Welcome to Keeping an Eye on Kids: Supervision and Injury

1. Welcome to Keeping an Eye on Kids: Supervision and Injury • If you are participating by computer and telephone, please make sure your computer speakers are turned off and your phone is on mute (mute button or *6) • We will begin shortly.

2. Keeping an Eye on the Kids:Supervision and Injury Sarah Amsbaugh, RN, BScN, MN Student April 3rd, 2014

3. Objectives: • To provide an overview of the role of supervision in child injury risk • To provide an overview of several key areas of focus related to child supervision • Identify ways that have been supported in the literature to deliver key messages to parents and caregivers to encourage a change in supervision behaviours.

4. Childhood Injury • In both Canada and the United States, unintentional injuries are a leading cause of death and disability during childhood. • Most injuries to young children happen in the home, when a caregiver is supposedly supervising to ensure the child’s well-being. • Lapses in caregiver attention have been associated with a wide variety of childhood injuries including: • Pedestrian injuries • Drowning • Poisoning • Choking • Burns • Playground injuries • Fall-related injuries Saluja et al., 2004

5. Childhood injury • Infants and toddlers (aged 0-4 years) rely directly on others for their safety, more than any other age age group in childhood. • To prevent unintentional injuries among this group, it depends on creating safer environments as well as influencing and educating those individuals who supervise and care for them. • With appropriate supervision, an environment can be created that promotes safe and successful accomplishment of the tasks they enjoy doing. • Supervision is reported as the most common injury prevention strategy adopted by caregivers. Petrass et al., 2009

6. Injury Prevention Approaches • Conceptualized as passive or active approaches • Passive approaches: • Typically require no individual action • Generally felt to be more effective than active strategies • Much of the literature focuses on passive approaches • Active Approaches: • For most injury events, there is a behavioural or active component that can contribute to prevention • Less attention has been paid to active strategies in the literature, likely due to challenges with assessment • Caregiver supervision is an active approach to injury prevention in children Saluja et al., 2004; Schwebel & Kendrick, 2009

7. Supervision • A 2009 study identified that lower levels of supervision resulted in a five times greater risk for a young child to experience an unintentional injury. • Individuals working in the area of injury prevention are challenged to define what supervision is and therefore it is assumed that it is also challenging for caregivers to state what adequate/appropriate supervision is. • Across the literature there are also challenges defining supervision, the 3 dimensions of proximity, attention and continuity have been shown to relate to children’s risk of injury. Morrongiello et al., 2013; Morrongiello et al., 2009, Petrass et al., 2009; Saluja et al., 2004

8. Supervision • Saluja et al. (2004) have developed a hierarchical model of supervision strategies relevant to injury prevention behaviours, which incorporates the 3 dimensions: • Attention – an interaction and engagement with the child, measured according to 2 components: • Visual: focal, peripheral • Auditory: focal, peripheral • Proximity – refers to the distance between the supervisor and the child. It is measured from the closest proximity to the least: • Touching • Within reach • Beyond reach, nearby • Beyond reach, distant • Continuity – the state of being uninterrupted: • Continuous • Intermittent • Absent Petrass et al, 2009; Saluja et al., 2004

9. Supervision • A combination of all 3 dimensions is required to measure supervision behaviours. • The level of supervision increases as 1 or more of the dimensions increase. “Maximum active supervision and lowest risk of injury presumably occurs when a supervisor is attentively watching, the child is in close proximity (i.e. within reach), and these behaviors are sustained over time” Morrongiello, Zdzieborski, Sandomierski, & Munroe, 2013

10. In the Literature • The literature presents several key areas of focus related to child supervision: • Lack of caregiver knowledge related to supervision • Role of older children/sibling supervision • Parenting Interventions for the prevention of unintentional injuries in early childhood • Positive ways to deliver key messages to promote behaviour change among caregivers

11. Knowledge Many parents lack awareness about normal child growth and development. Often not realizing the developmental, physical, and behavioural characteristics that contribute to child injury and are unique to preschoolers such as: Curiosity Impulsive behaviours Decreased cognitive understanding Gross motor skills that are more refined than fine motor skills, Smaller airways Lack of physical strength Incomplete skeletal ossification Higher metabolic rates Lack of caregiver knowledge related to supervision Garzon, D., 2005

12. Knowledge • There is a misconceptions about childhood injury among both mothers and fathers, related to gender differences. • Both mothers and fathers believe that girls should be supervised more closely than boys for both younger and older ages. • In a questionnaire study, parents believed that their level of supervision was low for boys and did not differ across ages. In this same study parents believed their level of supervision was significantly higher for girls in the younger ages than the older age group. • This may be a contributing factors to child injury, as injury data supports that males children are at a higher risk for risk taking behaviours and subsequent injury. Morrongiello, Walpole & McArthur, 2009

13. Knowledge • One of the most common environmental factors associated with increased childhood injury is low socioeconomic status. • In low socioeconomic areas, parents identified external factors of physical environment and equipment to be major risk factors, and did not see personal factors such as supervision as a strong factor in injury prevention. • This population may be more agreeable to passive factors to reduce risk rather than active strategies. • This may be due to lack of education, less information about injury, parents not wanting to assume responsibility for injuries seen out of their control, or it may be a self-serving bias, where they unconsciously attribute injuries to external factors beyond their control so they are not perceived as “bad” parents. • The perceptions and challenges of individuals from low socio-economic backgrounds should be considered when planning interventions to reduce childhood injuries in among these populations. Munro, van Niekerk, & Seedat 2006

14. Older child/Sibling Supervision The majority of literature related to supervision has focused on parental supervision or supervision by adult caregivers. More recently a Canadian child development researcher, Dr. Barb Morrongiello has began to focus on the role of sibling supervision. This has previously been considered a neglected topic in child injury research, however data is showing that child injury rates increase with the presence of a sibling in the home making it a priority area of research interest. Role of older children/sibling supervision Morrongiello, Schell & Keleher, 2013

15. Older child/Sibling Supervision • A greater number of children in the home has been shown to correlate to less parental supervision, indicating a reliance on sibling supervision. • Sibling supervision is improved when older siblings are made aware they are to be the current primary supervisor, however this is short term and the older sibling soon returns to inattentive behaviours and ineffective reactions to younger siblings risk taking behaviours. • When older siblings were made aware they were to be supervising, the older sibling demonstrated proactive supervisory strategies, such as checking hazards. However the actual watching behaviour by supervisors did not change significantly. • This may be because the older siblings had been proactive and checked the hazards, they may no longer see the need for continued visual supervision. Morrongiello & Schell, 2013

16. Older child/Sibling Supervision • Mothers believe sibling supervision is similar to their own style of supervision, however a 2010 study by Morrongiello et al. provides evidence that this may not be the case. • How older siblings supervised and what parents expected of them corresponded in just over 50% of cases. • Older siblings are less likely to respond to risk taking behaviours and violation of rules than the mothers were. • Mothers had a quicker reaction time to supervisees suggesting greater alertness and attention to the supervisee behaviours compared to the older siblings. • This increased attention places the caregiver in a state where they are ready to intervene to an prevent injury, which has been shown to prevent more injuries in young children. Morrongiello, Schmidt, & Schell 2010b

17. Parenting Interventions Parent education and training programs help enable parents to provide safer home environments and reduce injuries in children. Parenting programs may help parents develop knowledge related to their child’s stage of behavioural development and age. Programs of these types of usually provided to families who are disadvantaged, low-income, whose children were considered to be a risk of poor health, or individuals who may benefit from extra support such as some adolescent mothers or single mothers. A Cochrane review was published in 2013 to assess the effects of parenting interventions for preventing unintentional injury in children and found these programs are effective in reducing unintentional injuries in children and can improve home safety in families ‘at risk’. for the prevention of unintentional injuries in early childhood Kendrick et al., 2013

18. Parenting Interventions • Morrongiello et al. (2013) have also evaluated a parenting intervention program to assess for effect on supervision practices by the parents. • Comparison of post and pre-intervention data reported a positive change in home supervision practices and there was a significant decrease in the time that children were left unattended. • There was an increase in in-view supervision as well as increased supervision when children were out of view by the caregiver (auditory attention or continuity were maintained). • Parents also reported increased attention to their children when they were in a situation with potential hazards or at increased risk for injury. Morrongiello, Zdzieborski, Sandomierski, & Munroe, 2013

19. Delivering the Message Mothers indicate the use of graphic images is effective because emotional impact was needed to convince parents of the potential severity of injury. Parents endorsed the impact of testimonials - mothers related to these emotions knowing that they would be upset if their child had suffered a serious injury. Parents indicated that using statistics and facts added credibility to the information presented. Parents supported highlighting unexpected injury cases as this made them realize that they still had more to learn about risk factors. How can we get caregivers to change behaviours? Morrongiello, Zdzieborski, Sandomierski, & Lasenby-Lessard, 2009

20. Delivering the Message • Parents indicate that messages which include long-term consequences of injury were effective - evoked thoughts about how the family unit might be changed as a result of child injury. • Supporting parents that they should not ignore thoughts or doubts about leaving their children unattended was a positive and effective reminder. • Many mothers objected to the message “injuries are not accidents” and thought this indicated blame. • Mothers understood and appreciated the intent of this message but they felt that this was not always the case and sometimes things which happen are accidents. Morrongiello, Zdzieborski, Sandomierski, & Lasenby-Lessard, 2009

21. Delivering the Message • Traditional informational approaches may be too abstract, impersonal, and predictable to capture attention effectively and may not always motivate a actual behaviour change. • Story-based messaging that accounts a victim’s experience can be an effective method of delivering the injury prevention message. • A 19% improvement in actual safety behaviour change was demonstrated by one study compared with methods of non-narrative communications. • This can be an important factor to consider when developing messaging to the target audience. Ricketts et al., 2010

22. In Conclusion… • Supervision is the most common injury prevention strategy that is adopted by caregivers and is regarded throughout the literature as one of the most important determinants of children's unintentional injury risk. • As members of the injury prevention community or as individuals working with families and young children we need to work together to improve supervision strategies, together we can protect the health and wellbeing of our youngest populations.

23. Bibliography & References: • Garzon, D. (2005). Contributing factors to preschool unintentional injury. Journal of Pediatric Nursing, 20(6), 441-447. • Guilfoyle, S., Karazsia, B., Langkamp, D., & Wildman, B. (2012). Supervision to prevent childhood unintentional injury: Developmental knowledge and self-efficacy count. Journal of Child Health Care, 16(2), 141-152. doi:10.1177/1367493511423855 • Kendrick, D., Barlow, J., Hampshire, A., Stewart-Brown, S., & Polnay, L. (2008). Parenting interventions and the prevention of unintentional injuries in childhood: systematic review and meta-analysis. Child: Care, Health & Development, 34(5), 682-695. • Kendrick, D., Mulvaney, C., Ye, L., Stevens, T., Mytton, J., & Stewart-Brown, S. (2013). Parenting interventions for the prevention of unintentional injuries in childhood. Cochrane Database of Systematic Reviews, (3)& Health, 32(5), 517-529. doi:10.1002/nur.20346 • Landen, M., Bauer, U., & Kohn, M. (2003). Inadequate supervision as a cause of injury deaths among young children in Alaska and Louisiana. Pediatrics, 111(2), 328-331. • Morrongiello, B., Corbett, M., McCourt, M., & Johnston, N. (2006). Understanding unintentional injury risk in young children II. The contribution of caregiver supervision, child attributes, and parental attributes. Journal of Pediatric Psychology, 31(6), 540-551. • Morrongiello, B., & Schell, S. (2013). "You Have to Listen to Me Because I'm in Charge": Explicit Instruction Improves the Supervision Practices of Older Siblings. Journal of Pediatric Psychology, 38(3), 342-350. • Morrongiello, B., Schell, S. L., & Keleher, B. (2013). Advancing our understanding of sibling supervision and injury risk for young children. Social Science & Medicine, 96208-213. doi:10.1016/j.socscimed.2013.07.016

24. Bibliography & References: • Morrongiello, B., Schell, S., & Schmidt, S. (2010a). "Please keep an eye on your younger sister": sibling supervision and young children's risk of unintentional injury. Injury Prevention, 16(6), 398-402. doi:10.1136/ip.2010.026377 • Morrongiello, B., Schmidt, S., & Schell, S. (2010b). Sibling supervision and young children's risk of injury: a comparison of mothers' and older siblings' reactions to risk taking by a younger child in the family. Social Science & Medicine, 71(5), 958-965. doi:10.1016/j.socscimed.2010.05.047 • Morrongiello, B., Walpole, B., & McArthur, B. (2009). Brief report: Young children's risk of unintentional injury: a comparison of mothers' and fathers' supervision beliefs and reported practices. Journal of Pediatric Psychology, 34(10), 1063-1068. • Morrongiello, B., Zdzieborski, D., Sandomierski, M., & Lasenby-Lessard, J. (2009). Video messaging: What works to persuade mothers to supervise young children more closely in order to reduce injury risk? Social Science & Medicine, 68(6), 1030-1037. doi:10.1016/j.socscimed.2008.12.019 • Morrongiello, B., Zdzieborski, D., Sandomierski, M., & Munroe, K. (2013). Results of a randomized control trial assessing the efficacy of the Supervising Home Safety program: Impact on mothers’ supervision practices. Accident Analysis and Prevention, 50, 587-595. • Morrongiello, B. A., Zdzieborski, D., & Stewart, J. (2012). Supervision of children in agricultural settings: Implications for injury risk and prevention. Journal of Agromedicine, 17(2), 149-162. doi:10.1080/1059924X.2012.655127

25. Bibliography & References: • Munro, S., van Niekerk, A., & Seedat, M. (2006). Childhood unintentional injuries: the perceived impact of the environment, lack of supervision and child characteristics. Child: Care, Health & Development, 32(3), 269-279. • Petrass, L., Blitvich, J., & Finch, C. (2009). Parent/Caregiver supervision and child injury: a systematic review of critical dimensions for understanding this relationship. Family & Community Health, 32(2), 123-135. doi:10.1097/FCH.0b013e3181994740 • Ricketts, M., Shanteau, J., McSpadden, B., & Fernandez-Medina, K. (2010). Using stories to battle unintentional injuries: narratives in safety and health communication. Social Science & Medicine, 70(9), 1441-1449. doi:10.1016/j.socscimed.2009.12.036 • Saluja, G., Brenner, R., Morrongiello, B., Haynie, D., Rivera, M., & Cheng, T. L. (2004). The role of supervision in child injury risk: definition, conceptual and measurement issues. Injury Control and Safety Promotion, 11(1), 17-22. • Sinclair, K., Morrongiello, B., & Dowd, M. (2008). Parenting behaviors and attitudes about supervision among parents of acutely poisoned children. Ambulatory Pediatrics, 8(2), 135-138. • Spiller, H., Beuhler, M., Ryan, M., Borys, D., Aleguas, A., & Bosse, G. (2013). Evaluation of changes in poisoning in young children: 2000 to 2010. Pediatric Emergency Care, 29(5), 635-640. doi:10.1097/PEC.0b013e31828e9d00 • Woods, A. (2006). The role of health professionals in childhood injury prevention: a systematic review of the literature. Patient Education & Counseling, 64(1-3), 35-42.

26. Questions Contact: Sarah Amsbaugh samsbaug@ualberta.ca or Patti Stark Community Mobilization Coordinator Alberta Centre for Injury Control & Research Patti.stark@ualberta.ca 780-492-2330