OBJECTIVE: To assess whether low blood alcohol concentrations (BACs), at around half the UK legal driving limit, and undetectable by police roadside breathalysers, further impair driving already affected by sleepiness, particularly in young men, who are the most "at risk" group of drivers for having sleep related crashes.
METHODS: Twelve healthy young men drove for two hours in the afternoon, in an instrumented car on a simulated motorway. In a repeated measures, counterbalanced design, they were given alcohol or placebo under conditions of normal sleep or prior sleep restriction. Measurements were: driving impairment (lane drifting), subjective sleepiness, and EEG measures of sleepiness.
FINDINGS: Whereas sleep restriction and alcohol each caused a significant deterioration in all indices, the combined alcohol and sleep restriction further and significantly worsened lane drifting (which typifies sleep related crashes). This combined effect was also reflected to a significant extent in the EEG, but not with subjective sleepiness. That is, alcohol did not significantly increase subjective sleepiness in combination with sleep loss when compared with sleep loss alone.
COMMENTS: Modest, and apparently "safe" levels of alcohol intake exacerbate driving impairment due to sleepiness. The sleepy drivers seemed not to have realized that alcohol had increased their sleepiness to an extent that was clearly reflected by a greater driving impairment and in the EEG.
Strong repeat alcohol offender laws reduce crashes and injuries involving recidivists: evidence from Michigan.
Correspondence: David W. Eby, University of Michigan Transportation Research Institute, Social and Behavioral Analysis Division, USA; (email: eby@umich.edu).
On July 11, 1991, the Michigan legislature passed a set of bills designed to reduce the incidence of people driving while drunk or impaired. The underlying theme of this drunk and impaired driving package was to ensure expedient and potent sanctions to those arrested for driving while drunk or impaired. The University of Michigan Transportation Research Institute (UMTRI) conducted an evaluation of the impact and effectiveness of these laws during the first 2 years of implementation (Streff & Eby, 1994). We found that courts were implementing the laws and sanctions as intended, and that the laws appeared to reduce alcohol-involved traffic fatalities by as much as 25 percent. Unfortunately, the study also found that an estimated 30 to 70 percent of people with a suspected license drove at least some of the time during their sanction period and that this package of laws had little effect on reducing the incidence of repeat drunk driving.
Correspondence: Stephen B. Thacker, Epidemiology Program Office, MS C08, Centers for Disease Control and Prevention, Atlanta, GA 30333 (e-mail: sbt1@cdc.gov).
More young people in the United States aged 1-34 years die from injuries than from all other causes of death combined. Injuries, the fourth leading cause of death, kill nearly 150,000 US residents each year. They account for approximately 25 percent of all premature deaths before age 65 years in this country, 10 times the number of premature deaths from the human immunodeficiency virus. Injuries are responsible for an even greater burden when morbidity and disability are measured. For example, 30 million US citizens are treated in emergency departments annually for injuries, and injuries account for nearly 8 percent of hospital discharges. The World Health Organization projects that by the year 2020, traffic injuries alone will become the sixth leading contributor to disability-adjusted life-years worldwide.
Yet, injury prevention and control are not considered the public health problem that these statistics demonstrate. In the average morning newspaper, national public health coverage focuses on emerging issues such as severe acute respiratory syndrome and acquired immunodeficiency syndrome and, more recently, on cancer, obesity, and other chronic conditions. Local news coverage, on the other hand, features intimate partner violence, murder, suicide, teen car crashes, and fires in the home; injuries remain a local issue and are not seen in a broader public health context. Similarly, epidemiologists do not regard injury prevention as a field that offers career opportunities such as those for cancer, heart disease, or infectious diseases. Our research interests may be driven by the availability of dollars, not by data. Epidemiologists have a critical role in describing these problems, conducting studies to determine what prevention interventions work, and helping the media, policy makers, and ultimately the public appreciate the impact of injuries. An important public health goal is for society to understand that we cannot afford the human and monetary costs of injuries; we must invest in their prevention.
People around the world continue to accept injury as a necessary evil, an unavoidable fact of life. We, as epidemiologists, need to make the message on public health clearer - that injury is no more a necessary part of life than polio, measles, and other vaccine-preventable diseases. Just as diarrhea, tuberculosis, and other infections were eliminated as leading causes of death in the last century, injury, "the last major plague of the young," can be reduced as a health burden on society. Epidemiologists have a critical role in meeting this challenge. This special volume provides a glimpse of the avenues open to epidemiologists to do their part to make this a safer world.
Additional reviews from this special issue of Epidemiologic Reviews will be summarized in the next several SafetyLit updates.
Back to the future: revisiting Haddon's conceptualization of injury epidemiology and prevention.
Correspondence: Carol W. Runyan, The University of North Carolina Injury Prevention Research Center, Bank of America Building, Suite 500, CB 7505, 137 East Franklin Street, Chapel Hill, NC 27599-7505 (e-mail: carol_runyan@unc.edu).
Critiques of contemporary epidemiology have addressed the increasing gap between its scientific foundations and its contribution to the practice of public health. This debate has also addressed the value of using theory and conceptual models to guide both research and practice. Although seemingly unrecognized in this recent debate, Dr. William Haddon, Jr., widely considered the father of modern injury epidemiology, raised very similar issues some 35-40 years ago as he argued for both a more scientifically driven approach to injury control and also developed two complementary conceptual frameworks to guide epidemiologic research and prevention practice. This paper examines Haddon's advances from both a theoretical and a practical perspective and demonstrates the applicability of his approach not only to injury problems but also to other public health issues.
Correspondence: Jean Simpson, Injury Prevention Research Unit, University of Otago, P.O. Box 913, Dunedin, NEW ZEALAND; (email: jean.simpson@ipru.otago.ac.nz).
CONTEXT: It has been argued that developing community projects is an effective means by which to reduce injury. Two pilot community injury prevention projects (CIPPs) were established in small communities in New Zealand based on the World Health Organization (WHO) Safe Community model.
OBJECTIVES: The process and impact of the implementation of these CIPPs was monitored over 3 years.
METHODS: The setting was two small New Zealand communities with populations of < 10,000. An external process and impact evaluation was conducted, with data gathered from written documentation, informant interviews and observation. The WHO Safe Community criteria formed the basis of the evaluation framework used. Other essential factors included were identified through the literature and the projects themselves. Findings from each CIPP were considered independently, followed by an examination of the differences observed.
FINDINGS: The findings from the evaluation of the implementation of these CIPPs are reported in relation to the themes identified in the evaluation framework, namely: community context, ownership and participation, focus and planning, data collection, leadership, management, sustainability and external links. Despite the different contexts, a common conclusion was that if the CIPPs' success was dependent on achieving a meaningful reduction of injury, they were unlikely to succeed. There were, however, a number of strategies and outputs for achieving change that could contribute to increasing safety for the population of interest. These were closely linked to community development strategies and needed greater acknowledgement in the evolution of the CIPPs.
COMMENTS: Critical to the development of the CIPPs were community capacity and the context in which the projects were operating. These conclusions are likely to apply to other projects in such settings, irrespective of the health outcomes sought.
Correspondence: Frank I. Ross, Department of Academic Surgery, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, AUSTRALIA, (email: FrankR@CHW.edu.au).
or
Danny T. Cass, Trauma Research Unit, Australian Paediatric Surveillance Unit, The Children's Hospital at Westmead and Department of Paediatrics and Child Health, University of Sydney, New South Wales, AUSTRALIA; (email: dannyc@chw.edu.au).
OBJECTIVE: To characterize children aged under 5 years who present to pediatricians following near-drowning and the circumstances surrounding the event, identify high-risk groups and document short-term outcome.
METHODS: Monthly notifications to the Australian Paediatric Surveillance Unit (an active, national surveillance system) between 1994 and 1996. Collection of additional case information from reporting doctors by postal questionnaire.
FINDINGS: All 169 reported cases of near-drowning were admitted to hospital (mean (SD) stay 6 (17) days) and 15% required intensive care (mean (SD) stay 19 (32) days). The mean (SD) age for near drowning was 26 (13) months and 22% children were aged between 12 and 18 months. Males predominated (1.6:1) and 69 (41%) of episodes occurred in summer (December - February). The majority (82%) of near-drownings occurred in the child's home, usually in a swimming pool or bath. Children who nearly drowned at home were significantly younger than those who nearly drowned in natural waterways or public pools. Neurological damage at discharge following near-drowning was reported in 7%.
COMMENTS: Children reported in this national case series represent the severe end of the spectrum of those who nearly drown, as indicated by their presentation to a pediatrician, universal hospitalization and adverse neurological outcome. The home is the site of most near-drownings and males and toddlers were at particular risk. Unimpeded access to pools and lack of supervision were identified as potentially modifiable factors for prevention. The study suggests the need for additional community education regarding the risks of near-drowning and for further research on long-term neuro-developmental outcomes following near-drowning.
Age related differences in work injuries and permanent impairment: a comparison of workers' compensation claims among adolescents, young adults, and adults.
- Breslin C, Koehoorn M, Smith P, Manno M. Occup Environ Med 2003; 60(9): E10.
Correspondence: C. Breslin, Institute for Work & Health, Toronto, Ontario, CANADA; (email: cbreslin@iwh.on.ca).
CONTEXT: There is growing evidence that adolescent workers are at greater risk for work injury.
OBJECTIVE: To investigate the severity of work injuries across age groups.
METHODS: Workers' compensation records were used to examine work related injuries among adolescents (15-19 years old), young adults (20-24 years old), and adults (25+ years old) between 1993 and 2000. The incidence of compensated injuries was calculated for each age group and compared by gender, industry, and type of injury. The presence and degree of permanent impairment in each age group was also examined.
FINDINGS: For males, adolescents and young adults had higher claim rates than adults. For females, adults had the highest claim rates and young adults the lowest. Rates of permanent impairment indicated that age was positively associated with severity of injury.
COMMENTS: Indicators of health consequences, in particular presence of permanent impairment, provide preliminary evidence that compensated work injuries sustained by youth are not as serious as injuries sustained by adults. Nevertheless, there was evidence that some young workers sustain injuries that have long term consequences. Documenting the consequences of the injuries that young workers sustain has implications for secondary prevention efforts and health services policy.
Relationships of job, age, and life conditions with the causes and severity of occupational injuries in construction workers.
- Chau N, Gauchard GC, Siegfried C, Benamghar L, Dangelzer JL, Francais M, Jacquin R, Sourdot A, Perrin PP, Mur JM. Int Arch Occup Environ Health 2003; [Epub ahead of print].
Correspondence: Nearkasen Chau, Faculte de Medecine, National Institute for Health and Medical Research (INSERM), Unit 420, BP 184, 54505, Vandoeuvre-les-Nancy Cedex, FRANCE; (email: chau@u420.nancy.inserm.fr).
OBJECTIVES: To assess the relationships of job, age, and life conditions with the causes and severity of occupational injuries in male construction laborers.
METHODS. The sample included 880 male construction workers having had at least one occupational injury with subsequent sick leave. The survey used a standardized questionnaire, filled in by the occupational physician in the presence of the subject: socio-demographic data, job, safety training, smoking habit, alcohol consumption, sporting activities, physical disabilities, hearing, vision, and sleep disorders. Statistical analysis was via the logistic regression method.
FINDINGS: Logistic models showed that falls and injuries from the handling of objects or hand tools was similar for all jobs, while masons, plumbers and electricians had a higher risk of injury from moving objects, and carpenters, roofers and civil-engineering workers were more exposed to injury from construction machinery and devices. Age <30 was related to injury from hand tools [adjusted OR (95%CI) 2.20 (1.28-3.79)]; sleep disorders and hearing disorders to those from moving objects [ORs 2.29 (1.27-4.12) and 1.85 (1.01-3.41) respectively]; no sporting activity to those from the handling of objects [OR 1.54 (1.09-2.17)]; and being overweight to falls on the same level [OR 2.04 (1.30-3.21)] and falls to a lower level [OR 1.55 (1.13-2.13)]. Injuries from the handling of objects were less frequent in overweight workers [OR 0.62 (0.46-0.84)]. Injuries with hospitalization or sick leave >/=60 days were associated with age >/=30 and hearing disorders.
COMMENTS: The causes of injuries were related to jobs. Prevention through working conditions could be made against the revealed risks. The risks for each worker depended on age, body mass index, hearing disorders, sleep disorders, and sporting activities. The occupational physician could inform the workers of these risks and encourage them to practise sporting activities and reduce their hearing disorders and sleep disorders.
Flame burn protection: assessment of a new, air-cooled fireproof garment.
Eldad A, Salmon AY, Breiterman S, Chaouat M, BenBassat H. Mil Med 2003; 168(8): 595-599.
Correspondence: Arieh Eldad, The Department of Plastic Surgery and the Burn Unit, Hadassah University Hospital, Jerusalem, 91904 ISRAEL; (email: eldada@cc.huji.ac.il).
A new, air-cooled fireproof garment for tank crewmen was assessed regarding its efficacy for burn protection. A pig model was developed with a flame infliction instrument specially designed for this experiment. This pneumatic tool can initiate eight simultaneous flame injuries where the distance of skin from burn source and exposure time are adjustable. In the study, 1,000 degrees C, 5-second exposure flame burns were inflicted upon anesthetized pigs. Full-thickness injuries were caused to exposed animals or to animals that were protected by the single layer of old type Nomex protective garments. On day 21, the original burn size diminished to 42.3% +/- 6.3% and 41.2% +/- 7.9%, respectively. When the animals were dressed with the new type of air-cooled Nomex, only small and superficial burns could be detected when the air compressor was operating, and moderate burns were demonstrated when the compressor was not working. On day 21, postburn original burn size was diminished to 1.9% +/- 1.9% and to 17% +/- 6.5%, respectively. Quantitative burn wound histology followed the same trends with almost normal skin architecture after 7 days in the air-inflated new garments, moderate pathology, and an advanced wound healing process in the affected area when the compressor was not working and severe damage with only initial wound healing in the exposed skin or the areas that were protected by old type, single-layered fireproof garments. This new type of air-cooled fireproof garment was significantly better than the old garment under the experiment condition and seems to be very promising in burn prevention among tank crewmen.
To clarify the difference between flat-front vehicles and bonnet-front vehicles with regard to the patterns and mechanisms of vehicle-induced pedestrian injuries, we investigated 101 cases of pedestrians who were struck by the front of a vehicle. There were 33 flat-front vehicle collision cases and 68 bonnet-front vehicle collision cases. The frequency of chest injuries in flat-front vehicle collisions (30.3%) was significantly higher than that in bonnet-front vehicle collisions (11.8%). Lower leg fractures were more common in bonnet-front vehicle collisions than in flat-front vehicle collisions. Although head injuries were common in both cases, the mechanisms of these injuries differed. The pedestrians who were struck by flat-front vehicles tended to sustain more severe injuries at lower impact speeds. All of these results stem from the difference in the front shape of the two types of vehicle. Pedestrians who are struck by the front of flat-front vehicles receive the impact force to the trunk, particularly the chest, at the initial impact and are thrown out forward after the impact, because the front of these vehicles is perpendicular to the road.
Child and adult pedestrian impact: the influence of vehicle type on injury severity.
In the United States, the vehicle fleet is shifting from predominantly passenger cars (automobiles) to SUVs, light trucks, and vans (LTV). This study investigates how pedestrian severe injury and mortality are associated with vehicle type and pedestrian age. The Pedestrian Crash Data Study (PCDS) database for years 1994-1998 was used for a cross-sectional study design. Outcome measures were Injury Severity Score, Maximum Abbreviated Injury Score, Abbreviated Injury Scale, Pedestrian Mortality, Functional Capacity Index and Life Years Lost to Injury. Compared to children, adult pedestrians were more likely to sustain severe injury (OR = 2.81; 95% CI: 1.56-5.06) or mortality (OR = 2.91; 95% CI: 1.10-7.74) when examining all vehicle types. However, after adjusting for vehicle type and impact speed, this association was not statistically significant at p < 0.05. Compared to passenger cars, pedestrians struck by LTV were more likely to have severe injuries (OR = 1.31; 95% CI: 0.88-1.94) or mortality (OR = 1.40; 95% CI: 0.84-2.34) for all pedestrians. Adjusting for pedestrian age, this association was more obvious and significant at lower impact speeds ( </= 30 km/h); odds ratios of severe injury and mortality were 3.34 (p< 0.01) and 1.87 (p= 0.07), respectively. Adults hit by LTV had the highest risk of injury and mortality. These findings indicate that pedestrian age, vehicle engineering design and impact speed are highly contributing to risks of pedestrian injury and mortality.
Rural and urban fatal pedestrian crashes among United States American Indians and Alaskan Natives.
Correspondence: Jonathan LaValley, University of New Mexico, Department of Emergency Medicine, Albuquerque, New Mexico, USA; (email: JLaValley@salud.unm.edu).
The Fatality Analysis Reporting System (FARS) and the Web-based Injury Statistics Query and Reporting System (WISQARS) were used to compare fatal pedestrian crashes in American Indians and Alaskan Natives (AI/AN) between urban and rural locations for 2000-2001. There were significant differences between urban and rural crashes for driver, pedestrian, environmental, and engineering factors. Rural pedestrian crashes more often occurred on highways (p<0.0001) lacking traffic control devices (p<0.0001) and artificial lighting (p<0.0001). Alcohol was a significant cofactor in both environments (40% urban vs. 55% rural; p=0.0239). Prevention of AI/AN deaths should include engineering countermeasures specific to the needs of rural (lighting) and urban (medians with barriers) environments and address drinking behavior in both populations.
Behavioral accident avoidance science: understanding response in collision incipient conditions.
Hancock PA, De Ridder SN. Ergonomics 2003; 46(12): 1111-1135.
Correspondence: Peter A. Hancock, Department of Psychology, University of Central Florida, 411 Phillips Hall, P.O. Box 161390, Orlando, FL 32816-1390, USA; (email: phancock@pegasus.cc.ucf.edu).
CONTEXT: Road traffic accidents are the single greatest cause of fatality in the workplace and the primary cause of all accidental death in the US to the age of 78. However, behavioral analysis of response in the final seconds and milliseconds before collision has been a most difficult proposition since the quantitative recording of such events has largely been beyond cost feasibility for road transportation. Here, a new research strategy is reported that permits just such a form of investigation to be conducted in a safe and effective manner.
METHODS: Specifically, a linked simulation environment has been constructed in which drivers are physically located in two adjacent, full-vehicle simulators acting within a shared single virtual driving world. As reported here for the first time, this technology creates situations that provide avoidance responses paralleling those observed in real-world conditions. Within this shared virtual world 46 participants (25 female, 21 male) were tested who met in two ambiguous traffic situations: an intersection and a hill scenario. At the intersection the two drivers approached each other at an angle of 135 degrees and buildings placed at the intersection blocked the view of both drivers from early detection of the opposing vehicle. The second condition represented a 'wrong' way conflict. Each driver proceeded along a three-lane highway from opposite directions. A hill impeded the oncoming view of each driver who only saw the conflicting vehicle briefly as it crested the brow of the hill. Driver avoidance responses of steering wheel, brake, and accelerator activation were recorded to the nearest millisecond. Qualitative results were obtained through a post-experience questionnaire in which participants were asked about their driving habits, simulator experience and their particular response to the experimental events which they had encountered.
FINDINGS: The results indicated that: (1) situations have been created which provided avoidance responses as they have been recorded in real-world circumstances, (2) the recorded avoidance responses depended directly upon viewing times, and (3) the very short viewing times in this experiment resulted in a single avoidance action, largely represented by a random choice of swerve to either right or left.
COMMENTS: The present results lead us to posit that in order to be able to design accident avoidance mechanism that respond appropriately in the diverse situations encountered, there is a need to pay particular attention to mutual viewing times for drivers. The general implications for a behavioral science of collision-avoidance are evaluated in light of the present findings.
In Bangladesh all poisoning death cases are recorded as unnatural death and medico-legal autopsy is routine. This paper investigates the pattern, trend and incidence of unnatural poisoning deaths attended in Sir Salimullah Medical College Mortuary, Dhaka, Bangladesh from January 1, 1988 to December 31, 1997. A total of 2534 medico-legal autopsy cases were carried out during this period and 273 deaths by poisoning constituted 10.8%. The autopsies done were predominantly male (54.6%). The 13-24-year-old age group was the highest victim group (48.4%). The urban incidence was 60.8%. The main reasons behind taking poison were diseases, familial dispute, alleged insanity and marital discord. Organo-chlorine compounds were the main killer (51.6%) followed by organo-phosphorous compounds (37.7%). This study shows that poison death victims are gradually increasing, in terms of growth rate male death is higher than female, and maximum number of deaths occur below 24 years of age. The trend of poisoning with organo-chloride compounds is being replaced by organo-phosphorous compound use.
A death in a stationary vehicle whilst idling: unusual carbon monoxide poisoning by exhaust gases.
Osawa M, Horiuchi H, Yoshida K, Tada T, Harada A. Leg Med (Tokyo) 2003; 5 Suppl: S132-134.
Correspondence: Motoki Osawa, Department of Forensic Medicine, Yamagata University School of Medicine, 2-2-2 Iida-nishi, 990-9585, Yamagata, JAPAN; (email: mosawa@med.id.yamagata-u.ac.jp).
In this paper, we describe an autopsy case in which death was due to accidental carbon monoxide poisoning occurring in a stationary vehicle idling in an open space. To investigate the source of the fatal fumes, the death scene situation was reconstructed using the vehicle. Exhaust gases were found to invade the interior through the floor from a defective exhaust system. CO gas was detected while idling and the level in the cabin gradually rose to 1.5% over a 2-h period. Since the 8-year-old motor vehicle seemed to have been defective for some months, it was concluded that stationary idling overnight caused an accumulation of toxic gases in the interior.
A case of death associated with ingestion of liquid windshield-washer detergent.
Ago M, Ago K, Orihara Y, Ogata M. Leg Med (Tokyo) 2003; 5 Suppl: S135-137.
Correspondence: Mamoru Ogata, Department of Legal Medicine, Faculty of Medicine, Kagoshima University, 890-8520, Kagoshima, JAPAN; (email: oatam@m.kufm.kagoshima-u.ac.jp).
We report an autopsy case of a death associated with ingestion of liquid windshield-washer detergent. The deceased was a 49-year-old man who was found dead on a road near his truck. A bottle of liquid windshield-washer detergent containing an anionic surfactant and methanol was found under the passenger seat of the truck. At autopsy, slight abrasions and bruises were observed on his body. The small intestine contained dark greenish-brown mucoid matter with abundant froth. The mucous membranes of the esophagus, stomach and superior small intestine showed extensive necrosis, erosion, hemorrhage, edema and congestion. Using the methylene blue method to examine the contents of the small intestine, the presence of an anionic surfactant was indicated. We conclude that the cause of death was ingestion of liquid windshield-washer detergent.
OBJECTIVE: To investigate the potential relationship between life events and injury among high school football players.
DESIGN AND SETTING: This was a prospective cohort study. We collected athlete-exposure and injury data through 2 consecutive seasons at 13 high schools. Injury data consisted of injury status, frequency, severity, practice versus game, time of season, and total time lost from football participation. A life event survey was administered at the end of each season to obtain total, negative, and positive life event scores.
SUBJECTS: A total of 331 varsity high school football players.
MEASUREMENTS: Data collected included athlete exposures, injury reports, and life event surveys. Statistical analysis was completed using the Wilcoxon rank sum W test, the Pearson chi(2) test using an iterative proportional fitting procedure, and contingency chi(2) test.
FINDINGS: Total and negative life change measures significantly affected injury status and frequency of injury (P <.05). However, they did not reflect differences in severity of injury or time lost due to injury, and the positive life change measure was not associated with significant differences for any injury factor (P >.05). Preseason injury rates were significantly higher than season and playoff injury rates (P <.05).
COMMENTS: High school football players who experience high degrees of total and negative change were at greater risk of becoming injured and of sustaining multiple injuries. Playing situation and time of season also affected risk of injury.
Lacrosse Helmet Designs and the Effects of Impact Forces.
OBJECTIVE: To examine the effects of repetitive impact forces on lacrosse helmets and increase awareness of helmet safety standards about reconditioning and recertification practices.
DESIGN AND SETTING: The independent variables for this study consisted of 4 lacrosse helmets of various design: 2 contemporary helmets (Sport Helmets Cascade and Cascade Air) and 2 traditional helmets (Sport Helmets Ultralite and Bacharach Ultralite). The dependent variable was attenuation of impact forces as measured by the Gadd Severity Index (GSI). Helmets were tested at an independent testing facility certified by the National Athletic Equipment Reconditioners Association.
MEASUREMENTS: Helmets were raised to 152 cm and released onto an anvil padded with a 1.27-cm rubber modular elastomer programmer. Ten treatments to a front (FD) and right rear boss drop site (RD) were performed. A triaxial accelerometer within the head form measured impact force. Peak acceleration data were integrated into the GSI. We performed a 1-way analysis of variance and calculated descriptive statistics and the Tukey post hoc test.
FINDINGS: A statistically significant difference was seen in FD GSI score (F(3,36) = 9.680, P <.05) and in the RD GSI score (F(3,36) = 28.140, P <.05) between helmet types. Mean GSI scores were 1166.1, 1117.6, 857, and 1222.8 for the FD and 974.5, 1022.1, 1376.3, and 1496.5 for the RD for Sport Helmets Cascade, Cascade Air, Ultralite, and Bacharach Ultralite, respectively. With repetitive drops, GSI scores increased, indicating a greater chance for cerebral injury. Percentage increases in GSI scores from drops 1 to 10 were 48.8, 54.3, 45.6, and 18.8 on the FD and 22.6, 35.9, 71.7, and 57.4 on the RD for the Sport Helmets Cascade, Cascade Air, Ultralite, and Bacharach Ultralite, respectively.
COMMENTS: Our findings indicate differences between helmets at the 2 drop sites and decreasing capacity of the helmets to dissipate forces with repetitive impacts.
Catastrophic Head Injuries in High School and Collegiate Sports.
OBJECTIVE: To describe the incidence of catastrophic head injuries in a variety of high school and college sports.
METHODS: Data on catastrophic head injuries were compiled in a national surveillance system maintained by the National Center for Catastrophic Sports Injury Research. The data were compiled with the assistance of coaches, athletic trainers, athletic directors, executive officers of state and national athletic organizations, a national newspaper clipping service, professional associates of the researchers, and national sport organizations.
SUBJECTS: Data included all high school and college athletic programs in the United States.
MEASUREMENTS: Background information on the athlete (age, height, weight, experience, previous injury, etc), accident information, immediate and postaccident medical care, type of injury, and equipment involved. Autopsy reports were used when available.
FINDINGS: A football-related fatality has occurred every year from 1945 through 1999, except for 1990. Head-related deaths accounted for 69% of football fatalities, cervical spinal injuries for 16.3%, and other injuries for 14.7%. High school football produced the greatest number of football head-related deaths. From 1984 through 1999, 69 football head-related injuries resulted in permanent disability. Sixty-three of the injuries were associated with high school football and 6 with college football. Although football has received the most attention, other sports have also been associated with head-related deaths and permanent disability injuries. From 1982 through 1999, 20 deaths and 19 permanent disability injuries occurred in a variety of sports. Track and field, baseball, and cheer leading had the highest incidence of these catastrophic injuries. Three deaths and 3 injuries resulting in permanent disability have occurred in female participants.
COMMENTS: Reliable data collection systems and continual analysis of the data can help us to reduce the number of catastrophic head-related injuries. I include additional recommendations for injury prevention.
A ranking system is established whereby injury codes in the National Automotive Sampling System (NASS) are ordered by survivability based on actual mortality rates. Special provisions are made for cases in which injuries are coded as "not further specified" and "severity unknown." Once the ranking system is established, an injury analysis is carried out in which NASS crash victims are characterized by their two highest-ranking injuries. Then, each victim's probability of survival is estimated using a new "primary/secondary" fatality prediction procedure. When deviance statistics are considered, the new procedure predicts fatalities better than the Injury Severity Score, a commonly applied metric that is based on the Abbreviated Injury Scale. Ultimately, the new rankings - which single out specific injuries - provide a means to improve benefits analyses used to support crash injury research.
Unintentional residential child injury surveillance in Hong Kong.
Chan C, Luis B, Chow C, Cheng J, Wong T, Chan K. J Paediatr Child Health 2003; 39(6): 420-426.
Ching-hai Charles Chan, Department of Applied Social Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, CHINA; (email: sschchan@polyu.edu.hk).
OBJECTIVES: To provide an overall pattern of morbidity in unintentional residential childhood injuries (URCI) in Hong Kong.
METHODOLOGY: A cross-sectional telephone survey of caregivers of children aged under 16-years and adolescents suffering from URCI and admitted to three selected local Accident and Emergency Departments.
FINDINGS: Falls, cuts and scalds were the most common external causes of URCI observed, while boys predominated in the sample population. Most of the observed URCI were of moderate to mild severity. Children of new immigrant mothers were more likely to receive first aid immediately after the incidents. Parents were aware of potentially injurious behavior and intervened on occasion, but most resorted to verbal warnings only.
COMMENTS: Prevalence of falls among observed URCI offers evidence in support of the hypothesis that the high population density in Hong Kong plays an integral role in understanding mechanisms of morbidity. Parents show concern about URCI but often lack substantial action that modifies injury risk. Considering the local injury differentials, an active prevention effort such as behavioral intervention and education for parents may be useful.
The purpose of this study was to develop injury-based costs for Australia by body region and injury severity level of the Abbreviated Injury Scale (AIS). The AIS is a threat-to-life scale that classifies injuries by body region on a scale of minor, moderate, serious, severe and critical. Most other studies that have investigated the costs of road trauma have used the injured person or the crash as the costing unit rather than the injury. This study reports costs in Australian dollars for the year 2000.
Association of bullying with adolescent health-related quality of life.
Wilkins-Shurmer A, O'Callaghan M, Najman J, Bor W, Williams G, Anderson M. J Paediatr Child Health 2003; 39(6): 436-441.
Correspondence: Amanda Wilkins-Shurmer, Armadale Community Health and Development Centre, PO Box 460, Armadale, Western Australia 6992, Australia. Fax: +61 8 9391 2229; (email: amanda.wilkins@health.wa.gov.au).
OBJECTIVE: To examine the relationship between being bullied and health-related quality of life (HR-QOL) in adolescence.
METHODS: Subjects were a cohort of 805 adolescents with a mean age of 13.6 years (standard deviation 0.2 years). An adolescent questionnaire elicited the frequency of being bullied. HR-QOL was measured using the Child Health Questionnaire - Parent Report Form (CHQ-PF50) and Dartmouth COOP Functional Health Assessment Charts for Adolescents.
FINDINGS: Thirty-six per cent of boys and 38 per cent of girls reported being bullied at least weekly. Adolescent psychosocial HR-QOL was inversely related to frequency of being bullied, while physical HR-QOL was not related.
COMMENTS: Peer bullying is an important determinant of adolescent HR-QOL with a negative impact on psychosocial well-being.
OBJECTIVES: This study examined the effects of a 4-year randomized intervention program that combined a safety audit with safety behavior training in the prevention of farm injuries.
METHODS: From a random sample of farms in the county of Ringkoebing, Denmark, 393 farms with 1597 residents and employees participated in a weekly self-registration of work-related accidents and injuries during 1 year. Worktasks and time at risk were recorded. A questionnaire including items on safety behavior was also mailed to each farm. Thereafter, the farms were randomly assigned to an intervention or control group. Two hundred and one farms with 990 persons at risk participated in the intervention study. The main outcome measures were the number and severity of accidents, safety behavior, and farmsite safety audits.
FINDINGS: Pre- and post-measurements showed a substantial reduction in injury rates in the intervention group in comparison with a slight reduction in the control group. In a multivariate regression analysis the intervention effect was estimated to be a 30% injury-rate reduction of all injuries, while there was a 42% reduction for medically treated injuries only. Although none of these effects are statistically significant with the present sample size, their magnitude and direction support an intervention effect. The measures of safety behavior revealed significant improvements, and this finding supports the conclusion that the intervention effect was positive, since they concern some of the mediating factors on the pathway from intervention to improved injury rates.
COMMENTS: This intervention, which focused on safety behavior and was performed as a randomized controlled trial, was followed by a substantial reduction in the number of farm injuries. The reduction was particularly marked for the more severe injuries demanding medical treatment.
Some researchers have emphasized that, from the perspective of suicide prevention, research into the methods of suicide seemed to be particularly promising, as it has been shown repeatedly that restricting access to the prevailing method of suicide in a country will decrease suicide rates and that the lethality of the method used significantly correlated with the degree of intention to die. In this study, we examined changes in choice of method and the lethality score between the last attempted suicide (LAS) and completed suicide (CS) in 416 victims (male: 197, female: 219) to point out the tendency on their choice of method in LAS and CS. There was a significant difference in choice of suicide method between LAS and CS, and injury to themselves (33.7%) was the most common method of LAS, while hanging (37.5%) was the most common method of CS. The mean lethality score of CS method was significantly higher than that of LAS method in both sex groups, suggesting that at least one of the causes that drives suicide attempters to commit suicide finally may be the difference in the lethalities of LAS and CS. At the time of CS, suicidal victims tend to choose the same method as that of LAS again. These findings suggest that although suicide attempters tend to choose the same method, they will use a more lethal method if they change the suicide method. Interestingly, moreover, there was no sex difference in the percentage of the mean lethality score at CS.
Suicide prevention in first episode psychosis: the development of a randomized controlled trial of cognitive therapy for acutely suicidal patients with early psychosis.
Power PJ, Bell RJ, Mills R, Herrman-Doig T, Davern M, Henry L, Yuen HP, Khademy-Deljo A, McGorry PD. Aust N Z J Psychiatry 2003; 37(4): 414-420.
Correspondence: Patrick J.R. Power, Department of Psychiatry, Lambeth Early Onset service, South London & Maudsley NHS Trust, 108 Landor Road, London SW9 9NT, UK; (email: Paddy.Power@slam.nhs.uk).
CONTEXT: Young people with early psychosis are at particularly high risk of suicide. However, there is evidence that early intervention can reduce this risk. Despite these advances, first episode psychosis patients attending these new services still remain at risk. To address this concern, a program called LifeSPAN was established within the Early Psychosis Prevention and Intervention Centre (EPPIC). The program developed and evaluated a number of suicide prevention strategies within EPPIC and included a cognitively oriented therapy (LifeSPAN therapy) for acutely suicidal patients with psychosis. We describe the development of these interventions in this paper.
METHODS: Clinical audit and surveys provided an indication of the prevalence of suicidality among first episode psychosis patients attending EPPIC. Second, staff focus groups and surveys identified gaps in service provision for suicidal young people attending the service. Third, a suicide risk monitoring system was introduced to identify those at highest risk. Finally, patients so identified were referred to and offered LifeSPAN therapy whose effectiveness was evaluated in a randomized controlled trial.
FINDINGS: Fifty-six suicidal patients with first episode psychosis were randomly assigned to standard clinical care or standard care plus LifeSPAN therapy. Forty-two patients completed the intervention. Clinical ratings and measures of suicidality and risk were assessed before, immediately after the intervention, and 6 months later. Benefits were noted in the treatment group on indirect measures of suicidality, e.g., hopelessness. The treatment group showed a greater average improvement (though not significant) on a measure of suicide ideation.
COMMENTS: Early intervention in psychosis for young people reduces the risk of suicide. Augmenting early intervention with a suicide preventative therapy may further reduce this risk.
Correspondence: Kristy B. Arbogast, The Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; (email: arbogast@email.chop.edu).
Passenger air bags experienced considerable design modification in the late 1990s, principally to mitigate risks to child passengers. This study utilized Data from the Partners for Child Passenger Safety study, a large-scale child-focused crash surveillance system, to examine the effect of vehicle type on the differential performance of first and second generation air bags on injuries to restrained children in frontal impact crashes. Our results show that the benefit of second-generation air bags was seen in passenger cars - those children exposed to second-generation air bags were half as likely to sustain a serious injury - and minivans. However, in SUVs the data suggest no reduction in injury risk with the new designs. This field data provides crucial real-world experience to the automotive industry as they work towards the next generation of air bag designs.
Changes in injury patterns in frontal crashes: injuries to drivers of vehicles model year 1993-1997 vs. drivers of vehicles 1998-2002 - an analysis of NASS / CDS data.
In this analysis, bivariate and multiple logistical regression analyses were used to evaluate whether there have been any changes in the frequency and severity of injuries to drivers of 1998 and newer model year vehicles and, if so, whether those changes were related to differences in driver, vehicle, or crash characteristics including airbag deployment. The cross sectional study design used NASS/CDS data for years 1993-2001. The bivariate analyses showed that there were no differences in gender, age, and crash severity distribution in model year 1998-2002 vehicles compared with model year 1993-1997 vehicles. However, model year 1998-2002 vehicles were more likely to be SUVs or minivans, have higher drivers seat belt use rates, and have lower airbag deployment rates, and their drivers sustained fewer injuries.
Comparison of frontal crash protection for front seat occupants in pre-1998 and 1998 and newer model vehicles.
The University of Michigan Transportation Research Institute (UMTRI) has been conducting an in-depth crash investigation program for 35 years with sponsorship from the Alliance and its predecessor organizations. The investigations focus on moderate severe crashes involving late-model vehicles. Crash data collected since 1990 can help address two key questions related to the performance of depowered airbags (1998 and newer model Is there a reduction in airbag-induced injuries and fatalities? And, there any change in frontal crash protection? The data consist of pre-1998 model year vehicles and 249 1998 and newer model vehicles for which good estimates of crash severity using vehicle crush measurements are available and for which there were no significant crash or rollover events that may have produced injuries to the occupants of the case vehicle. Few of the crashes involving later model vehicles involved passengers, so the following case descriptions and analyses focus on drivers.
Effectiveness of collision-involved motorcycle helmets in Thailand.
The purpose of this study was to analyze variables present in selected motorcycle crashes involving helmeted riders to find the best injury predictors. The helmets used in this study were collected from motorcycle crashes in Thailand. Pertinent data were collected, a conventional helmet impact drop test apparatus was used to quantify the head impact forces, and stepwise multiple regression analyses were performed. The results indicate that the geometry of the object impacting the head and GSI were the best predictors for MAIS (R ( 2 ) =.875) while geometry of the object, liner thickness and impact energy were the best predictors for ISS (R ( 2 ) =.911).
Requirements for the crash protection of older vehicle passengers.
This study compares injury outcomes in vehicle crashes involving different age groups of belted passengers. Two datasets were considered. Firstly, UK national data revealed that younger passengers are much more likely to be involved in crashes per million miles traveled compared to older passengers although older passengers are much more likely to be killed or seriously injured compared to younger passengers. Secondly, in-depth vehicle crash injury data were examined to determine some of the underlying reasons for the enhanced injury risk amongst older passengers. In crashes of approximately equal severity, the older passenger group were significantly more likely to be fatally injured in frontal crashes (p<0.001). However young passengers were as equally likely to be killed in struck-side crashes compared to the older group. The results also showed that older passengers sustained more serious injuries to the chest region in frontal crashes compared with the younger aged group (p<0.0001) and it is this body region that is particularly problematic. When the data were analyzed further, it was found that a large proportion of passengers were female and that in the majority of cases, the seat belt was responsible for injury. Since by the year 2030, 1 in 4 persons will be aged over 65 in most OECD countries, the results suggest a need for intervention through vehicle design including in-vehicle crashworthiness systems that take into account reduced tolerance to impact with ageing.
The present status of graduated licensing in the United States.
In recent years, a revolution has occurred in the United States in how we license drivers. Since the mid-1990s, most states have adopted some form of graduated licensing, a phase-in system for young beginners, designed to protect them and others on the road while they are learning. In this session, we will assess and summarize the present status of graduated licensing in the United States. Topics covered are: the risk factors a graduated system should address; how adequately the legislation that has been enacted addresses these risks; what the early evaluations are showing about the effects of graduated licensing systems on crashes and injuries; and other risk factors for young drivers - how graduated licensing does, does not, or could address them.
Association of main driver-dependent risk factors with the risk of causing a vehicle collision in Spain, 1990-1999.
- Lardelli-Claret P, Luna-Del-Castillo JD, Jimenez-Moleon JJ, Rueda-Dominguez T, Garcia-Martin M, Femia-Marzo P, Bueno-Cavanillas A. Ann Epidemiol 2003; 13(7): 509-517.
Correspondence: Pablo Lardelli-Claret, Department of Preventive Medicine and Public Health, University of Granada, Facultad De Farmacia, Campus De Cartuja s/n, 18071 Granada, SPAIN; (email: lardelli@ugr.es).
OBJECTIVES: To assess the strength of association of main driver-dependent risk factors with the risk of causing a collision between vehicles in Spain, from 1990 to 1999.
METHODS: The data for this paired-by-collision, case-control study were obtained from the Spanish Direccion General de Trafico traffic crash database. The study included all 220,284 collisions involving two or more vehicles with four or more wheels, in which only one of the drivers involved committed an infraction. Infractor drivers comprised the case group; noninfractor drivers involved in the same collision were their corresponding paired controls.
FINDINGS: All driver-dependent factors were associated with the risk of causing a collision. The highest adjusted odds ratio estimates were obtained for sleepiness (64.35; CI, 45.12-91.79), inappropriate speed (28.33; CI, 26.37-30.44), and driving under the influence of alcohol with a positive breath test (22.32; CI, 19.64-25.37). An increase in the number of years in possession of a driving license showed a protective effect, albeit the strength of the effect decreased as age increased.
COMMENTS: Our results emphasize the urgent need to implement strategies aimed mainly at controlling speeding, sleepiness, and alcohol consumption before driving-the main driver-dependent risk factors for causing a vehicle collision.
CONTEXT: Disasters greatly affect the mental health of children and adolescents, but quantification of such effects is difficult. Using prospective predisaster and postdisaster data for affected and control populations, we aimed to assess the effects of a severe disaster on the mental health and substance use of adolescents.
METHODS: In January, 2001, a fire in a cafe in Volendam, Netherlands, wounded 250 adolescents and killed 14. In the 15 months before the disaster, all grade 2 students (aged 12-15 years) from a school in Volendam (of whom 31 were in the cafe during the fire), and from two other schools, had been selected as controls for a study. 124 Volendam students and 830 from the other two schools had provided data for substance use, and completed the youth self-report (YSR) questionnaire about behavioral and emotional problems. 5 months after the disaster, we obtained follow-up data from 91 (response rate 73.4%) Volendam adolescents and 643 (77.5%) controls from the other two schools. The primary outcome measures were changes in score in YSR categories of total problems, alcohol misuse, smoking, and substance use. We compared changes in scores between groups using logistic regression.
FINDINGS: Volendam adolescents had larger increases in clinical scores than controls for total problems (odds ratio 1.82, 95% CI 1.01-3.29, p=0.045) and excessive use of alcohol (4.57, 2.73-7.64, p < 0.0001), but not for smoking or use of marijuana, MDMA (ecstasy), and sedatives. Increases in YSR scores were largest for being anxious or depressed (2.85, 1.23-6.61), incoherent thinking (2.16, 1.09-4.30), and aggressive behavior (3.30, 1.30-8.36). Intention-to-treat analyses showed significantly larger for increases in rates of excessive drinking and YSR symptom subscales in Volendam adolescents than controls. Effects were mostly similar in victims and their classmates.
COMMENTS: Mental health interventions after disasters should address anxiety, depression, thought problems, aggression, and alcohol abuse of directly affected adolescents and their peer group.
Deindividuation, anonymity, and violence: findings from Northern Ireland.
The author examined the relation between anonymity and aggression in violent interpersonal assaults that occurred in Northern Ireland. Of the 500 violent attacks that the author studied, 206 were carried out by offenders who wore disguises to mask their identities. The findings revealed that significant positive relationships existed between the use of disguises and several measures of aggression. Disguised offenders inflicted more serious physical injuries, attacked more people at the scene, engaged in more acts of vandalism, and were more likely to threaten victims after the attacks. The author discussed these results within the framework of deindividuation theory.
Expectations test: trauma scales for sexual abuse, physical abuse, exposure to family violence, and posttraumatic stress.
Correspondence: K.J. Gully, Center for Safe and Healthy Families, Primary Children's Medical Center, Wasatch Canyons, Salt Lake City, Utah 84123, USA; (email: pckgully@ihc.com).
Gully's 2000 Expectations Test was developed as a tool to use with children ages 4 through 17 to measure social information processing. Prior research suggested it could help identify abused and emotionally traumatized children. Results from regression analyses were used to develop four scales that could be calculated simply. Prior research demonstrated excellent interrater reliability for the variables from the Expectations Test used in the regression analyses. The minimum Cronbach's alpha for any scale is .75. The minimum test-retest reliability is .88. Classification results indicated each scale can provide data to help evaluate children: Sexual Abuse Scale (sensitivity = 81% and specificity = 78%), Physical Abuse Scale (84% and 78%), Exposure to Family Violence Scale (65% and 63%), and Posttraumatic Stress Scale (86% and 54%). However, careful attention needs to be given to the potential limitations of these scales to prevent their misuse.
Regional differences in homicide patterns in five areas of Japan.
- Hata N, Kominato Y, Shimada I, Takizawa H, Fujikura T, Morita M, Funayama M, Yoshioka N, Touda K, Gonmori K, Misawa S, Sakairi Y, Sakamoto N, Tanno K, Thaik-Oo M, Kiuchi M, Fukumoto Y, Sato Y. Leg Med (Tokyo) 2001; 3(1): 44-55.
Correspondence: Hisao Takizawa, Department of Legal Medicine, Faculty of Medicine, Toyama Medical and Pharmaceutical University, 2630 Sugitani, 930-0194, Toyama-shi, JAPAN; (email: hta.kilm@toyama-mpu.ac.jp).
This article describes regional differences in the homicide patterns which occurred in Sapporo City and the surrounding area, and in Akita, Ibaraki, Chiba and Toyama prefectures in Japan. Information collected from each case of homicide included factors such as age, sex of the victim and assailant, causes of death, disposition of the offender, relationship between assailant and victim, reasons for criminal action, et al. The statistical features of homicidal episodes among the five different regions showed considerable variation, as follows. The mean death rates for homicide (number of victims per 100,000 of population) during the period 1986-1995 were 0.44 (Sapporo), 0.8 (Akita), 0.58 (Toyama), 0.7 (Ibaraki) and 0.75 (Chiba), respectively. Close family relationship between the victim and assailant was observed in the homicidal acts which occurred in Sapporo, Akita and Toyama. Assailant's relationship to victim was commonly extra-familial in Ibaraki and Chiba-neighboring megalopolis Tokyo, where some events of murder by a foreigner occurred. Homicide by female assailant, murder by mentally abnormal killers and homicide-suicide events were closely associated with family members. And these factors contributed to the considerable number of victims in Sapporo, Akita and Toyama. But, this close family relationship of the victim to the assailant did not correspond with the elevation in the number of deaths, and it was rather inversely related to the higher death rates recognized in Ibaraki and Chiba. This comparative study suggested that rapid urbanization considerably affects regional differences in homicide patterns.
Firearm counseling by physicians: coverage under medical liability insurance policies.
Correspondence: F. Paola, Division of Medical Ethics and Humanities, Department of Internal Medicine, University of South Florida College of Medicine, Tampa, FL 33612-4799, USA; (email: fpaola@hsc.usf.edu).
CONTEXT: Physicians who offer firearms counseling may increase their legal liability, depending on the attitudes of their medical malpractice insurance carriers.
METHODS: A survey was mailed to the 100 largest medical malpractice insurers. Requested data included their experience with claims involving allegations of negligent firearm counseling by physicians, their opinion regarding whether firearm counseling by physicians would be covered under their medical malpractice policies, and their prediction of how their insurance group or company would handle such claims.
FINDINGS: Fourteen surveys were returned. No respondents reported having dealt with a case involving an allegation of negligent firearm counseling by a physician. Eight respondents (57%) thought that such counseling would not be covered under their medical malpractice policy, whereas six respondents (43%) said that it would.
COMMENTS: A majority of responding insurers thought that physician firearm counseling would not be covered under their medical malpractice policies. Physicians wishing to counsel their patients about the risks and benefits of owning and using firearms are advised to seek assurance of medical malpractice insurance coverage from their insurers or the annexation of a rider to their current policies.
This report describes the dangers of using a loaded gun as a blunt force object and of designing toy guns to mimic realistic weapons. The ultimate goals of this report are to increase public education by promoting strict adherence to standard guidelines for safe gun usage, and to re-evaluate the future of toy gun designs that realistically mirror designs of current weapons. In a review of firearm deaths in the Wayne County Medical Examiner's Office (Detroit, Michigan, USA) over 10-year period from 1990 to 2000, there was an average of 500 cases of firearm deaths per year. This figure includes homicides, suicides and accidents. Among the 500 cases, seven of the most unusual self-inflicted accidental gunshot deaths are selected for this report.
Child maltreatment training in doctoral programs in clinical, counseling, and school psychology: where do we go from here?
Correspondence: Kelly M. Champion, Arizona State University West, Department of Behavioral and Social Sciences, Phoenix 85306-7100, USA; (email: Kelly.Champion@asu.edu).
The American Psychological Association (APA) has called for improving knowledge regarding child abuse and neglect among psychologists by increasing training. The present study examined the extent of child abuse training provided by APA-accredited doctoral programs in clinical, counseling, and school psychology by surveying the training directors in 1992 and 2001. The survey assessed available coursework, practica, and research experience in the area of child maltreatment. Findings indicated that more than half of all programs cover child maltreatment in three or more courses, and most programs discuss child maltreatment in ethics/professional seminars. Most students have some exposure to clients with abuse-related problems, and some have opportunities to participate in maltreatment research. Nonetheless, training falls short of APA recommendations for minimal levels of competence in child maltreatment, with no change in training in the past decade. Recommendations for improving training include more discussion among program faculty, attention to essential competencies, and specific suggestions for developing interdisciplinary training.
