Introduction
In 1996, the Emergency Medical Services for Children (EMSC) Program took a leadership
role in injury prevention for children and adolescents with special health care
needs. At that time, little was known about the epidemiology of injury for children
with special needs and the risk factors associated with these injuries.
To improve our understanding of this issue, EMSC staff requested data from the
National Pediatric Trauma Registry. This data, while not population-based, clearly
identified trends for children with pre-existing conditions at the time of injury
and only tracks children admitted to a Level 1 Trauma Center.
The data showed that children with pre-existing chronic illness, which includes
children diagnosed with asthma, diabetes, and seizure disorders, are at the
same risk of injury as children without chronic illness. Children with pre-existing
physical limitations appear to have some special issues related to injury. However,
children with pre-existing limitations in the cognitive, social, and emotional
categories had a significantly higher rate of injury than their peers without
limitations.
This data, coupled with information from teachers and injury prevention specialists,
indicates that children and adolescents with special health care needs are at
greater risk for injury. Additionally, parents of special needs children report
that parents of healthy children receive more general injury prevention messages
about subjects like fire and burn prevention, motor vehicle safety, fall prevention,
and materials about safe home, work, and community practices.
To address this deficiency, the EMSC Program organized the Injury Prevention
for Children with Special Health Care Needs Work Group. This group includes
representatives from the injury prevention, health, rehabilitation and disability
communities. The goals of the group are to build a bridge between the injury
prevention, health, rehabilitation, and disability communities and to provide
additional data sources, including population-based data, to improve the understanding
of injury risks for children with special health care needs.
The information provided below is intended to help advocates, parents, and local
organizations take an active role in promoting and practicing safety for ALL
children.
Magnitude of the Injuries
Injuries are the leading cause of death and disability among children under
the age of 20 in the United States. In 1995, more than 18,000 children under
the age of 20 in the United States died from injuries. Nearly 180,000 children
were permanently disabled (Centers for Disease Control and Prevention, 1998).
Each year, more than 22 million children age 19 and under sustain injuries serious
enough to require medical attention. (Weiss et al, 1997).
In general, children and adolescents are primarily at risk of injury-related
death from motor vehicle crashes that include children as occupants, pedestrians,
and bicyclists; drownings; fires and burns; suffocation; poisoning; choking;
firearm-related injuries; falls; and for injuries sustained at work. Injury
rates vary with a child's age, gender, race, and socioeconomic status. Children
that are younger, male, part of a minority group, or in a low socioeconomic
group suffer disproportionately from injuries.
Additionally, the cause and consequence of injuries vary considerably by age
and developmental level, reflecting differences in children's cognitive, perceptual,
and motor/language abilities, as well as the environment and exposure to hazards.
Children with special needs are likely to have a disproportionate share of these
injuries considering their health status and lack of access to appropriate prevention
education. These injuries have enormous financial, emotional, and social effects
on not only the child and the family, but the community and society (Weiss et
al, 1997).
Injury Costs
Injury is the leading cause of medical spending for children ages 5 to 14. (Children's
Safety Network National Economics and Data Analysis Resource Center, 1998).
The annual lifetime cost for injuries among children under the age of 20 is
nearly $457 billion, which includes $20 billion in medical spending, $53 billion
in future earnings lost, and $384 billion in quality of life improvement. Children
with special health care needs are at unique risk for injury-related costs due
to their complex pre-existing health status.
Injury Prevention Saves Money
Every child safety seat saves our country $85 in direct medical costs and an
additional $1,275 in other costs by reducing the risk of death for infants by
71%, for toddlers by 54% and reducing the need for hospitalization in children
under the age of five by 69%. Every bicycle helmet saves this country $395 in
direct medical costs and other costs by reducing the risk of head injury by
85% and brain injury by 88%. Every smoke detector saves $35 in direct medical
costs and an additional $865 in other costs to society by cutting the probability
of dying in a residential fire in half (National SAFE KIDS Campaign). Finally,
every dollar spent on poison control centers saves our country more than $6.50
in medical costs (Children's Safety Network National Economics and Data Analysis
Resource Center, 1998).
Injuries Are Not Random Acts
In fact, injuries are both predictable and preventable incidents. Through a
combination of education, environmental improvement, engineering modifications,
enactment and enforcement of legislation and regulation, economic incentives,
and community empowerment, the incidence and severity of injury-related death
and disability can be reduced.
Risk Areas and Prevention Strategies for Children with Special Health Care
Needs
Addressing injury prevention for children with special health care needs requires
a thorough assessment of each child's unique risks. As with all children, it
is important to conduct a simple assessment of the child's individual skills
as well as their physical and social environment. This assessment should address
the following areas: mobility, sensory-neuro, and cognitive abilities.
This assessment should address the following areas: mobility, sensory-neuro,
and cognitive abilities.
Mobility: This includes assessment of how a child "gets around". An example of a mobility limitation is the child who uses special equipment such as a cane, walker, or wheelchair. It is important to understand each child's individual mobility skills and to assess the environment for potential hazards from a prevention perspective. These hazards may include clutter, steep ramps, or uneven surfaces. Some children may require additional equipment or supervision to help assure their safety
Sensory-neuro: Children with visual limitations, hearing loss, and decreased sensation as a result of their physical condition are placed in this category. This group of children may have a difficult time differentiating between hot and cold temperatures, which put them at risk at bath time, on a hot playground slide, or at work in a fast food restaurant setting.
Cognitive Limitations: Some children with cognitive limitations have difficulty understanding directions or staying with a group activity. They often need additional supervision and activities with more structure. It is important to provide both physical and verbal cues that help a child remember safety rules. (University of Colorado, 1996).
Regardless of their abilities, all children need and deserve to be safe. All
parents should have the opportunity to receive information about home, school,
work, and community safety initiatives. In addition, children with disabilities
and their families should receive prevention information that addresses their
unique needs and risks. After determining a child's risks, a plan for education,
behavior, and environmental modification should be established to reduce or
eliminate the child's risks.
The following chart provides examples of common prevention interventions and
special concerns for children and adolescents with special health care needs.
Many of the prevention interventions apply to all children.
|
Injury Mechanism |
Education/Behavior Change |
Enforcement/ Legislation |
Environment/ Technology |
Special Interventions for CSHCN |
|
Motor Vehicle |
Provide education to parents on correct child safety seat/booster seat and seatbelt use. Implement media campaign about correct use and positioning of child safety seats/booster seats, and seatbelts. |
Promote the establishment and enforcement of primary restraint laws. Promote child safety seat and seatbelt laws. Conduct child safety seat checks. Encourage enforcement of DUI laws. |
Distribute free child safety seats/booster seats to low income families. Reduce speed limits in neighborhoods with children. Install speed bumps. |
Distribute special child safety seats/booster seats to CSHCN. Check seat temperature during hot weather to prevent burns. Assure proper positioning of child safety seats and booster seats. |
|
Pedestrian |
Counsel parents about traffic dangers, and provide pedestrian safety programs at elementary schools. Teach parents to practice safe walking routes with their child and encourage the use of reflective clothing. |
Enact and enforce pedestrian right-of-way laws. |
Improve lighting and crosswalks at problem inter-sections. Utilize crossing guards. Increase the use of reflective clothing. |
Install curb cuts at crosswalks and audible crosswalk signals. Install surfaces to differentiate the street from the sidewalk. Mark safe places to stand while waiting for the bus. Identify children who need constant supervision when crossing streets. |
|
Bicycle |
Conduct bicycle safety rodeos at schools and community fairs; increase bicycle safety information in health curricula. Motivate parents to practice safe riding routes with their child. Promote use of bicycle helmets. |
Promote bicycle helmet legislation; enforce current bicycle helmet laws. |
Distribute free bicycle helmets to low income families; provide free bicycle repair workshops; increase number and quality of bicycle lanes and trails; distribute bike reflectors and flags. |
Teach safe riding practices, including using the proper size bike and staying on trails or sidewalks. Enforce helmet use while in a racing wheelchair, rowcycle, or hand cycle. Advocate for production of smaller bike helmets. |
|
Fires/Burns |
Educate homeowners and rental property owners about anti-scalding devices and smoke detectors; encourage fire fighters to lead school assemblies on fire safety. Provide education on risks of smoking and keeping lighters and matches away from children and the safe use of candles, fireplaces, and grills. |
Enforce building codes for smoke detector use; encourage building code regulators to require hot water heater settings below 120 degrees. Encourage fire fighters to check hot water temperature during home visits for smoke detector usage. |
Promote the use of anti-scalding devices. Promote the use of smoke detectors and the importance of periodic battery testing and replacement. |
Develop evacuation plans with appropriate exits. Install fire alarms that have flashing lights for children who are hearing impaired. Develop individualized evacuation plans for children that may have difficulty with changes in their environment. |
|
Injury Mechanism |
Education/Behavior Change |
Enforcement/ Legislation |
Environment/ Technology |
Special Interventions for CSHCN |
|
Home Hazards |
Educate parents about gates and stairs; sharp-edged furniture; furniture near windows; proper crib construction; mini-blind cords; and storing poisons, medicines, and alcohol. Educate parents about installing window guards and moving furniture away from windows to prevent falls. Teach parents to not leave young children unattended. |
Do not purchase mobile baby walkers that do not meet the U.S. Consumer Product Safety Commission’s standards. |
Distribute “no-choke” tubes to determine safe objects for small children, encourage increased availability and use of window guards and stair gates and distribute cabinet lock products. |
Teach parents to remove unsafe objects and clutter, and cover glass edges and sharp corners on furniture. Avoid the use of loft beds of top bunk beds for a child with a seizure disorder, cerebral palsy, encephalopathy, etc Encourage use of bumber pads for cribs. Teach parents about correct sleeping positions. |
|
Schools |
Educate students and staff regarding potential hazards and prevention measures. |
Inspect childcare facilities and schools for fall hazards and unsafe design features. |
Maintain equipment and facilities (smoke detectors, lockers, playground and sports equipment). |
Teach the appropriate use of wheelchair locks during transfers. |
|
Work |
Educate teens about their jobs, including safety procedures for each task and their rights. Provide teens and parents with education on child labor laws, hour restrictions and prohibited tasks. Teach and adolescents to comply with state regulations requiring work permit completion for teens. |
Provide work and workplaces that comply with OSHA health and safety standards. Promote enforcement of child labor laws and workplace safety standards. |
Provide workplaces that are free from hazards. Provide and use all safety equipment on the job as required. |
Teens transitioning into the workforce may need special environmental orientation. Consider appropriate workplaces for adolescents, e.g. exposure to air pollution or second hand smoke may be a greater hazard for teens with asthma or cystic fibrosis. |
|
Firearms |
Develop a media campaign promoting trigger locks and lock boxes and encourage parents to remove guns from their homes. |
Encourage restrictive licensing for handguns and enforcement of existing firearm laws. |
Work with police on community policing initiatives; promote development of product safety modifications for handguns. |
Teach parents to remove firearms from the home when a child is depressed and/or possibly suicidal. |
|
Child Abuse and Other Violence. |
Provide parent education programs to young and at-risk parents; develop self-help groups. Provide conflict resolution, anger management, and other prevention programs in schools and childcare facilities. |
Work with local officials to maximize effectiveness of child protective services. |
Support home visitor programs for new parents; provide affordable childcare. |
Provide affordable childcare and respite care. Educate parents and siblings about behavior management and establishing regular sleeping patterns for children with special needs |
|
Injury Mechanism |
Education/Behavior Change |
Enforcement/ Legislation |
Environment/ Technology |
Special Interventions for CSHCN |
|
Playgrounds |
Provide seminars on playground safety for school officials, teachers, park and recreation administrators, childcare providers, and parents. |
Promote or mandate the use of CPSC standards for playground equipment and surfaces. |
Support community development projects that improve play-ground equipment and surfaces |
Install soft surfaces and accessible play space. Schedule individual or small group times on equipment. |
|
Sports |
Provide parents, students, and coaches with educational material on the proper sports equipment, skill development, and importance of physical conditioning. |
Promote and mandate the use of proper safety equipment by school and community sports programs. Promote injury prevention training for coaches. |
Promote the use of breakaway bases, mouth guards, and eye protection equipment. |
Enhance individual skill development. Match sport activity to child’s ability. Enforce the use of protective gear and follow appropriate game rules. Provide special protection for children who need to use assistive technology. |
|
Drowning |
Provide information to pool owners about drowning risks and appropriate pool barriers. Educate parents about the risks of bathtubs, open toilets, and buckets. Provide education on open water drowning risks. Encourage parents to learn CPR. |
Establish and enforce pool barrier codes for home, community, and public pools. |
Promote use of pool barriers, including four-sided isolation fencing with self-closing and self-latching gates. Promote use of personal floatation devices. |
Use supervision. Teach swimming skills and water safety. Swim with a buddy and only in areas with lifeguards on duty. Protect skin from rough surfaces (wear socks). |
Coalition Building
The complex nature of injuries and the multiple factors involved with each injury
incident require a multi-dimensional approach to prevention. Effective prevention
interventions involve the use of education, enforcement, and environmental changes,
as well as the cooperation of numerous individuals, agencies, and organizations.
Collaboration and coalition building are key to developing effective injury
prevention interventions.
State and local public health agencies, both for children with special health
care needs and injury
prevention, are key partners in injury prevention initiatives. Making contact
with these agencies should be a first step to organizing a collaborative injury
prevention initiative and to determine what initiatives already exist.
Most communities have one or more networks of organizations that address childhood
injury prevention. The most common participants include:
Individuals interested in injury prevention will serve as a foundation for effective interventions. Additional partners for childhood injury prevention include:
For more information on the Injury Prevention for Children with Special Health Care Needs Work Group, contact the EMSC National Resource Center at (202) 884-4927 or via e-mail at info@ emscnrc.com.
The Work Group included representatives from the following agencies and organizations:
References
CDC, National Mortality Data: 1995. Centers for Disease Control and Prevention,
Public Health Service, USDHHS, Atlanta, GA, 1998
Children's Safety Network Economics and Insurance Resource Center, Childhood
Injury: Cost & Prevention Facts, Rockville, MD, 1997.
National SAFE KIDS Campaign, Fact Sheets, Washington, DC, 1998.
University of Colorado, School of Nursing, Safe at School: Planning for Children with Special Needs (video), Colorado, 1996.
Weiss, H., Child and Adolescent Emergency Data Book, Pittsburgh, PA: University of Pittsburgh, 1997.