The unique experience of Disaster Psychiatry Outreach, a voluntary organization devoted to providing psychiatric assistance to people affected by disasters, provides a valuable substrate for exploring the role of psychodynamics in the human experience of disaster and trauma. This article offers a theoretical framework for such an experience that takes into account personal meaning, ego psychology and defenses, and grief work and suggests how to employ this framework in the setting of a disaster by way of examples from the events of Sept. 11. A useful clinical construct for future disaster work known as the "trauma tent" is ultimately proposed, as are novel applications of psychodynamics toward the prevention and mitigation of manmade and natural disasters.
Correspondence: M. O. Titus, Vanderbilt University Medical Center, Nashville, Tennessee, USA; (email: otitus1@yahoo.com).
(Copyright 2003, American Academy of Pediatrics)
Scald burns to the feet and lower extremities in children are described in the literature as often resulting from forced immersions. This report illustrates 3 cases of burns whose distribution and historical factors identify them as accidental. The location of these accidental burns is similar to those found in inflicted injury, but the patterns were indicative of flowing water burns, not forced immersions. Burns in these locations may be confused with abuse. Medical providers need to be aware of information that may enable them to distinguish the 2 causes. Effective caregiver education regarding the importance of lowering the temperature of water heaters and discouraging play in household sinks is critical to prevent additional tap water scald burn injuries.
Regular rest breaks are recommended to prevent accumulation of accident risk during sustained activities. We examined the effect of rest breaks on temporal trends in industrial accident risk, by assessment of accident records from a large engineering company, obtained over 3 years. In 2 h of continuous work, relative risk of an accident in the last half-hour of a shift was 2.08 (95% CI 1.73-2.43) higher than in the first half-hour. Trends in risk did not seem to differ between three 2-h work periods. Regular rest breaks seem to be an effective way to control accumulation of risk during industrial shift-work.
Disabling occupational injury in the US construction industry, 1996.
- Courtney TK, Matz S, Webster BS. J Occup Environ Med 2002; 44(12): 1161-1168.
Correspondence: Theodore K. Courtney, Liberty Mutual Research Center for Safety and Health, 71 Frankland Road, Hopkinton, MA 01748, USA; (email: theodore.courtney@libertymutual.com).
In 1996 the US construction industry comprised 5.4% of the annual US employment but accounted for 7.8% of nonfatal occupational injuries and illness and 9.7% of cases involving at least a day away from work. Information in the published literature on the disability arising from construction injuries is limited. The construction claims experience (n = 35,790) of a large workers' compensation insurer with national coverage was examined. The leading types and sources of disabling occupational morbidity in 1996 in the US construction industry were identified. Disability duration was calculated from indemnity payments data using previously published methods. The average disability duration for an injured construction worker was 46 days with a median of 0 days. The most frequently occurring conditions were low back pain (14.8%), foreign body eye injuries (8.5%), and finger lacerations (4.8%). Back pain also accounted for the greatest percentage of construction claim costs (21.3%) and disability days (25.5%). However, the conditions with the longest disability durations were sudden-onset injuries, including fractures of the ankle (median = 55 days), foot (42 days), and wrist (38 days). Same-level and elevated falls were the principal exposures for fractures of the wrist and ankle, whereas elevated falls and struck by incidents accounted for the majority of foot fractures. Manual materials handling activities were most often associated with low back pain disability. The results suggest that these most disabling injuries can be addressed by increasing primary prevention resources in slips and falls and exposures related to injuries of sudden-onset as well as in reducing manual materials handling and other exposures associated with more gradual-onset injuries.
Coverage of work related fatalities in Australia by compensation and occupational health and safety agencies.
- Driscoll T, Mitchell R, Mandryk J, Healey S, Hendrie L, Hull B. Occup Environ Med 2003; 60(3): 195-200.
Correspondence: T R Driscoll, Elmatom Pty Ltd, 49 Taleeban Road, Riverview, NSW 2066, AUSTRALIA; (email: elmatom@optushome.com.au).
OBJECTIVE: To determine the levels of coverage of work related traumatic deaths by official occupational health and safety (OHS) and compensation agencies in Australia, to allow better understanding and interpretation of officially available statistics.
METHODS: The analysis was part of a much larger study of all work related fatalities that occurred in Australia during the four year period 1989 to 1992 inclusive and which was based on information from coroners' files. For the current study, State, Territory, and Commonwealth OHS and compensation agencies were asked to supply unit record information for all deaths identified by the jurisdictions as being due to non-suicide traumatic causes and which were identified by them as being work related, using whatever definitions the agencies were using at the relevant time. This information was matched to cases identified during the main study.
FINDINGS: The percentage of working deaths not covered by any agency was 34%. Only 35% of working deaths were covered by an OHS agency, while 57% were covered by a compensation agency. The OHS agencies had minimal coverage of work related deaths that occurred on the road (to workers (8%) or commuters (3%)), whereas the compensation system covered these deaths better than those of workers in incidents that occurred in a workplace (65% versus 53%). There was virtually no coverage of bystanders (less than 8%) by either type of agency. There was marked variation in the level of coverage depending on the industry, occupation, and employment status of the workers, and the type of injury event involved in the incident.
DISCUSSION: When using data from official sources, the significant limitations in coverage identified in this paper need to be taken into account. Future surveillance, arising from a computerised National Coroners Information System, should result in improved coverage of work related traumatic deaths in Australia.
Neighborhood environment, racial position, and risk of police-reported domestic violence: a contextual analysis.
- Pearlman DN, Zierler S, Gjelsvik A, Verhoek-Oftedahl W. Public Health Rep 2003; 118(1): 44-58.
Correspondence: Deborah N. Pearlman, Dept. of Community Health and Center for Gerontology and Health Care Research, Brown Univ., 2 Stimson Ave., Box G-ST 103, Providence, RI 02912 USA; (email:deborah_pearlman@brown.edu).
OBJECTIVES: The purpose of this study was to examine the contribution of neighborhood socioeconomic conditions to risk of police-reported domestic violence in relation to victim's race. Data on race came from police forms legally mandated for the reporting of domestic violence and sexual assault.
METHODS: Using 1990 U.S. census block group data and data for the years 1996-1998 from Rhode Island's domestic violence surveillance system, the authors generated annual and relative risk of police-reported domestic violence and estimates of trends stratified by age, race (black, Hispanic, or white), and neighborhood measures of socioeconomic conditions. Race-specific linear regression models were constructed with average annual risk of police-reported domestic violence as the dependent variable.
FINDINGS: Across all levels of neighborhood poverty (< 5% to 100% of residents living below the federal poverty level), the risk of police-reported domestic violence was higher for Hispanic and black women than for white women. Results from the linear regression models varied by race. For black women, living in a census block group in which fewer than 10% of adults ages > or = 25 years were college-educated contributed independently to risk of police-reported domestic violence. Block group measures of relative poverty (> or = 20% of residents living below 200% of the poverty line) and unemployment (> or = 10% of adults ages > or = 16 years in the labor force but unemployed) did not add to this excess. For Hispanic women, three neighborhood-level measures were significant: percentage of residents living in relative poverty, percentage of residents without college degrees, and percentage of households monolingual in Spanish. A higher degree of linguistic isolation, as defined by the percentage of monolingual Spanish households, decreased risk among the most isolated block groups for Hispanic women. For white women, neighborhood-level measures of poverty, unemployment, and education were significant determinants of police-reported domestic violence.
DISCUSSION: When data on neighborhood conditions at the block group level and their interaction with individual racial position are linked to population-based surveillance systems, domestic violence intervention and prevention efforts can be improved.
Effects of the characteristics of neighbourhoods and the characteristics of people on cause specific mortality: a register based follow up study of 252 000 men.
Correspondence: P. Martikainen, Population Research Unit, Department of Sociology, University of Helsinki, Finland International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, UK; (email: unavailable).
OBJECTIVE: To assess the strength of the associations between neighbourhood characteristics and mortality, after adjusting for individual characteristics.
DESIGN AND SETTING: 1990 census records of over 25 year old men in the Helsinki Metropolitan area linked to death records in 1991-1995; almost 1.22 million person years and 15 000 deaths. Individual characteristics were education, occupation based social class, housing tenure, housing density, and living arrangements. Proportion of manual workers, proportion of over 60 year olds, and social cohesion were measured for 55 small areas, and SAS Glimmix was used to fit multilevel models.
FINDINGS: Men in areas with high proportion of manual workers and low social cohesion have high mortality, particularly among 25-64 year olds. About 70% of this excess mortality is explained by compositional differences of people living in these areas. Accidents and violence, circulatory diseases, and alcohol related causes contribute most to these area effects. Area characteristics do not consistently modify or mediate the effects of individual socioeconomic characteristics on mortality.
DISCUSSION: As compared with individual characteristics neighbourhood characteristics have modest independent effects on male mortality. Furthermore, individual socioeconomic characteristics are associated with mortality independently of area characteristics. Rather than the characteristics of areas, other social contexts, such as peer groups and family settings may be more fruitful targets for further research and policy on contextual effects on mortality.
Severe ocular injuries in Greek children.
- Mela E, Georgakopoulos C, Georgalis A, Koliopoulos J, Gartaganis S. Ophthalmic Epidemiol 2003; 10(1): 23-29.
Correspondence: E. Mela, Department of Ophthalmology, University of Patras Medical School, Patras, GREECE; (email: unavailable).
Objective: To determine the epidemiological characteristics of severe eye injuries in childhood, in a mixed urban and rural Greek setting.
Methods: Retrospective analysis of 95 cases (103 eyes) of eye injuries in children younger than 17 years of age admitted to the Department of Ophthalmology, University Hospital of Patras, Greece,during a five-year period. The data were analyzed with respect to age, sex, type, cause and mode of injury, method of management, duration of hospitalization and final visual deficit.
Findings: The average age was 9.8 years and males were involved in 80% of the cases. The most common type of eye injury was mechanical closed-globe injury (71.8%). Mechanical open-globe injuries were found in 21.3% of the eyes, while burns comprised 6.7% of the injuries. Most injuries were agent-related, with blows and falls being responsible most often. Multiple operations were part of the treatment in 11.6% of the eyes; 14.5% of the eyes were blinded and 15.5% had significant final visual acuity loss.
Discussion: These hospital-based data suggest that there is a need for health education of both parents and children, since some injuries in children could easily have been prevented.
Etiology of traumatic brain injury: characterization of differential outcomes up to 1 year postinjury.
Correspondence: Tamara Bushnik, Rehabilitation Research Center and Deptartment of PM&R,Santa Clara Valley Medical Center, San Jose, CA 95128, USA; (email: tamara@tbi-sci.org).
OBJECTIVE: To characterize outcomes after traumatic brain injury (TBI) resulting from vehicular crashes, violence, falls, or other causes.
DESIGN: Prospective, multicenter, longitudinal.
SETTING: Seventeen Traumatic Brain Injury Model Systems.
PARTICIPANTS: A total of 1,170 individuals with moderate to severe TBI with data from initial medical and rehabilitation stays and 1-year follow-up.
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURES: At rehabilitation discharge, FIM instrument, Disability Rating Scale (DRS), and Rancho Los Amigo Levels of Cognitive Functioning Scale. At 1 year postinjury, FIM, DRS, Community Integration Questionnaire (CIQ), employment, residence, marital status, and seizure occurrence.
FINDINGS: The 4 etiology groups could be distinguished based on premorbid characteristics. Severity of injury indices indicated that individuals in vehicular crashes showed a trend toward incurring more severe injuries than the other 3 groups. At rehabilitation discharge, there were no functional differences between groups. At 1 year postinjury, the groups could be differentiated: individuals in violence-related TBI had higher unemployment rates and lower CIQ scores; persons in vehicular crashes reported the best functional and psychosocial outcomes; and individuals in the falls and other groups had outcomes lying between the vehicular and violence groups.
DISCUSSION: This study elucidated important differences between persons with violence-related TBI and those with non-violence-related TBI. Further research is needed to find effective interventions to address these differences.
A Population-Based Analysis of Socioeconomic Status and Insurance Status and Their Relationship With Pediatric Trauma Hospitalization and Mortality Rates.
- Marcin JP, Schembri MS, He J, Romano PS. Am J Public Health 2003; 93(3): 461-466.
Correspondence: James P. Marcin, Department of Pediatrics, Section of Critical Care Medicine, 2516 Stockton Blvd, Sacramento, CA 95817 USA; (e-mail: jpmarcin@ucdavis.edu).
OBJECTIVES: We investigated socioeconomic disparities in injury hospitalization rates and severity-adjusted mortality for pediatric trauma.
METHODS: We used 10 years of pediatric trauma data from Sacramento County, Calif, to compare trauma hospitalization rates, trauma mechanism and severity, and standardized hospital mortality across socioeconomic strata (median household income, proportion of households in poverty, insurance).
FINDINGS: Children from lower-socioeconomic status (SES) communities had higher injury hospitalization and mortality rates, and presented more frequently with more lethal mechanisms of injury (pedestrian, firearm), but did not have higher severity-adjusted mortality.
DISCUSSION: Higher injury mortality rates among children of lower SES in Sacramento County are explained by a higher incidence of trauma and more fatal mechanisms of injury, not by greater injury severity or poorer inpatient care.
Neighborhood Physical Conditions and Health.
- Cohen DA, Mason K, Bedimo A, Scribner R, Basolo V, Farley TA. Am J Public Health 2003; 93(3): 467-471.
Correspondence: Deborah A. Cohen, RAND Corporation, 1700 Main St, Santa Monica, CA 90405 USA; (e-mail: dcohen@rand.org).
OBJECTIVES: We explored the relationship between boarded-up housing and rates of gonorrhea and premature mortality.
METHODS: In this ecological study of 107 US cities, we developed several models predicting rates of gonorrhea and premature death before age 65 from all causes and from specific causes. We controlled for race, poverty, education, population change, and health insurance coverage.
FINDINGS: Boarded-up housing remained a predictor of gonorrhea rates, all-cause premature mortality, and premature mortality due to malignant neoplasms, diabetes, homicide, and suicide after control for sociodemographic factors.
DISCUSSION: Boarded-up housing may be related to mortality risk because of its potential adverse impact on social relationships and opportunities to engage in healthful behaviors. Neighborhood physical conditions deserve further consideration as a potential global factor influencing health and well-being.
Suicidal explosions that lack a terrorist background are only rarely encountered in the field of forensic pathology. The investigation of explosion-related fatalities can be a substantial challenge in medicolegal casework. Determining whether the manner of death is suicide, homicide, or accident in such cases can present an especially difficult task to the forensic pathologist. This study considers the pathologic features of suicidal deaths caused by explosives without a terrorist background. The modus operandi of the decedents reflected familiarity and proficiency, or at least a degree of specialized knowledge, with the construction and use of explosive devices. All explosions were set off in confined spaces. The injury patterns consisted of a combination of primary blast injuries (e.g. decapitation, traumatic amputation of limbs, gross lacerations of the body surface, blast injuries of gas-containing and hollow organs), secondary blast injuries (e.g. splinter-induced penetrating trauma), tertiary blast injuries (e.g. abrasions and contusions), and burn injuries (mostly of the flash type). The previously described symmetric distribution pattern of injuries in suicidal explosions was apparent only to a certain degree in the present series. Our observation of superficially sharp-edged wound margins with bridging in the depths of the lesion in blast-induced lacerations of the skin should deserve further attention in forthcoming cases of explosion-related fatalities because this finding is a diagnostic possibility that may support the theory of an explosion-related fatality under special circumstances, e.g. when the body has been dumped away from the place of death. Because a terrorist attack may be initially suspected in each case of suicide involving explosives, the importance of a joint inquiry based on expertise from police investigators, bomb experts, and forensic pathologists is evident.
A cross-cultural investigation of the communication of suicidal intent in Swedish and Turkish adolescents.
A recent study found that Swedish adolescents were more disapproving of a suicidal disclosure by a fictional friend than their Turkish counterparts. Given this finding, the present study investigated whether or not more adolescents in Turkey than in Sweden disclose their own suicidal thoughts to someone, to whom adolescents disclose their suicidal thoughts, what reactions such disclosures produce, and reasons for not disclosing suicidal feelings among 966 Swedish and 956 Turkish high school students. A questionnaire was used to collect information about different aspects of suicidal disclosures. More Turkish than Swedish adolescent suicide ideators disclosed their thoughts. More Turkish than Swedish students believed also that young people thinking about and planning suicide tell others of their plans and thereby ask for help. An overwhelming majority of adolescents in both groups revealed their thoughts to peers. The social reactions to suicidal disclosures in both samples were mainly positive. The two most common reasons for not disclosing in both groups involved interpersonal hopelessness. Adolescents who disclosed their past suicidal thoughts to someone reported having lower current suicidal ideation than those who had not. In line with favorable social attitudes towards suicidal disclosures and lower suicidal mortality rates in Turkey compared with Sweden, more Turkish than Swedish adolescents reported having disclosed their own suicidal thoughts to someone in their social milieu.
Predicting repeat self-harm in children. How accurate can we expect to be?
Correspondence: Prathiba Chitsabesan, The University Department of Child and Adolescent Psychiatry, Central Manchester and Manchester Children's University Hospitals, Hospital Road, Pendlebury, Manchester, M27 4HA, UK; (email: unavailable).
The main objective of the study was to find which variables predict repetition of deliberate self-harm in children. The study is based on a group of children who took part in a randomized control trial investigating the effects of a home-based family intervention for children who had deliberately poisoned themselves. These children had a range of baseline and outcome measures collected on two occasions (two and six months follow-up). Outcome data were collected from 149 (92 %) of the initial 162 children over the six months. Twenty-three children made a further deliberate self-harm attempt within the follow-up period. A number of variables at baseline were found to be significantly associated with repeat self-harm. Parental mental health and a history of previous attempts were the strongest predictors. A model of prediction of further deliberate self-harm combining these significant individual variables produced a high positive predictive value (86 %) but had low sensitivity (28 %). Predicting repeat self-harm in children is difficult, even with a comprehensive series of assessments over multiple time points, and we need to adapt services with this in mind. We propose a model of service provision which takes these findings into account.
On November 5-7, 2002, the Symposium on Graduated Driver Licensing in Chatham, MA, brought together 75 researchers and practitioners from the United States, Canada, Australia, and New Zealand to document the current science of graduated driver licensing (GDL) and to outline research needs. Participants reviewed 12 background papers and discussed the papers in depth. The symposium's background papers are published in this issue of the Journal of Safety Research.This paper summarizes and provides a quick reference to information from the symposium papers and participant discussions. It cites the 12 symposium papers, which in turn provide more information and cite original sources. Issues and recommendations not followed by a citation were raised in the symposium discussions.This paper is divided into seven sections. The first six sections summarize information from the symposium papers and discussions. The sections are: (1) The need for graduated driver licensing; (2) Effectiveness of GDL as implemented; (3) The learner's permit phase; (4) The provisional license phase; (5) The roles of teens, parents, and public agencies; and (6) Enacting and implementing GDL. In each of these six sections, research needs are classified as either high priority (important for designing and implementing effective GDL programs) or lower priority (useful but not critical for GDL at this time).The final section summarizes the discussion of research issues and priorities from the symposium's closing session. This section has three topics: general research, issues involving parents, and issues involving graduated licensing legislation and implementation. It presents participants' collective views on both broad priorities and specific issues.In providing a concise summary of presentations and discussions from the symposium, this paper necessarily omits some information and points of discussion. The views and judgments expressed are the authors' best attempt to capture the symposium's consensus, but they do not necessarily represent the views of the authors, their organizations, or any other individual symposium participant. In particular, they are not necessarily endorsed by the symposium's sponsors: General Motors, the National Highway Traffic Safety Administration, the National Safety Council, and Nationwide.
Intimate partner violence and drinking: new research on methodological issues, stability and change, and treatment.
- Caetano R, Schafer J, Fals-Stewart W, O'Farrell And T, Miller B. Alcohol Clin Exp Res 2003; 27(2): 292-300.
Correspondence: Raul Caetano,University of Texas School of Public Health, 5323 Harry Hines Boulevard, Room V8.112; Dallas, TX 75390-9128 USA; (email: raul.caetano@utsouthwestern.edu.).
This article represents the proceedings of a symposium at the 2002 RSA meeting in San Francisco, California. The presentations were (1) Assessing couples' agreement about alcohol involvement in intimate partner violence, by John Schafer; (2) The occurrence of partner physical aggression on days of alcohol consumption: a longitudinal diary study, by Williams Fals-Stewart; (3) The 5-year stability of intimate partner violence and drinking among White, Black, and Hispanic couples, by Raul Caetano; (4) Partner violence before and after individually-based alcoholism treatment for male alcoholic patients, by Timothy O'Farrell. The discussant was Brenda Miller.
Diverse research on alcohol and aggression in humans.
- Giancola PR, White HR, Berman ME, McCloskey MS, Greer TF, Widom CS, Chermack ST, Leonard KE, Collins And RL, Quigley BM. Alcohol Clin Exp Res 2003; 27(2): 198-208.
Correspondence: Peter R. Giancola, Department of Psychology, University of Kentucky, 115 Kastle Hall, Lexington, KY 40506-0044 USA; (email: peter@uky.edu).
This article summarizes the proceedings of a symposium, chaired and co-organized by Helene Raskin White and co-organized by Peter R. Giancola, that was presented at the 2002 RSA Meeting in San Francisco. The goal of this symposium was to integrate findings from methodologically divergent studies on the topic of alcohol-related aggression in humans. The investigators focused on isolating mediators and moderators of the alcohol-aggression relationship. Peter R. Giancola presented laboratory data demonstrating how alcohol's acute effects on aggression are moderated by individual difference and contextual factors. Mitchell E. Berman presented laboratory data on alcohol's acute effects on self-induced aggression. Helene Raskin White reviewed prospective data on how alcohol affects the intergenerational transmission of family violence. Stephen Chermack reviewed data on the impact of a family history of alcoholism and a family history of violence on the development of childhood behavioral problems and adult problems with drugs, alcohol, and violence. Finally, Kenneth E. Leonard presented data on personal and contextual factors influencing alcohol-related barroom violence.
The prevalence of PTSD following the violent death of a child and predictors of change 5 years later.
- Murphy SA, Johnson LC, Chung IJ, Beaton RD. J Trauma Stress 2003; 16(1): 17-25.
Correspondence: S.A. Murphy, Department of Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, Washington 98195-7263, USA; (email: Samurphy@u.washington.edu).
In this study, we examined the violent death bereavement trajectories of 173 parents by following them prospectively for 5 years after their children's deaths by accident, suicide, homicide, or undetermined causes. Using latent growth curve methodology, we examined how the initial level of PTSD and the rate of change over time were influenced by 9 predictors: the deceased children's causes of death, parents'gender, self-esteem, 3 coping strategies, perceived social support, concurrent levels of mental distress, and an intervention offered in early bereavement. Six of the nine factors predicted initial levels of PTSD; however, only parents' gender and perceived social support predicted change in PTSD over the 5-year time frame. Five years postdeath, 3 times as many study mothers (27.7%) met diagnostic criteria for PTSD and twice as many study fathers (12.5%) met diagnostic criteria for PTSD compared with the normative samples.
Anger, aggression, risky behavior, and crash-related outcomes in three groups of drivers.
- Deffenbacher JL, Lynch RS, Filetti LB, Dahlen ER, Oetting ER. Behav Res Ther 2003; 41(3): 333-349.
Correspondence: J. L. Deffenbacherb, Department of Psychology and Tri-Ethnic Center for Prevention Research, Colorado State University, 80523-1876, Fort Collins, Co, USA; (email: jld6871@lamar.colostate.edu).
High anger drivers who acknowledged problems with driving anger and were interested in treatment were compared to high and low anger drivers who did not acknowledge problems with driving anger or want treatment. Although high anger drivers who acknowledged problems reported greater anger on two measures than high anger drivers who did not acknowledge problems, both high anger groups tended not to differ from one another and were more frequently and intensely angered when driving, reported more aggressive and less adaptive/constructive forms of expressing anger while driving, engaged in more aggressive and risky behavior on the road, and experienced more of some accident-related outcomes than low anger drivers. High anger groups did not differ from each other, but reported more trait anxiety and anger and more outward negative and less controlled general anger expression than the low anger group. The two groups of high anger drivers, however, require different types of interventions given their state of readiness for driving anger reduction. Results were also interpreted as supportive of the state-trait model of anger and construct validity of the Driving Anger Scale.
