Accid. Anal. & Prey. Vol. 12. pp. 275-281 Pergamon Press Ltd.. 1980. Printed in Great Britain

S O C I E T A L I N F L U E N C E S O N C H I L D H O O D A C C I D E N T S

DAVID KLEIN

Department of Social Science, Michigan State University, East Lansing, MI 48824, U.S.A.

(Received 7 March 1980)

Abstract--Efforts aimed at the prevention of accidents to children have, at w~rious times, focused on the behavior of the child, the behavior of the child+s parents, and the physical environment of the child. Whatever their focus, many of these efforts have been unsuccessful because they have failed to take into account social factors which influence not only the behavior of both children and parents but also the nature and number of hazards in the child's environment, both at home and elsewhere. This paper reviews briefly each of the several loci of accident countermeasures in order to identify social factors that have been overlooked and to indicate why these factors must be recognized and dealt with if future countermeasures are to be effective,

THE FOCUS ON THE CHILD There are two reasons why the earliest efforts at the prevention of childhood accidents focused on the behavior of the child without regard to the social environment. First, the possibility of reducing accidental injury by removing hazards from the environment rather than by changing the behavior of the potential victim had not yet been developed. Secondly, and more important, until as recently as a century ago, accidents were seen largely as God's punishment for individual wrongdoing. Hence, teaching children to behave not only safely but also virtuously was perceived as a countermeasure to all sorts of injury from all sorts of hazards [Wigglesworth, 1978].

If, in those days, modern epidemiology had existed, it would almost certainly have revealed that accidents were more common among lower-class than among upper-class children [Engels, 1892]. Such a finding, however, would merely have confirmed the notion that accidents were a form of divine retribution because, according to the Social Darwinist thinking of the time, the lower classes were more sinful or "vicious" than the upper classes and this, of course, explained why they were destined to remain in the lower classes.

Today few if any people regard a childhood accident as a direct response from God. Yet a significant proportion of parents, most of them with low incomes and little education, demon- strate a fatalistic attitude toward their child's exposure to hazard. In interviews I conducted with parents who exposed their children to recreational hazards, a frequent response to questions about their child's safety was that "Somebody up there is looking out for Johnny."

This fatalism is to a large extent justified by a social environment which, in fact, allows people with low levels of income and education relatively little control over many aspects of their lives. It is evident, for example, in their attitudes toward education, employment, illness or pregnancy. But with respect to their child's safety it not only leads to an almost total abdication of responsibility for reducing the child's exposure to risk but it may also immunize the parents against most forms of safety education.

Yet another factor reinforcing the focus on the child has been the concept of accident- proneness. This notion that some individuals possess certain stable psychological charac- teristics that predispose them to accidental injury has yet to be confirmed by sophisticated statistical studies. For example, a three-year study of all medically treated childhood injuries in a New York community revealed that the so-called accident repeater constituted a negligible fraction of the population of victims and manifested no easily recognizable characteristics [Rockland County, 1%2]. Yet despite the almost complete lack of evidence to support it, the concept of accident-proneness lingers on--not only in the minds of harried, guilt-ridden mothers attempting to understand why their child has had his third accident in as many months but also in the minds of many pediatricians and psychologists, who presumably have access to the considerable literature that tends to discredit it.

275

276 D. Kt+EIN

The concept of accident-proneness is dysfunctional in two ways. First, it diverts our attention from the removal or modification of environmental hazards--hazards that are usually implicated directly in injuries attributed to accident proneness. Secondly, it diverts research resources from relevant and well-designed studies to further wild-goose chases.

The focus of attention on the child was not entirely without some useful outcomes. One benefit that emerged was a clearer understanding of child behavior. Like the notion of accidents as divine retribution, the concept of the child as a miniature adult flourished as recently as a century ago and has not yet disappeared entirely. But systematic studies of children's percep- tions and responses, especially with respect to hazards, have demonstrated why many coun- termeasures designed to teach children to avoid hazards are largely ineffective [Sandels, 1%81. Not only are children's attention spans shorter than those of adults but children differ sharply from adults in their interpretation of symbols, in their ability to orient the source of a sound, and even in their taste responses to such toxic substances as petroleum products. One study has shown that significant numbers of children interpret the skull-and-crossbones symbol on bottles containing toxic substances as a label for "medicine that makes your bones grow" [Sandels, personal communication]. And, as any pediatrician can testify, children will drink readily such substances as kerosene, which most adults would not swallow. All of these facts may cause us to reject the definition of a child as a miniature adult and substitute a more recent definition formulated by an unidentified pediatrician: "A child is a psychotic dwarf with a good prognosis." The prognosis is, of course, good, but the immediate problem is how to prevent injury to what at the moment is a psychotic dwarf. Given this definition, the conventional methods have not been promising.

THE FOCUS ON PARENTS

As understanding of the etiology of accidents increased, attention turned away from the behavior of individuals and toward the various mechanical, chemical and thermal hazards that cause injury, because it became clear that in many situations it is both more effective and more economical to modify or remove the hazard than to attempt to teach the individual to avoid it.

With respect to childhood accidents, this led to a focus on the parent, since it was the parent rather than the child who presumably controlled the environment. Efforts to motivate parents to remove environmental hazards took numerous forms: pamphlets, lectures, community safety campaigns, checklists distributed by the school for the child to take home, group discussions and even visits by volunteers and professionals to individual homes for the purpose of identifying and removing hazards. The hazards generally specified in these efforts were toxic drugs and cleaning compounds, faulty electrical wiring, flammable substances, poorly designed cribs and dangerous cooking and heating appliances.

The effectiveness of these approaches to environmental safeguarding via the parents is difficult to assess--in part because data on nonfatal accidents are notoriously unreliable and in part because the efficacy of tiny single countermeasure is virtually impossible to measure in a natural, nonlaboratory context. Nevertheless, the consensus is that all of these efforts were generally ineffective--for several reasons.

To begin with, many lower-class parents--whose children confront a higher-than-average number of environmental hazards, such as traffic congestion, dilapidated housing, unguarded railroad lines, faulty electrical wiring--proved to be virtually immune to such essential middle-class modes of communication as pamphlets, community campaigns, group discussions and school-originated check lists. For more than 20 years, studies have shown that these types of communication are attended to almost exclusively by middle-class individuals who usually already know what the communication is intended to convey, and that they are persistently ignored by the very audience that most needs the information [Klein, 1%3]. Yet these efforts seem to continue unabated. This illustrates one problem that arises when middle-class profes- sionals, who owe much of their professional status to reading and who rely on print media as their major source of information, make ethnocentric assumptions about the information sources of people at other socioeconomic levels.

But this misjudgement about modes of communication was only one of several ethnocentric errors that the middle-class professionals made about their target audience. Even had the

Societal influences on childhood accidents 277

parents read the pamphlets and attended the lectures, they would not have been able to afford to remove some of the hazards that these materials identified. Kerosene space heaters, floor heaters and the fuel they burn, for example, are extremely hazardous to children in the United States, as the fatality figures for burns and poisonings demonstrate. Yet in many parts of the country, heaters of this type constitute the only source of heat available to low-income families, and there is no way that the families themselves can replace them with something safer. Regulation has in some cases influenced the design of these heaters so as to lower the maximum temperatures and to reduce the likelihood of explosion, but if such regulation contains a grandfather clause, it could be decades before all the old-style heaters are eliminated.

The same demographic profile holds true for gunshot injuries. A recent study of gunshot fatalities among American children [Klein et al., 1978] revealed that more than 80% of the victims belonged to low-income urban families. These families kept loaded guns within easy reach because they had no confidence that the police offered them protection against neighbor- hood crime. And representatives of this group opposed gun-control legislation on the grounds that it would deprive its members of essential protection against burglars and other intruders. In short, what appears as a hazard from the point of view of the middle-class professional turns out to be a basic necessity from the point of view of the low-status family. And it will remain so until either the redistribution of income or a government program of some kind eliminates those hazards that inevitably accompany poverty.

On the other hand, some parents introduce hazards into the child's environment not because the hazards are daily necessities but because they serve as status symbols. In Australia, Nixon and Pearn [1979] have documented an increase in child drownings as the home swimming pool has proliferated among upper-income families. But in the United States, the hazardous status symbol--the snowmobile, the minibike, the high-horsepower outboard boat, guns for hunting or for target shooting, high-powered woodworking and garden tools--seems to be more common in the working-class than in the middle-class household. It is possible, in either case, that parental desire for the status symbol outweighs parental concern for (or awareness of) the risk that it poses for the child. On the other hand, a number of working-class parents that I have interviewed tell me that they regard their children's confrontation of physical risk as useful preparation for "what life is all about."

Parents may also expose their children to risk because of the high value that our culture places on personal distinction earned through competitive effort. In our culture, children are urged from an early age to be smarter, faster, stronger, more skillful, or more daring than their fellows--to stand out from the crowd, to be, in one way or another, better than their peers. In middle-class families, this competitive drive is likely to find outlets in areas that do not involve physical risk--in academic achievement, or musical activities, or hobbies of some sort, or carefully supervised and taught athletic activities such as riding, sailing or skiing. The working- class child, by contrast, is more likely to be encouraged to engage in activities that involve greater physical risk: little-league football, minibiking, and generally unsupervised activities in an unprotected environment.

There are important social-class differences too, in general styles of child-rearing [Shostak, 1%9; Schulz, 1%9; Kohn, 1977; Pines, 1%9]. In addition to the higher degree of fatalism among lower-class families, there is also substantially less supervision of children and less spending of time with them in shared activities. There is, moreover, a general style of household manage- ment that from a middle-class point of view would appear to be irresponsible, unsystematic or slovenly. Children are allowed to play unmonitored for longer periods of time than in middle-class families, and they are not expected to account for their whereabouts or their activities with the same degree of precision. Mealtimes are likely to be irregular, and daily activities are often unplanned. Children may be left in the care of older but immature siblings. Toxic chemicals are often stored in unsuitable containers--empty soft-drink bottles, for example. Electric cords remain in use after they have become dangerously frayed, and broken stair treads are left unrepaired.

There are several possible explanations for this deviation from the orderliness and planning that characterize middle-class life style. It may be due simply to a lack of resources. Or it may stem from a feeling of powerlessness to control many aspects of life and hence to an abdication of any efforts at control. It may be due to a greater amount of stress, less ability to

278 D. KLEIN

cope with problems, or simply a condition of overload produced by too many children in inadequate quarters [Backett and Johnston, 1959]. Or, as some investigators believe, it may stem from a style of perception and cognition that is focused on the immediate present and is rarely future-oriented. Under such conditions, concern with child safety receives low priority.

Whatever the causes, such a lifestyle does not tend to include safety measures that involve a considerable level of child supervision and a modicum of order and planning. Such families cannot afford to buy a childproof medicine cabinet; if one is already available, it is likely to be left open. And, even if they are specified by law, childproof drug vials may well be left open because wrestling with the lids each time medication is required is simply too much for an already stressed mother. In such households, the telephone number of the poison control center is unlikely to be readily available, even assuming that the household has a telephone.

THE FOCUS ON LEGISLATION A growing awareness of the severe limitations of countermeasures designed by middle-class

professionals who are unaware of the lifestyle of other socioeconomic levels has led to the enactment of legislation aimed at implementing certain countermeasures by making them mandatory.

Generally speaking, this kind of legislation takes one of two directions. First, it can require that the individual buy for himself on the open market a device that is designed to protect himself or others. It can require him, for example, to wear a helmet when riding a motorcycle or to keep his dog on a leash to restrain it from biting people. Alternatively, it can require specific industries to desist from producing items that have proved to be hazardous or to provide those items with safeguards to render them innocuous. It can specify, for example, that aerosol containers be equipped with triggers that are not operable by young children. Occasionally legislation of this kind is double-barreled: it may require, for example, that all automobiles be equipped with seat belts and it may further require all vehicle occupants to wear them.

The effectiveness of legislation directed at the ultimate users depends on the demographic characteristics of the users and on the level of enforcement. Legislation requiring protective fencing around home swimming pools, for example, will be effective in so far as the essentially middle-class pool owner tends to obey the law even when compliance costs money and even when the level of enforcement is low.t Legislation requiring the use of seat belts, on the other hand, will be effective only if the level of enforcement remains continuously high, because the population for whom seatbelts are intended contains a large proportion of people who are unlikely to comply voluntarily.

It would be naive, of course, to expect any legislation regulating user behavior to be 100% effective, and consequently many people involved in safety promote specific pieces of legisla- tion on the grounds that they will be effective at least to some extent and that they "can't do any harm." This is a dangerous approach for two reasons. First, it can give the public a quite unjustified feeling that the legislation has solved the problem when. in fact, the mortality and morbidity it is producing remain largely unchanged. More important, there is a limit to the amount of such legislation that is politically tolerable; hence the legislative potential must be carefully husbanded and used only when it is likely to be highly effective. The current trend in the United States to repeal legislation requiring the use of motorcycle helmets exemplifies what happens when people feel that government intervention in their private behavior has become excessive.

Legislation directed toward the manufacturer seemingly avoids the problem of noncom- pliance by the ultimate user--but only to some extent. Childproof medicine bottles or cabinets, even when required by law, can be left open by the user, and electrical fuses can be bypassed with nonprotective materials. But perhaps a more important limitation stems from the fact that legislation of this type usually cannot even be proposed until sufficient morbidity or mortality has occurred to justify it. And, of course, further mortality and morbidity are likely to occur between the formulation of the legislation and its passage.

tWhether, in fact, the fencing of home swimming pools effectively reduces the incidence of child drownings is another question. Vimpani and Vimpani in a study reported at the IYC Conference on the Prevention of Childhood Accidents in Brisbane, Australia, in 1979 cast serious doubts on this assumption.

Societal influences on childhood accidents 279

One solution here is to formulate certain design (as distinct from performance) specifications a priori for toys, household appliances, automobiles and other manufactured products that are likely to cause injury. This has been done to some extent in the United States, but it has severe limitations in any society that is dedicated to some extent to the principle of free enterprise. The sporadic and often successful campaigns mounted by American industry against the U.S. Occupational Safety and Health Administration, the U.S. Consumer Products Safety Commission, and the Federal Trade Commission illustrate this point unmistakably.

THE CONCEPT OF RISK IN A POST-INDUSTRIAL SOCIETY

A further serious obstacle to the reduction of accident mortality and morbidity stems from our society's conception of and attitude toward risk-taking.

In frontier societies, the technology was low, knowledge and information were limited, and, although natural resources often were ample, their successful exploitation required con- frontation of many dangers and much uncertainty. Many such societies placed a high value on risk-taking, because the successful risk-taker--the explorer, the inventor, the entrepreneur-- enriched the society as a whole. And the prestige, money, or power accorded the risk-taker was important in motivating people to take risks.

In a modern, highly developed society, with its sophisticated technology based on a high level of knowledge, many dangers can be identified and circumvented, uncertainties can be reduced to a minimum, and hence risk-taking has not only lost much of its social value but has in most cases become clearly dysfunctional. Contrary to what some people think, most leaders in major enterprises reach their position of leadership not because they are daring risk-takers but because, on the contrary, they use information with maximal effectiveness to reduce risk to a minimum before committing huge resources to a new venture. What we seek today is not high risk but rather "a sure thing." Some risks are still necessary, of course, but these tend to be social, economic, or political risks, not physical risks.

Nevertheless, because a society's values and beliefs almost inevitably lag behind social, technological and economic realities, many modern societies still tend to accord high status to the risk-taker, especially the physical risk-taker, whether or not the purpose of his risk-taking has any social value. In our own society, the test pilot enjoys more status than the librarian; the hang-gliding enthusiast more than the antiquarian book-collector or the amateur harpsichordist.

In modern industrialized societies, the facing of risk undoubtedly has a nostalgic appeal, but it is also believed to be essential to the building of sound character. How else can we account for the popularity of such programs as Outward Boundt, which teaches its participants skills in meeting physical challenges that they are quite unlikely ever to encounter in the course of their modern urban lives? Such programs are promoted on grounds that they build character, despite the fact that they produce injuries and that the skills they teach have very little practical value.

In their choices of riskful situations, individuals differ in ways that seem clearly related to social-class membership. McClelland (1961), although he does not connect his concept of "achievement" directly with social class, notes that, when offered an array of activities ranging from high-risk to no-risk, individuals who score high on measures of achievement tend to choose activities in which the level of risk is moderate but in which a successful outcome depends very heavily on performance. Individuals who score low on achievement, on the other hand, tend to choose either no-risk activities or activities in which the risk is high and in which a successful outcome does not depend in any way on personal performance. Thus, hang-gliding is usually chosen by high achievers (Krissoff and Eiseman, 1975), whereas state lotteries tend to be patronized by people who score low on achievement (Kallick et al., 1976). This difference would also explain why achievement-oriented upper-middle-class families involve adolescent children in Outward Bound whereas people of lower class levels permit their adolescent children to engage in sports-parachuting, motorcycle racing, and other activities in which injuries may be produced as frequently by mechanical failure or errors on the part of other participants as by lapses in the individual's performance level.

tThis is a private nonprofit outdoor program for adolescents which purports to develop self-confidence by confronting the participants with a series of increasingly difficult wilderness-survival challenges. The requirement for graduation is a solo wilderness experience similar to the Australian aboriginal "walkabout."

AAP VoL 12, No.

280 D. KLEIN

But there is yet another reason why risk-takers of higher social class are less vulnerable to injury. As we have noted earlier, most risks that are highly rewarded in a modern society are not physical; they are technological, social, artistic and financial--risks in which an unsuccess- ful outcome will not result in injury. Eligibility for these types of nonphysical risk-taking, however, requires education, persistence and resources. Parents in the higher socioeconomic levels prepare their children for these requirements through a variety of childhood activities: music-lessons, games of skill, supervised homework. A young child's first ballet or piano recital can be a highly riskful performance, but the morbidity and mortality rates for ballet dancing arid piano playing are low indeed.

Individuals of lower social class, on the other hand, feel the same social pressures toward risk, but they have neither the education, the persistence nor the resources to confront nonphysical risks that are socially useful. For this reason they may be virtually forced into situations of high physical risk in which personal skill is of little relevance in reducing the uncertainty of outcome: sky-diving and stock-car racing, for example. Their employment histories do not reflect planning and deliberate choice but depend, rather, on the vagaries of the economy, and their recreational patterns are similarly characterized by an absence of control over outcome. To the extent that this fatalistic style is transmitted to their children, and to the extent that the context of their risk-taking is physical rather than intellectual or artistic, their children are likely to be at high risk of physical injury.

SOME IMPLICATIONS

If the foregoing contrasts between social class levels are valid, they have significant implications for the formulation and implementation of accident countermeasures. Most im- mediately, they suggest that safety messages are usually transmitted through media that are inappropriate for the population at greatest risk. The suggest, too, that the middle-class concept of child safety is not an integral part of lower-class values and, hence, that certain prophylactic behaviors taken for granted in middle-class families are by no means universal. Lastly, they suggest that effective approaches to injury reduction must involve changes in the physical and social environments of lower-class families and changes in the educational system so that those children currently disadvantaged by it become motivated and equipped to take risks that are not physical, that depend on personal skill, and that are useful to society as a whole.

On the other hand, some of these contrasts are admittedly speculative, and some are based not on actual morbidity and mortality data but on the application to accident situations of class-related behaviors that have been observed in other areas of activity. There exists, in fact, very little satisfactory research on the relationship between social-class level and the incidence of accidental injury. In fact, even if an inverse relationship were established between the number of environmental hazards in the home and socioeconomic level of the family, there would be no justification for inferring that the same relationship would hold for actual injury. Baltimore and Meyer (1%9) have found that injuries are more closely related to parent-child relationship than to the presence of environmental hazard.

There are two basic reasons for the lack of reliable findings. First, basic data are difficult to obtain either from medical records (because of social-class differences in the utilization of medical services) or from interviews (because of social-class differences in perception of what constitutes "disabling injury"). Secondly, investigators differ among themselves in the criteria they use to determine the social class of the people they study. One study, for example, using data from a large health maintenance organization, found no differences in the incidence of injury between middle-class and working-class children. One could argue, however, that blue-collar workers employed by corporations which provide health maintenance benefits are not typical of working-class people in general but demonstrate some middle-class charac- teristics despite their blue-collar occupations. When income alone is used as a measure of socioeconomic status, on the other hand, differences in the incidence of injury become apparent [Advance Data, 1978]. The same holds true when adult literacy is used as a socioeconomic indicator [Waller and Hall, 1980].

This is not to imply that the obstacles to research are insuperable. The considerable literature on laboratory studies of human behavior, some of which deals with risk4aking

Societal influences on childhood accidents 281

[Kogan and Wallach, 1964], offers numerous suggestions for study design. If the National Electronic Injury Survey, which monitors product-related injuries that receive medical atten- tion in hospital emergency departments, were to include demographic information on each victim, some evidence would soon become available on the relationship between social class and the circumstances surrounding the injury. Similarly, if either driver license applications or vehicle accident reports were to include data from which social class could be inferred, much more could be learned about the relationship between social class and both the quantity and quality of driving exposure.

This kind of information is not merely of academic interest. It seems essential to the design of countermeasures that take account of the perceptual differences, the value differences, and the lifestyle differences that exist among social classes.

R E F E R E N C E S Advance Data, U.S. Department of Health, Education, and Welfare, No. 18, p. 3, 7 March 1978. Backett M. and Johnston A. M., Social patterns of road accidents to children. Brit. Med../. 1,409-13, 14 Jan. 1959. Baltimore C., Jr. and Meyer R. J., A study of storage, child behavioral traits, and mother's knowledge of toxicology in 52

poisoned families and 52 comparison families. Pediatrics, 44(5, Part II), 816-820, I%9. Engels F., Conditions o[ the Working Classes in England, 1844. London, 1892. Kallick M., Suits D., Dielman T. and Hybels J., Gambling in the United States. Institute for Social Research, University of

Michigan, 1976. Klein D., Who reads all those pamphlets? Rehabilitation Literature 24(6), 162, 1%3. Klein D., Reizen M. S., Van Amburg G. H. and Walker S. A., Some social characteristics of young gunshot fatalities.

Accid. Anal. & Prey. 9, 177-182, 1978. Kogan N. and Wallach M., Risk Taking. Holt, Rinehart & Winston, New York, 1964. Kohn M., Class and Con/ormity. University of Chicago Press, 1977. Krissoff W. B. and Eisman B., Injuries associated with hang gliding. J. Am. Med. Assoc. 233(21), 159-160, 14 July 1975. McClelland D., The Achieving Soc&ty. Van Nostrand, Amsterdam, 1%1. Nixon J. and Pearn J., An investigation of socio-demographic factors surrounding childhood drowning accidents. Social

Sci. and Med. 12, 387-390, 1978. Pines M., Why some 3-year-olds get A's--and some get C's. New York Times Magazine, 6 July 1%9. Rockland County, 1%2. This large study analyzed all medically reported injuries to children 5 years old and under for a

period of approximately 3 years in an attempt to assess the et~cacy of various forms of safety education. The complete findings were never published, possibly because none of the several programs of safety education attempted made a signifi- cant difference in the injury rates. The analysis of accident repeaters was done by the present author, who served as a consultant but was not a member of the research group.

Sandels, Stina 1%8: Sm~ Barn i Tra~ken. Stockholm, Laromedelssorlaget, (Svenska Bokforlaglit/Norstedt), 1%8. Schulz D. A., Coming up Black. Prentice Hall, Englewood Cliffs, 1969. Shostak, A., Blue-Collar Li[e. Vimpani G. and Vimpani A., Secular trends in child drowning in Australia. Paper presented at the IYC Conf. Childhood

Accidents and Prevention, Brisbane, Australia, 21 Sept. 1979. Waller P. and Hall R. G., Literacy--a human factor in driving performance. Accident Causation SP-461, 15-26. Society of

Automotive Engineers, 1980. Wigglesworth E. C., The fault doctrine and injury control. J. o[ Trauma 18(12), 789-94, Dec. 1978.