Parenting and the Prevention of Childhood Injuries 18

(1)

Chapter 18 Parenting and the Prevention of Childhood Injuries

Ronald J. Prinz

18.1. INTRODUCTION

Injuries in childhood represent a serious public health problem in the United States. Unintentional injury is the most common cause of death and disability for children. For example, injuries are the cause of half the deaths that occur for children 1–4 years of age. Over 600,000 children are hospitalized annually for injuries, and approximately 16 million children yearly are seen in emergency rooms as a result of injury (Centers for Disease Control and Prevention [CDC], 1990). Inju- ries that are clearly unintentional are not the only sources of the problem. Child maltreatment adds to the number of injury-based fatalities, disabilities, and medical treatments. For example, in 2001 an estimated 903,000 children were conﬁrmed by child protective agencies in the United States to have been maltreated (i.e., abuse and/or neglect), and an estimated 1,300 children died from abuse or neglect (a rate of 1.81 per 100,000 children in the population). Many more children suffered from nonfatal injuries (U.S. Department of Health and Human Services [HHS], 2003).

Prevention of both unintentional and maltreatment-based injuries in childhood is obviously of utmost importance. This chapter focuses on parenting-related interventions aimed at the prevention of childhood injury. Parents and other family caregivers are logical contributors to prevention of childhood injuries, in part because the injuries often occur in the home or in close proximity to a parent. This chapter focuses only on the preadolescent age group (children from infancy to 12 years of age) and does not consider injury prevention among adolescents.

Two isolated areas of unintentional injury and child maltreatment have grown up side by side with little interaction between the two. The boundaries between inadvertent (unintentional) injuries and injuries attributable to child maltreatment are somewhat blurred and artiﬁcial. Peterson (1994) and others have argued that the commonalities between the two areas outnumber the differences and that it is

333

(2)

often difﬁcult to reliably classify childhood injuries as either unintentional or not.

With respect to parenting-based preventive interventions, the boundaries between prevention of unintentional injury and prevention of child maltreatment are even more blurred because many of the parenting strategies and intervention methods are of generic utility.

18.2. PRELIMINARY CONSIDERATIONS

Three lines of parenting-based intervention research potentially relate to the prevention of childhood injuries. The ﬁrst line of work involves preventive interventions that are aimed at preventing childhood injuries in the general population and reducing risk in selected populations (e.g., economically disadvantaged groups, families already having experienced a child injury). The second line examines interventions aimed at preventing child maltreatment (physical abuse, neglect, or both), with the possible additional goal (either explicit or implicit) of reducing risk for childhood injury. The third line of research focuses on interventions aimed at strengthening parenting efﬁcacy, mainly applied to parents of children with behavioral or emotional problems but also includes preventative strategies (Taylor & Biglan, 1998).

Some of the parenting-based approaches to prevention of childhood injuries target only one domain (e.g., the use of smoke alarms in the home or the prevention of scalding from hot tap water), whereas other approaches target multiple domains. Because preventive interventions that concentrate on only one domain involve relatively lower prevalence rates, a large segment of the population must be tested to detect effects on injury reduction. By contrast, preventive interventions with a broader focus have higher cross-injury rates and thus the effects can be detected in a smaller sample; however, a more comprehensive program would be needed to measure these effects. There is a trade-off between maximizing the number of target domains to produce a wide effect and the extent of programming coverage needed.

Descriptive research on parenting strategies and home-safety practices in the general population provides some clues about potentially effective methods to prevent childhood injuries (Morrongiello & House, 2004; Morrongiello & Kiriakou, 2004; Morrongiello, Ondejko, & Littlejohn, 2004; Peterson, DiLillo, Lewis, & Sher, 2002). Parents use a mixture of strategies to prevent child injury, depending on the child’s developmental level, the particular location of the home or environment (e.g., living room versus child’s play area), the parent’s goal in the situation, and the parent’s perception of risk (Morrongiello & Lasenby, 2006). Space does not permit coverage of the rich details from this important line of descriptive research.

Some of the observations, however, provide an appropriate backdrop to the review of interventions. It appears that caregivers who are efﬁcacious at preventing childhood injury (1) use active strategies of monitoring and supervision that change as a function of child age, activity, and setting; (2) have a broad repertoire of strategies for use with their children; (3) are not completely consistent in adopting and enforcing every possible safeguard and precaution; and (4) usually have rationales for their prevention/action responses that they communicate in age-appropriate ways to their children so that the children acquire self-regulation skills over time.

All of the interventions reviewed in this chapter involve parents in some way.

Interventions that involve only interventionist contact with the children (e.g., in

(3)

some of the work on latchkey children) were excluded. Nonetheless, the interventions vary considerably in terms of goals and targets. The reviewed interventions focus on parental knowledge about speciﬁc injury risks (e.g., hot water scalding, bicycle riding without a helmet), safe caregiver practices in the home, parental involvement and supervision, elimination of neglectful or unhealthy conditions, promotion of noncoercive parenting practices, or some combination of these. The parent/caregiver role in interventions also varies along a passive–active continuum—for example, from simply receiving information or materials to interacting with program staff to receiving high levels of coaching and consultation.

18.3. INTERVENTIONS AND EXTENT OF EVIDENCE

The interventions involving parents and parenting cut across a wide array of strategies and approaches. Some of the intervention studies come from research on prevention of unintentional injury in the general population, whereas others are from research on prevention of child maltreatment in high-risk groups. Both domains are considered. Interventions from the general parent-training literature are brieﬂy considered as well.

18.3.1. Interventions from Unintentional Injury Research 18.3.1.1. Safety Counseling and Education with Parents

There is some evidence that brief, focused parent education about a speciﬁc topic such as smoke alarm use or burn prevention can yield positive results. A number of studies have found that parent education about scald burns and prevention resulted in signiﬁcantly greater likelihood that parents tested and lowered their home tap- water temperature (Katcher, Landry, & Shapiro, 1989; Kelly, Sein, & McCarthy, 1987; Thomas, Hassanein, & Christophersen, 1984).

Parent education via brief consultation or home visits, supplemented by free safety items, such as smoke alarms, safety latches, outlet plugs, and poison stickers, appears to have some promise in promoting home safety. Gallagher, Hunter, and Guyer (1985) tested a home-injury prevention program that involved parent education about safety hazards, installation of safety devices, and notiﬁcation about changes in legal requirements for safety standards. They found that safety counseling plus provision of safety supplies resulted in signiﬁcantly better home safety behaviors than safety counseling alone. Similar decreases in home hazards were found by Paul, Sanson-Fisher, Redman, and Carter (1994) and by Bablouzian, Freeman, Wolski, and Fried (1997), although improvements found in the latter study occurred only in those domains for which safety materials were distributed.

A research group in Canada found that parent education plus provision of low-cost helmets produced increased children’s bicycle helmet use compared to both parent education and control conditions (Morris & Trimble, 1991).

DiGuiseppi and Roberts (2000) reviewed parenting-related interventions to increase smoke alarm use in homes and found that those involving small parenting classes or safety counseling with individual parents were more effective if smoke alarms were provided to families at a discounted price. An exception was a brief intervention that involved 15 minutes of safety education from a physician plus an information sheet but did not include ﬁnancial incentives (Kelly et al., 1987):

(4)

the intervention group showed greater acquisition of smoke alarms compared to the control group. A wide-scale educational campaign that included provision of smoke alarms produced a decrease in fatality rates from home ﬁres in Oklahoma City (Mallonee et al., 1996), suggesting, at least for the increased use of smoke alarms, that parenting interventions might not be essential but provision of free or cheap alarms is critical.

Burn-prevention programs aimed at encouraging parents to test and lower tap- water temperatures have been tested and shown to be successful. A 1-hour well-child parenting class about burn prevention, hot water equipment, and water thermom- eters found that 44% of participating parents, compared to 29% of control parents, lowered their tap-water temperature at home (Barone, 1988). Similar effects were found in a study aimed at teaching parents about scald burns (Corrarino, Walsh,

& Nadel, 2001). In a pediatric clinic, Katcher et al. (1989) found that brief advice about tap-water temperature and a free thermometer led to 44% of parents testing their home tap water (compared with 23% of control parents) and 14% (compared with 9%) lowering the water temperature. What is not clear is whether this intervention (and the interventions in the aforementioned studies) ultimately led to a lower incidence of child scald burns. Finally, a study by Thomas et al. (1984), testing a parent-education intervention aimed at lowering hot water temperature settings and encouraging installation of smoke alarms, demonstrated that a signiﬁcant pro- portion of parents lowered their hot water heater temperatures but did not install smoke alarms at a signiﬁcantly greater rate than controls.

18.3.1.2. Brief Home Visitation by Safety Inspectors

Another strategy of potential utility is brief home visitation by safety inspectors. A cogent example of this was tested by King et al. (2001) using a randomized controlled trial with a case-control study. The key sample included families with a child under 8 years of age (median age 8 years) who had presented at a hospital emergency room for one of the targeted injuries (i.e., tap-water scald, burn from a fire in the home, poisoning or other dangerous ingestion, choking from ingestion of a foreign object, injury from a fall, bicycle-related head injury). Home inspections were conducted for households in both the intervention and the control conditions. Parents in the intervention condition received a detailed information packet on injury prevention, review of findings from the home inspection, instructions on how to correct home safety deficiencies, detailed instruction regarding prevention of each of the targeted injuries, discount coupons for purchase of recommended safety devices, demonstration of the appropriate use of the safety devices, and follow-up telephone calls 4 and 8 months after the initial home visit. The investigators found that despite lack of intervention effects on parental awareness and knowledge about childhood injury risk and prevention, there was a lower rate of reported medical visits for child injury by families in the intervention condition (King et al., 2001).

In a study with Head Start families, Johnston, Britt, D’Ambrosio, Mueller, and Rivara (2000) deployed a safety home visiting protocol that included a baseline home inspection, a prevention-knowledge assessment, three monthly home visits, safety information for parents in areas identiﬁed as safety concerns, and safety items for the families (e.g., smoke alarm, batteries for smoke alarms, syrup of ipecac, a booster car seat). Home visits were conducted by family service case workers. It was not clear from the published report how the home visitors interacted with

(5)

parents in terms of process. Families in the intervention condition differed from the comparison families at the 3-month follow-up in terms of being more likely to have a smoke detector, a car seat, or syrup of ipecac and less likely to have poison- ous substances in the home.

In an injury prevention program conducted within an urban African American community, Schwarz, Grisso, Miles, Homes, and Sutton (1993) made use of safety inspectors who helped parents identify home hazards, modeled how to correct the problems, and provided low-cost materials. The investigators found that intervention parents, compared with control parents, created significantly safer homes with respect to the less challenging safety issues (e.g., maintaining functional smoke alarms and keeping medications away from children) but not with respect to more difficult problems (e.g., poor lighting or major floor repairs). Although the inspectors modeled safety-promoting behaviors for the parents to emulate, they did not appear to provide concerted opportunities for parents to engage in specific preventive actions and receive feedback.

18.3.1.3. Use of Rewards for Parents and Children

Roberts and Turner (1986) demonstrated that rewarding parents if their children were buckled in car seats or seat belts when arriving at daycare produced a higher use of car safety restraints. The rewards were lottery tickets that could be redeemed for various prizes. Foss (1989) conducted a similar study and essentially replicated the results; other investigators distributed lottery tickets for rewards (e.g., coloring books, pizzas, stickers) if everyone in the family car was buckled up when the child arrived at school also with favorable results (Roberts & Fanurik, 1986; Roberts, Fanurik, & Wilson 1988). Other studies have found that systematic implementation of reward-based behavioral training with parents produced greater short-term and to some extent long-term use of child safety restraints (Liberator, Eriacho, Schmiesing, & Krump, 1989; Stuy, Green, & Doll, 1993). Britt, Silver, and Rivara (1998) used similar principles with low-income parents to increase children’s use of bicycle helmets. In a systematic review of the literature, Zaza et al. (2001) found that incentives plus education increased the use of child safety seats.

18.3.1.4. Training Parents as Safety Instructors

Peterson, Mori, Selby, and Rosen (1988) conducted a series of small studies examining the viability of training parents to serve as “safety-skills instructors” for their 8- to 10-year-old children. They found that the parents were reasonably good at acquiring the necessary training skills, but there was only a modest effect on the children’s acquisition of safe behaviors. Subsequent injury prevention with the small samples was not assessed. Despite the low cost of the procedures, the intensity of the intervention apparently was not high enough to produce sufﬁcient positive effects on the children.

18.3.2. Interventions from Research on Prevention of Child Maltreatment

18.3.2.1. Comprehensive Home-Safety Training for Parents

By far the most intensive and one of the best examples of training parents in home safety is Project 12-Ways (Gershater-Molko, Lutzker, & Sherman, 2002; Lutzker,

(6)

Bigelow, Doctor, Gershater, & Greene, 1998; Lutzker, Campbell, Newman, &

Harrold, 1989; Lutzker, Frame, & Rice, 1982; Lutzker & Rice, 1984, 1987; Lutzker, Wesch, & Rice, 1984; Wesch & Lutzker, 1991). A derivative program is Project Saf- eCare (Gershater-Molko, Lutzker, & Wesch, 2002, 2003; Lutzker et al., 1998; Met- chikian, Mink, Bigelow, Lutzker, & Doctor, 1999; Taban & Lutzker, 2001). These programs were designed primarily for parents who have entered the child protective services system for child neglect and other forms of child maltreatment and are mandated to participate in safety training and parenting improvement. Project 12-Ways and Project SafeCare are both delivered in the home using an ecobehavioral framework for assessment and programming. Project 12-Ways involves selected intervention components based on needs identified in an in-depth assessment of each family and home. Services components include basic skills training related to child toilet training and general hygiene, home safety, health maintenance, nutrition, parent–child interactions, and stress reduction, and provides training related to money management, job finding, and practical problem solving. Project SafeCare, which is a distillation of Project 12-Ways, focuses only on child health care, parent–child interactions (and the associated parenting skills), and safety (i.e., home safety and injury prevention). Data from multiple studies support the utility and efficacy of this overall approach in improving household safety and hygiene, reducing child neglect, reducing coercive parenting practices, increasing positive strategies, and reducing referrals for child maltreatment. The approach is particu- larly noteworthy because it is focused, easy for parents to understand and accept, practical in terms of parenting actions, and researchable because the elements are replicable and readily documented.

18.3.2.2. Home Visitation

A popular modality of intervention in child maltreatment is home visitation, partic- ularly for high-risk caregivers with very young children (i.e., infants and toddlers).

Most home visitation programs have multiple facets that address, for example, child health and development, basic infant care, parent–child interaction, strategies for prevention of child abuse and neglect, adjustment of the caregiver, and broader family issues. Home visitation programs for the prevention of child maltreatment were extensively reviewed by the Task Force on Community Preventive Services (convened by the CDC and other agencies) and are summarized by Bilukha et al.

(2005). Of the 20 studies reviewed that examined child abuse and neglect as an outcome, only 6 demonstrated a positive effect of home visitation. Only 5 home visitation studies examined childhood injury as an outcome, and none of these showed a positive effect in reducing or preventing child injury. The field is con- flicted about the value and preventive effect of home visitation on child abuse and neglect (Chaffin, 2004).

Worthy of special note as one of the more extensive strategies for prevention of childhood injury and child maltreatment is the Olds home visitation program (Olds et al., 1999). Focused primarily on young economically disadvantaged mothers giving birth for the ﬁrst time, the Olds home visitation program involves recurring visits by nurses beginning in the prenatal period and continuing throughout the ﬁrst 2 years of the child’s life. The visits last 75–90 minutes, and the nurses make eight prenatal visits on average per mother (up to 18 visits) and 25 visits per family (up to 71 visits) from birth to the child’s second birthday. In a randomized controlled trial, the Olds research team was able to demonstrate that children of the

(7)

mothers receiving the nurse visitation program showed significantly lower rates of injury during the first 2 years of life compared with children of mothers providing usual care (Kitzman et al., 1997). The impressive aspect of this work is that the investigators were able to demonstrate actual preventive benefits in terms of reductions in injury rates. This approach relies heavily on enhancement of social support, confidence building with the mothers, and general assistance related to health and daily living. From an injury prevention standpoint, it is not clear how to tease out which facets of parenting and which elements of the intervention are critical to the reduced rate of childhood injuries. Given that the intervention accrued benefits in other areas as well (e.g., employment, mental health, unintentional injury), this approach seems quite promising for the selected population (i.e., young economically disadvantaged single first-time mothers) and developmental period (i.e., first 2 years of the children’s lives).

18.3.2.3. Cognitive-Behavioral Parent Training

A promising cognitive-behavioral approach to prevention of child maltreatment was developed by Peterson, Tremblay, Ewigman, & Saldana (2003) and tested in a randomized controlled trial with high-risk mothers. The program included model- ing, role-playing, interactive (Socratic-style) dialogue, home practice, and home visits (with observation and feedback). Intervention effects were demonstrated in the seven target areas: parenting skills, developmentally appropriate parenting responses, acquisition of developmentally appropriate beliefs about their children, regulation of negative affect, acceptance of responsibility for parent role, acceptance of nurturing role, and self-efﬁcacy. Gains were maintained at follow-up. There was not sufﬁcient power to detect reductions in subsequent referrals for child maltreatment, but the participating mothers did show reductions in coercive parenting practices and maladaptive beliefs.

A study by Sanders and colleagues (2004) demonstrated that retraining parental attributions and undergoing anger management as part of a parenting intervention called Triple P—Positive Parenting Program—can positively effect parents at risk for maltreatment of their preschool-age children. The investigators found that Pathways Triple P (a variant of the well-tested Triple P system) reduced coercive parenting practices, negative parental attributions, unrealistic parental expectations, potential for child maltreatment, and child behavioral problems;

the gains were maintained at the 6-month follow-up. Although subsequent child maltreatment referrals and child injuries were not examined, the Pathways Triple P program shows promise as a relatively efﬁcient and focused intervention for the prevention of the physical abuse of children and the reduction of risk for maltreatment-related childhood injuries.

18.3.3. Generic Behavioral Training for Parents and Children

There is a large area of research on interventions aimed at improving parenting skills and reducing or preventing child behavioral and emotional problems without being tied speciﬁcally to the prevention of either unintentional childhood injury or child maltreatment (Chronis, Chacko, & Fabiano, 2004; Griest & Wells, 1983;

Kazdin, 2003; Miller & Prinz, 1990; Prinz & Dumas, 2003; Prinz & Jones, 2003;

Sanders, Turner, & Markie-Dadds, 2003). Nonetheless, to the extent that children with behavioral and emotional problems (e.g., ADHD, oppositional-deﬁant

(8)

disorder) are at heightened risk for injury during childhood and adolescence, effective parenting interventions that mitigate the behavioral and emotional problems have the potential to reduce risk for injury. Some evidence supports an association between childhood behavioral and emotional problems and greater risk for injury, although the data are not consistent. There are a number of ways in which parenting interventions might conceivably contribute to injury prevention. Young children with high rates of wild and reckless behavior place themselves in dangerous situations, and effective parenting interventions can assist parents in strategies to reduce the problematic behaviors. Increased supervision and monitoring of children and, perhaps, adolescents might afford parents opportunities to prevent some injuries (e.g., from playing with matches, getting into the medicine cabinet, climbing to unsafe heights, playing in the street, getting into unsafe environments).

Despite the potential for this large category of parenting interventions with respect to prevention and reduction of childhood injury, there have been no published population-level studies of this proposition to date.

18.3.4. Summary of Findings for Interventions

Each of the interventions discussed here was rated in terms of effectiveness based on the available scientific evidence and summarized using a 5-point scale: 5, effec- tive; 4, promising; 3, insufficient evidence; 2, not effective, and 1, iatrogenic (Table 18.1). The summary focuses on two types of outcomes. The first is childhood injury;

some of the intervention studies did not assess childhood injury directly, whereas others found no preventive effects on childhood injury. The second outcome is risk reduction, which typically includes improvement in parental safety practices, parent knowledge about injury prevention, and parenting practices or lower rate of referral for child maltreatment. The assumption behind the risk-reduction category is that these variables are clearly linked to risk for child injury.

Table 18.1. Summary of Effectiveness for Parenting-Based Interventions Aimed at Preventing Child Injury^a

Injury

Intervention Prevention Risk Reduction

Drawn from unintentional injury research

Safety counseling and education with parents 3 4

Safety counseling and education with parents plus 4 4

provision of safety materials

Brief home visitation by safety inspectors 3 3

Use of rewards for parents and children Unknown 4

Training parents as safety instructors Unknown 3

Drawn from child-maltreatment prevention research

Comprehensive home-safety training 4 5

Home visitation (general approaches) 3 4

Nurse home visitation model 4 5

Cognitive-behavioral parent training 3 5

Generic Parent Training Unknown 5

aThe scale is as follows: 5, effective (supported by two or more well designed studies); 4, promising (supported by one well-designed study); 3, insufﬁcient (not enough evidence or mixed evidence); 2, not effective (no effect found in two or more well-designed studies); 1, iatrogenic (potentially harmful effect supported by two or more well-designed studies); unknown, no studies found.

(9)

18.4. IMPLICATIONS AND LIMITATIONS FOR PUBLIC HEALTH PRACTICE

Taking into account prevention research on both childhood injury in the general population and child maltreatment in high-risk samples, some common themes emerged that have implications for public health practice:

• The more successful interventions emphasize active parental involvement, speciﬁc parenting practices, concrete actions that parents can readily take, and program implementation in naturalistic settings (i.e., primarily in the home).

• Providing safety items such as car seats, smoke alarms, and tap-water thermometer for free or at reduced cost seems to add signiﬁcantly to the effect of preventive interventions. A number of factors may account for this.

Providing these items to families with limited ﬁnancial resources frees parents from having to choose between paying for subsistence and housing and purchasing safety materials. Providing safely items at reduced or no cost to other families facilitates the process of acquisition and perhaps gives a built-in incentive to act. The latter point is consistent with data on safety interventions involving provision of explicit incentives for parents and children.

• Programming delivered in the home makes ecological sense but does not in and of itself ensure effectiveness. Home visitation programs and other home-delivered interventions vary in effect. Process and content of home- delivered programs and ﬁdelity of implementation clearly are important facets to consider, even though the huge variation in actual substance is masked by the catch-all term home visitation.

Some of the interventions are predicated on the assumption that educat- ing, or at least informing, parents on what to do and how to do it is suffi - cient to prevent child injury. The evidence for this is minimal. Some parents might benefit from information about smoke alarms; seat belt arrangements for infants, toddlers, and children; safe tap-water temperatures; bicycle helmets; and safety-proofing the home for infants and toddlers. However, it is not clear how different methods of providing this information (e.g., via media, pamphlets, brief primary care explanation) affect the success of such interventions. What is clear is that it is important to have parents take action and practice with feedback or consultation, rather than just learn cognitively about the topic. This is apparent from home inspections, which help parents figure out what they need to change. The advantages of this approach over just providing information to parents are relatively obvious. First, the safety inspectors can see what parents are actually doing (or not doing) at home that needs to be augmented or changed. Second, parents can ask questions in the context of actual rather than hypothetical conditions. And third, the interventionists can tailor their actions to meet each family’s situation and needs. On the downside, some parents may find the visits intrusive or may balk because they fear the possibility of involvement by child protective services.

What seems to be missing or at least underspeciﬁed in most of the reviewed interventions is how parents might interact with their children to optimize safe

(10)

conditions. Parents could beneﬁt from coaching, skill building, practice feedback, and tips on how to enlist the cooperation of their children in implementing safe practices. For example, depending on the age of the children in the home, parents could beneﬁt from learning how to get children to respond appropriately if a smoke alarm goes off. On a related issue, interventions need to better address the processes of parent–child interactions and parents’ parenting practices, which may play into how safe or unsafe the home and family are for the children.

An exception to this limitation is found in Project 12-Ways and Project SafeC- are, which are exemplars of how to address parenting practices in an explicit manner within an injury prevention approach. These programs accomplish multiple goals through home visits that are structured, practical, and oriented to problem solving. These two programs were designed primarily for parents who have entered the child protective service system because of child neglect. It might be possible to draw critical elements from this approach (e.g., skills training, application in an ecological context, positive action orientation) and adapt them to a broader segment of the population.

To increase cost effectiveness and effect at a population level, it is necessary to combine goals in the design of intervention programs. For example, programs for parenting in which safety and injury reduction are but one part make sense and are more likely to be adopted. The prime examples of this are Project 12-Ways, Project SafeCare, and the Olds home visitation program. Project 12-Ways and Project SafeCare pursue multiple goals related to parental functioning, including but not restricted to home safety and hygiene. This type of program is a model for child protective services intervention with neglectful families. The Olds home visitation program, which has shown some long-term prevention of childhood injuries, is geared toward a particular segment of the population—namely, young economically disadvantaged single mothers during the ﬁrst 2 years of their children’s lives.

Given the level of intensity and the associated cost, this approach does not lend itself readily to universal application to the general population. Nonetheless, the promise of this intervention model suggests that a consolidated version might prove useful for the general population of ﬁrst-time parents, a concept that will require further testing. When considering the broader population, policymakers should consider programming for parents that similarly pursues multiple goals but is invoked without the requirements of entry into the social-services system or the initial childbirth of a young single mother living in poverty.

An example of a population approach that has potential utility for multiple goals is found in the Triple P system of interventions (Sanders et al., 2003). Triple P is a multitiered system of interventions of increasing intensity; it consists of ﬂex- ible delivery formats based on a unifying set of parenting principles and a broad array of positive parenting strategies. The Triple P system, which has a large evidence base supporting it (to date, 25 clinical trials), has program levels that can be applied universally in a cost-effective manner (e.g., in primary care and early childhood educational settings), and other levels that provide more intensive programming for parents facing greater challenges, including risk for child maltreatment.

This population approach can provide an integrated framework that potentially addresses multiple goals, including promotion of effective parenting practices, reduction or prevention of child behavioral and emotional problems, risk reduction for child maltreatment, and risk reduction for childhood injuries (across the continuum of intentionality).

(11)

18.5. RESEARCH GAPS

It is not clear to what extent improvements in intermediary goals ultimately lead to prevention or reduction of childhood injuries. Examples of intermediary goals include awareness of a safety issue (e.g., risk of scalding from hot tap water), knowledge of safe practices (e.g., installing and checking smoke alarms, making medicines and household cleaners inaccessible to young children), and imple mentation of safe practices. It is possible to have made significant changes in parental awareness, knowledge, and implementation practices and yet still have not produced positive changes in injury prevalence rates at a population level. Part of the difficulty lies in the research samples being studied. Most of the samples are too small to test population effects on the low-rate childhood injuries being addressed because the effects would not be detectable or the outcome measure not sufficiently reliable. A related problem is that some of the interventions are too intensive and expensive to implement at a population level.

Researchers need to test the extent to which programming for effective parenting can be implemented in a cost-effective manner, addressing injury prevention and child-welfare promotion simultaneously and evaluating the effect at a population level. This approach is consistent with the surgeon general’s recent call for a national strategic plan aimed simultaneously at preventing child maltreatment and optimizing (promoting) healthy child development.

18.6. CONCLUSIONS

Parents obviously can and do play a large role in moderating (or not moderating) childhood risk of injury. Preventive interventions that actively promote proactive efforts on the part of parents have promise to reduce childhood injury. The more effective strategies emphasize parent–child interaction, knowledge of safety practices linked to speciﬁc actions, in vivo practice and implementation, use of feedback and incentives, and provision of safety materials such as car seats and smoke alarms.

The ﬁeld needs to focus on dissemination methods that combine goals, both across injury domains and with respect to other areas (e.g., promotion of noncoercive parenting, strengthening of parental involvement) and that demonstrate population-level beneﬁts in terms of reduced injury rates.

REFERENCES

Bablouzian, L., Freeman, E. S., Wolski, K. E., & Fried, L. E. (1997). Evaluation of a community based childhood injury prevention program. Injury Prevention, 3, 14–16.

Barone, B. J. (1988). An analysis of well-child parenting classes: The extent of parent compliance with health care recommendations to decrease potential injury of their toddlers. Lawrence, KS: University of Kansas.

Unpublished doctoral dissertation, Lawrence.

Bilukha, O., Hahn, R., Crosby, A., Fullilove, M., Liberman, A., Moscicki, E., Snyder, S., Tuma, F., Corso, P.,

& Schoﬁeld, A. (2005). The effectiveness of early childhood home visitation in preventing violence:

A systematic review. American Journal of Preventive Medicine, 28, 11–39.

Britt, J., Silver, I., & Rivara, F. P. (1998). Bicycle helmet promotion among low-income preschool chil- dren. Injury Prevention, 4, 238–283.

Centers for Disease Control and Prevention. (1990). Childhood injuries in the United States. American Journal of Diseases in Children, 144, 627–646.

(12)

Chafﬁn, M. (2004). Is it time to rethink healthy start/healthy families? Child Abuse & Neglect, 28, 589–595.

Chronis, A. M., Chacko, A., & Fabiano, G. A. (2004). Enhancements to the behavioral parent training paradigm for families of children with ADHD: Review and future directions. Clinical Child & Family Psychology Review, 7, 1–27.

Corrarino, J. E., Walsh, P. J., & Nadel, E. (2001). Does teaching scald burn prevention to families of young children make a difference? A pilot study. Journal of Pediatric Nursing, 16, 256–262.

DiGuiseppi, C., & Roberts, I. G. (2000). Individual-level injury prevention strategies in the clinical setting. Future of Children, 10, 53–82.

Foss, R. (1989). Evaluation of a community-wide incentive program to promote safety restraint use.

American Journal of Public Health, 79, 304–306.

Gallagher, S., Hunter, P., & Guyer, B. (1985). A home injury prevention program for children. Pediatric Clinics of North America, 1, 95–112.

Gershater-Molko, R. M., Lutzker, J. R., & Sherman, J. A. (2002). Intervention in child neglect: An applied behavioral perspective. Aggression & Violent Behavior, 7, 103–124.

Gershater-Molko, R. M., Lutzker, J. R., & Wesch, D. (2002). Using recidivism data to evaluate Project SafeCare: Teaching bonding, safety, and health care skills to parents. Journal of the American Profes- sional Society on the Abuse of Children, 7, 277–285.

Gershater-Molko, R. M., Lutzker, J. R., & Wesch, D. (2003). Project SafeCare: Improving health, safety, and parenting skills in families reported for and at risk for child maltreatment. Journal of Family Violence, 18, 377–386.

Griest, D. L., & Wells, K. C. (1983). Behavioral family therapy with conduct disorders in children.

Behavior Therapy, 14, 37–53.

Johnston, B. D., Britt, J., D’Ambrosio, D., Mueller, B. A., & Rivara, F. P. (2000). A preschool program for safety and injury prevention delivered by home visitors. Injury Prevention, 6, 305–309.

Katcher, M. L., Landry, G. L., & Shapiro, M. M. (1989). Liquid-crystal thermometer use in pediatric ofﬁce counseling about tap water burn prevention. Pediatrics, 83, 766–771.

Kazdin, A. E. (Ed.). (2003). Evidence-based psychotherapies for children and adolescents. New York: Guilford.

Kelly, B., Sein, C., & McCarthy, P. L. (1987). Safety education in a pediatric primary care setting.

Pediatrics, 79, 818–824.

King, W. J., Klassen, T. P., LeBlanc, J., Bernard-Bonnin, C., Robitaille, Y., Pham, B., Coyle, D., Tenenbein, M., & Pless, I. B. (2001). The effectiveness of a home visit to prevent childhood injury. Pediatrics, 108, 382–388.

Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., McConnochie, K. M., Sidora, K., Luckey, D. W., Shaver, D., Engelhardt, K., James, D., & Barnard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: A randomized controlled trial. Journal of the American Medical Association, 278, 644–652.

Liberator, C. P., Eriacho, B., Schmiesing, J., & Krump, M. (1989). Safesmart safety seat interven- tion project: A successful program for the medically indigent. Patient Education & Counseling, 13, 161–170.

Lutzker, J. R., Bigelow, K. M., Doctor, R. M., Gershater, R. M., & Greene, B. F. (1998). An ecobehavioral model for the prevention and treatment of child abuse and neglect: History and applications.

In J. R. Lutzker (Ed.), Handbook of child abuse research and treatment (pp. 239–266). New York:

Plenum.

Lutzker, J. R., Campbell, R. V., Newman, M. R., & Harrold, M. (1989). Ecobehavioral interventions for abusive, neglectful, and high-risk families. In G. H. S. Singer & L. K. Irvin (Eds.), Support for caregiv- ing families: Enabling positive adaptation to disability (pp. 313–326). Baltimore: Brookes.

Lutzker, J. R., Frame, R. E., & Rice, J. M. (1982). Project 12-Ways: An ecobehavioral approach to the treat- ment and prevention of child abuse and neglect. Education & Treatment of Children, 5, 141–155.

Lutzker, J. R., & Rice, J. M. (1984). Project 12-Ways: Measuring outcome of a large in-home service for treatment and prevention of child abuse and neglect. Child Abuse & Neglect, 8, 519–524.

Lutzker, J. R., & Rice, J. M. (1987). Using recidivism data to evaluate Project 12-Ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect. Journal of Family Violence, 2, 283–290.

Lutzker, J. R., Wesch, D., & Rice, J. M. (1984). A review of Project 12-Ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect. Advances in Behaviour Research &

Therapy, 6, 63–73.

Mallonee, S., Istre, G., Rosenburg, M., Reddish-Douglas, M., Jordan, F., Silverstein, P., & Tunnell, W.

(1996). Surveillance and prevention of residential-ﬁre injuries. New England Journal of Medicine, 335, 27–31.

(13)

Metchikian, K. L., Mink, J. M., Bigelow, K. M., Lutzker, J. R., & Doctor, R. M. (1999). Reducing home safety hazards in the homes of parents reported for neglect. Child & Family Behavior Therapy, 21, 23–34.

Miller, G. E., & Prinz, R. J. (1990). The enhancement of social learning family interventions for child- hood conduct disorder. Psychological Bulletin, 108, 291–307.

Morris, B. P., & Trimble, N. E. (1991). Promotion of bicycle helmet use among schoolchildren: A ran- domized clinical trial. Canadian Journal of Public Health, 82, 92–94.

Morrongiello, B. A., & House, K. (2004). Measuring parent attributes and supervision behaviors rel- evant to child injury risk: Examining the usefulness of questionnaire measures. Injury Prevention, 10, 114–118.

Morrongiello, B. A., & Kiriakou, S. (2004). Mothers’ home-safety practices for preventing six types of childhood injuries: What do they do, and why? Journal of Pediatric Psychology, 29, 285–297.

Morrongiello, B. A., & Lasenby, J. (2006). Supervision as a behavioral approach to reducing child-injury risk. Chapter 18. In A. C. Gielen, D. A. Sleet, & R. DiClemente (Eds). Injury and violence prevention:

Behavior change theories, methods and applications (pp 395–418). San Francisco, CA: Jossey-Bass.

Morrongiello, B. A., Ondejko, L., & Littlejohn, A. (2004). Understanding toddlers’ in-home injuries: II.

Examining parental strategies, and their efﬁcacy for managing child injury risk. Journal of Pediatric Psychology, 29, 433–446.

Olds, D. L., Henderson, C. R., Kitzman, H. J., Eckenrod, J. J., Cole, R. E., & Tatelbaum, R. C. (1999).

Prenatal and infancy home visitation by nurses: Recent ﬁndings. The Future of Children, 9, 44–65.

Paul, C., Sanson-Fisher, R., Redman, S., & Carter, S. (1994). Preventing accidental injury to young children in the home using volunteers. Health Promotion International, 9, 241–249.

Peterson, L. (1994). Child injury and abuse-neglect: Common etiologies, challenges, and courses toward prevention. Current Directions in Psychological Science, 3, 116–120.

Peterson, L., DiLillo, D., Lewis, T., & Sher, K. (2002). Improvement in quantity and quality of prevention measurement of toddler injuries and parental interventions. Behavior Therapy, 33, 271–297.

Peterson, L., Mori, L., Selby, V., & Rosen, B. N. (1988). Community interventions in children’s injury prevention: Differing costs and differing beneﬁts. Journal of Community Psychology, 16, 188–204.

Peterson, L., Tremblay, G., Ewigman, B., & Saldana, L. (2003). Multilevel selected primary prevention of child maltreatment. Journal of Consulting and Clinical Psychology, 71, 601–612.

Prinz, R. J., & Dumas, J. E. (2003). Prevention of oppositional-deﬁant disorder and conduct disorder in children and adolescents. In P. Barrett & T. H. Ollendick (Eds.), Handbook of interventions that work with children and adolescents: From prevention to treatment (pp. 475–488). West Sussex, Great Britain: Wiley.

Prinz, R. J., & Jones, T. L. (2003). Family-based interventions. In C. A. Essau (Ed.), Conduct and opposi- tional deﬁant disorders: Epidemiology, risk factors, and treatment (pp. 279–298). Mahwah, NJ: Erlbaum.

Roberts, M. C., & Fanurik, D. (1986). Rewarding elementary school children for their use of safety belts.

Health Psychology, 5, 185–196.

Roberts, M. C., Fanurik, D., & Wilson, D. (1988). A community program to reward children’s use of seat belts. American Journal of Community Psychology, 16, 395–407.

Roberts, M. C., & Turner, D. S. (1986). Rewarding parents for their children’s use of safety seats. Journal of Pediatric Psychology, 11, 25–36.

Sanders, M. R., Pidgeon, A. M., Gravestock, F., Connors, M. D., Brown, S., & Young, R. W. (2004). Does parental attributional retrainng and anger management enhance the effects of the Triple P–Positive parenting program with parents at risk of child maltreatment? Behavior Therapy, 35, 513–535.

Sanders, M. R., Turner, K. M. T., & Markie-Dadds, C. (2003). The development and dissemination of the Triple P—Positive Parenting Program: A multilevel, evidence-based system of parenting and family support. Prevention Science, 3, 173–189.

Schwarz, D. F., Grisso, J. A., Miles, C., Homes, J., & Sutton, R. (1993). An injury prevention program in an urban African American community. American Journal of Public Health, 83, 675–680.

Stuy, M., Green, M., & Doll, J. (1993). Child care centers: A community resource for injury prevention.

Journal of Developmental & Behavioral Pediatrics, 14, 224–229.

Taban, N., & Lutzker, J. R. (2001). Consumer evaluation of an ecobehavioral program for prevention and intervention of child maltreatment. Journal of Family Violence, 16, 323–330.

Taylor, T. K., & Biglan, A. (1998). Behavioral family interventions for improving child-rearing: A review of the literature for clinicians and policy makers. Clinical Child & Family Psychology Review, 1, 41–60.

Thomas, K. A., Hassanein, R. S., & Christophersen, E. R. (1984). Evaluation of group well-child care for improving burn prevention practices in the home. Pediatrics, 74, 879–882.

U.S. Department of Health and Human Services. (2003). Child maltreatment 2001. Washington, DC:

Administration on Children, Youth and Families.

(14)

Wesch, D., & Lutzker, J. R. (1991). A comprehensive 5-year evaluation of Project 12-Ways: An ecobe- havioral program for treating and preventing child abuse and neglect. Journal of Family Violence, 6, 17–35.

Zaza, S., Sleet, D. A., Thompson, R. S., Sosin, D. M., & Bolen, J. C. (2001). Task Force on Community Preventive Services. Reviews of evidence regarding interventions to increase the use of child safety seats. American Journal of Preventive Medicine, 21 (4S), 31–47.