : a sociometric study. Sociometrv, 14:210, 1951.
6. Langford, W., et al. : Pilot study of
child-hood accidents: preliminary report. PEDI-ATRICS, 11:405, 1953.
7. Dietrich, H. F. : The robe of education in
accident prevention. PEDIArRIC5, 17:297,
1956.
8. Arbous, A. G. : Accident statistics and the concept of accident proneness. Part I. A
critical evaluation. Biometrics, 7:340, 1951.
NEW PUBLICATIONS RECEIVED
CATALOG OF THE GRULEE COLLECTION OF
PE-DIATIIICS. Chicago, The John Crerar Library, 1959, 340 pp., $15.00.
INVOLUTION OF THE DUCTUS AnTEmosus: A
MORPHOLOGICAL AND EXPERIMENTAL STUDY,
WITH A CRITICAL REVIEW OF THE
LITERA-TURE, A. Sciacca and M. Condorelli. New
York, S. Karger, 1960, 52 pp.
THE HEINZ HANDBOOK OF NUTRITION, H.
J.
Heinz Company. New York, McGraw-Hill
Book Company, Inc., 1959, 439 pp., $5.75.
PRENATAL AND PARANATAL FACTORS IN THE DEVELOPMENT OF CHILDHOOD READING DIS-ORDERS, Au A. Kawi and Benjamin
Pasaman-ick. Lafayette, Indiana, Society for Research in Child Development, Inc., 1959, 80 pp., $3.00.
ADOLESCENT AGGRESSION: A STunY OF THE
IN-FLUENCE OF CHILD-TRAINING PRACTICES AND
FAMILY INTERRELATIONSHIPS, Albert Ban-dura and Richard H. Walters. New York, The Ronald Press Company, 1959, 475 pp.’
$7.50.
GROWTH DIAGNOSIS, Leona M. Bayer and
Nancy Baylev. Chicago, The University of
Chicago Press, 1959, 241 pp., $10.00.
A MANUAL OF PAEDIATRICS FOR Somi-EAsT As, Edited by Pinchas Robinson. Calcutta, Orient Longmans Private Ltd., 1959, 463 pp., $7.50.
THE MOTHER-CHILD INTERACTION IN
PSYCHO-SOMATIC DISORDERS, Ann M. Garner and Charles Wenar. Urbana, University of
Illinois Press, 1959, 290 pp., $6.00.
THE EMERGENCY SYNDROMES IN PEDIATRIC
PRACTICE, Alfred
J.
Vignec, M.D. New York,Landsberger Medical Books, Inc., 1959, 382 pp., $9.00.
RHEUMATIC FEVER : EPIDEMIOLOGY AND
PRE-VENTION, Edited by R. Cruickshank, M.D., and A. A. Gbynn, M. B. Springfield, Illinois, Charles C Thomas, Publisher, 1959, 193 pp., $5.50.
NORMAL CHILDREN AND MOTHERS, Irving D.
