Clinical Psychology Review, Vol. 19, No. 4, pp. 415–434, 1999
Copyright © 1999 Elsevier Science Ltd
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PREVENTION OF CHILDHOOD INJURY:
CLINICAL AND PUBLIC POLICY
CHALLENGES
George C. Tremblay and Lizette Peterson
University of Missouri at Columbia
ABSTRACT. Injuries are the leading killer of children in the United States, at a rate significantly higher than in other industrialized countries. In this article, we outline how a behaviorally
and developmentally based model of prevention may assist in determining effective interventions
for various injury risks. Two conclusions emerge: (a) the strength of perceived costs and consequences for taking effective safety actions greatly influences the probability that they will be implemented; and (b) intervening at the most developmentally appropriate time is likely to result in
more effective outcomes. Further, clinical psychologists are uniquely suited to assess contingencies
that maintain unsafe practices, but we need to enlist the participation of citizens and other professionals to mount persuasive intervention campaigns. Despite strong demonstration projects,
childhood injury reduction has lagged behind other public health endeavors. Obstacles to injury
prevention include (a) the diffusion of injury threats, complicating the identification of effective
targets for intervention; (b) the tendency of parents and even some health professionals to regard
injuries as products of fate, which fosters complacency; (c) the failure of U.S. social service policy
to support preventive strategies; and (d) an American cultural tradition of opposing regulation.
Suggestions for improved public policy and intervention procedures are advanced. © 1999
Elsevier Science Ltd
KEY WORDS. Childhood injury, Prevention, Policy.
EACH YEAR, MORE than 16 million children require emergency medical treatment
for preventable injuries in the United States (Rodriguez, 1990). Six hundred thousand children are hospitalized, 30,000 permanently disabled, and more than 22,000
killed annually due to injuries (Baker & Waller, 1989; Rodriguez, 1990). By far the
greatest risk children face in our society, injuries currently cut short more young lives
than all other causes of child death combined (Baker, O’Neill, Ginsburg, & Li, 1992).
Correspondence should be addressed to Lizette Peterson, Department of Psychology, 210 McAlester Hall, University of Missouri-Columbia, Columbia, MO 65211; E-mail: psyliz@showme.
missouri.edu
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Clearly, the tragic loss of life or functional capacity at such a young age is cost enough,
but in matters of public policy it is sometimes helpful also to measure costs in a more
familiar currency. For injuries to children under the age of 14 in the single year 1985,
direct medical care costs alone were estimated at over $4.5 billion (Rice et al., 1989).
Economics fail utterly, of course, to capture the human suffering that results from serious injury or bereavement.
UNDERFUNDED AND UNDERRESEARCHED
Despite this overwhelming demonstration of morbidity and mortality, injury prevention commands a disproportionately small share of our culture’s health promotion efforts. For example, the threats posed by cancer and heart disease pale by comparison
with injuries throughout the first four decades of life, and only slightly exceed that of
injury across the entire lifespan (Baker et al., 1992). Yet, while federal funds of $1,400
million were committed to the National Cancer Institute in 1985, and $930 million to
the National Heart, Lung, and Blood Institute, comparable injury-related research expenditures for the same year were estimated at just $160 million (Rice et al., 1989).
Public health initiatives have been remarkably successful in reducing childhood mortality from illness in recent decades. Infectious diseases, for example, which claimed
870 of every 100,000 children at the turn of this century, were constrained to 43 of
100,000 by 1977 (Califano, 1979), a reduction of some 95%. During the same time
span, injury-related fatalities have declined by only about 30% in the United States
(Baker et al., 1992). It is important to note that this circumstance is not an inevitable
cost of modern society; the rate of injury-related child fatalities in the United States is
considerably higher than that observed in other industrialized countries (Fingerhut &
Kleinman, 1989). Our child mortality rate stems less from a deficiency of means for effective prevention of injuries, than from a deficiency of will to implement them.
Mobilizing a constituency for preventive measures of any kind has always been a
challenge (Broskowski & Baker, 1974), and children are at particular risk for weak
representation among policy makers. Injury prevention faces an additional obstacle in
the frequent assumption among parents (Peterson, Farmer, & Kashani, 1990) and occasionally even physicians (Berger, 1981), that most injuries are chance events and, as
such, are largely unavoidable. If injuries are perceived as stemming from either fate or
deliberate intent to harm, few parents are likely to identify their child as the potential
victim of a serious injury. Injuries that are serious are also perceived as low base rate,
improbable events. Such perceptions fail to encourage either parents or society at
large to assume responsibility for preventive measures. In an effort to minimize this
diffusion of responsibility, injury professionals have come to eschew the term accident,
which implies randomness and lack of control, in favor of “unintentional injury,”
which acknowledges that the event, though not deliberate, might have been avoided.
A CONTINUUM OF RESPONSIBILITY FOR INJURIES
Unintentional injury is typically construed to exclude child maltreatment, on the assumption that these are very different problems requiring qualitatively different solutions. It is becoming increasingly apparent, however, that inflicted and unintentional
injuries share a similar constellation of risk factors, which may justify treating them
within the same prevention framework (Peterson & Brown, 1994). Moreover, the dis-
Prevention of Childhood Injury
417
tinction between inflicted and unintentional injuries is not always readily made. Garbarino (1988) proposed placing injuries on a continuum from assault, to neglect, to
preventable injury, and on to “random” accidents. He noted that the classification of
an event along this continuum reflects a community-based judgement about how
much fault to assign to a caregiver for the child’s injury.
Such judgements change over time, as we learn more about the causes of injury,
and community standards adapt to reflect greater expectations for precautionary
measures by caregivers. Garbarino used the example of an automobile injury to a toddler sitting in a parent’s lap in the front seat of a car. Whereas this event would have
been considered a random tragedy a few decades ago, it migrated into the preventable region of the continuum once child safety restraints became widely available, and
was viewed as negligent by the 1980s, in a social climate where the relative danger of
the front seat—particularly in the absence of safety restraints—was widely publicized,
and where child safety restraints were mandated by law in all 50 states. In the 1990s,
parents have been charged with manslaughter in the deaths of their unrestrained
children.
We see little to be gained from regarding inflicted injuries as conceptually distinct
from “unintentional” ones; even patently abusive parents often do not specifically intend to cause the degree of injury they actually inflict, and both types of injury can be
reduced by fostering on the part of caregivers, the immediate community, and society at
large, a deliberate intent to protect children. Given, however, the charge of this particular article, we focus most intensively on the literature relevant to unintentional injury.
A ROLE FOR PSYCHOLOGY IN INJURY PREVENTION
We have argued that injury prevention demands a higher priority on our public
health agenda. Traditionally, urgent mental health needs of children have tended to
consume the majority of child psychologists’ attention (e.g., Weissberg & Greenberg,
in press). Although this is perhaps understandable, we feel compelled to observe that
if a child does not survive to puberty, no amount of public attention and resources directed to mental health issues will help him or her. In this article, we first describe a
conceptual model for classifying injury prevention efforts, and provide a few representative examples of each type. The field is not lacking for innovative and effective injury prevention programs to guide future initiatives, but badly needs the support of
broader legal, psychological, and medical communities.
The role of clinical psychologists in identifying and modifying a broad spectrum of
health-related behaviors has rapidly expanded over the past two decades (Belar,
1997), into a realm traditionally dominated by more overtly medical professions. This
expansion reflects an increasing appreciation throughout the health sciences that virtually all disease or wellness states have important behavioral antecedents, and that behavioral responses play a critical role in coping with or maintaining those conditions
(Chesney, 1993). Psychologists are actively involved in prevention and treatment of
HIV (Sikkema & Kelly, 1996), cardiac disease (Littman, 1993), obesity (Brownell &
Wadden, 1992), smoking (Klesges, Ward, & DeBon, 1996), and drug abuse (CritsChristoph & Siqueland, 1996), to name but a few health-related examples. Thus, psychology has an established and growing niche in the public health and primary care
enterprise. In this same vein, we have much to contribute to the prevention of childhood injuries. In the final section of this article, following our presentation of a model
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for conceptualizing injury prevention efforts, and some representative examples interpreted in the context of that model, we attempt to identify some of the hindrances to
injury prevention measures in our culture, and to explore possible strategies for reducing those obstacles.
DIMENSIONS OF INJURY PREVENTION
One of the foremost challenges to injury prevention is the sheer variety of modes of
injury, and thus of potential intervention strategies. A toddler mastering the operation of the gate blocking access to the swimming pool, a 7-year-old riding a bicycle
without a helmet, and a 16-year-old driving with peers who ridicule him when he stays
within the speed limit, are all candidates for a variety of potential interventions to prevent drowning, head injury, and motor vehicle injuries, respectively. Peterson and her
colleagues (Peterson & Mori, 1985; Peterson, Zink, & Downing, 1993) offered a theoretical framework for categorizing these interventions, organizing them by the tactics,
methods, targets, and contingencies they employ.
Tactics
“Tactics” describe how the intervention is introduced to its intended target, that is, the
vehicle used for disseminating the intervention. Injury risks arise from a particular
constellation of vector (injury-causing agent) characteristics, caregiver behaviors and
child behaviors. For example, the risk of ingesting household poisons (vector) is concentrated where the poisons are accessible, where children are not under the constant
supervision of caregivers (caregiver behavior), and where children are old enough to
explore their environment but still young enough to impulsively ingest most substances they encounter (child behavior). The choice of tactics should derive from an
effort to define the nature of the injury risk, followed by a calculation of how to influence the most accessible component of that risk constellation. If the risk is considered to
be evenly distributed across all families, then the goal may be to intervene with the entire
population, and the tactic may involve a multimedia campaign in which information is
delivered via television and radio talk shows, public service announcements, billboards, bulk mailings, or print stories and advertisements. This information could address
specific risks, such as storing poisons, or more general parenting strategies to decrease
unintentional injury resulting from the child being shaken or thrown into a crib.
When injury risk is concentrated within an identifiable subset of the population, the
intervention may be communicated via high-risk tactics, such as public announcements in a certain geographical area, contacts with consumers of a service associated
with elevated risk (e.g., families involved with Head Start, parents enrolled in GED
programs), or printed information delivered to consumers of high-risk products (e.g.,
those who purchase bicycles or swimming pools).
Milestone tactics are appropriate when risk peaks as a function of age or other developmental factors. Such tactics often attempt to reach parents prenatally or at other
specific phases of child development (e.g., “well baby” visits), and later to approach
children in school or public health settings. As examples, prenatal rather than later attempts appear to be most effective in introducing some household safety measures
(Christophersen, 1993), safety-seat initiatives are effectively aimed at preschool popu-
Prevention of Childhood Injury
419
lations (Roberts & Farunik, 1986), and bicycle helmet initiatives may be most effective
in grade schools (Thompson, Thompson, & Rivara, 1990).
Methods
“Methods” refer to the actual mechanism of injury reduction, with particular attention to the level of response the intervention demands of the consumer, on a continuum from passive to active. Purely passive or environmental change methods would
demand no behavior change whatsoever from the consumer, relying instead on modifications of the environment to increase safety. The safety benefits of a purely active
method would depend entirely on consumers’ motivation to initiate and maintain an
altered pattern of behavior; active methods thus require a high degree of persuasion
in order to be successful. Most preventive interventions lie somewhere between these
two extremes, requiring some participation from the consumer in order to take advantage of environmental features that reduce risk (e.g., fastening seat belts that are
mandated equipment in automobiles, replacing the batteries in smoke detectors installed to meet building codes, replacing lids on child-resistant medication containers).
In order to highlight this dimension of injury-prevention strategies, in this article
we will maintain a somewhat artificial distinction between relatively passive or environmental changes and intensive behavioral efforts, even though it will be clear to the
reader that many, if not most interventions require a combination of the two. We will,
for example, discuss the use of automobile safety restraints under passive methods,
even though the parent must actively purchase and install them, and fasten the buckle
each time they are used. Here, a small behavioral act is completed in seconds, and
then the child is protected by the barrier for the duration of travel. By contrast, supervision in the bathtub or near a busy street demands continuous attention and intervention by the caregiver. Thus, we have attempted to designate the type of prevention
according to the end of the active-passive continuum that contributes the bulk of protection in a given circumstance.
Far from minimizing the importance of behavioral components of “passive” interventions, we wish to emphasize that it is the degree of deliberate response demanded of
the consumer that is critical. Other considerations aside, the smaller the effort required by any preventive intervention, the lower the cost to the participant, and thus
the more likely compliance is to follow. For this reason alone, relatively passive interventions are more likely than more active alternatives to be implemented. Nevertheless, there will always be some risks that simply cannot be reduced by passive intervention (e.g., the danger of bathtub drowning), and for which nothing will substitute for
active parental monitoring.
Targets
Under our discussion of tactics, we defined injury risk as a constellation that includes
an injury vector, caregiver and child behaviors, and perhaps other relevant circumstances. “Target” refers to the element(s) of that constellation that the intervention
most directly aims to alter. If a particular product or device is known to be associated
with a high rate of injuries, then the injury vector may be the target of intervention
(e.g., legislation requiring childproof caps on medication containers). Intervention
targets may also include policy makers, to mandate environmental change, caregivers
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and, of course, children themselves. It should be noted that regulations directed at
the environment, such as requiring fences around swimming pools or refrigerator
doors that cannot trap someone inside, are relatively easy to enforce, once legally
mandated. By contrast, legislation directed at parents is much more difficult to pass
and less consistently enforced. Because enforcement and other incentives for implementing safe practices are an important component of their effectiveness, we have recently expanded our injury prevention model to consider the “strength” of these contingencies.
Contingencies
“Contingency” refers to the extent to which there is a direct, discernible, and relatively immediate consequence for the target’s cooperation with the intervention. Initiatives soliciting voluntary action from manufacturers may appeal to their conscience,
to improved sales, or to a reduced risk of costly litigation, but the probability of a response is significantly increased by stiff legal penalties for failure to comply. The U.S.
government has been loathe to apply sanctions to manufacturers, and even more reluctant to impose them upon individual families (unless the child is under imminent
danger; see subsequent section on contingency and risk group interactions). Even if
an intervention targets an intact family with a strong attachment to a child (the “best
case scenario”), the combination of an objectively low probability of injury in any
given instance, and the additional underestimation of that risk by most parents (e.g.,
Eichelberger, Gotschall, Feely, Harstad, & Bowman, 1990), renders the perceived
threat of injury alone often too remote to motivate behavior change. Perceived danger, though, all too frequently constitutes the only, albeit very weak, contingency. Similarly, attempts to sensitize children to injury risks are unlikely to result in behavior
change, in the absence of additional contingencies for compliance, such as praise,
peer approval, or access to favored activities. Not surprisingly, interventions that entail
strong contingencies tend to be more effective than those with weak or inconsistently
enforced contingencies (Peterson & Roberts, 1992).
As will become increasingly apparent throughout this discussion, contingencies related to injury prevention can take many forms. Most of the injury-relevant contingencies operating in a given circumstance were not, of course, deliberately implemented,
and indeed can be difficult to identify. They may, for example, include peer pressure
for both caregivers and children to conform to community norms regarding safety behavior (or lack thereof; wearing a life jacket or bike helmet may bring ridicule). At the
same time, for some types of safety decisions, community norms are often not explicit,
in flux (cf. Garbarino’s [1988] discussion of automobile safety restraints), or utterly
lacking. Peterson and her colleagues, for example, found a complete absence of consensus among community samples of pediatricians, Division of Family Services professionals, and mothers as to what constitutes adequate supervision for children of different ages under a variety of levels of risk (Peterson, Ewigman, & Kivlahan, 1993).
Psychologists are uniquely qualified to assess and propose modifications to the contingencies impinging on injury-relevant behaviors. One of our goals for this article is to
emphasize the need to attend to naturally occurring as well as engineered contingencies of injury-prevention initiatives.
In the following section, we apply the above-described dimensions to a sample of
existing interventions. Our goal here is not a comprehensive review, but a demonstra-
Prevention of Childhood Injury
421
tion of the utility of the proposed framework for examining injury prevention efforts,
and an illustration of the range of current prevention strategies.
REPRESENTATIVE INTERVENTIONS
One could conceive of an injury-prevention matrix as a complex interaction of methods (passive vs. active), targets (injury vector, caregiver, child), and contingencies imposed by the intervention (strong vs. weak). Table 1 diagrams this matrix, with designations to indicate which cells of the matrix correspond to each section of the
following discussion of preventive interventions. The compression of these dimensions into categories is an oversimplification, to be sure, but a useful one for purposes
of this discussion. Further, we would argue that consideration of these differing dimensions is essential to designing an effective intervention. Specifically, one must ask
the extent to which a general, population-wide approach may be cost effective,
whether circumstances can be identified that confer a particularly high risk for injury,
or whether a developmental juncture exists where intervention would be particularly
relevant. In all of these instances, the strength of the contingency associated with the
intervention is likely to have a substantial impact on its efficacy. Similarly, when a passive method of intervention is feasible, it is to be preferred over more active methods,
as noted earlier. Finally, it remains to the intervening agent to select a target that is
likely to provide an effective locus of intervention.
Passive Methods for Preventing Injuries
IA. Injury vector as target—Weak contingency. Manufacturers occasionally make voluntary efforts to improve the safety of their products. Sorenson (1976), for example, described a Danish firm’s move to redesign the electric plug on their vacuum cleaner after learning that it was associated with infant mouth burns. Recently, automobile
advertising has begun to emphasize safety features as selling points to an unprece-
TABLE 1. Three-Dimensional Injury-Prevention Matrix: Targets,
Methods, and Contingencies
Contingencies
Passive Methods
Target:
Injury vector
Target:
Caregiver
Active methods
Target:
Caregiver
Target
Child
Weak
Strong
Section IA
Section IB
Section IIA
Section IIB
Section IIIA
Section IIIB
Section IVA
Section IVB
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G. C. Tremblay and L. Peterson
dented degree, particularly for family-oriented vehicles, such as minivans. There have
also been initiatives from the manufacturers of certain high-risk products, such as bicycles, to offer supplemental safety equipment as part of a discount package.
These are exciting trends. The consensus among safety experts, however, is that
meaningful improvements in product safety are rarely achieved by simply alerting
manufacturers to the dangers associated with their product. With some exceptions,
such as those noted above, the conscience of the company’s executives is considered a
weak, or at least undependable, contingency for motivating safety improvements. A
somewhat more compelling motive may be the expectation that well-publicized safety
features will improve sales, or reduce costly product litigation. Still, none of these consequences is particularly reliable, and some companies have continued to manufacture unsafe children’s products even in the face of numerous injury-related lawsuits,
ceasing production only when insurance carriers cancel their coverage (Smith & Falk,
1987). Others make only ineffectual gestures toward safety, for example, by enclosing
small disclaimers in toy packaging such as “Do not point or fire missiles into mouth or
toward face” (Berger, 1981, p. 32), without any attempt to reduce the actual danger
posed by the product. In the absence of a clear and consistent contingency for the
manufacturer, the injury-prevention potential of passive methods targeting the injury
vector is substantially compromised.
IB. Injury vector as target—Strong contingency. This portion of the matrix encompasses
many of the most historically successful strategies for preventing children’s injuries,
relying entirely on environmental or product modifications, mandated by law and demanding little or no deliberate participation on the part of the child or caregiver. The
Poison Prevention Packing Act of 1970 (Walton, 1982), for example, dramatically reduced the incidence of child poisonings by accomplishing two things: (a) mandating
child-resistant caps (which have an active component in that the lids must be properly
replaced with each use), and (b) limiting the quantity of medication that could be
placed in a single container (a purely passive intervention imposed on manufacturers). The Refrigerator Safety Act, simply by requiring that refrigerator doors be operable from the inside, has virtually eliminated children’s suffocation in refrigerators, via
a purely passive intervention (Robertson, 1983). Similarly, burns to children have
been reduced via the introduction of flammability standards for children’s sleepwear
(Smith & Falk, 1987).
As effective as mandated regulation of environmental hazards has been, such initiatives have traditionally faced strong objections, either to their financial cost or to their
curtailment of choices available to the public. Legislators show great reluctance to
support regulatory measures. Thus, for example, despite mounting child injuries resulting from minibikes that travel up to 50 miles per hour (Rivara, 1982), toys that fire
eye-piercing projectiles (Berger, 1981), fireworks (Smith & Falk, 1987), and handguns
(Christoffel & Christoffel, 1989), regulatory response to these injury vectors in the
Unites States has been slow, and shows wide regional variation. Americans believe the
Consumer Products Safety Commission is actively protecting their children; most existing data would suggest this is a perilously misguided assumption (Peterson & Roberts, 1992).
IIA. Caregiver as target—Weak contingency. Educational initiatives that exhort parents
to undertake one-time-only, relatively minor environmental modifications to reduce
the risk of child injury might be said to fall into this portion of the matrix. Thomas,
Prevention of Childhood Injury
423
Hassanein, and Christophersen (1984) undertook such a program to convince parents to install smoke detectors and lower the temperature setting of water heater thermostats. The information was delivered as part of a group well-child care clinic, an
economical alternative to traditional, and often minimal, one-on-one well-child appointments. Subsequent observations indicated that many parents had, in fact, reduced the temperature of their hot water, but few had undertaken the more effortful
installation of smoke detectors. Similarly, Dershewitz and Williamson (1977), utilizing
brief, office-based health education strategies, were able to increase the use of small
plastic electrical outlet covers to reduce the risk of electric shock, but much less successful at getting parents to install cabinet safety latches in their homes. Relatively few
of these educational initiatives include an evaluation component, and those that do
have generally yielded disappointing results (Christophersen & Purvis, 1991), demonstrating that increased knowledge alone rarely establishes a sufficient contingency for
motivating even minor behavior change among caregivers. Some attempts to decrease
the cost to caregivers of implementing these simple changes, for example, by giving
away safety equipment, have shown promise (Gorman, Charney, Holtzman, & Roberts, 1985; Spiegel & Lindaman, 1977). To the extent that these methods incorporate
cost reductions for consumers, they begin to shift toward the stronger contingency
portion of the matrix.
IIB. Caregiver as target—Strong contingency. Passive methods must demand relatively little deliberate effort from consumers, and thus involve primarily strategies for modifying the injury vector. Although we can conceive of preventive actions that involve minimal effort on the part of the caregiver, few have strong external contingencies
attached to them. Perhaps the best exemplar of this category is the use of child safety
restraints in automobiles, now mandated by law in all 50 of the United States. The use
of safety restraints appears to be increasing with the expansion of such legislation
since the 1970s (Baker et al., 1992; Morbidity and Mortality Weekly Report, 1988), yet
failure to properly restrain child passengers continues to be a serious problem, contributing to the majority of child motor vehicle deaths in several samples where statistics have been compiled (e.g., Zins, Garcia, Tuchfarber, Clark, & Laurence, 1994).
Many states and municipalities have hampered enforcement of seatbelt laws by designating them “secondary” violations, prohibiting citations for this offense unless the vehicle has already been apprehended for a different, “primary” offense. Even when violators are prosecuted, the penalties for failure to use child safety restraints tend to be
minimal. Thus, what is ostensibly a strong contingency may be rendered impotent if
not consistently applied. The contingencies favoring the use of both child and adult
safety restraints would be stronger if all states enacted “primary enforcement” statutes
for seatbelt violations, and consistently applied more serious penalties.
Programs to increase the use of child safety restraints have ranged from brief educational efforts to some of the most innovative and comprehensive campaigns within the
realm of prevention. Christophersen, Sosland-Edelman, and LeClaire (1985) reported a trial of a hospital-based car seat loaner program that combined education
and encouragement from nurses and pediatricians about the need for restraint use,
provision of child safety seats at low cost, and community education efforts. A relatively low-cost intervention, it was nonetheless able to achieve over 90% correct use of
safety restraints at discharge from the hospital, and approximately 85% correct use 12
months later. Roberts and Turner (1986) monitored the use of safety restraints for
children arriving at day-care sites, and rewarded parents whose children were properly
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restrained with lottery tickets that could be exchanged for prizes. Rates of restraint
use rose significantly, and although they declined after the reward program was discontinued, they remained substantially higher than at baseline.
An example of a broader community campaign is provided by Zins et al. (1994). Initiated by the Cincinnati Children’s Hospital Medical Center, which contributed educational expertise and evaluation, the program targeted parents and prospective parents in prenatal and pediatric clinics and throughout the community, high-risk
teenage mothers in high schools, and children themselves in preschools. Educational
videos were produced by a local television station, funded and distributed by Kiwanis
clubs, and shown to parents in numerous educational and health-care settings, including obstetricians’ and pediatricians’ offices. Law enforcement officials were trained in
the proper use of safety restraints, and began immediately installing appropriate
equipment whenever they issued a citation for failure to properly restrain a child. Violators appearing in court would receive a waiver of the fine if they returned the seat issued by the officer and furnished proof of possessing appropriate equipment. This
process emphasized the priority of the child’s safety over punishment of the parent,
yet maintained strong contingencies for noncompliance with the citation. The business community subsidized loaner car seats and discount coupons for needy families,
in addition to providing funding for education and evaluation. Finally, a multimedia
advertising campaign publicized the initiative. Early evaluation focusing on preschool
settings showed proper restraint usage to be about 10% higher in schools that had
participated in the intervention compared with those that had not (82% vs. 72%);
both intervention and evaluation are slated to continue for several years. Thus, this
combination of a strong contingency (a law) with appropriate environmental support
and teaching resulted in a relatively successful preventive intervention.
Child as target. As was the case for caregivers, this portion of the matrix presents a
challenge for safety professionals: how to bring about behavior change with the least
possible effort on the part of the target? Given that children rarely control their own
environments, their making structural, passive changes on their own is difficult, if not
impossible. As will be seen later, almost all programs targeting children have attempted to influence their behavior, rather than their environment. Thus, this portion of the matrix is absent from Table 1.
Active Methods for Preventing Injuries
Similarly, active change strategies are rarely directed toward the injury vector itself.
Active prevention strategies focus on modifying the behavior of the caregiver or child,
reducing risky behaviors, or increasing safe responses. By definition, methods that target the injury vector rather than the consumer involve environmental modification
rather than behavior change; thus, there is no section on active methods aimed at the
injury vector, either in the text or in Table 1.
IIIA. Caregiver as target—Weak contingency. Most safety promotion programs that require more than minimal effort from caregivers, and aim to promote behavior that is
not legally mandated, fall within this category. The broad array of approaches represented here include education and exhortation from pediatricians to purchase bicycle
helmets for children (e.g., Cushman, James, & Waclawik, 1991), national television
campaigns targeted at home safety (e.g., Colver, Hutchinson, & Judson, 1982), and
Prevention of Childhood Injury
425
neighborhood discussion groups with trained team leaders and monthly newsletters
to increase home safety (e.g., Schlesinger et al., 1966). None of the interventions cited
above offered explicit contingencies for increasing safe behavior, and none demonstrated an increase in safety or a decrease in injuries.
Lest we be tempted to attribute the lack of success of these interventions to weak
programming or inadequate dissemination, consider the following example of an outstandingly thorough safety education program. Project Burn Prevention (McLaughlin, Vince, Lee, & Crawford, 1982) provided extensive, community-wide education regarding causes and prevention of burns in children to the entire Boston metropolitan
area. Information was delivered through a combination of multimedia campaigns, a
plethora of community agencies in Quincy, and a school program in the town of Lynn
that targeted children directly. Following 8 months of intervention, during which television spots were aired an average of 22 times per month, 26 newspaper articles were
generated, and over 100,000 informational books were distributed, no improvements
in parental knowledge of burn prevention or in the actual incidence or severity of
burns could be detected.
The investigators (McLaughlin et al., 1982) concluded that even this sophisticated
program had essentially failed to prevent burns, and expressed some skepticism about
the effectiveness of active versus passive prevention methods. The advantages of passive over active methods have already been acknowledged, yet we would also draw attention in this instance to the absence or weakness of contingencies for behavior
change, which may have had a greater impact in this instance.
IIIB. Caregiver as target—Strong contingency. We have previously defined strong external contingencies as legislative mandates, with legal penalties for noncompliance.
Very few aspects of caregiving are subject to such penalties, short of blatant abuse or
neglect. In many communities, serious deficiencies of parental monitoring or caretaking behavior may result in court-mandated treatment, accompanied by strong contingencies for participation. Tertinger, Greene, and Lutzker (1984) worked with parents
whose history of neglect resulted in court referral to their Project 12-Ways. Part of the
program focused on helping parents recognize and reduce numerous safety hazards
in the home, and more actively monitor their child’s environment. Substantial decreases in environmental hazards were apparent at a follow-up evaluation more than
1 year later.
Given that such potent contingencies as court mandated treatment are likely to be
applied only to a small proportion of the population, and that consumers respond
more favorably when they feel that they have been enticed rather than coerced, a few
investigators have experimented with positive incentives for safer caregiver behavior.
The Seattle Children’s Bicycle Helmet Campaign (Bergman, Rivara, Richards, & Rogers, 1990; Rivara et al., 1994) utilized a broad array of delivery mechanisms, including
multimedia exposure, school and health service provider programs, to effect improved safety behavior across a large metropolitan area. In addition, the Seattle program offered more potent contingencies for parents, such as discount coupons for
the purchase of bicycle helmets, which served as a positive incentive for parents to
subscribe to the program’s goals. Observations at sites throughout the city showed
that helmet use among 5- to 12-year-olds increased from 5.5% at the start of the campaign in 1987, to over 40% in 1992 (Rivara et al., 1994). Across the same period, medically treated head injuries to children in a representative subset of this population
(all those served by a particular health maintenance organization) declined by ap-
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proximately 67%. Concluding that it was impossible to isolate the impact of any one
facet of the campaign, or of national trends in helmet use, the investigators nevertheless speculated that “. . . the discount coupon played a central role by lowering the
cost and barriers to helmet use” (p. 568), lending further support to the critical role
of contingencies in effecting safety related behavior, and to the potential for positive
incentives to act as powerful contingencies even in the absence of legal penalties.
IVA. Child as target—Weak contingency. Among the most common of all injury prevention endeavors are the safety messages delivered to children at elementary schools
across the country, and occasionally at malls, health fairs, or other community settings. These loosely organized presentations often incorporate visits from various
safety experts, such as fire, police, or medical professionals, who offer tips on safety
behaviors such as escaping a house fire, crossing a street, or responding to emergency
situations. Rarely are the presentations designed with the input of child education
professionals, and rarely do they include any opportunity for children to rehearse relevant skills. They rely on didactic teaching and occasional verbal memorization of
words (“stop, drop, and roll” when one’s clothing is on fire). The consensus among
injury specialists is that brief, isolated interventions, limited to verbal encouragement
and lacking opportunities for practice or continued, potent levels of reinforcement,
are generally ineffective at improving children’s safety knowledge or skills (Pless & Arsenault, 1987).
Ironically, these brief interventions may actually have a detrimental influence
through the (unwarranted) confidence they inspire among caregivers, concerning
their children’s safety-related competencies. The same body of evidence that reveals a
tendency among parents to grossly overestimate their children’s safety knowledge, indicates that a prime source of such optimism is visits of safety experts to children’s
classrooms (Peterson, 1989). To the extent that highly publicized but poorly validated
safety initiatives contribute to complacency on the part of caregivers, we must consider whether they may sometimes do more harm than good.
IVB. Child as target—Strong contingency. From a behavioral perspective, interventions
targeting children have tended to be in some ways more sophisticated than those
aimed at adults. Injury prevention initiatives for children are not only more likely to
include explicit contingencies, but the latter tend also to be weighted in favor of positive incentives rather than penalties for noncompliance—both factors known to be associated with successful modification of behavior. The Seattle campaign described
above, for example, in addition to targeting the behavior of parents, also actively promoted child behavior change, using attractive promotional materials, such as stickers,
as well as highly publicized activities for children, including health fairs, school assemblies, and an annual bike rodeo, at which prizes (e.g., tickets to sporting events, coupons for fast food) were given to children wearing helmets (Bergman et al., 1990). In
addition, interventions that target children often include opportunities to rehearse
new skills, with feedback about performance and rewards for mastery. This skill-building model has been widely and successfully applied to clearly defined behaviors, such
as pedestrian safety among elementary school children (Yeaton & Bailey, 1978), recognition and response to emergencies among preschoolers (Rosenbaum, Creedon, &
Drabman, 1981), and fire safety skills (Jones, Kazdin, & Haney, 1981).
As the proliferation of “latchkey children” came to the attention of child health
professionals during the 1980s, Peterson and her colleagues (Mori & Peterson, 1986;
Prevention of Childhood Injury
427
Peterson, 1984a, 1984b, 1989; Peterson, Mori, & Scissors, 1986; Peterson & Thiele,
1988) sought to extend the skill-building model beyond narrowly defined responses
to cover a broader array of safety behaviors in the absence of parental supervision.
The researchers were able to train appropriate safety skills among school-aged children utilizing intensive groups (Peterson, 1984a), individual tutoring (Peterson,
1984b), and classroom settings (Peterson & Thiele, 1988). Such findings were eventually extended to preschool children (Mori & Peterson, 1986). They were less successful in promoting generalization of some skills (Peterson & Mori, 1985), or in condensing the intervention into an intensive, 1-day workshop (Peterson, Mori, Selby, &
Rosen, 1988). Taken together, these efforts reinforced the importance of both positive incentives (verbal praise, food and activity rewards) and extensive and specific behavioral rehearsal for enhancing children’s safety skills. Furthermore, follow-up evaluations revealed that periodic practice of these skills was critical for successful
maintenance (e.g., Peterson, 1984a).
FALSE STARTS
Before proceeding to summarize effective injury-prevention strategies, it would seem
well to expand briefly on the need for careful evaluation of interventions. As suggested above, well-intentioned prevention programs may not always have the desired
effect, or may have unforeseen and harmful side effects. An illustration of the latter
involved early attempts to incorporate flame-resistant materials in children’s sleepwear
(Blum & Ames, 1977), and in public schools (Nicholson, Rohl, Sawyer, Swooszowski,
& Todara, 1979), which have subsequently been identified as possible carcinogens.
For a more contemporary example of an intervention yielding unforeseen results,
consider automobile airbags. Through the efforts of the National Highway Traffic
Safety Administration, dual airbags will be mandated equipment in all new cars and
light trucks purchased in the United States by 1999. Predictions concerning the safetyenhancing effects of driver-side airbags have been largely borne out: data collected
during the last decade indicate that the risk of fatal injuries is reduced by about 10%
for drivers protected by an airbag, and that the lives of 75 drivers are being saved for
every one that is lost due to airbags (Graham & Segui-Gomez, 1997). Similar benefits
are reported for passenger-side airbags, provided that the passenger is an adult. The
picture is very different, however, for child passengers in the front seat, who experience a net increase in mortality risk of 21 to 88% when “protected” by an airbag. The
benefits of passenger-side airbags are thus equivocal, with the best estimates indicating they result in the loss of one life, usually that of a child, for every five lives saved.
Graham and Segui-Gomez (1997) observed, “We are aware of no precedent in the history of preventive medicine where a mandatory measure was sustained with such a
poor ratio of lifesaving benefit to fatal risk. Allowing young children to incur the bulk
of the risk is particularly questionable” (p. 2).
The point is not that these safety initiatives with undesirable consequences were irretrievably bad ideas. Potentially carcinogenic flame retardants in clothing and public
buildings have since been replaced by safer protective compounds. Although the response to airbag fatalities has yet to coalesce, as the risks are only beginning to come
to light, there have been some promising suggestions. Among these are various adjustments to the force with which the bags inflate, and regulations prohibiting children
from the front seat, where some 30 to 50% of American children currently ride (Gra-
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ham & Segui-Gomez, 1997). Airbags may ultimately come to justify the optimism of
their early advocates; if so, it will be through a cycle of thorough evaluation and feedback of information to refine their design and implementation. This model is equally
applicable to all safety initiatives: We must recognize the early design and delivery of
an intervention as only a first step.
WHAT WORKS, AND WHY WE DON’T DO MORE OF IT
The sampling of injury-prevention initiatives offered here illustrates some of the variety and ingenuity of the field. It provides some evidence bearing on the effectiveness
of various strategies, sufficient to warrant a few recommendations for constructing
successful interventions. It is clear, for example, that interventionists should incorporate environmental changes that support safety-relevant behavior wherever possible,
for it is easier to target the physical properties or availability of injury vectors, than the
composite of attitudes, skills, and motivation that determine the behavior of consumers. When we do target consumer behavior, we should attend to the reduction of logistic, social, and cognitive obstacles to behavior change. These include prevailing “wisdom” antagonistic to safe practices (e.g., “once burned, twice shy” might lead parents
to assume that children who have suffered an injury are less likely to do so in the future; the data simply do not bear this out), fear of being thought a “nerd” for wearing
a bike helmet, and the costs or inconvenience to parents of installing household
smoke detectors, or of monitoring the child during the entire bathtime. We must also
seek opportunities for behavioral rehearsal and reinforcement of new skills. Whether
the target is an injury vector or a consumer, the evidence favoring strong contingencies is so compelling that any proposed intervention that neglects to address contingencies for change must be regarded with skepticism. Researchers have only begun to
explore the range of possible contingencies for safety behavior, and there is much
room for innovation here, particularly in the realm of positive incentives.
Although we have asserted that clinical psychologists are uniquely well-suited to the
task of assessing contingencies for injury-relevant behavior, we would not make that
claim with respect to the tasks of disseminating knowledge about injury risks, lobbying
legislators, and general advocacy that are necessary to bring about modification of
contingencies at the community, state, or federal levels. Social, community, and clinical psychology can offer expertise in these domains, but the injury-prevention enterprise also needs a great deal of support from experts in other disciplines, such as public health and pediatric medicine, and from concerned citizens in the community,
who can assist in defining goals, building coalitions for change, and, when necessary,
exerting their considerable influence with legislators.
It seems likely that the most significant injury reduction will ultimately be achieved
by broad, community-level interventions that utilize a multitude of strategies to target
both injury vectors and product consumers (cf. Finney & Gulotta, unpublished manuscript). The Seattle Children’s Bicycle Helmet Campaign (Bergman et al., 1990), outlined above, might be described as one such effort, albeit aimed at a rather circumscribed behavior. As a potential model for more comprehensive community initiatives,
we briefly consider the Harlem Safe Kids/Healthy Neighborhoods Injury Prevention
Program (Davidson et al., 1994). Prompted by an escalating trend of pediatric injuries
during the latter half of the 1980s in Harlem, investigators determined that falls, motor vehicle collisions, assaults, and gunshot wounds were among the prime causes of
Prevention of Childhood Injury
429
injury. Dilapidated and unsupervised playgrounds were identified as the locus for
many of these injuries, and thus became a focal point for intervention. The Safe Kids/
Healthy Neighborhoods Coalition grew from a collaboration of city agencies, citizens’
groups, and volunteer organizations. Municipal agencies repaired and upgraded park
facilities and playgrounds, and provided intensive traffic safety education for all children during the third grade. More than 500 bicycle helmets were provided to the
community. Perhaps most importantly, community residents were involved in planning these improvements, and children participated, first by painting murals in the
neighborhood, and later in ongoing dance, art, Little League, and soccer programs
that provided children with healthy, supervised activities.
The Harlem project spans several of the cells of our injury prevention matrix, targeting injury vectors (unsafe environments, including use of barriers such as shock absorbing surfaces in playgrounds), caregivers (safety education, adults supervising children and actively rewarding safe activities), and children (acquiring traffic safety
skills). Increased supervision of recreation areas no doubt strengthened punitive contingencies for illegal activities, such as drug dealing or assault, but the majority of contingencies introduced by the intervention were positive incentives for healthy activities. The opportunity for direct citizen involvement provided additional contingencies
favoring participation from the community. Injury surveillance data from two local
hospitals revealed a significant reduction in several targeted injuries across the first
few years of the intervention, and it is hoped that further follow-up will continue to
elucidate its impact.
It would seem that scientists and practitioners in the field of injury prevention have
developed a sufficient body of techniques, and evidence for their efficacy, to support
many more such programs. Why, then, has injury prevention fallen short of other
public health initiatives: What prevents us from implementing what we already know?
We offer some observations that may help to focus on potential obstacles in the realm
of public policy as well as in the modification of injury-relevant behavior.
Diffusion of Injury Threats
The diffusion and sheer volume of injury threats make it difficult to identify a few targets that might yield highly effective interventions. Prevention of infectious disease
can best be accomplished by identification of a particular pathogen, followed by
highly specific measures, such as pasteurization of milk, or development of a vaccine,
to eradicate or greatly diminish the threat. With relatively few exceptions (e.g., the relation of bicycle riding without a helmet to pediatric head injuries, the relation of accessible medications to child poisoning), the causal pathways leading to childhood injuries have not been sufficiently developed to generate such focused interventions.
We need to better understand behavioral mechanisms of injury in order to identify
optimal intervention targets and strategies (Scheidt, 1988). Mathews and Lattal
(1994), for example, demonstrated how a behavioral analysis of dog bites might inform prevention strategies targeting the dog, the child, and community regulations.
Current work in our own laboratory is attempting to clarify behavioral precursors to
injury in several ways. Laboratory simulations of injury have shown that children’s exhilaration and lack of fear contribute to the risk of injury (Peterson, Gillies, Cook,
Schick, & Little, 1994). We have also observed a negative correlation between family
safety rules and levels of actual minor injuries, as reported by the child and the
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mother (Peterson & Saldana, 1996). These relationships only hint at the behavioral
mechanisms responsible for injuries, which require elaboration with future research.
Injuries as “Accidents”
It has already been noted that parents and even some health professionals tend to regard injuries as products of fate. The combination of multiple, diffuse threats, a relatively low objective probability that any one of these threats will result in injuries on
any given occasion, and further underestimation of that probability by parents, contributes to a perception on the part of caregivers that children’s injuries are neither
likely nor preventable (Peterson & Roberts, 1992). Christophersen and his colleagues
(Christophersen, 1993; Williams, Barone, Hassanein, & Christophersen, 1990) have
suggested that parents develop a false sense of security from a history of engaging in
unsafe practices that they and their children have thus far been fortunate enough to
survive unscathed. Thus, Williams et al. (1990) found expectant parents significantly
more likely to utilize household safety suggestions than parents of toddlers, who frequently asserted that they had practiced “unsafe” procedures for years without any
detrimental consequences. This perceived immunity to consequences on the part of
caregivers presents a challenge to interventions that aim to protect children. The experiences of Williams et al. indicate that safety information may have a more beneficial impact if it is delivered before caregivers have had the opportunity to develop and
rationalize a history of competing, more risky practices. A potentially helpful milestone tactic would involve estimating an optimal intervention point prior to the caregiver’s or the child’s “investment” in an unsafe practice, but not so far in advance that
the information is not considered relevant (e.g., prenatally for setting water heater
temperature and using automobile safety restraints, perhaps at age 4 or 5 for wearing
bicycle helmets).
Lack of Support for Prevention
Social service policy in the United States is organized around remediating deficits,
rather than promoting health. In order to become eligible for services such as caregiver support and education in most communities, children or parents must exhibit
developmental deficits, disability, or abusive behavior. Service providers are often
forced to function at the level of rehabilitation rather than prevention. Chamberlin
(1994) has characterized family support policies in the United States as “waiting until
children are drowning” (p. 35). By the time families have reached a level of dysfunction necessary to achieve access into the social service system, the cost and difficulty of
responding to their needs, with neonatal intensive care, foster care, incarceration,
etc., has escalated unnecessarily.
Secondary prevention, or the identification and treatment of high-risk populations,
is a step in the right direction, but prediction of risk is far from perfect. Secondary
prevention strategies should supplement, rather than supplant, primary prevention
efforts. The technology and economic feasibility of delivering family support services
to entire communities has been demonstrated through projects in the United States
and, on a broader scale, in Great Britian, Europe, and the Scandinavian countries
(Chamberlin, 1994). Clinical psychologists must increasingly be trained not only to
study the behavioral mechanisms of injury and find the most effective routes to intervention, but also to convince policy makers and their constituents that resources dedi-
Prevention of Childhood Injury
431
cated to community-wide family support extend beyond charity; they can be wise investments, with tangible social and financial dividends.
Resistance to Regulation: “Give Me Liberty or Give Me Death”
The sentiment expressed in this phrase by the patriot Patrick Henry, at the 1775 Virginia Convention, catalyzed the American Revolution. It lives on in several official
state slogans (e.g., “Live Free Or Die,” “Don’t Tread On Me”), as well as in the consciousness and conduct of contemporary American society. We pride ourselves on the
defense of personal liberty as a preeminent value, and regard any intrusion with the
utmost skepticism and resentment. Perhaps no issue better illustrates this cultural resistance to regulation than the controversy surrounding the availability of handguns
and assault weapons. As of the mid-1980s, firearms generated a mortality rate second
only to motor vehicle injuries in the United States, with pediatric gunshot wounds escalating dramatically during that decade (e.g., Ordog et al., 1988). Handguns, though
comprising only 25%–30% of the more than 100 million firearms in the U.S. (National Committee for Injury Prevention and Control, 1989), account for the vast majority of lethal injuries, at a rate 90 times higher than in any other country in the world
(Rice et al., 1989). Yet, strong regulatory limits on handgun use have thus far been
successfully opposed by a citizenry who regard possession of these weapons as their
birthright, and the recent ban on assault weapons had to first overcome vigorous objection from those who claimed a legitimate use for them.
We submit that our culture’s adamant defense of the personal liberty to indulge in
activities, recreational equipment, or childrearing practices that carry an elevated injury risk, must be weighed against the cost to innocent parties in the transaction, who
cannot make an informed choice concerning those risks. We are sacrificing children’s
health to purchase increased liberty for parents and other adults. Where do we take
into account the personal liberty of children whose injuries or death could have been
prevented by bicycle helmets, automobile safety restraints, restriction of handguns,
stronger building codes, or parent education concerning safety risks? For that matter,
how do we assess the infringement on the personal liberty of a populace that must
bear the enormous financial burden of injuries? Even if we limit consideration to direct medical costs alone, the weight of this burden is often well beyond the capacity of
a single family to absorb, and is distributed across society at large either through private insurance, government funding, or “cost shifting” by health care providers
(Runge, 1993). Unless we are prepared to utterly abandon the injured, we must be
compelled by self interest, if nothing else, to regard injury prevention as everyone’s
business. In the realm of injuries, unfettered liberty and death are not so often on opposite sides of the dilemma, as Henry would have it; if we are to contain the tragedy
and social cost of injury, we must be prepared to tolerate some infringements on our
freedom to behave in whatever way we wish.
Once our society has agreed that the cumulative costs of childhood injury are simply intolerable, we will have reduced many of the obstacles to implementation of practices we know to be effective. We will be less reluctant to employ both positive incentives (e.g., reduced prices for bicycle helmets, lottery tickets for utilizing child safety
seats) and negative consequences (e.g., fines for failure to use child safety restraints
and legislation that sanctions unsafe products) to prevent injuries. We will be less inclined to regard child welfare as the exclusive province of parents, and more willing to
envision a role for child-care agencies, schools, and even the business community in
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the deliberate prevention of harm to children. We will not reflexively shrink from legislation to protect children, so that the Consumer Product Safety Commission need
no longer feel compelled to heed the voices of manufacturers over the testimony of
health professionals (see Berger, 1981; Rivara, 1982). We will be better prepared to
explore all levels of both legislative and educative endeavors, always with an eye toward potent consequences for safe behavior, to create the best, multifaceted approach
to preventing childhood injuries.
Acknowledgment—This work was supported by the Maternal and Child Bureau (MCJ290635-01) of the Health Resources and Service Administration.
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