448 Child Health Psychology
apply rules are made, rules cannot be generated for all of the
unusual and unexpected accidents that lead to injury in chil-
dren (Hillier & Morrongiello, 1998; Peterson & Saldana,
1996). Therefore, successful prevention efforts are aimed at
both active behavior change and environmental change
(Finney et al., 1993) and are implemented on multiple levels:
individual/family, community, and population/policy.
Although the concept of the •accident-proneŽ child has
been retired due to a lack of empirical support (Rivara &
Mueller, 1987), studies suggest that some child characteris-
tics are associated with increased risk for injury. First, the
types of accidents and injuries that occur depend on child age
due to development of motor skills and cognitive abilities.
Infants are more likely to die of asphyxiation; preschool-age
children, from falls; school-age children, from pedestrian
accidents, drowning, or “re; and adolescents, from motor ve-
hicle accidents (Rivara & Mueller, 1987). Second, statistics
show that males are more likely to be involved in accidents
and experience injuries than females, speci“cally injuries in-
volving gross motor skills and a mechanical transfer of en-
ergy (fractures for males versus poisonings equally for males
and females; Rivara & Mueller, 1987). In terms of psycho-
logical characteristics, Schwebel and Plumert (1999) showed
prospectively that children who are high on extroversion and
low on inhibitory control when they are preschoolers tend to
overestimate their physical abilities and to experience more
injuries as they grow older (school age). Children low on
extroversion and high on inhibitory control underestimated
their abilities and had fewer injuries. Finally, factors that
reduce families• abilities to supervise children, including
stressful life events and poverty, increase the likelihood of
injury (Kronenfeld & Glik, 1995).
Prevention aimed at environmental change has impacted
signi“cantly the health and safety of children. Helping fami-
lies make home environments more secure for their children
by using education, modeling, and feedback has shown
measured success (see Roberts, Fanurik, & Lay“eld, 1987).
Additionally, community standards for safe surface areas in
playgrounds, policies regarding toy safety, and the use of
childproof caps on medications illustrate environmental
changes that have reduced accidents and injuries among chil-
dren (Finney et al., 1993).
A notable example of moderate success in prevention ef-
forts aimed at behavior change is the use of child restraints to
reduce morbidity and mortality associated with motor vehicle
accidents (Klassen, MacKay, Moher, Walker, & Jones, 2000).
On a policy level, by 1985 all U.S. states had passed laws
mandating child restraint use, and there is evidence that in-
fant and child seatbelt laws have signi“cantly reduced mor-
bidity and mortality associated with automobile accidents
(Rock, 1996). On the community level, prevention has tar-
geted primarily the child under the assumption that the child
will monitor restraint use in the family and that families are
more likely to use seatbelts if their children do not resist
(Klassen et al., 2000). In one program, a school-based educa-
tional program (kindergarten through second grade) was
linked with public education on television, in radio, and in
newspapers (Hazinski, Eddy, & Morris, 1995). The study•s
authors reported that motor vehicle restraint use improved
signi“cantly only in low-income schools with high adherence
to the program. There was less impact in high-income
schools where use of restraints was higher at baseline. In an-
other study, preschool-age children who received stickers if
they arrived at daycare in a restraint showed signi“cantly
higher motor vehicle restraint use (Roberts & Lay“eld,
1987). However, there remains room for improvement as
child restraints are often used incorrectly, rates of restraint
use are reduced over time without continual reinforcement
(Roberts & Lay“eld, 1987), and nearly 15% of infants and
40% of toddlers are still not regularly restrained (Klassen
et al., 2000). Psychologists are challenged to develop pro-
grams that will impact larger portions of the population by
better understanding the factors that lead to behavior change
and the mechanisms in action between risk factors and in-
juries (Finney et al., 1993).SELECTIVE INTERVENTIONSManagement of Pain and DistressThe biobehavioral model of pediatric pain (Varni, Blount,
Waldron, & Smith, 1995) serves as a useful framework for
guiding the development of interventions for procedure-
related and disease-related pain and for understanding the
targets of the intervention studies reviewed next. The core of
this model places pain (perception and behaviors) in the con-
text of precipitants and intervening variables on the one hand
and functional status outcomes on the other. The precipitant
may be unpredictable disease-related pain, as in vaso-
occlusive crises in SCD or headache pain, or predictable pain
from procedures such as bone marrow aspirations in child-
hood cancer and needle sticks for blood tests, insertion of IV
for provision of ”uids, antibiotic, or blood transfusion in
SCD. The intervening variables are cognitive appraisal of
pain and of one•s ability to impact pain, coping strategies for
handling pain and painful procedures, and perceived social
support. Finally, pain perception and pain behaviors impact
and are impacted by functional status outcomes including
school attendance, depression and anxiety symptoms, behav-
ior problems, and interpersonal relations.