Published online June 2, 2008
PEDIATRICS Vol. 121 No. 6 June 2008, pp. e1668-e1675 (doi:10.1542/peds.2007-1255)
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow P3Rs: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when P3Rs are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Zolotor, A. J.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Zolotor, A. J.
Related Collections
Right arrow Office Practice

ARTICLE

Maternal Psychological Adjustment and Knowledge of Infant Development as Predictors of Home Safety Practices in Rural Low-Income Communities

Adam J. Zolotor, MD, MPHa,b, Margaret Burchinal, PhDc,d, Debra Skinner, PhDc,e, Marjorie Rosenthal, MD, MPHf,g and the Key Family Life Project Investigators

a Department of Family Medicine
b Injury Prevention Research Center
c Frank Porter Graham Child Development Institute
e Department of Anthropology, University of North Carolina, Chapel Hill, North Carolina
d Department of Education, University of California, Irvine, California
f Department of Pediatrics
g Robert Wood Johnson Clinical Scholars Program, Yale University, New Haven, Connecticut


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 APPENDIX: ETHNOGRAPHIC CASE...
 REFERENCES
 
BACKGROUND. Unintentional injury is the leading cause of death among toddlers in the United States. Toddlers spend the majority of time at home, and the use of recommended safety practices can prevent many injuries.

OBJECTIVE. Maternal psychological adjustment and understanding of child development are thought to influence the implementation of safety practices; however, the extent to which either factor is related has been examined with small samples and without attention to potential confounding. We hypothesize that mothers' use of safety practices will be higher when mothers have more knowledge of development and better psychological adjustment.

METHODS. This study is part of the Family Life Project, a longitudinal birth cohort of children from poor rural communities (n = 1611) and an ethnographic sample (n = 36). Mothers in the birth cohort completed scales to measure knowledge of development, psychological adjustment, and home safety practices. Factor analysis of the safety scale resulted in 4 subscales. Each subscale was predicted from maternal knowledge and adjustment in multivariable regression. Mothers in the ethnographic study described sources of information about home safety, current practices, and barriers.

RESULTS. Analyses indicated that mothers with better psychological adjustment were more likely to implement all of the safety practices, and mothers with more knowledge about development were more likely to minimize subtle hazards and install safety devices. An interaction between maternal adjustment and knowledge suggested that mothers with psychological distress were more likely to install safety devices if they had greater knowledge of development. Mothers reported that health care providers were the primary source of safety information, and barriers to implementation included poverty and lack of stable housing.

CONCLUSIONS. Knowledge of development and better psychological adjustment are associated with improved home safety. Knowledge about development is especially important for mothers with poor mental health. Pediatricians and designers of injury-prevention programs should consider the role of maternal mental health in child safety.

Key Words: home safety • injury • maternal knowledge and practice • maternal mental health

Abbreviations: FLP—Family Life Project • RKKSS—Russell Keeping Kids Safe Scale • KIDI—Knowledge of Infant Development Instrument • BSI—Brief Symptom Index-18 • GSI—Global Severity Index • IBR—Infant Behavior Record

Accounting for 43.3% of deaths, unintentional injury is the leading cause of death among children in the United States. Moreover, 20.6 million children each year sustain nonfatal injuries requiring medical attention or limiting activities.1 Risk factors for childhood injury include poverty,2,3 male gender,2,4 child age,5 child activity level,2,5 single-parent household,6 maternal mental health symptoms,7–9 and parental alcohol abuse.10

The Consumer Product Safety Commission and the American Academy of Pediatrics advocate that the implementation of home safety practices may prevent injury.11–13 Rivara14 describes how home safety practices function best if they are inexpensive, widely available, easy to understand, well accepted, reliable, and independent of the need for vigilance. Home safety practices, however, are used at low rates.15–19

Previous studies have shown that the use of home safety practices is increased for parents with greater knowledge of child development and decreased for parents with increased psychological symptoms.4,8–10 Although suggestive, these studies were limited by small sample sizes, lack of representative sampling, and failure to adjust for potential confounding demographic, family, and child factors.20

This study uses data from an ongoing longitudinal study of infants in low-income rural communities that includes both a large birth cohort and a smaller ethnographic sample. Our primary aim was to determine whether parents who demonstrate better psychological adjustment or knowledge of infant development report higher rates of home safety practices, controlling for documented risk factors for injury. Our secondary aim was to determine how frequently mothers report using these safety practices, their primary sources of information, and perceived barriers to implantation.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 APPENDIX: ETHNOGRAPHIC CASE...
 REFERENCES
 
The Family Life Project (FLP) was designed as a mixed-method, longitudinal study of families living in 2 US rural areas with high rates of child poverty. Eastern North Carolina and central Pennsylvania were selected to represent the black South and Appalachia regions. A stratified sample was used to oversample low-income families in both states and black families in North Carolina.21

FLP recruiters identified 5471 women who gave birth between September 2004 and August 2005, 72% of whom were eligible because they spoke English and planned to live in the state for 2 years. Of those eligible, 68% were willing to participate, of whom 58% were randomly sampled for recruitment. Of those invited to participate, 82% completed their first home visit and were considered enrolled. At each subsequent home visit, the primary caregiver of the selected child was identified for interviews (2, 6, 15, 24, and 36 months). The current study uses data from the 2-, 6-, and 15-month interviews. This is the period of development most critical for implementing home safety practices included in this study.22

The FLP includes an ethnographic component to provide another methodologic perspective on the meaning and context of parent beliefs and practices.23 A separate sample of 36 families in North Carolina was selected for the ethnographic study. These families resided in the same counties as the birth cohort and were similar in terms of poverty status and race. Pregnant women were recruited between February 2003 and February 2004 from health departments, parenting classes, a home health agency, clinics, and health fairs. Mothers were interviewed on a variety of topics related to parenting practices and child development every 6 to 8 weeks beginning prenatally and continuing for 2 years with 2 follow-up interviews conducted in the third year for an average of 17 to 18 interviews per mother.

Measures
Structured interviews were conducted at enrollment, at 6 months, and at 15 months. Home visits lasted 2 to 3 hours and included mother and child observations, child-based tasks, and structured questionnaires. At the North Carolina site, the ethnographic sample participated in a semistructured interview to provide more in-depth information on the mothers' knowledge of and barriers to implementing safety practices. The structured interview was not administered to these mothers.

The primary dependent variable of interest in this study is the use of home safety measures. These were assessed by interview of the primary caregiver at the 15-month visit. The Russell Keeping Kids Safe Scale (RKKSS) is an observational checklist,24 which we adapted for maternal self-report. This instrument includes questions about use of 24 common home safety measures, such as electrical socket covers. Mothers responded using a 5-point scale, reporting whether they do these activities never, hardly ever, half the time, most of the time, and all of the time. This scale has not been used previously with self-report; however, a similar home safety checklist has been validated by comparing maternal self-report with observed implementation.25 We used maternal self-report to minimize the length of the home interview.

Knowledge of infant development was measured at the 2-month visit using an abbreviated version of the Knowledge of Infant Development Inventory (KIDI), a 20-item scale designed to assess adults' knowledge of typical child development and parenting of children from birth to 2 years, including statements such as, "Infants do some things just to make trouble for their parents like crying a long time or pooping in their diapers (agree, disagree, not sure)."26 In this study, we used the number of correct answers divided by 20, resulting in a continuous proportion (0–1). This summary score showed moderate reliability with, an {alpha} of .63.

The Brief Symptom Inventory-18 (BSI)27 was filled out by the primary caregiver at the 6-month visit. This is a short, sensitive, self-report index for psychological distress. The BSI contains 18 items that are divided evenly across 3 dimensions: somatization, depression, and anxiety. A total score, referred to as the Global Severity Index (GSI), was computed from the 3 dimensions and converted to a t score. Within this sample, the GSI had an excellent reliability ({alpha} = .91), and scores ranged from 33 to 81, with higher scores representing more psychological symptoms.27

At the 6-month interview, primary caregivers were asked to report demographic information, education, race, ethnicity, and an inventory of people in the home. At each visit, primary and secondary caregivers were asked about household income. This was divided by the federal poverty level to calculate a ratio of income to need.

After the 15-month visits, an adaptation of the Infant Behavior Record (IBR)28 was completed by both home visitors to measure infant activity. The IBR has been used to study children during administration of various cognitive and developmental tests.29 In the present study, the IBR was applied to behavior observed during the entire visit.28,29 Two interviewers rated gross body movements on a 9-point scale between 1 ("stays quietly in one place, with practically no self-initiated movement") and 9 ("hyperactive; cannot be quieted for sedentary tests"). Mean scores of the 2 observers were calculated.

Analytic Methods
Analyses of the cohort sample data were conducted by using Stata 8.2 (Stata Corp, College Station, TX), and survey weights were applied to adjust for oversampling of low-income families in both sites and for black families in North Carolina. The use of survey weights calculated based on census date for race and income allows for the calculation of population-based estimates of effect representing rural areas of Pennsylvania and North Carolina with concentrated child poverty. Descriptive statistics were calculated according to region to facilitate comparisons.

To identify underlying constructs and to reduce the number of dependent variables from the RKKSS home safety questionnaire, we used a factor analysis with varimax rotation. Four factors emerged based on loadings with eigenvalues >1. A new variable was created for each factor by calculating a mean of the items loading on that factor.

The home safety scale scores were correlated with the ratings of maternal adjustment, knowledge of development, and child and family characteristics. We then used regression to predict home safety total and scale scores from maternal psychological adjustment and knowledge of development, with all of the covariates included as potential confounders resulting in 5 main-effects models. A second step assessed the interaction between adjustment and knowledge development for the home safety total and scale scores, resulting in 5 additional regression models.

Analysis of the ethnographic data entailed content analysis of the transcriptions, aided by reduction and display of data in matrices that summarized relevant information for each family. These approaches are widely used and well established in qualitative social science research,30–32 providing systematic procedures for extraction, reduction, and comparison of textual data. Two researchers, including the third author, independently read all of the transcripts and summarized in a data display matrix information about mothers' safety beliefs and practices, barriers to implementing safety practices, and sources of safety information. They then examined these categories across respondents to determine the range of responses and predominant themes related to each topic.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 APPENDIX: ETHNOGRAPHIC CASE...
 REFERENCES
 
Descriptive statistics for the birth cohort sample are shown in Table 1. Almost half (49%) of the North Carolina sample but only 5% of the Pennsylvania sample was black. The mean maternal age was 27 years. Most mothers (64% North Carolina and 84% Pennsylvania) reported a partner or husband in the home. The average number of children in subject households was just over 2 years. Half of the index children selected for the study were boys. The average maternal mental health symptoms on the BSI was similar (mean t score: 47), suggesting that most mothers were not reporting high levels of distress (t score: >60). The average infant gross motor activity score suggested that most infants were not viewed as hyperactive.


View this table:
[in this window]
[in a new window]

  		TABLE 1 Descriptive Statistics of Each Rural Region

 
Analysis of both the birth cohort data and the ethnographic sample indicated that most mothers reported high levels of implementation of home safety practices. In the birth cohort, the RKKSS mean score was high in both sites (4.6 in North Carolina and 4.7 in Pennsylvania of a possible 5). Ethnographic findings also indicated a high implementation of home safety practices. Mothers expressed an awareness of hazards in the household and identified a range of practices that they implemented to safeguard their children. Constant and close supervision was most noted, followed by moving dangerous items out of reach and child-proofing the house with outlet covers, safety gates, and locks.

The ethnographic data revealed that mothers reported learning about safety practices primarily through their health care providers and yielded insights into barriers to implementation. Mothers said that at every visit their health care providers gave written information and verbal advice on practices such as infant-proofing the house, monitoring the child, and installing smoke detectors. Reasons given in the ethnographic interviews for not implementing safety features included: (1) living in someone else's home and not being able to alter the environment; (2) being without a job and not having the money to buy devices; and (3) believing that the child would quickly learn how to outmaneuver safety devices so there was little use installing them.

Factor analysis of the RKKSS safety items from the birth cohort yielded 4 factor results: (1) a factor for minimizing obvious hazards (medicines, bags, and poisons) with 9 items ({alpha} = .81); (2) a factor representing minimizing subtle hazards (tripping, entrapment, and falling) with 9 items ({alpha} = .74); (3) a factor representing the use of safety items that require purchase and installation (socket covers, gates, and cabinet locks) with 4 items ({alpha} = .68); and (4) a factor representing keeping hazards locked up with 2 items ({alpha} = .72). See Table 2 for a description of items loading on each factor.


View this table:
[in this window]
[in a new window]

  		TABLE 2 Specific Items Related to Each Factor of the RKKSS

 
The correlations in Table 3 show the associations between home safety total and factor scores with selected predictors. Mothers reporting more psychological distress reported implementing fewer safety practices. Mothers with more knowledge about development reported adopting more home safety practices on the total score and on the factors representing minimizing obvious hazards and installing safety equipment. In contrast, knowledge was negatively correlated with reducing subtle hazards. The covariates showed expected associations: higher income was related to installing safety equipment; mothers of boys were more likely to report minimizing obvious hazards, installing safety equipment, and locking up hazards; older and white mothers were more likely to report installing safety devices and minimizing subtle hazards; and mothers with more active infants were more likely to report locking up hazards.


View this table:
[in this window]
[in a new window]

  		TABLE 3 Correlations Between Total and Factor Scores for the Implementation of Home Safety Practices, Knowledge of Infant Development, and Potential Confounding Variables

 
Regression analyses of the birth cohort data indicated that maternal psychological adjustment was related to all of the types of safety practices, and knowledge of development was related to installation of safety equipment and minimizing subtle hazards (Table 4). Maternal distress was negatively related to all of the safety practices as expected, and knowledge of infant development was positively associated with installation of safety equipment as expected (β = .57; P < .05), and negatively associated with minimizing subtle hazards (β = –.23; P < .05). In addition, poverty, black race, and number of children in the household were modest negative predictors of installing safety devices; infant activity level was a positive predictor of 2 of the summary scores; and maternal age was a negative predictor of 3 summary scores.


View this table:
[in this window]
[in a new window]

  		TABLE 4 Survey Weighted Linear Regression Models Predicting Home Safety Practices From Maternal Knowledge and Psychological Adjustment (n = 1083)

 
In addition, we tested whether knowledge about development moderated the association between maternal adjustment and home safety practices. The interaction term significantly contributed to predicting installation of safety devices (β = .06; P = .005). The interaction term was not significant in any other model and was, therefore, dropped from the models, as shown. Furthermore, for ease of interpretation, the simple model without the interaction term is shown for the regression predicting installation of safety devices. The interaction indicated that knowledge of development was a strong predictor of installing safety devices among mothers with more psychological distress but not among less distressed mothers. The interaction is graphically represented in Fig 1 by estimating the predicted regression line for mothers whose psychological adjustment scores were low (1 SD below the mean), average (at the mean), and high (1 SD above the mean). Figure 1 demonstrates that knowledge of development is important in predicting the use of safety practices requiring installation among respondents with high mental health symptoms but not for mothers with average or fewer mental health symptoms. Two mothers from the ethnographic sample illustrate these relationships (see Appendix). Both had significant mental health symptoms. The mother in case 1 had inappropriate expectations of her toddler's development and failed to implement safety measures. In case 2, the mother had depression, but with appropriate education about development from her child's doctor and an early childhood education program, she successfully implemented home safety practices.


Figure 1
View larger version (10K):
[in this window]
[in a new window]

  		FIGURE 1 Association between maternal knowledge of infant development and implementation of home safety practices that require installation for mothers who report low, medium, and high levels of psychological symptoms (predicted regression lines at GSI mean: –2 SDs = 2 SDs).

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
APPENDIX: ETHNOGRAPHIC CASE...
 REFERENCES
 
This study demonstrates that parents of young children in rural, low-income areas in the Appalachian region in Pennsylvania and eastern North Carolina report high implementation of recommended home safety practices. In the ethnographic study, pediatricians were reported as the primary source of information regarding these practices, but mothers reported that they were less likely to implement these recommended practices when they were unemployed, lived in someone else's home, or believed that their child would quickly learn how to get around them. Implementation of all types of home safety practices was more common when mothers reported better psychological adjustment. Installation of devices was more common for mothers with more knowledge of infant development only when mothers reported psychological distress.

This study extends the literature in several ways. A previous study using a small convenience sample without consideration of potential confounders demonstrated that knowledge of infant development was associated with increased use of home safety practices.20 The current study adds to that work by demonstrating that, when demographic and child characteristics are also considered, this is true only for those safety practices requiring installation. Second, it offers a possible explanation for the previously identified association between injury and maternal depressive symptoms,8 low internal locus of control,7 or general stress3,9; that is, maternal psychological adjustment predicts home safety practices, which may predict injury rates. Finally, this study is important in its explicit targeting of low-income and minority mother-infant dyads. Poor and minority children have been shown to be at higher risk for nearly all types of injuries.2,33–35 Findings that can be applied to this population may have a greater potential to impact injury rates.

The interaction between maternal psychological symptoms and knowledge may be especially important to injury prevention. Mothers with low levels of psychological distress report high levels of implementing safety practices requiring installation regardless of knowledge of infant development. Improved knowledge only increases implementation of these practices among mothers with high levels of psychological symptoms. This is demonstrated by Fig 1 and is illustrated by case examples in the Appendix. Injury-prevention efforts may best be targeted to mothers with both high levels of psychological symptoms and low knowledge, and these efforts could be directed at improving knowledge or treating depression.

A noteworthy finding indicated that, whereas poverty was not a consistent predictor when psychological adjustment was also considered, it was related to whether families installed safety devices in both the regression analysis of the birth cohort data and the ethnographic interviews. Children living in poverty are at higher risk of nearly all types of injury.1,5 Installed devices are passive and do not require caregiver vigilance to improve safety. The use of safety devices by poor families may be as simple as giving them these inexpensive devices. Poor families have been found to have more child safety hazards in the home3 and express the most interest in low-cost safety equipment.36

Child gender is closely related to the total implementation of home safety practices and 3 of 4 subscales when examined alone but not when considered with other factors. This is likely because of confounding of gender with observed infant activity, with boys having higher levels of gross motor activity. This is consistent with previous work that has shown that boys are at greater risk of injury but that this is mostly explained by activity level and behavioral factors of boys.7,37

In the ethnographic component of this study, nearly all of the subjects reported that their child's pediatrician, family physician, or clinic was an important source of information regarding safety. This extends the finding that primary care providers are the preferred source of information about child safety to include rural, low-income families. A previous study found that, in more typical, nonpoor American families, physicians were the preferred source of information regarding safety.15 This is in contrast to a large multinational study in Europe where the most commonly sited sources of information were family, television, and friends.38

This study has several limitations. First, the outcome of interest, the use of home safety practices, relies on self-report. The instrument was derived from an observational checklist of home safety practices, but the validity of self-report is unknown. However, the checklist items demonstrate good scalability; self-report of home safety measures has been used in many previous injury research studies39–41; has been validated as consistent with observed home safety practices25; and self-report is how clinicians and injury-prevention specialists make decisions about services, anticipatory guidance, and policy. Second, this study is an observational cohort study. Because of its longitudinal design (KIDI collected at 6 months and RKKSS at 15 months), an association provides a necessary, but not sufficient, condition for determining a causal inference. Lastly, we chose to report statistical significance for P values of <.05 rather than correct for multiple testing. We had 2 primary explanatory variables of interest: knowledge of development and psychological adjustment. The relationship between knowledge of development and home safety practices is of marginal significance (P < .05) but is reported because of consistency with previous research and our wish to balance the risk of a type 1 error with the risk of a type 2 error.

Findings from this study can be applied directly to the design of emerging strategies for injury prevention. First, the identification and treatment of maternal mental health disorders may be critical elements of childhood injury programs that seek to increase the use of home safety practices. Second, educating parents about infant development may improve home safety practices, especially those practices that require installation. This is particularly true for mothers experiencing high levels of psychological distress. Third, the ethnographic component of this study confirms the importance of the role of the primary care clinician in providing information and education around home safety for toddlers. Mothers with low knowledge of infant development and high levels of mental health symptoms may have children with the greatest risk of injury in the home. These families may be in greatest need of parenting education, safety education, and maternal mental health assessment and treatment.


   APPENDIX: ETHNOGRAPHIC CASE STUDIES THAT ILLUSTRATE THE RELATIONSHIP AMONG MATERNAL PSYCHOLOGICAL SYMPTOMS, KNOWLEDGE, AND IMPLEMENTATION OF HOME SAFETY PRACTICES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 APPENDIX: ETHNOGRAPHIC CASE...
REFERENCES
 
Case 1
Pearl had 2 children, including Todd, born 8 weeks premature. Pearl lived in a single-wide mobile home with Todd's father. Pearl was diagnosed with depression and hospitalized with postpartum depression after her oldest child's birth. She described herself as "moody" and seemed exhausted and listless. She took antidepressants but stopped taking them because of adverse effects like nightmares. Pearl described Todd at age 2 as "always being into stuff." Her main strategy to ensure his safety was "just to watch him." When asked about what else she did to keep her 2 children safe, she said, "You can't protect 'em, not unless you put pillows around 'em in a padded room. I mean you can like put the safety things up for the knobs and the plugs and the stuff like that and go all out and buy that. But it's not gonna do you no good 'cause once it's been around long enough and they see you open it they're gonna learn how to open it eventually."

Case 2
Kriste was 32 when she had her son, Evan. She lived with her husband and 4 children in a single-wide mobile home. Kriste was diagnosed with depression in 2002 and took medication until she began breastfeeding. When Evan was a toddler, Kriste occasionally felt the need for antidepressant medication but said she could not afford to buy it or go to the doctor to get her prescription renewed. For Evan, she saw danger all around because he "was into everything." She talked about her steps to child proofing the house: "I figured out that if they're going in there I need to buy a gate and put it up. The plugs, I got them free from a baby store. And then I seen them little locks in the store, so I bought them for the cabinets. I seen 'em and said, ‘oh that's a good idea!’" Kriste said that she learned about all of these safety precautions from the child's doctor and from a person associated with an early childhood education program.


   ACKNOWLEDGMENTS
 
Funding for this project was provided by the National Institute of Child Health and Human Development grant P01-HD-39667, with cofunding provided by National Institute on Drug Abuse and by the Maternal and Child Health Bureau grant R40-MC04293-01-03.

The Family Life Project key investigators included Lynne Vernon-Feagans (principal investigator), Martha Cox, Clancy Blair, Margaret Burchinal, Linda Burton, Keith Crnic, Ann Crouter, Patricia Garrett-Peters, Mark Greenberg, Stephanie Lanza, Roger Mills-Koonce, Debra Skinner, Emily Werner, and Michael Willoughby.

We thank the families for allowing us into their lives. We also thank Jim Peak, Eloise Neebe, and Karen Cai for managing the data; Carol Runyan for assistance with the article; and Karolyn Forbes for editorial assistance.


   FOOTNOTES
 
Accepted Nov 28, 2007.

Address correspondence to Adam J. Zolotor, MD, MPH, University of North Carolina, CB 7595, Chapel Hill, NC 27599-7595. E-mail: ajzolo{at}med.unc.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Maternal psychological adjustment and understanding of child development are thought to influence implementation of safety practices; however, the extent to which either factor is related has been examined with small samples and without attention to potentially confounding variables.

 

What This Study Adds

Maternal psychological symptoms are strongly associated with the use of all types of home safety practices, and knowledge of development is only associated with implementation of practices requiring installation. This study demonstrates high rates of implementation and barriers to implementation.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 APPENDIX: ETHNOGRAPHIC CASE...
 REFERENCES
 

  1. Danseco ER, Miller TR, Spicer RS. Incidence and costs of 1987–1994 childhood injuries: demographic breakdowns. Pediatrics. 2000;105 (2). Available at: www.pediatrics.org/cgi/content/full/105/2/e27
  2. Schwebel DC, Brezausek CM, Ramey SL, Ramey CT. Interactions between child behavior patterns and parenting: implications for children's unintentional injury risk. J Pediatr Psychol. 2004;29 (2):93 –104[Abstract/Free Full Text]
  3. Glik DC, Greaves PE, Kronenfeld JJ, Jackson KL. Safety hazards in households with young children. J Pediatr Psychol. 1993;18 (1):115 –131[Abstract/Free Full Text]
  4. Rivara FP, Bergman AB, LoGerfo JP, Weiss NS. Epidemiology of childhood injuries. II. Sex differences in injury rates. Am J Dis Child. 1982;136 (6):502 –506[Abstract]
  5. Dal Santo JA, Goodman RM, Glik D, Jackson K. Childhood unintentional injuries: factors predicting injury risk among preschoolers. J Pediatr Psychol. 2004;29 (4):273 –283[Abstract/Free Full Text]
  6. O'Connor TG, Davies L, Dunn J, Golding J, for the ALSPAC Study Team. Distribution of accidents, injuries, and illnesses by family type. Pediatrics. 2000;106 (5). Available at: www.pediatrics.org/cgi/content/full/106/5/e68
  7. Damashek AL, Williams NA, Sher KJ, Peterson L, Lewis T, Schweinle W. Risk for minor childhood injury: an investigation of maternal and child factors. J Pediatr Psychol. 2005;30 (6):469 –480[Abstract/Free Full Text]
  8. Methany AP. Injuries among toddlers: contributions from child, mother, and family. In: Chess S, Thomas A, Hertzig M, eds. Annual Progress in Child Psychiatry and Child Development 1987. New York, NY: Brunner/Mazel; 1988:521–535
  9. Greaves PE, Glik D, Kronenfeld J, Jackson K. Determinants of controllable in-home child safety hazards. Health Educ Res. 1994;9 (3):307 –314[Abstract/Free Full Text]
  10. Bijur PE, Kurzon M, Overpeck MD, Scheidt PC. Parental alcohol use, problem drinking, and children's injuries. JAMA. 1992;267 (23):3166 –3171[Abstract]
  11. American Academy of Pediatrics. Tipp: The Injury Prevention Program. Available at: www.aap.org/family/tippmain.htm. Accessed November 2, 2007
  12. Consumer Product Safety Commission. Baby safety checklist. Available at: www.cpsc.gov/cpscpub/pubs/shower/images/206.pdf. Accessed November 2, 2007
  13. Consumer Product Safety Commission. Childproofing your home: 12 safety devices to protect your children. Available at: www.cpsc.gov/cpscpub/pubs/grand/12steps/12steps.html. Accessed November 2, 2007
  14. Rivara FP. Epidemiology of childhood injuries. I. Review of current research and presentation of conceptual framework. Am J Dis Child. 1982;136 (5):399 –405[Abstract]
  15. Eichelberger MR, Gotschall CS, Feely HB, Harstad P, Bowman LM. Parental attitudes and knowledge of child safety: a national survey. Am J Dis Child. 1990;144 (6):714 –720[Abstract]
  16. Mock C, Arreola Rissa C, Trevino Perez R, et al. Childhood injury prevention practices by parents in Mexico. Inj Prev. 2002;8 (4):303 –305[Abstract/Free Full Text]
  17. Morrongiello BA, Kiriakou S. Mothers' home safety practices for preventing six types of childhood injuries: what do they do, and why? J Pediatr Psychol. 2004;29 (4):285 –297[Abstract/Free Full Text]
  18. Peterson L, Farmer J, Kashani JH. Parental injury prevention endeavors: a function of health beliefs? Health Psychol. 1990;9 (2):177 –191[CrossRef][ISI][Medline]
  19. Hu X, Wesson D, Parkin P, Rootman I. Pediatric injuries: parental knowledge, attitudes and needs. Can J Public Health. 1996;87 (2):101 –105[ISI][Medline]
  20. Rivara FP, Howard D. Parental knowledge of child development and injury risks. J Dev Behav Pediatr. 1982;3 (2):103 –105[ISI][Medline]
  21. Vernon-Feagans L, Pancsofar N, Willoughby MT, Odum E, Quade A. Predictors of maternal language input during a picture book task in the home: the mediational role of the quality of the home environment. J Appl Dev Psychol. 2008; In press
  22. American Academy of Pediatrics. Implementing Safety Counseling in Office Practice. Elk Grove Village, IL: American Academy of Pediatrics; 1994
  23. Creswell JW, Plano VL. Designing and Conducting Mixed Method Research. Thousand Oaks, CA: Sage; 2006
  24. Russell KM, Champion VL. Health beliefs and social influence in home safety practices of mothers with preschool children. Image J Nurs Sch. 1996;28 (1):59 –64[Medline]
  25. Morrongiello BA, House K. Measuring parent attributes and supervision behaviors relevant to child injury risk: examining the usefulness of questionnaire measures. Inj Prev. 2004;10 (2):114 –118[Abstract/Free Full Text]
  26. McPhee DL. Knowledge of Infant Development Inventory. Chapel Hill, NC: University of North Carolina; 1981
  27. Derogotis L. Brief Symptom Inventory 18. Minneapolis, MN: NCS Pearson, Inc; 2000
  28. Bayley N. Bayley Scales of Mental Development. New York, NY: Psychological Corporation; 1969
  29. Stifter CA, Corey J. Vagal regulation and observed social behavior in infancy. Soc Dev. 2001;10 :189 –201[CrossRef][ISI]
  30. Bernard HR, Ryan GW. Text analysis: qualitative and quantitative methods. In: Bernard HR, ed. Handbook of Methods in Cultural Anthropology. Walnut Creek, CA: AltaMira Press; 1998
  31. Miles MB, Huberman M. Qualitative Data Analysis, an Expanded Source Book. 2nd ed. Thousand Oaks, CA: Sage; 1994
  32. Tashakkori A, Teddlie C. Handbook of Mixed Methods in the Social and Behavioral Sciences. Thousand Oaks, CA: Sage; 2003
  33. Delgado J, Ramirez-Cardich ME, Gilman RH, et al. Risk factors for burns in children: crowding, poverty, and poor maternal education. Inj Prev. 2002;8 (1):38 –41[Abstract/Free Full Text]
  34. Shenassa ED, Stubbendick A, Brown MJ. Social disparities in housing and related pediatric injury: a multilevel study. Am J Public Health. 2004;94 (4):633 –639[Abstract/Free Full Text]
  35. Khambalia A, Joshi P, Brussoni M, Raina P, Morrongiello B, Macarthur C. Risk factors for unintentional injuries due to falls in children aged 0–6 years: a systematic review. Inj Prev. 2006;12 (6):378 –381[Abstract/Free Full Text]
  36. van Weeghel I, Kendrick D, Marsh P. Accidental injury: risk and preventative interventions. Arch Dis Child. 1997;77 (1):28 –31[Abstract/Free Full Text]
  37. Morrongiello BA, Ondejko L, Littlejohn A. Understanding toddlers' in-home injuries: I. Context, correlates, and determinants. J Pediatr Psychol. 2004;29 (6):415 –431[Abstract/Free Full Text]
  38. Vincenten JA, Sector MJ, Rogmans W, Bouter L. Parents' perceptions, attitudes and behaviours towards child safety: a study in 14 European countries. Int J Inj Contr Saf Promot. 2005;12 (3):183 –189[CrossRef][Medline]
  39. Posner JC, Hawkins LA, Garcia-Espana F, Durbin DR. A randomized, clinical trial of a home safety intervention based in an emergency department setting. Pediatrics. 2004;113 (6):1603 –1608[Abstract/Free Full Text]
  40. Hapgood R, Kendrick D, Marsh P. Do self reported safety behaviours predict childhood unintentional injuries? Inj Prev. 2001;7 (1):14 –17[Abstract/Free Full Text]
  41. Gielen AC, Wilson ME, McDonald EM, et al. Randomized trial of enhanced anticipatory guidance for injury prevention. Arch Pediatr Adolesc Med. 2001;155 (1):42 –49[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow P3Rs: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when P3Rs are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Zolotor, A. J.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Zolotor, A. J.
Related Collections
Right arrow Office Practice