childhood trauma mar3,2008

Pediatric Injuries:Risks and Prevention Among Ages

<1-15 in Los Angeles County

James M. DeCarli, PhD Candidate, MPA, MPH, CHESResearch Analyst III/Behavioral SciencesInjury & Violence Prevention Program

Department of Public Health, Los Angeles County

Overview

Background: Overall Childhood Injury Among

Children Ages <1-15 in Los Angeles County

Specific Age Category (<1, 1-4, 5-12, 13-15):

Leading Causes of Injury Fatality & Hospitalization

Anatomical injuries Associated with Injury Mechanisms

Contributing & Protective Factors

Injury Prevention Planning Tools

Childhood Injury in Los Angeles County

Data Sources

Fatalities:California Department of Health Services, Vital Statistics Death Statistical Master File

Hospitalizations:California Office of Statewide Health Planning and Development, Patient Discharge

Childhood Injury in Los Angeles County

Injuries are the leading cause of death among 1-44 year olds in Los Angeles CountyInjuries are the leading causes of death among 2.5 million children in Los Angeles County (2006)In 2006, among ages <1-15:

159 injury deaths5,830 injury hospitalizations

Leading Causes of Injury–All Child Ages <1-15Los Angeles County, 2006

Hospitalizations

Sources:

[Fatalities] California Department of Health Services, Vital Statistics Death Statistical Master File

[Hospitalizations] California Office of Statewide Health Planning and Development, Patient Discharge

Falls61%

Pedestrian11%

MV Occupant

10%

MV Occupant17%

Drowning15%

Pedestrian11%

MTV Occup35%

Unint. Drown

29%

MVT Unspec

20%

MVT Ped16%

Fatalities

Fall60%

Suicide11%

MVT Occupant

10%

MVT Ped10%

Struck by Obj9%

Infants Age <1Leading Causes of Injury

Los Angeles County, 2006

Fatality (Freq)

Assault/Homicide 13

Untint-Suffocation 2

MVT Occupant 1

Hospitalization (Freq)

Fall 158

Assault/Homicide 42

Unint-Burn, Hot Obj. 30

Untint-Suffocation 30

Unint-Nat Env 19

Fatal InjuriesInfants Age <1


Fatal Assault/Homicides by CauseInfants Age <1

Los Angeles County, 2001-2006

HospitalizationsInfants Age <1


100%

Where are infants falling from?(Hospitalizations by Cause)


0

5

10

15

20

25

30

35

40

45

Stairs Bed Other Furniture One Lever to Another Other

Most common anatomical fall-related hospitalization among infants: TBI’s

(Hospitalizations)Los Angeles County, 2004

Traumatic Brain Injury (TBI)

80%90%

60%

77%

0%

20%

40%

60%

80%

100%

Stair Chair Bed From different level

Toddler Ages 1-4 Leading Causes of Injury


Fatality (Freq)

Drowning 10

Assault/Homicide 9

MVT Occupant 6

MVT Pedestrian 4

MVT-Unspecified 3

Pedestrian-Other 3


Fall 718

Unint-Burn, Hot Obj. 145

Poisoning 116

MVT Pedestrian 107

Unint-Nat Env 106

Fatal InjuriesToddlers Ages 1-4 Los Angeles County, 2004

Fatalities

Drowning28%

Homicide26%

Occupant17%

Pedestrian11%

MVT Unspecified

9%

Pedestian-Other9%

Where are toddlers drowning?(Fatalities)


11%2%

63%

2% 2%

14%6%

0%

10%

20%

30%

40%

50%

60%

70%B

atht

ub

Fall

into

Bath

tub

Pool

Fall

into

Pool

Ope

nW

ater

Res

ervo

ir

Unsp

ec

Perc

ent

Fatal Assault/Homicides by CauseToddler Ages 1-4


29%

20%

5%

46%

05

101520253035404550

Abuse &Neglect

Cut/Pierce Firearm Other

Perc

ent

HospitalizationsToddlers Ages 1-4


Hospitalizations

Falls60%Burns

12%

Poisoning10%

MVT Ped9%

Nautral-Env9%

Where are toddlers falling from?(Hospitalizations)


1

72

61

11

0.1

11

24

6

1318

05

1015202530

Esca

lato

r

Stai

r

Ladd

er

Bui

ldin

g/St

ruct

ure

Into

Hol

e

Play

grou

ndEq

uipm

ent

Clif

f

Cha

ir

Bed

Oth

er F

urni

ture

Diff

eren

t Lev

el

Sam

e Le

vel

Perc

enta

ge

Common anatomical fall-related hospitalizations: Upper Extremity & TBI

Toddler Ages 1-4Los Angeles County, 2004

68 71

36

54

69

39

01020304050607080

Play

grou

ndEq

uipm

ent

Bed

Diffe

rent

Leve

l

Sam

eLe

vel-T

rips

Cha

ir

Perc

enta

ge

Upper ExtremityTBI

Children Ages 5-12Leading Causes of Injury


Fatality (Freq)

Assault/Homicide 11

Drowning 8

MVT Occupant 7

MVT Pedestrian 7

MVT-Unspecified 6


Fall 1033

MVT Pedestrian 236

MVT Occupant 191

Unint-StruckByObject 154

Bicyclist, Other 144

Fatal InjuriesChildren Ages 5-12


Fatalities

Homicide28%

Drowning21%

Occupant18%

Pedestrian18%

MVT Unspecified

15%

Fatal Assault/Homicides by CauseChildren Ages 5-12


69%

24%

5%2%0

10

20

30

40

50

60

70

80

Abuse &Neglect

Cut/Pierce Firearm Other

Perc

ent

Where are children drowning?Children Ages 5-12


13%

44%

19%

6%

18%

05

101520253035404550

Bathtub Pool OpenWater

Reservoir Unspec

Perc

enta

ge

HospitalizationsChildren Ages 5-12


Hospitalizations

Fall59%MVT Ped

13%

MTV Occupant

11%

Struck by object

9%

Bicyclist, other8%

Where are children falling from?Children Ages 5-12


6%1% 3% 1%

35%

2%8%

2%

18%25%

0%5%

10%15%20%25%30%35%40%

Stai

r

Ladd

er

Build

ing/

Stru

ctur

e

Into

Hol

e

Play

grou

ndEq

uipm

ent

Chai

r

Bed

Oth

er F

urni

ture

Diffe

rent

Lev

el

Sam

e Le

vel

Perc

ent

Common anatomical fall-related hospitalizations: Upper & Lower Extremity

Children Ages 5-12 Los Angeles County, 2004

84%

61% 57%

4% 8%

21%

6% 10%18%

0102030405060708090

Playground From DifferentLevel

Same Level-Trip

Per

cent Upper Extremity

Lower ExtremityTBI

Adolescent Ages 13-15Leading Causes of Injury


Fatality (Freq)

Assault/Homicide 10

MVT Occupant 9

MVT-Unspecified 6

Suicide 4

Drowning 3


Fall 718

Suicide 145

Assault/Homicide 116

Struck-By-Object 107

MVT Occupant 106

Adolescent Ages 13-15Leading Causes of Injury


Fatalities

Homicide57%

Suicide9%

Occupant13%

MVT Unspecified

9%

Drowning4% Pedestrian

4%

Fall4%

Common weapon of choice(Fatal Assault/Homicides)

Adolescent Ages 13-15Los Angeles County, 2000-2004

84%

1%7%1% 4% 3%0

102030405060708090

Hang

/Stra

ngul

,Su

ffoca

t.

Hand

gun

Riflt

/Sho

tgun

Oth

er F

irear

m

Shar

p O

bjec

t

Unsp

ec(m

urde

r,m

ansl

)

Per

cent

HospitalizationsAdolescent Ages 13-15


Hospitalizations

Homicide18%

Struck by object13%

Occupant10% Fall

38%

Suicide21%

Where are adolescents falling from?Adolescent Ages 13-15


1%6%

.5%4%

1% .5%7%

.5% .5% .5%

24%

36%

19%

05

10152025303540

Cur

b

Stai

rs

Ladd

er

Bui

ldin

g/St

ruct

ure

Into

Hol

e

Stor

m D

rain

Play

grou

nd

Cha

ir

Bed

Oth

er F

urni

ture

Diff

eren

t Lev

el

Sam

e Le

vel-T

rip

Spor

ts A

ctiv

ity

Perc

ent

Common anatomical fall-related hospitalizations: Upper & Lower Extremity

Adolescent Ages 13-15 Los Angeles County, 2004

30 29

4240%34%

42%

13% 14% 13%

05

1015202530354045

SportsActivity

FromDifferent

Level

Same Level-Trip

Per

cent Upper Extremity

Lower ExtremityTBI

Common methods of choice for suicide-related hospitalizations: pain relievers

Adolescent Ages 13-15Los Angeles County, 2004

59%

2%

18%

1% 2% 1% 1%

16%

010203040506070

Ana

lges

ics/

Antip

yret

ics

Tran

quili

zers

Oth

er D

rugs

/Che

mic

als

Chem

ical

s

Cor

rosi

ve A

gent

s

Gas

Vap

or

Hang

ing

Cut/P

ierc

e

Perc

ent

ReviewLeading Causes of Injury

Ages Fatality Hospitalization

<1 Assault/Homicide Falls

1-4 Assault/HomicideDrowning

Falls

5-12 Assault/HomicideDrowning

Falls

13-15 Assault/Homicide FallsSuicide

Contributing FactorsAssault/Homicide & Suicide

Intimate Partner Violence/Domestic ViolenceParental abuse of alcohol & drugsUse of alcohol & drugs among youthPersonality Disorders/Mental HealthDepressionLack of resources/access to careGang ActivityMalnutrition-aggression & violence behaviors

Childhood Exposure to IPV

Children observe traumatic events (IPV-family violence) to varying degrees:

Home Environment: May see mothers use violence in self-defense or see both parents trading self-defense See parents occasionally slap, shove, and throw thingsObserves violence or threats, while the victim does not leave the home or report to police or public agencies

(Straus & Gelles, 1990)

Symptoms of Children Exposed to IPV

29 different studies of children who witnessed IPV

BehavioralEmotionalSocialCognitivePhysical

(Kolbo, Blakely, & Engleman, 1996)

Behavioral Effects

AggressionTantrums "acting out" ImmaturityTruancy and Delinquency

(Davies, 1991; Dodge, Pettit, & Bates, 1994; Graham-Bermann, 1996c; Hershorn & Rosenbaum, 1985; Hughes & Barad, 1983; Jouriles, Murphy, & O'Leary, 1989; Sternberg, Lamb, Greenbaum, Cicchetti, Dawud, Cortes, et al., 1993)

Emotional Effects

AnxietyAngerDepressionWithdrawal Low self-esteem

(Carlson, 1990; Davis & Carlson, 1987; Graham-Bermann, 1996c; Hughes, 1988; Jaffe, Wolfe, Wilson, & Zak, 1986)

Social Effects

Poor social skillsPeer rejectionInability to empathize with others

(Graham-Bermann, 1996c; Strassberg & Dodge, 1992)

Cognitive Effects

Language lagDevelopmental delaysPoor school performance

(Kerouac, Taggart, Lescop, & Fortin, 1986; Wildin, Williamson, & Wilson, 1991).

Physical Effects

Failure to thriveProblems sleepingEating problemsRegressive behaviorsPoor motor skills, and Psychosomatic symptoms (eczema, bed wetting, etc.)

(Jaffe, et al., 1990; Layzer, Goodson, & Delange, 1986)

Specific Signs & Symptoms:Toddler/Preschooler (<5)

Become more aware of their environment (easily aroused)Sleeping & Eating DisordersSomatic Complaints

StomachachesHeadaches

Separation Anxiety (clinging to mother/victim)Speech, motor skill & cognitive delaysDepression & anxietyDifficulty in expressing emotions-but anger

(National Resource Center on Domestic Violence, 2002)

Specific Signs & Symptoms:Childhood (5-12)

Poor in School-Exhibit few options/low successSelf esteem limitations

Frequent mood swingsErratic attendanceInability to concentrate

Poor social skillsConflicts with classmates & teachers

Excel in School-Try to overcome & suppress family dysfunctionSeek approval by doing well in structured school environment

Perfect studentMaking many friends

However:Live with unpredictable home environmentsConflict-loving/hating their parentsExperience guilt, depression, sadness, powerlessnessUnable to relax/sleepSigns of PTSD


Specific Signs & Symptoms:Adolescence (13-15)

Eating difficulties resulting in anorexia, bulimia, or obesityAcademic difficulties-leading to dropping outFeeling powerless, fear, delinquency, substance abuse, suicideIntimate partner relationships

Without proper intervention-exhibit sex roles and communication patterns learned from dysfunctional home environment-contributing to the generational cycle of violence


Contributing & Protective FactorsFalls

Risks:Infant changing and sleeping locationsPreschool aged children-greatest risk of fall-related fatalities50% occurring among children <480% fall related injuries among children <4 occur at home and mostly during noontime and early evening (playtime)

Prevention:Supervision (home & playground)Changing tables & beds-use of railsUse of safety gates leading to different levels/stairsAvoid asphalt, concrete, grass or soil surfaces under playground equipment-use of mulch, rubber, etc.

Contributing FactorsDrowning

Seasonal: 72% occur during summer monthsLocation: 51% occur in private swimming poolsAge: Infants and toddlers:

88% occur in private swimming pools 70% of these children were not expected to be in or at the pool, but somewhere in the home

Lack of “Active” Supervision: SAFE KIDS Worldwide study: 90% of children who had drowned, had been supervised by an adultChild wading and inflatable pools: Carry similar risks

Protective FactorsDrowning

“Active” Supervision (Lifeguard)Barrier FencingSelf-closing/Self-latching gates (open outward)Locks and Alarms on all windows/doors (leading to pool area)Wading/Inflatable pools:

Smaller: Empty/turn over after useLarger: Require fencing/Electrical requirements

Contributing & Protective FactorsMVT-Occupant

Riding improperly restrained-greatest risk factorCurrently 85% misuse rate (Child Passenger Safety)

63% seat belt not anchored tightly33% harness straps not snug20% harness straps improperly routed11% forward-facing before age 1 and 20 lbs

More than 80% of the children under 4 years old killed in car crashes in California since 1990, would have survived if buckled properlyWhen used properly CPS can reduce the risk of fatal injury by 70% for infants, 55% for toddlers, and 59% booster seats

Contributing & Protective FactorsBicycle

Poorly fitted helmets=twice the risk of head injury in a crash compared with children whose helmet is properly fittedChildren who wear their helmets tipped back on their heads have a 52% greater risk of head injury than those who wear their helmets centered on their heads.Bicycle helmets have been shown to reduce the risk of TBI by as much as 88%

Contributing & Protective FactorsPedestrian

Walking too close to a school bus at drop off zonesWalking between cars and school bussesNot obeying traffic pedestrian lawsChildren <12 not to walk without an adult

Contributing & Protective FactorsSeasonal-Summer Months

Childhood injuries increase during summer months both nationally and in Los Angeles County51% childhood injuries in Los Angeles County occur between June-August

72% drowning56% bicycle41% pedestrian38% MVT-occupant

Summary

Leading causes of injury fatality & hospitalizations

Specific pediatric ages at-risk of injury

Contributing & Protective Factors

Conclusion

Five Handouts (Injury Prevention Planning Tools):

1. Behavioral & developmental factors by age2. Review of anatomic and physiologic factors that

contribute to pediatric injury3. Pediatric Injury Prevention Project Planning

Worksheet 4. Haddon Matrix sample5. Haddon Matrix template

Preventive Resources

Injury & Violence Prevention Program (IVPP) Website:

www.lapublichealth.org/ivpp

Contact Information:

[email protected](213) 351-7888

mailto:[email protected]

childhood trauma mar3,2008

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pediatric injuries