typical violent act, which involves intent to do harm.
Rather, it often results from attempts to quiet a
cranky baby by an individual unaware of the risks. Yet
the physiological results are often devastating.
Injuries occur as part of a process that can be un-
derstood within the social-ecological framework as
described by Urie Bronfenbrenner in 1979. This
framework can be extended in a public health context
to conceptualize behaviors or health outcomes such as
injury as a result of interactions among individual
characteristics (intrapersonal level) and interactions
among individuals (interpersonal), as well as with the
physical and social environment, including institu-
tional and cultural elements. Developmental charac-
teristics enhance or reduce the possibilities that a
child will experience an injury. For example, young
children are not developmentally prepared cognitive-
ly to assess and avoid risk. Toddlers are curious and
developmentally eager to explore. They also have rel-
atively large heads that can throw off their balance
and contribute to their risk of falling headfirst (e.g.,
into a toilet or bucket) while exploring their sur-
roundings. Similarly, characteristics of young chil-
dren learning to pull themselves up may create
problems as they may pull objects down on them-
selves (e.g. a hot cup of coffee or books).
Injuries often occur when there is a mismatch in
the performance of the person and demands of a task.
For example, if a task demands that a certain level of
judgment of risk avoidance is required to prevent an
injury, a person unable to exert that level of judgment
or avoidance behavior will be more likely to experi-
ence an injury. A child’s developmental status may
mitigate against being able to judge risks appropri-
ately, identify preventive measures, and/or perform
proper avoidance behaviors. Consequently, interven-
tions must be designed that are sensitive to the per-
formance capacities of the individual to be protected
and that do not place the burden of protection on the
exposed individual. Rather, interventions are gener-
ally most successful if they are devised to address fea-
tures of the environment common to all individuals
and that do not rely exclusively on individual actions.
Such approaches typically employ engineering or de-
sign changes as opposed to efforts designed only to
change knowledge, attitude, or behavior.
Incidence of Injuries to Children
To fully understand the problem of childhood in-
juries, it is important to examine how many cases of
injury are occurring, in which population groups, for
example, distributions by age, race, and gender. Data
across sources are not always comparable due to dif-
ferences in measurement, definitions, or data compi-
lation practices. Hence, understanding of the
incidence of any public health problem necessitates
careful review of the data sources and consideration
of what they can and can’t reveal about the problem.Measurement Issues
As with any public health problem, it is important
to have data available from routine surveillance—the
systematic, ongoing collection of information about
illnesses, injuries, or events. To fully understand the
magnitude of the problem, one must consider both
the mortality (fatalities) and morbidity (nonfatalities)
associated with injury. Mortality is readily assessed
using data available from death certificates. Data are
coded as to the underlying causes of death and can
yield valuable information about factors contributing
to the injury. In states having medical examiner sys-
tems, these records can provide more detail about the
circumstances of death.
The Centers for Disease Control and Prevention
report that for every child who dies as a result of an
injury, there are an estimated 34 who are injured seri-
ously enough to require hospitalization, and another
1,000 who receive medical care in an outpatient set-
ting. Even more children experience injuries that re-
sult in limitations of their activities or cause
discomfort but that do not require medical attention.
Hospitalized injuries can be examined using hospital
discharge data compiled in each state as well as na-
tionally. The standards of reporting, however, are not
as stringent as with death statistics. Underlying causes
are not uniformly coded in all states, some requiring
that this information be included and others report-
ing on a voluntary basis.
Data about nonhospitalized cases are even less
uniformly compiled. There are few statewide and no
national reporting systems for emergency depart-
ment cases. Injuries treated in private doctor’s offices,
urgent care centers, or by school nurses may or may
not be routinely documented, but there are no na-
tional record-keeping systems to monitor these
events systematically. Consequently, information
about injury morbidity is of variable quality.Types of Injuries
Causes of injury death differ by age and by type
of injury, as demonstrated in Table 1. The data pres-
ented in these figures reflect only mortality.
In 1998, 18,292 U.S. children died as a result of
injuries, for an overall death rate of 23.55 per
100,000 population. Of these fatalities, 12,416 were
classified as unintentional, 3,461 as homicide, and
2,061 as suicide. Rates varied by race and gender,
with boys (aged zero to nineteen) experiencing an
overall death rate of 32.04 per 100,000, compared to
14.63 for girls. As shown in Table 2, racial differencesINJURIES 211