Journal of Pediatric Psychology, Vol. 27, No. 8, 2002, pp. 727-737
© 2002 Society of Pediatric Psychology
Unintentional Injury in Preschool Boys With and Without Early Onset of Disruptive Behavior
1 University of Alabama at Birmingham, 2 University of Washington School of Medicine, 3 Children's Hospital and Regional Medical Center, Seattle, 4 University of Washington
All correspondence should be sent to David C. Schwebel, Department of Psychology, University of Alabama at Birmingham, 1300 University Blvd., CH 415, Birmingham, Alabama 35294. E-mail: schwebel{at}uab.edu.
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Abstract |
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Objective: To determine subsequent risk of unintentional injury among preschool boys diagnosed with ODD, boys with comorbid ODD and ADHD, and boys matched demographically to the clinical sample; to test predictive validity of a measure of injury proneness; and to examine factors that might predict injury beyond clinic status.
Methods: Seventy-nine consecutive clinic-referred preschool-age boys and 76 demographically matched boys without disruptive behavior participated in a 2-year prospective longitudinal design. Time 1 assessment included clinical diagnosis, parent-reported injury proneness, attachment, and verbal abilities. Injury history was measured 1 and 2 years later.
Results: Clinic-referred children had more injuries than the comparison group. Children with comorbid ODD and ADHD had approximately the same injury rate as those with ODD but not ADHD. Parent-reported injury proneness was unrelated to subsequent injuries. Neither attachment nor verbal ability predicted injury significantly beyond clinic status.
Conclusions: Children with early disruptive behavior are at increased risk of unintentional injury and therefore should be considered prime candidates for injury prevention campaigns.
Key words: disruptive behavior; ODD; ADHD; injury; safety; children.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Unintentional injury is the leading cause of mortality for children ages 1-18 (National Safety Council, 2001
) and is annually responsible for the loss of nearly one and a
half million years of children's productive life
(Finney et al., 1993;
Routh, 1997). Children with
disruptive behavior disorders and attention deficits are believed to be
particularly susceptible to unintentional injuries
(Davidson, 1987;
Manheimer & Mellinger,
1967). Indeed, DSM-IV (American
Psychiatric Association [APA], 1994) includes unintentional injury
as an associated feature of attention-deficit/hyperactivity disorder (ADHD)
and conduct disorder (CD). However, the empirical basis for this assertion is
unclear, and data regarding the relation between psychopathology and
unintentional injury are generally limited.
In 1987, Davidson published the most comprehensive review to date
concerning unintentional injuries among children with externalizing behavior
problems. His review concluded that children with antisocial and oppositional
behavior patterns have increased risk of injury. Data for children with
hyperactive and impulsive behavior problems, he believed, were inconsistent
and not conclusive. In his review, Davidson emphasized that most research
suffers from deficits in research design and that most findings show only
small increases in risk of injury for children with disruptive behavior
patterns. Most of the studies Davidson reviewed were conducted from an
epidemiological perspective with large samples and imprecise measures of
children's behavior patterns and injury history. No studies were available
that used clinically diagnosed samples of children to compare injury rate in
clinical and comparison samples. Wazana
(1997) conducted an
abbreviated review 10 years later and reached similar conclusions.
Since Davidson's review, empirical efforts to clarify relations between
behavior disorders and unintentional injuries have been few and far between.
Davidson, Hughes, and O'Connor
(1988) studied a birth cohort
of nearly 1,000 children in South Wales in one of the few relevant studies
that considered both oppositional and hyperactive behavior problems. A
behavioral interview was conducted with each child's mother at about the time
the child turned 5 years old to screen for behavioral problems, including high
activity, poor concentration, discipline problems, and temper tantrums. Injury
history was deduced through an examination of hospital emergency rooms serving
the geographic area of the study. Results replicated those described in
Davidson's (1987) literature
review: there was slightly increased risk of injury in those children reported
in parental interview to be discipline problems, but overactivity was not a
predictor of increased injury risk.
Other studies have focused primarily on hyperactivity symptoms. Davidson,
Taylor, Sandberg, and Thorley
(1992) prospectively studied a
cohort of 1,740 6- to 8-year-old boys in London, England. Both parents and
teachers completed a brief questionnaire that assessed children's
hyperactivity at the beginning of the study and again 16 months later; injury
history was assessed through systematic review of medical records in area
hospital emergency rooms. Results matched previous work: hyperactivity was
unrelated to injury both prospectively and retrospectively and in both parent
and teacher reports.
More recent studies have studied clinically diagnosed children with ADHD.
DiScala, Lescohier, Barthel, and Li
(1998) conducted a
retrospective review of hospital charts to examine patterns of injuries to
children with ADHD versus those without ADHD. Results suggested that children
with ADHD were at increased risk for pedestrian and bicycling accidents and
had more severe injuries than other children
(DiScala et al., 1998).
Barkley and his colleagues found in two studies that adolescents and young
adults with ADHD are at increased risk for automobile crashes
(Barkley, Guevremont, Anastopoulos, DuPaul,
& Shelton, 1993; Barkley,
Murphy, & Kwasnik, 1996). One problem with this research
utilizing clinic samples is a failure to either control for or precisely
identify patterns of comorbidity, known to occur at high rates in children
with ADHD, especially diagnoses of oppositional defiant disorder (ODD) and
conduct disorder (Biederman, Faraone, &
Lapey, 1992). In the DiScala et al.
(1998) study, for example,
nearly a third of the sample had comorbid conditions that could influence the
occurrence of injury.
The available evidence provides preliminary support for a modest link
between disruptive behaviors (e.g., disobedience and aggression) and
unintentional injury history. Results are mixed for the relation between
injury history and behavioral patterns of hyperactivity, impulsivity, and
inattention, perhaps due to the complication of unresolved comorbidity issues.
To unravel the relations among behavior problems, comorbid illnesses, and
injury, one should consider the process by which children with behavior
disorders might develop increased risk for injury. Although the process is
likely complex and multifaceted, preliminary evidence suggests that two
factors in particular might contribute disproportionately:
cognitive/neuropsychological factors and social factors. Children with
behavior disorders typically have deficits in neuropsychological functioning,
most frequently presented as poor attentional capacity, poor cognitive
judgment, and impulsive behavior patterns
(Moffitt & Silva, 1988).
Behavior disorders characterized primarily by oppositional/defiant and conduct
problems (with or without attention deficits) are associated with striking
deficits in verbal processes. Research in this area is well summarized by
Moffitt and Lynam (1995), who
concluded that children with conduct problems generally perform more poorly
than their peers on tasks that are administered orally, require language
mediation, or call for a verbal response.
Many of the temperamental and cognitive factors linked to children's
injuries in nonclinical samples are consistent with deficits in these same
areas of neuropsychological functioning, including the inability to engage in
"cause-and-effect" reasoning about the potential dangers of
environmental hazards (Coppens,
1985,
1986), poor self-awareness of
physical capabilities and limitations
(Plumert, 1995;
Plumert & Schwebel, 1997),
poor problem-solving strategies to prevent injury
(Farmer & Peterson; 1995),
and temperamental impulsivity, aggression, and undercontrol
(Bijur, Golding, & Haslum,
1988; Schwebel & Plumert,
1999). These findings with community samples are supported by one
study with a clinical sample, in which boys with ADHD were able to identify
risky situations as well as comparison boys without ADHD but anticipated less
severe consequences from risky behaviors and generated fewer means to avoid
injury than the comparison group (Farmer
& Peterson, 1995). Again, comorbidity of behavior patterns,
such as oppositionality, limits interpretation of the results of this
study.
A second factor that may help explain the process by which children with
disruptive behavior are at increased injury risk is the quality of the
parent-child relationship. In highly conflicted or distant parent-child
relationships—often found in clinic samples of children with behavior
disorders (Johnston & Mash,
2001)—there may be poor parental monitoring of the child,
which may result in increased child exposure to environmental hazards and
other unsafe conditions (Peterson,
Bartelstone, Kern, & Gillies, 1995). Clinical observations
suggest that toddlers or preschool children with chronically unresponsive
parents may try to regulate the parent's attention and proximity by engaging
in risky behaviors that increase the probability of parental intervention and
protective action (Lieberman & Pawl,
1990). This hypothesis is reflected in at least one proposed
diagnostic system for very young children, which includes an "injury
prone" subclassification of parent-child "attachment
problems" (Zeanah,
1996).
Primary Questions
This study used a prospective longitudinal design to examine injury risk of
clinic-referred preschool boys with diagnosed ODD or ODD and ADHD over a
2-year period. A comparison group of boys without clinical-level behavior
problems was matched to the clinic sample by age, race, family constellation,
and socioeconomic status (SES); these matching variables have been associated
with injury liability in previous research
(Matheny, 1988). The
comparison group was also followed for the 2-year study period. Three
questions were of primary interest:
- Are preschool boys with clinically diagnosed behavior disorders more likely
to show subsequent injury than matched comparison boys? As discussed, previous
research suggests that children with diagnosed behavioral disorders will be
more prone to injury than matched controls
(APA, 1994;
Davidson, 1987).
- Among boys with ODD, are those with comorbid ADHD more prone to injury than
those with QDD alone? As noted, there has been little previous study of the
relations between specific dimensions of externalizing problem behavior and
injury occurrence. Given how poorly these processes are currently understood,
no hypothesis was tendered for these analyses.
- After controlling for clinical diagnosis, do other child characteristics
contribute to the prediction of subsequent injury? What might these
characteristics suggest about the linkage between disruptive behavior and
injury risk? As discussed, child variables other than problem behavior are
likely to influence the probability of subsequent injury and may help explain
the process by which children are placed at increased risk for injury. We
tested the role of verbal/cognitive ability and of attachment as possible
predictors of injury beyond clinical status, and therefore as factors that
might help explain the process by which children with behavior disorders place
themselves at increased risk for injury.
Secondary Question
Beyond these hypotheses, the opportunity to test a second, peripheral
hypothesis was available. The distinction between "injury proneness' and
"injury occurrence" is frequently blurred by injury researchers.
Injury proneness refers to a person's tendency to engage in dangerous,
potentially injury-causing, and therefore "risky" behavior, a
construct distinct from the actual occurrence of injury, which is potentially
influenced by factors other than the individual's behavior (e.g., extent to
which environmental hazards are present). Previous findings with children are
mixed on how strongly injury proneness, as measured by instruments such as the
Injury Behavior Checklist (IBC; Speltz,
Gonzales, Sulzbacher, & Quan, 1990), is related to children's
actual rate of injury. Some studies have reported close correspondence between
the two (Potts, Martinez, & Dedmon,
1995; Potts et al.,
1997; Speltz et al.,
1990), while other research has found that injury proneness is
more closely related to parent reports of impulsivity, undercontrol, and
activity level than to injury itself
(Schwebel, 2000). In these
studies, the IBC has been administered either concurrently or following the
injury; there has been no examination of the predictive relation between the
IBC and subsequent injury. Thus, we examined in both the clinic and
comparison groups the extent to which injury proneness, as reported by
parents, predicted boys' subsequent injuries.
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Method |
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Participants
Parents and children were drawn from a longitudinal study of 172 preschool boys with and without clinically diagnosed oppositional defiant disorder and other disorders (see Coy, Speltz, DeKlyen, & Jones, 2001
, for details). This research was primarily
designed to test hypotheses about the influence of attachment and
neuropsychological variables on the etiology of early-onset disruptive
behavior disorders in boys. However, the inclusion of injury measures at the
outset of the study allowed us to achieve the secondary goal of investigating
relations among early psychopathology and injury risk in young children.
Participants in this study were 155 preschool-age boys and their families.
The preschool years are among the most vulnerable for children's unintentional
injury (Matheny, 1988).
Seventy-nine of the boys were consecutive referrals to an early childhood
behavior problem clinic, and 76 were normally developing boys without
clinically significant disruptive behavior. This group of 155 was selected
from the larger sample of 172 on the basis of having complete injury data for
the entire 2 years of this project (i.e., excluding 17 families for whom
complete injury data were missing, either because of dropout or failure to
obtain all relevant information; analyses comparing these 17 with the 155
found no differences on the measures reported here). Boys' ages ranged from 47
to 68 months (M = 57 months) when they were first assessed (Time 1).
Participants were evaluated again 1 year (Time 2) and 2 years (Time 3)
following the initial evaluation. Mean ages were 69 and 82 months for Time 2
and Time 3, respectively. Family socioeconomic level was 2.3 on the 5-point
Hollingshead scale (1 = professional, 5 = unemployed;
Hollingshead, 1975). Mothers
identified 82% of the sample as European-American; the remainder was African
American (3%) or children of mixed ethnicity (15%). Children of mixed
ethnicity typically had one European American parent with an Asian American,
African American, or Native American partner. Most boys in the sample (67%)
lived with both biological parents; the remainder lived with single mothers.
Table I shows demographic
variables by group (clinic or comparison).
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Recruitment
Clinic Families. The Preschool Families Clinic was established as
part of an outpatient child psychiatry clinic within an urban children's
medical center. Among the clinic boys, 67% were referred by a health care
professional (physician, psychologist, nurse), 23% by an educator (preschool
teacher or daycare staff), and 10% were self (parent) referrals. This group
differed from boys seeking services from similar clinics in that families
received $50 reimbursement for completion of the assessment, agreed to be
available for follow-up assessments 1 and 2 years later, and were asked
questions about their sons' behavior, out-of-home care, and home environment
in order to determine eligibility. Criteria for clinic group membership in the
larger study included (1) unsolicited referral for disruptive, oppositional,
and/or aggressive behavior; (2) age between approximately 4 and 5.5 years; (3)
a T score of 65 or above on the parent version of the Child Behavior
Checklist Aggression scale (CBCL;
Achenbach, 1991); (4) a primary
diagnosis of oppositional defiant disorder (ODD), with or without other Axis I
disorders (e.g. anxiety, ADHD, encopresis/enuresis); (5) participation in
out-of-home daycare or preschool (in order to obtain the reports of a
nonfamilial, adult caregiver); (6) in cases of single parent families, that
the mother was the primary caregiver in residence; and (7) child was free of
an identified language, cognitive, motor, major health, or neurological
disorder. Only boys were included in the sample because ODD occurs primarily
among boys, girls with early-onset disruptive behavior are less common than
boys and therefore difficult to recruit, and the factors associated with
girls' disruptive behavior problems may differ from those for boys
(Greenberg, Speltz, & DeKlyen,
1993). Boys also have moderately higher risk of injury than girls
(Morrongiello, 1997). Only
children with ODD were included in the sample because this best met the goals
of the primary hypotheses of the original study (see
Coy et al., 2001); no boys
with ADHD but not ODD were in the sample.
Comparison Families. Comparison families were recruited through posters placed in pediatricians' offices, daycare centers, public libraries, and social service facilities. After telephone screening, parents completed child behavior checklists and family information forms to confirm the absence of significant behavior problems and to permit case matching to enrolled clinic families. Eligible comparison families were then called and a visit was scheduled. Comparison families were also reimbursed for their participation in the study.
Families of comparison boys were invited to participate in at least the first evaluation session if they met the criteria outlined for clinic boys, with three exceptions: (1) unlike clinic children, comparison boys were invited to participate in the study if they received a T score below 65 on the CBCL Aggression scale; (2) they were characterized by parents and teachers as typical children; and (3) they could be case-matched to a clinic subject with respect to age, ethnicity, family structure, and SES. There were 12 eligible clinic families for whom exact matches could not be found, due to statistically infrequent combinations of matching variables (e.g., it was difficult to find exact matches on all four matching variables when remarried parents had differing ethnic backgrounds). To maximize power, we included these clinic families in these analyses. These "unmatched" clinical cases did not differ from matched clinic cases on any of the case-matching variables (i.e., age, ethnicity, family structure, and family SES). Comparison boys were retained in the study if they met the further criterion of having no diagnosable psychiatric condition (determined by a diagnostic interview given during the first evaluation session).
Procedure
Once eligible participants were identified, questionnaire packets were sent
home and the family participated in clinic visits that included a diagnostic
interview with parents, testing, observation of parent-child interactions, and
teacher behavior checklists. Families were seen in the clinic at Times 1, 2,
and 3. Only findings from measures relevant to injury status are included in
this report (see Greenberg, Speltz,
DeKlyen, & Jones, 2001;
Speltz, DeKlyen, & Greenberg,
1999, for findings regarding other measures).
Time 1 Measures
DSM Diagnosis. DSM-III-R diagnoses were determined following a
diagnostic interview, review of behavior checklist information from parents
and teachers, and observations of boys during neuropsychological testing and
parent-child interactions (DSM-IV was not yet available). A consensus
diagnosis based on all available information was assigned during a team
meeting including the interviewing clinician and at least one licensed
psychologist or psychiatrist on the research team. The diagnostic interview
incorporated most of the parent version of the Diagnostic Interview Schedule
for Children (DISC; Fisher, Wicks,
Schaffer, Piacentini, & Lapkin, 1992). As the DISC was
designed for children ages 6 years and older, the Disruptive Behavior Disorder
portion of the DISC was modified in several ways to better accommodate
children slightly younger than that cutoff: (1) questions were modified to
eliminate references to activities or events specific to older children (e.g.,
homework); (2) parents were prompted to consider whether behaviors such as
activity level and short attention span were excessive for the child's age;
and (3) examples of child behaviors and context were revised to reflect
age-appropriate possibilities (e.g., noncompliance when asked "to put
blocks away"). Team decision rules regarding diagnosis also considered
the young age of the patients. Evidence for the functional impairment of
symptoms was required (as in DSM-IV) and distinctions between normal
development and maladaptation were emphasized (e.g., ADHD was evaluated in
light of the expected high rate of motor activity and distractibility in
4-year-old boys). In assessing for CD, the symptom "often initiates
physical fights" required a pattern of deliberate confrontation and
initiation of physical fighting; occasional shoving or hitting that occurs
commonly in preschools was not counted, nor was hitting of a parent or sibling
during a tantrum. All other disorders were assessed by first asking parents
screening questions taken from the DISC (parent version) and then, when
indicated, with a semi-structured clinical interview (reviewing all relevant
DSM-III-R criteria).
A random selection of 30 cases at intake and 24 cases at follow-up were
coded by a second clinician using videotaped DISC interviews. At intake,
agreement for ODD diagnosis was 94% (
= .88), 97% for ADHD ( =
.91), and 97% for CD ( = .78). At follow-up, agreement for ODD was 96%
( = .78), 96% for ADHD ( = .83), and 96% for anxiety disorders
( = .65). Agreement for CD and mood disorders at follow-up was 100%
( = 1.00).
Injury Proneness. Mothers completed the Injury Behavior Checklist
(IBC; Speltz et al., 1990), a
24-item scale designed to rate children's display of specific injury-prone
behaviors over the previous 6 months. Each item is answered on a 5-point
scale. Sample items include "Runs out into the street,"
"Falls down," and "Jumps down stairs." Internal
reliability is good (alpha =.87; Speltz et
al., 1990). Convergent validity with related measures such as
self- and teacher-report of risk-taking and sensation-seeking has also been
demonstrated (Potts et al.,
1995).
Verbal-Cognitive Ability. In a previous study
(Speltz, DeKlyen, Calderon, Greenberg,
& Fisher, 1999), all of the boys in this sample were
administered a battery of cognitive and language measures, including a short
form of the Wechsler Preschool and Primary Scale of Intelligence-Revised
(WPSSI-R; Wechsler, 1989); the
Expressive One-Word Picture Vocabulary Test—Revised (EOWPVT-R;
Gardner, 1990); the Peabody
Picture Vocabulary Test (PPVT; Dunn &
Dunn, 1981); the Test of Early Reading Ability-2 (TERA-2;
Reid, Hresko, & Hammill,
1989) and the Developmental Test of Visual Motor Integration (VMI;
Beery, 1989). Speltz, DeKlyen,
Calderon, et al. (1999) used
confirmatory factor analysis to test a model of neuropsychological development
in this data set that included verbal, visual-motor, and executive function
domains. Goodness of fit indices indicated that this model provided an
acceptable fit to the data (e.g., Bentler-Bonnett Normed Fit Index = .94,
Comparative Fit Index = .94). The verbal ability factor was used in this study
to examine the hypothesized relation between verbal skills and injury. This
factor included the WPPSI-R Arithmetic and Comprehension subtests, EOWPVT-R,
PPVT, and TERA-2. In univariate tests conducted by Speltz, DeKlyen, Calderon,
et al. (1999) with this
sample, the clinic group was found to perform more poorly than the comparison
group on this factor, F(1, 155) = 37.8, p < .001.
Quality of Child's Attachment to the Mother. The Preschool
Attachment Assessment System (PAAS; Cassidy
& Marvin, 1992) was used to assess the quality of the child's
relationship, or attachment, to the mother. The methodology and analyses of
these data in this sample of participants are fully reported by Speltz,
DeKlyen, and Greenberg (1999),
who also include a full review of the concurrent and predictive validity of
the PAAS and similar coding methods. Briefly, the PAAS was applied to
videotaped clinic observations of parent-child separations and reunions,
resulting in a 5-category attachment classification and two ratings of the
child's verbal and nonverbal interactions with the mother during the reunion
episode: (1) "secure" attachment, as indicated by comfortable,
relaxed, and positive approach to and interaction with the mother and (2)
"avoidant" attachment, as indicated by remote neutrality with or
avoidance of the mother. As these ratings were significantly (inversely)
correlated, we used only the avoidance ratings in this study (classification
data were not used due to small attachment subgroups within the comparison
group). Higher ratings indicate greater avoidance. Each mother-child pair was
classified by two coders who were unaware of children's clinic or injury
status. Four coders were involved in the coding; all were certified as
reliable on standard reliability tapes by Cassidy and Marvin
(1992). Interrater reliability
for avoidance ratings was r = .71, p < .001. Speltz,
DeKlyen, and Greenberg (1999)
found that the clinic group showed significantly greater avoidance during
reunions with their mothers than the comparison group (clinic boys also showed
lower security ratings and higher rates of insecure attachment
classifications).
Measures at Time 2 and 3
When families returned to the clinic 1 and 2 years after intake (Times 2
and 3), parents were asked to provide detailed information about any injuries
their children experienced since the last clinic visit. Injury reports were
included only if the injury required direct examination by a medical
professional (i.e., a physician, dentist, or nurse). Children's scores from
both years were summed to form a single index of injury occurrence over the
2-year period following the intake.
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Results |
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Intercorrelations Among Variables
Table II shows the intercorrelations among injury and predictor variables for each group separately (clinic and comparison). In neither group was there a significant relation between children's injury proneness (as reported by parents on the IBC) and subsequent injury occurrence; indeed, these bivariate correlations were very near zero in both groups. In the clinic group only, there was an inverse relation between verbal ability and injury occurrence (r = -.32, p < .01) and a positive relation between avoidant attachment ratings and injury occurrence (r = .22, p = .05). No significant bivariate relations were found in the comparison group.
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Injury Occurrence and Injury Proneness by Group and Diagnosis
Table III shows the number
of injuries by group and by diagnosis within the clinic group (ODD with or
without ADHD). A total of 33 boys reported injuries over the 2-year study
period. Nearly all injured boys experienced a single injury (30, or 19.4% of
the entire sample). Only three boys experienced two injuries (1.9% of the
entire sample; all were clinic boys), and none experienced more than two
injuries. Given the highly skewed distribution of injury frequency, we
consolidated these data to form a two-category injury variable for all
subsequent analyses (no injuries vs. one or two).
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Most of the injuries reported were lacerations (14 in clinic group, 2 in control group). Other types of injuries reported included bruises/bumps (two in clinic group), broken limbs (two in control group), dental injuries (three in clinic group, one in control group), objects in the nose or ear (two in clinic group), dislocations (one in clinic group), animal bites (one in clinic group), concussions (one in control group), sprains (one in control group), and eye injuries (one in control group). For five injuries (three clinic group, two control group), insufficient details were available to identify the type of injury incurred.
As shown in Table III, the rate of injury in the clinic group (29%) was over twice the rate in the comparison group (13%), a statistically significant difference (x2 [1] = 5.89, p < .01). The clinic group also had higher mean IBC scores (M = 33.9, SD = 13.3) than the comparison group (M = 17.0, SD = 9.0, t [151] = 9.12, p < .01).
Within the clinic group, boys with ODD alone had a slightly higher rate of injuries (33%) than those with ODD and ADHD (25%); however, this difference was not significant (x2 [1] = .54, p = .46).
Contribution of Verbal Ability and Attachment to Prediction of
Injury
Logistic regression was used to examine the contribution of verbal ability
and attachment to the prediction of injury, after controlling for clinical
status (i.e., clinic or comparison group membership). The dependent variable
was injury occurrence (none vs. one or two). A two-step model was tested: in
the first step, only clinic status was entered; in the second, verbal ability
and attachment were entered together. A classification cutoff score of.20 was
used, based on the rate of injury obtained in this sample. As anticipated by
the univariate analysis reported, clinic status was a significant predictor of
injury (x2 [1] = 6.03, p < .05), correctly
predicting 70% of those with injuries, but only 54% of those without (overall
prediction accuracy was 57%). When avoidant attachment and verbal cognitive
ability were entered on the second step, the model was also significant
(x2 [3] = 12.43, p < .01). Verbal ability was
the only significant univariate predictor in the final model
(R2 = -.15, Wald [1] = 5.43, p <
.05). This model correctly predicted 67% of boys with injuries and 62% of
those without (63% overall).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Results demonstrate that boys with clinically diagnosed behavior problems have an increased rate of injury compared to those without clinical diagnoses. Boys with ODD had twice the number of injuries over the two years following diagnosis than the matched comparison group; the presence of comorbid ADHD did not appear to increase or decrease injury risk.
Injury Rate in Clinically Diagnosed and Nonpathological Boys
Clinicians have long suspected that clinic-referred children with
disruptive behavior are at increased risk of injury
(APA, 1994;
Dunbar, Wolfe, & Rioch,
1939; Krall,
1953). This study confirms that belief empirically: clinically
diagnosed children had a significantly higher rate of injury than matched
controls.
We did not find a significant difference between injury rate of boys
diagnosed with ODD and those diagnosed with comorbid ODD and ADHD. One might
suppose comorbid ADHD would increase injury risk because of the increased rate
of hyperactive and impulsive behavior. However, previous findings from
literature reviews (Davidson,
1987; Wazana,
1997), empirical studies with nonclinical samples (e.g.,
Bijur et al., 1988; Davidson et
al., 1988,
1992;
Manheimer & Mellinger,
1967; Petridou et al.,
1998), recent reports in the interntional (i.e., abusive) injury
literature (Ford et al., 1999,
2000), and a study of driving
safety in adolescents and young adults with behavior disorders
(Barkley et al., 1993) support
the possibility suggested by these data that hyperactivity and ADHD symptoms
may be less important than oppositionality and ODD symptoms as predictors of
injury. Studies that contradict this possibility have reported elevated injury
rates in children with ADHD, but those studies generally focus on injuries
that are the result of poor decision making, poor motor control, and poor
attentional capacity—most frequently pedestrian and bicycling injuries
in children (DiScala et al.,
1998) and motor vehicle crashes in adolescents and young adults
(Barkley et al., 1996). They
are also limited by high rates of comorbid illness in the samples.
Other Characteristics That May Contribute to Injury Risk Beyond
Clinic Status
We tested whether verbal ability and parental attachment might predict
injuries beyond clinic status. Although we felt it reasonable to hypothesize
poor verbal ability or poor attachment to the parent might predict injury
proneness beyond clinic status, regressions found that clinic status alone
predicted injury as well as a model that also included verbal ability and
attachment. In both cases, the model predicted about 70% of the boys with
injuries over the subsequent 2 years. Verbal ability was the strongest
predictor when it was included in the model, but its power of prediction was
not significantly greater than the contribution of clinic status alone.
From an applied perspective, one might interpret these results as an indication that the predictive power of clinic status and verbal ability overlap greatly, enough so that one "substitutes" for the other in a predictive model. Thus, one could use either clinic status or verbal ability to predict children at risk for injury with reasonable accuracy. Since identification of a child's clinic status is less costly than individualized psychometric testing, we suggest a focus on the former as a means of identifying candidates for injury prevention campaigns; such identification will generally use liberal criteria for program inclusion.
From a theoretical viewpoint, one might interpret these results as an
indication that poor verbal abilities help explain the process by which
children with disruptive behavior disorders have increased risk for injury.
Although further research is needed, it is reasonable to hypothesize that the
cognitive and neuropsychological deficits known to be present in children with
disruptive behavior disorders (Moffitt
& Silva, 1988), and that also have been linked to increased
injury rate in nonclinical samples
(Coppens, 1986;
Plumert, 1995), might mediate
the relation between disruptive behavior patterns and increased rate of
unintentional injury (see also Farmer
& Peterson, 1995).
Measures of "Injury Proneness" as Predictors of Injury
Rate
Injury proneness, as measured by the parent-report IBC, had near-zero
correlations with subsequent injury history, as measured by the number of
visits children had to a medical professional over the subsequent 2 years.
Previous reports of concurrent validity found the IBC was related to previous
injury history (Potts et al.,
1995,
1997;
Speltz et al., 1990), but this
was the first test of the IBC's prospective validity with future injuries.
One possible explanation for this finding is that our measure of injury history was invalid. Although parent report of major injuries is among the most frequently used techniques to measure injuries, it is subject to reporting biases. A more likely explanation for the weak correlation between IBC scores and injury reports is that the parent completing the IBC is biased by the child's previous injury history when completing the measure. In other words, previous injuries may influence the parent's reporting of the child's injury-prone behaviors. Of further import is the fact that the IBC is designed to measure injury proneness rather than actual injuries. Some children might be injured more frequently because of environmental hazards, parenting issues, or other external factors even if they do not engage in injury-prone behaviors, as assessed by the IBC. Other children might be injured less frequently because of close parental supervision and monitoring and relatively safe environments, even though those children engage in dangerous behaviors frequently as measured by the IBC.
Limitations
Several limitations of this study deserve comment. First, because the data
were collected with the primary purpose of examining etiological factors for
early-onset conduct problems, boys with ADHD but not ODD were not recruited.
Attempts to replicate these findings should clearly include this group of
clinically diagnosed children to further clarify the contribution of
comorbidity to injury occurrence in clinical samples. Second, the sample
included only boys. Although boys are at increased risk for both disruptive
behavior problems and for unintentional injuries, it is unknown whether
results might generalize to girls. Third, injury history was assessed only
through a measure of injuries requiring professional medical attention. Future
research would benefit from inclusion of an assessment of minor injuries.
Finally, this was an opportunistic study, taking advantage of injury-relevant measures in research primarily designed to address other issues. Many of the findings are therefore tentative, particularly our examination of verbal-cognitive ability and attachment as factors that mediate the relation between behavior disorders and injury. Further investigation of these factors is needed, as is investigation of other neuropsychological, cognitive, social, and temperamental factors that may elucidate the process by which children—those with behavior disorders and ultimately all children—experience unintentional injury.
Implications for Injury Prevention and Clinical Practice
Unintentional injuries are caused by countless independent factors, and no
single intervention will prevent all of them. But injury remains the leading
cause of death for children (National
Safety Council, 2001), and any intervention that might prevent a
substantial number of injuries is worth pursuing. These data indicate that
children with ODD, with or without ADHD, are at a greatly increased risk of
injury (nearly a third of children with ODD experienced at least one injury
requiring professional medical attention over the 2-year study period) and
therefore should be targeted for active intervention. We recommend that
children with clinic-referred early-onset behavior problems be routinely
screened for injury history and liability. Just as pediatricians routinely
enact primary prevention toward children at increased risk of disease, child
clinicians should enact primary prevention with behavior-disordered children
who are at increased risk for injury. Prevention techniques might include
education of the child and parent on safety issues, investigation and removal
of hazards in the home and community, and alerting school officials to the
child's increased risk of injury.
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Acknowledgments |
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This research was supported by NIMH grant R01-MH4537 to Dr. Speltz. We thank Sharman Conner for her help with data management and manuscript preparation.
Received August 10, 2001; accepted May 1, 2002
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TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Achenbach, T. M. (1991). Manual for the Child Behavior Checklist and 1991 Profile. Burlington: University of Vermont Department of Psychiatry.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Barkley, R. A., Guevremont, D.C., Anastopoulos, A. D., DuPaul, G.
J., & Shelton, T. L. (1993). Driving-related risks and
outcomes of attention deficit hyperactivity disorder in adolescents and young
adults: A 3- to 5-year follow-up survey. Pediatrics,
92, 212-218.
Barkley, R. A., Murphy, K. R., & Kwasnik, D.
(1996). Motor vehicle driving competencies and risks in teens and
young adults with attention deficit hyperactivity disorder.
Pediatrics, 98,
1089-1095.
Beery, K. E. (1989). The VMI: Developmental test of visual motor integration (3rd rev.). Cleveland, OH: Modern Curriculum Press.
Biederman, J., Faraone, S. V., & Lapey, K. (1992). Comorbidity of diagnosis in attention-deficit hyperactivity disorders. In G. Weiss (Ed.), Child and adolescent psychiatric clinics of North America: Attention-deficit hyperactivity disorder (pp. 335-360). Philadelphia: Saunders.
Bijur, P. E., Golding, J., & Haslum, M. (1988).
Persistence of occurrence of injury: Can injuries of preschool children
predict injuries of school-aged children? Pediatrics,
82, 707-712.
Cassidy, J., & Marvin, R. S., with the MacArthur Working Group on Attachment. (1992). Attachment organization in three- and four-year-olds: Coding manual. Unpublished manuscript.
Coppens, N. M. (1985). Cognitive development and locus of control as predictors of preschoolers' understanding of safety and prevention. Journal of Applied Developmental Psychology, 6, 43-55.
Coppens, N. M. (1986). Cognitive characteristics as
predictors of children's understanding of safety and prevention.
Journal of Pediatric Psychology,
11, 189-202.
Coy, K., Speltz, M. L., DeKlyen, M., & Jones, K. (2001). Social-cognitive processes in preschool boys with and without oppositional defiant disorder. Journal of Abnormal Child Psychology, 29, 107-119.[ISI][Medline]
Davidson, L. L. (1987). Hyperactivity, antisocial behavior, and childhood injury: A critical analysis of the literature. Developmental and Behavioral Pediatrics, 8, 335-340.
Davidson, L. L., Hughes, S. J., & O'Connor, P. A.
(1988). Preschool behavior problems and subsequent risk of
injury. Pediatrics, 82,
644-651.
Davidson, L. L., Taylor, E. A., Sandberg, S. T., & Thorley, G.
(1992). Hyperactivity in school-age boys and subsequent risk of
injury. Pediatrics, 90,
697-702.
DiScala, C., Lescohier, I., Barthel, M., & Li, G.
(1998). Injuries to children with attention deficit hyperactivity
disorder. Pediatrics, 102,
1415-1421.
Dunbar, H. R., Wolfe, T., & Rioch, J. (1939).
Psychic component in fracture. American Journal of
Psychiatry, 95,
1319-1342.
Dunn, L. M., & Dunn, L. M. (1981). Peabody Picture Vocabulary Test-Revised. Circle Pines, MN: American Guidance Service.
Farmer, J. E., & Peterson, L. (1995). Injury risk factors in children with attention deficit hyperactivity disorder. Health Psychology, 14, 325-332.[ISI][Medline]
Finney, J. W., Christophersen, E. R., Friman, P. C., Kalnins, I.
V., Maddux, J. E., Peterson, L., Roberts, M. C., & Wolraich, M.
(1993). Society of Pediatric Psychology Task Force Report:
Pediatric psychology and injury control. Journal of Pediatric
Psychology, 18,
499-526.
Fisher, P., Wicks, J., Schaffer, D., Piacentini, J., & Lapkin, J. (1992). DISC—Second edition (Disc 2,3). Washington, DC: National Institute for Mental Health.
Ford, J. D., Racusin, R., Daviss, W. B., Ellis, C. G., Thomas, J., Rogers, K., Reiser, J., Schiffman, J., & Sengupta, A. (1999). Trauma exposure among children with oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). Journal of Consulting and Clinical Psychology, 67, 786-789.[ISI][Medline]
Ford, J. D., Racusin, R., Ellis, C. G., Daviss, W. B., Reiser, J.,
Fleischer, A., & Thomas, J. (2000). Child maltreatment, other
trauma exposure, and posttraumatic symptomatology among children with
oppositional defiant and attention deficit hyperactivity disorders.
Child Maltreatment, 5,
205-217.
Gardner, M. F. (1990). Expressive One-Word Picture Vocabulary Test, Revised. Novato, CA: Academic Therapy Publications.
Greenberg, M. T., Speltz, M. L., & DeKlyen, M. (1993). The role of attachment in the early development of disruptive behavior problems. Development and Psychopathology, 5, 191-213.
Greenberg, M. T., Speltz, M. L., DeKlyen, M., & Jones, K. (2001). Correlates of clinic referral for early conduct problems: Variable- and person-oriented approaches. Development and Psychopathology, 13, 255-276.[ISI][Medline]
Hinshaw, S. P. (1994). Attention deficits and hyperactivity in children. Thousand Oaks, CA: Sage.
Hollingshead, A. B. (1975). Four factor index of social status. New Haven, CT: Yale University.
Johnston, C., & Mash, E. J. (2001). Families of children with attention-deficit/hyperactivity disorder: Review and recommendations for future research. Clinical Child and Family Psychology Review, 4, 183-207.[ISI][Medline]
Krall, V. (1953). Personality characteristics of accident repeating children. Journal of Abnormal and Social Psychology, 48, 99-107.
Lieberman, A. F., & Pawl, J. H. (1990). Attachment in the preschool years: Theory, research, and intervention. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 375-397). Chicago: The University of Chicago Press.
Manheimer, D. I., & Mellinger, G. D. (1967). Personality characteristics of the child accident repeater. Child Development, 38, 491-513.[ISI][Medline]
Matheny, A. P. (1988). Accidental injuries. In D. K. Routh (Ed.), Handbook of pediatric psychology (pp. 108-134). New York: Guilford Press.
Moffitt, T. E., & Lynam, D., Jr. (1995). The neuropsychology of conduct disorder and delinquency: Implications for understanding antisocial behavior. In D. Fowles, P. Sutker, & S. Goodman (Eds.), Psychopathology and anti-social behavior: A developmental perspective (pp. 233-262). New York: Springer.
Moffitt, T. E., & Silva, P. A. (1988). Neuropsychological deficit and self-reported delinquency in an unselected birth cohort. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 233-240.[ISI][Medline]
Morrongiello, B. A. (1997). Children's perspectives on
injury and close call experiences: Sex differences in injury-outcome
processes. Journal of Pediatric Psychology,
22, 499-512.
National Safety Council. (2001). Injury facts: 2001 edition. Chicago: Author.
Peterson, L., Bartelstone, J., Kern, T., & Gillies, R. (1995). Parents' socialization of children's injury prevention: Description and some initial parameters. Child Development, 66, 224-235.[ISI][Medline]
Petridou, E., Trichopoulos, D., Mera, E., Papadatos, Y., Papazoglou, K., Marantos, A., & Skondras, C. (1998). Risk factors for childhood burn injuries: A case-control study from Greece. Burns, 24, 123-128.[ISI][Medline]
Plumert, J. M. (1995). Relations between children's overestimation of their physical abilities and accident proneness. Developmental Psychology, 31, 866-876.[ISI]
Plumert, J. M., & Schwebel, D.C. (1997). Social and temperamental influences on children's overestimation of their physical abilities: Links to accidental injuries. Journal of Experimental Child Psychology, 67, 317-337.[ISI][Medline]
Potts, R., Martinez, I. G., & Dedmon, A. (1995).
Childhood risk taking and injury: Self-report and informant measures.
Journal of Pediatric Psychology,
20, 5-12.
Potts, R., Martinez, I. G., Dedmon, A., Schwarz, L., DiLillo, D.,
& Swisher, L. (1997). Brief report: Cross validation of the
Injury Behavior Checklist in a school-age sample. Journal of
Pediatric Psychology, 22,
533-540.
Reid, D. K., Hresko, W. P., & Hammill, D. D. (1989). Test of Early Reading Ability-2. Austin, TX: Pro-Ed.
Routh, D. K. (1997). Injury control research in
pediatric psychology: A commentary and a proposal. Journal of
Pediatric Psychology, 22,
495-498.
Schwebel, D.C. (2000). Relations between children's temperament, ability estimation, and unintentional injuries. Unpublished doctoral dissertation, University of Iowa, Iowa City.
Schwebel, D.C., & Plumert, J. M. (1999). Longitudinal and concurrent relations among temperament, ability estimation, and injury proneness. Child Development, 70, 700-712.[ISI][Medline]
Speltz, M. L., DeKlyen, M., Calderon, R., Greenberg, M. T., & Fisher, P. A. (1999). Neuropsychological characteristics and test behaviors of boys with early onset conduct problems. Journal of Abnormal Psychology, 108, 315-325.[ISI][Medline]
Speltz, M. L., DeKlyen, M., & Greenberg, M. T. (1999). Attachment in boys with early onset conduct problems. Development and Psychopathology, 11, 269-285.[ISI][Medline]
Speltz, M. L., Gonzales, N., Sulzbacher, S., & Quan, L.
(1990). Assessment of injury risk in young children: A
preliminary study of the Injury Behavior Checklist. Journal of
Pediatric Psychology, 15,
373-383.
Wazana, A. (1997). Are there injury-prone children? A critical review of the literature. Canadian Journal of Psychiatry, 42, 602-610.[ISI][Medline]
Wechsler, D. (1989). Wechsler Preschool and Primary Scale of Intelligence—Revised. San Antonio, TX: The Psychological Corporation.
Zeanah, C. (1996) Beyond insecurity: A reconceptualization of attachment disorders of infancy. Journal of Consulting and Clinical Psychology, 64, 42-52.[ISI][Medline]
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