Objectives

  • Indicate who is most at risk for unintentional childhood injury.
  • Distinguish the role of the health-care provider from law enforcement in unintentional injury prevention.
  • Identify two of the eleven steps that health-care providers can follow to successfully integrate The Injury Prevention Program (TIPP) into their practices.
  • Differentiate between two of the five sets of safety-counseling guidelines for developmental stages and injury risks.

From 1987 to 2005, the fatality rate from unintentional injury in children ages 14 and under in the U.S. decreased 45 percent (Safe Kids USA, 2008). Despite this decline, unintentional injury remains the leading cause of death among this age group. Unintentional injury deaths vary according to a child’s age and developmental characteristics. According to Gilchrist & Ballesteros (as cited in Liller, 2007), every one and one-half minutes, an infant is seen in an emergency department for an unintentional injury, with injuries varying according to the child's developmental stage. According to this national study, traumatic brain injury was highest in 3-month-old infants and lowest in 12-month-old infants.

Unintentional injury is one of the five leading causes of death among teenagers, accounting for nearly one-half of all teenage deaths (National Center for Health Statistics [NCHS], 2010).

Common Unintentional Injuries in Texas

Some common causes of unintentional injury death for children and adolescents in Texas include but are not limited to:

Unintentional injury type Total 5-year incidence of deaths for birth to 24 year olds, Texas, 2002-2006
Motor vehicle crashes 6,100
Poisoning 981
Drowning 412
Asphyxia 257
Fire/burns 167
Falls 17 (2006 only)*

Chart used with permission from the Children’s Safety Network, Texas Fact Sheet, 2010. 2009 Texas Injury Epidemiology and EMS/ Trauma Registry Group Top 5 Causes of Death Due to Injury—2006 Vital Statistics Data.

Unintentional Injury Risk

Several factors contribute to a child’s risk for unintentional injury. These factors range from age and gender to income and household composition.

Research into the patterns of unintentional injuries (NCIPC, 2006) reveals that:

Certain children are at a higher risk for unintentional injury. For example, a study examining individual and family risk factors for injuries in toddlers (Bishai, et al., 2008) found that household composition plays a key role in a child’s risk for injury. According to researchers, “Children are at higher risk for medically attended injury when their parents are unmarried.” The first to analyze an association between grandparental caregivers and child injury, the study also found that “having grandparents as caregivers was protective, cutting the odds for injury roughly by half as compared with having a stay-at-home mother.”

In another study on unintentional injury deaths among children in Texas (Parks, Mirchandani, Rodriguez, & Hellsten, 2011), researchers found the mechanisms and circumstances surrounding unintentional injury deaths among children with a history of maltreatment to differ from those without a history of maltreatment. For example, among deaths in which there was no maltreatment history, 54 percent were due to motor vehicle-related incidents, whereas 51 percent of deaths among children with maltreatment history were caused by drowning, asphyxia, and poisoning.

Additionally, research by Safe Kids USA (2007) has found that:

According to research by Mercy, Sleet, & Doll (2006), a child’s risk for injury increases as the child grows and develops. As children gradually encounter increasing injury risk, it is hoped that they simultaneously develop improved perceptual and cognitive abilities to evaluate risks as well as the motor skills to avoid them. As children grow older, they become increasingly independent and responsible for their own actions and decisions. Risk-taking during this time is normal; however, excessive risky behavior and exposure to high-risk environments can be particularly dangerous.

Identifying and Treating Young People with High-Risk Behaviors training module is part of the Texas Health Steps curriculum. To learn more about this module, consult the course listing on the Texas Health Steps website.

The Health-Care Provider’s Role

The family is the primary influence for safety from infancy to early adolescence (Mercy, Sleet, & Doll, 2006). Educating families about risks and safe practices is crucial to unintentional injury prevention.

In a revised policy statement published in Pediatrics (2007), Gardner and the Committee on Injury, Violence, and Poison Prevention state:

Pediatricians play a key role in educating parents about the risks of unintentional injuries and specific measures to minimize those risks, including environmental modification or the use of safety equipment. Anticipatory guidance is a major component of well-child care and injury visits, and parents value the advice and counseling they receive from their pediatricians. Anticipatory guidance for injury prevention is an integral part of the medical care provided for all infants, children, and adolescents.

A required component of every Texas Health Steps medical checkup is health education and anticipatory guidance. The Texas Health Steps program recommends typical developmentally appropriate health education topics for each checkup age. You can access the Texas Health Steps Periodicity Schedule by visiting this link to the Texas Department of State Health Services’s Texas Health Steps page.

Several studies have shown childhood injury-prevention or safety counseling in primary care settings to have positive outcomes in increasing knowledge and behavior and in decreasing injury rates in children (Gardner, Committee on Injury, Violence, and Poison Prevention, 2007). Additionally, parents consistently report a desire for provider-recommended injury-prevention strategies (Nansel, Weaver, Jacobsen, Glasheen, & Kreuter, 2008). However, barriers for health-care providers to more actively engage in injury prevention counseling keep the frequency of such counseling low. These barriers include attitudes toward the importance of a health issue, self-confidence in counseling ability, perceptions around the effectiveness of counseling, training, office time constraints, professional and personal experience, and practice settings.

In 1983, to address some of the abovementioned barriers and equip health-care providers with the information and tools they need to integrate injury-prevention counseling into their practices, the AAP’s Committee on Injury, Violence, and Poison Prevention introduced The Injury Prevention Program (TIPP). TIPP is designed to provide a systematic method for pediatricians to counsel parents and children about adopting behaviors to prevent injuries—behaviors that are effective and capable of being adopted by most families.

TIPP was developed and is maintained by the AAP Committee on Injury, Violence, and Poison Prevention. Development of the original TIPP materials was partially supported by the Division of Maternal and Child Health, U.S. Department of Health and Human Services.

The following information on integrating unintentional injury prevention in health-care practice is based on TIPP’s A Guide to Safety Counseling in Office Practice.

Click this link to the AAP’s website to download the TIPP: Guide to Safety Counseling in Office Practice.

The TIPP Safety Surveys and Safety Sheets referred to below are not included in the downloadable guide. They are available in English and Spanish for purchase at the AAP Bookstore, along with a wide variety of safety program materials and safety slips, which target specific injury hazards. Click the following link to the AAP Bookstore to access these materials.

Integrating Unintentional Injury Prevention into Practice

TIPP is designed to help health-care providers meet the individual needs of their patients and practices. The clearly defined and easy-to-integrate materials include:

Safety Counseling Schedule adapted with permission from TIPP: The Injury Prevention Program, A Guide to Safety Counseling in Office Practice, p. 7. Produced by American Academy of Pediatrics, Committee on Injury and Poison Prevention, 1994.

Safety sheet adapted with permission from TIPP: The Injury Prevention Program, A Guide to Safety Counseling in Office Practice, p. 5. Produced by American Academy of Pediatrics, Committee on Injury and Poison Prevention, 1994.

To successfully integrate TIPP into a health-care practice, it is recommended that providers consider the following steps:

  1. Begin by familiarizing yourself and your staff with the TIPP materials.
  2. During the initial use of TIPP and until you are familiar with it, it’s not necessary to survey your entire practice. Start gradually, with 3- to 4-year-olds, for example. As you become more familiar with the questionnaire, you will find it easy to expand your counseling efforts to include more of your patients.
  3. Have parents complete the safety surveys while in the waiting room. Instruct them to use an “X” to mark their answers. Children ages 10 and older can complete their own surveys.
  4. Have staff attach completed surveys and the appropriate safety sheets to the child’s record before you see the child.
  5. Note “at risk” answers on surveys.
  6. TIPP Safety Sheets work best when parents know why they should rethink protective measures for their child at different age levels. While taking the patient’s history, use the counseling guidelines to ask parents about safety behavior. For example, do they use a child safety seat every time the baby rides in the car? Where is the child when parents are cooking?
  7. While the child is being examined, point out his or her developmental capabilities and the risk for specific injuries, such as falling off a table, swallowing foreign objects, poisoning, or choking. Use the safety sheets and safety surveys as guides for what injuries to discuss with the parent.
  8. Ask parents what makes it hard for them to establish recommended safety practices. Ask them to come up with ways they can make these practices a habit.
  9. Stress that injuries pose the greatest threat to their child’s life. Talk about protecting their child against possible death and disability by adopting recommended behaviors.
  10. Remember to record in the patient’s record the counseling given, and include the physician’s copy of the safety survey. Institute a method for recording completed parts of the program on the patient’s chart—for example, a stamp with a check-off list.
  11. Giving periodic reminders to staff to use these TIPP materials will underscore the goals to incorporate TIPP as a permanent addition to your practice.

Counseling Guidelines

TIPP counseling guidelines are broken into five stages of child development: a child’s first year, 1 to 4 years (in two parts), 5 to 9 years, and 10 to 12 years. These guidelines developed by the AAP follow a standard format and help providers instruct parents and caregivers in ways to prevent car injuries, water injuries and other common childhood injuries, including falls, burns, and poisonings.

1. Counseling Guidance for a Child’s First Year

HOUSEHOLD HAZARD QUESTIONS COUNSELING GUIDELINES
Do you put the crib side up whenever you leave your baby in the crib? Keep crib sides raised.
Is your child’s bed near a window? Place your baby’s bed away from windows.
Do you leave the baby alone on tables or beds, even for a brief moment? If you leave, even for a moment, place your baby in a playpen or a crib with the sides up.
Do you leave the baby alone at home? Provide constant supervision.
Do you keep plastic wrappers, plastic bags, and balloons away from your children? Keep plastic wrappers, plastic bags, and balloons away from your children.
Does your child wear a pacifier or jewelry around his or her neck? Do not put anything around a baby’s neck—objects around the neck may strangle the baby.
Does your child play with small objects, such as beads or nuts? Do not allow your child to play with small objects.
Are any of your baby-sitters younger than 13 years? Select an experienced baby-sitter.
How frequently is the heating system checked where you live? Check heating systems and fireplaces at least once a year.
Are your operable window guards in place? Place operable window guards on all windows in your home.
Do you ever place your baby in an infant walker? Do not place your child in a walker.
BURN HAZARD QUESTIONS COUNSELING GUIDELINES
Does anyone in your home ever smoke? About one third of home fires involving fatalities are caused by smoking.
Do you have a plan for escape from your home in the event of a fire? Develop an escape plan in the event of a fire in the home.
Do you have working fire extinguishers in your home? Buy a fire extinguisher for the home.
Do you have working smoke alarms in your home? Install smoke alarms in your home.
Do you ever drink or carry hot liquids when holding your baby? Do not drink or carry hot liquids when holding your child or when children are nearby.
Do you ever use woodstoves or kerosene heaters? Erect barriers around space heaters.
WATER HAZARD QUESTIONS COUNSELING GUIDELINES
Do you leave the baby alone in or near a tub, pail of water, toilet, or pool, even for a brief moment? Never leave a child alone in or near a tub, pail, toilet, or pool of water.
Do you have a pool or hot tub where you live? Fence in your pool or hot tub on all sides.
AUTO HAZARD QUESTIONS COUNSELING GUIDELINES
Do you use a child safety seat in the car on every trip at all times? Your child should ride in a child safety seat during every trip, even if you will only be traveling a short distance.
Does your car have a passenger air bag? NEVER place an infant in front of an air bag.
Where do you place your child’s car safety seat in the car? Seat a child in the rear seat of the car.
BICYCLE HAZARD QUESTIONS COUNSELING GUIDELINES
Does your child ride on your bicycle with you? Do not carry children younger than 12 months old on bicycles.
FIREARM HAZARD QUESTIONS COUNSELING GUIDELINES
Is there a gun in your home or the home where your child plays or is cared for? Remove all guns from places where children live and play.

Chart of counseling guidelines for a child’s first year adapted with permission fromTIPP: The Injury Prevention Program, A Guide to Safety Counseling in Office Practice, p. 10–11. Produced by American Academy of Pediatrics Committee on Injury and Poison Prevention, 1994.

About Sudden Infant Death Syndrome (SIDS)

The CDC defines Sudden Infant Death Syndrome (SIDS) as “the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history.”

In the U.S., SIDS is the leading cause of death among infants ages 1 to 12 months and the third leading cause overall of infant mortality. Most SIDS deaths occur in children between 2 and 4 months of age, and usually during sleep.

According to AAP’s SIDS Task Force (2005), the following are consistently identified as independent risk factors for SIDS:

Additionally, consistently higher rates of SIDS are found among African American and American Indian/Alaskan Native children.

The AAP expanded its policy statement on SIDS in October, 2011. Click this link to Pediatrics to read the statement, “SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment.”

The Back to Sleep campaign was designed to educate parents, caregivers, and health-care providers about ways to reduce the risk for SIDS. Campaign materials and publications are based on research findings defined by the AAP Task Force on SIDS.

SIDS RISK REDUCTION COUNSELING GUIDELINES
Always place your baby on his or her back to sleep—for naps and at night.
Place your baby on a firm sleep surface, such as a safety-approved crib mattress, covered by a fitted sheet.
Keep soft objects, toys, and loose bedding out of your baby’s sleep area. Don’t use pillows, blankets, quilts, sheepskins, or pillow-like crib bumpers in your baby’s sleep area, and keep all items away from your baby’s face.
Do not allow smoking around your baby.
Keep your baby’s sleep area close to, but separate from, where you and others sleep. Your baby should not sleep in a bed or on a couch or armchair with adults or other children.
Offer a clean, dry pacifier when placing the infant down to sleep, but don’t force the baby to take it.
Do not let your baby get overheated during sleep. Dress your baby in light sleep clothing, and keep the room at a temperature that is comfortable for an adult.
Avoid products that claim to reduce the risk of SIDS—most have not been tested for effectiveness or safety.
Do not use home monitors to reduce the risk of SIDS.
Reduce the chance that flat spots will develop on your baby’s head by providing “tummy time” when your baby is awake and someone is watching, changing the direction in which your baby lies from one week to the next, and avoiding too much time in child safety seats, carriers, and bouncers.

Counseling guidelines used with permission from the Back to Sleep campaign’s Infant Sleep Position and SIDS: Questions and Answers for Health Care Providers publication (NICHD, 2007).

Back to Sleep campaign materials and publications can be ordered or downloaded by clicking on this link to the National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

2. Counseling Guidance for Children 1–4 years old (Part 1)

HOUSEHOLD HAZARD QUESTIONS COUNSELING GUIDELINES
Do you leave your child alone at home? Never leave small children alone in the home.
Are any of your babysitters younger than 13 years? Select an experienced babysitter.
Do you keep plastic wrappers, plastic bags, and balloons away from your children? Keep plastic bags and balloons out of reach.
Do you know how to prevent your child from choking? Small objects and solid foods such as hot dogs, peanuts, grapes, carrots, and popcorn may block your child’s airway.
Do you have mechanical garage doors? Mechanical garage doors may crush a child.
Are your operable window guards in place? Place operable window guards on all windows in your home.
Is your child in the yard while the lawn mower is in use? Keep small children out of the yard while the lawn mower is in use.
Do you place gates at the entrance to stairways (for children younger than 3 years)? Place a gate at the entrance of stairways.
Is your child’s bed near a window? Place your baby’s bed away from windows.
Do you check for safety hazards in the homes of friends or relatives where your child may play? Check for hazards in homes your child may visit.
Have any of your children ever had an injury requiring a visit to the doctor or hospital? Report any history of injuries to the pediatrician.
FIREARM HAZARD QUESTIONS COUNSELING GUIDELINES
Is there a gun in your home or the home where your child plays or is cared for? Remove all guns from places children live and play.
POISONING HAZARD QUESTIONS COUNSELING GUIDELINES
Do you keep household products, medicines (including acetaminophen and iron), and sharp objects out of the reach of your child and in locked cabinets? Keep medicines and hazardous products out of the sight and reach of children.
Do you dispose of old medicines? Dispose of old medicines.
Do you have safety caps on all bottles of medicine? Purchase medicines with child-resistant safety caps.
Does your child chew on paint chips or window sills? Inspect walls for peeling paint.
Do you have the number of the Poison Help Line by your phone? Keep this number by the phone and learn first aid for poisoning.
How frequently is the heating system checked where you live? Heating ventilation systems and fireplaces should be checked at least once a year.

Chart of counseling guidelines for children 1–4, (Part 1) adapted with permission from TIPP: The Injury Prevention Program, A Guide to Safety Counseling in Office Practice, p. 12–13. Produced by American Academy of Pediatrics Committee on Injury and Poison Prevention, 1994.

Counseling Guidance for Children 1–4 years old (Part 2)

BURN HAZARD QUESTIONS COUNSELING GUIDELINES
Do you use electrical appliances in the bathroom? Do not leave electrical appliances within the reach of a child in the bathroom.
Do you keep electrical appliances and cords out of your child’s reach? Keep electrical cords out of a child’s reach.
Do you keep matches and cigarette lighters out of the reach of your children? Keep matches and lighters out of the reach of children.
Does anyone in your home ever smoke? Most deaths due to home fires are caused by smoking.
Do you have an escape plan in the event of a fire in the home? Develop an escape plan in the event of a fire in the home.
Do you have working fire extinguishers in your home? Buy a fire extinguisher for your home.
Do you have working smoke alarms in your home? Install smoke alarms in your home.
Have you checked the temperature of the hot water where you live? Check hot water temperature.
Do you keep the handles of pots and pans on the stove out of the reach of children? Keep hot pots and pans out of the reach of children.
WATER HAZARD QUESTIONS COUNSELING GUIDELINES
Do you leave your child alone in the bathtub? Don’t leave your child alone in a tub, even for a moment.
Do you take your child on a boat? Always have the child wear a Coast Guard-approved life jacket.
Do you have a pool or hot tub where you live? Fence in your pool or hot tub on all sides.
Do you allow your child to swim unsupervised? Do not let children swim without supervision.
BICYCLE HAZARD QUESTIONS COUNSELING GUIDELINES
Does your child ride on your bicycle with you? Use an approved child carrier.
AUTO HAZARD QUESTIONS COUNSELING GUIDELINES
How are your children restrained when they ride in a car? Children this age should always be properly restrained in a child safety seat. Select a safety seat that fits your child’s size and weight and that can be installed properly in your car.
Do you leave your child alone in the car? NEVER leave a child alone in a car.
Where do you seat your children in the car? Seat a child in the rear seat of the vehicle.
Does your car have a passenger air bag? Never put children in front of passenger air bags.
Do you lock the car doors before driving? Buckle up and lock up!
Does your child play in the driveway or in or near the street? Young children should not play in driveways or near busy streets.
TOY HAZARD QUESTIONS COUNSELING GUIDELINES
Do you check your child’s toys for safety hazards? Inspect toys for safety hazards.

Chart of counseling guidelines for children 1–4, (Part 2) adapted with permission from TIPP: The Injury Prevention Program, A Guide to Safety Counseling in Office Practice, p. 14–15. Produced by American Academy of Pediatrics Committee on Injury and Poison Prevention, 1994.

3. Counseling Guidance for Children 5–9 years old

FIREARM HAZARD QUESTIONS COUNSELING GUIDELINES
Is there a gun in your home or the home where your child plays or is cared for? Do not keep guns in your home.
HOUSEHOLD HAZARD QUESTIONS COUNSELING GUIDELINES
Do you let your child operate a power lawn mower? Never let children this age operate a lawn mower or ride with you on one.
Have any of your children ever had an injury requiring a visit to the doctor or hospital? Report any history of injuries to the pediatrician.
How frequently is the heating system checked in your home? Heating ventilation systems and fireplaces should be checked at least once a year.
BURN HAZARD QUESTIONS COUNSELING GUIDELINES
Do you and your children know how to get out of your home safely in the event of a fire? Develop an escape plan in the event of a fire in the home.
Does anyone in your home ever smoke? A third of deaths due to home fires are caused by smoking.
Does your child play with matches or lighters? Do not let children play with fire.
Do you have working fire extinguishers in your home? Buy a fire extinguisher for your home.
Does your child play with firecrackers or sparklers? Do not let children play with fireworks.
Do you have working smoke alarms in your home? Install smoke alarms in your home.
WATER HAZARD QUESTIONS COUNSELING GUIDELINES
Does your child know how to swim? Teach children how to swim.
Does your child know the rules of water and diving safety? Teach and enforce the rules of swimming and diving safety.
Does your child wear a life jacket when on a boat? Be sure your child wears a life jacket when on a boat.
AUTO HAZARD QUESTIONS COUNSELING GUIDELINES
Does your child use a booster seat or seat belt when riding in the car? A booster seat should be used on every trip by all children who have outgrown their car safety seats (usually when around 40 pounds). Harnesses should be used until the safety belt fits correctly (usually around 4’9” tall or between 8 and 12 years old).
Does your car have a passenger air bag? Never seat a child in front of a passenger air bag.
PEDESTRIAN HAZARD QUESTIONS COUNSELING GUIDELINES
Do your children cross the street by themselves? Teach your child pedestrian safety skills.
BICYCLE HAZARD QUESTIONS COUNSELING GUIDELINES
Has your child learned about bicycle safety? Teach and enforce bicycle safety rules.
Does your child wear a helmet every time he or she rides a bike? Wear a bicycle helmet.
RECREATIONAL HAZARD QUESTIONS COUNSELING GUIDELINES
Does your child participate in sports? Children should always wear protective gear during sports.
Does your child participate in horseback riding? All children should wear an approved equestrian helmet when riding a horse.

Chart of counseling guidelines for children 5–9 adapted with permission from TIPP: The Injury Prevention Program, A Guide to Safety Counseling in Office Practice, p. 16–18. Produced by American Academy of Pediatrics Committee on Injury and Poison Prevention, 1994.

4. Counseling Guidance for Children 10–12 years old.

These guidelines are to be directed to the child.

FIREARM HAZARD QUESTIONS COUNSELING GUIDELINES
Is there a gun in your home or any of your friends’ homes? Do not play with guns!
BURN HAZARD QUESTIONS COUNSELING GUIDELINES
Do you have working smoke alarms in your home? Check to see that your home has smoke alarms.
BICYCLE HAZARD QUESTIONS COUNSELING GUIDELINES
Do you ever ride with passengers on your bike? Never ride with passengers on your bike.
Do you wear a helmet when you ride your bike? Always wear a helmet when riding a bike.
AUTO HAZARD QUESTIONS COUNSELING GUIDELINES
Do you wear a safety belt in the car? Buckle up every time for every trip.
Do you ride in cars that have passenger air bags? Do not sit in front of a passenger air bag.
Where do you sit in the car? The safest place for you to ride is in the back seat, buckled up.
PEDESTRIAN HAZARD QUESTIONS COUNSELING GUIDELINES
When you want to cross the street, what is the first thing you should always do? Follow safety rules when crossing the street.
WATER HAZARD QUESTIONS COUNSELING GUIDELINES
When playing near water (for example, pools, rivers, ponds, lakes, oceans), is it OK to play alone? Never play near water without an adult nearby.
FARM HAZARD QUESTIONS COUNSELING GUIDELINES
Do you live or work on a farm? Farm equipment is very dangerous to children.

Chart of counseling guidelines for children 10–12 adapted with permission from TIPP: The Injury Prevention Program, A Guide to Safety Counseling in Office Practice, p. 19. Produced by American Academy of Pediatrics Committee on Injury and Poison Prevention, 1994.

Additional tools and resources for health-care providers and parents can be found by clicking this link to Safe Kids USA; this link to the Children’s Safety Network; and this link to the CDC's Safe Child site.

TIPP counseling guidelines are designed for children from birth to 12 years old only. The following guidelines are adapted from other sources identified therein.

5. Counseling Guidance for Adolescents 13 years of age and older.

The following counseling recommendations aim to prevent the most prevalent unintentional injuries affecting today’s teens. These include:

About motor vehicle crashes and teen driving

According to the AAP’s policy statement on teen driving, regarding the total crashes per million miles driven, 16- to 19-year-olds have a crash rate almost twice that of 20- to 24-year-olds, almost three times that of 25- to 29-year-olds, and more than four times that of 30- to 69-year olds. Within the 16- to 19-year age range, the crash rate for 16-year-olds is almost nine times greater than that of the general population (Council on Injury, Violence, and Poison Prevention and Committee on Adolescence, 2006). In Texas, motor vehicle crashes were the leading cause of injury or death for children and youth ages 1 to 24 and the second leading cause of injury or death for children under age 1 from 2003–2007 (CSN, 2011).

Several risk factors contribute to the alarming rate of teen-related motor vehicle crashes. These include:

According to the Texas Youth Risk Behavior Survey (2009):

A study by D’Angelo & Halpern-Felsher (2008) indicates that health-care providers are not doing all they can to reduce the rates of automobile morbidity and mortality in teens. According to the authors, health-care providers with “adequate knowledge, training, and charting tools or electronic prompts can increase rates of screening, educating, and counseling youth and their parents about safe driving,” and “these efforts can be effective at increasing safety and reducing risk.”

Use the chart below to counsel adolescents and their parents about motor vehicle safety.

TEEN DRIVER COUNSELING GUIDELINES
Know Texas laws regarding teen drivers, teen driver-licensing process, and physician reporting requirements for medical conditions that could impair driving ability.
Distribute educational materials about local GDL programs and teen driver safety.
Alert parents and teens to high-risk situations mentioned earlier.
Encourage safety belt use.
Discourage distractions when driving (eating, drinking, music, cell phone use, makeup).
Encourage teen-parent written contracts that place restrictions on the teen driver. At a minimum, parents should place restrictions on nighttime driving (preferably after 9:00 PM) and limits on the number of teen passengers. Initially, the rules should be fairly strict, but they can be relaxed as the teen becomes older and gains more driving experience.
Counsel teens about the dangers of driving while impaired (under the influence of alcohol, drugs, or medications or feeling ill, tired, depressed, or angry). Encourage a “safe-ride” agreement in which the teen agrees to call the parent rather than drive while impaired, and the parent promises to assist in arranging a ride home in a nonjudgmental manner.
Encourage parents to require that the vehicle driven by the teen is safe and in good condition.
Advise parents that in many states, they have the authority to request that the driver’s license of their minor child be revoked.
Encourage parents to be positive role models.
Advise parents about the various driving schools, websites, computer driving simulations, and parent-supervised driving lessons that are available.

Chart of counseling guidelines for teen driver safety used with permission from the American Academy of Pediatrics (Council on Injury, Violence, and Poison Prevention and Committee on Adolescence, 2006).

Click this link to Pediatrics to see the article on teen driving in full. See Appendix 2 within the article to view a sample teen-driving contract.

Click this link to the Texas Department of Public Safety to access information on teen driving laws and GDL programs in Texas.

Sports and Water Safety

Bicycle, sports and water injuries can occur at any age, but children and adolescents are especially vulnerable. Following is information that health-care providers can use in developing anticipatory guidance for young patients and their families.

About Bicycle Safety

In 2009, of the 630 bicyclists who died on U.S. roads, 74 were children age 14 or younger (National Highway Traffic Safety Administration, 2010). Bicycle injuries rose sharply from 43,000 in 2007 to 51,000 in 2009. In addition, young cyclists are more likely than adult cyclists to die of head injuries, most of which are caused by collisions with motor vehicle. The risk of injury for children age 14 and under is five times greater than for an older cyclist. Helmet use has been estimated to reduce head injury risk by 85 percent (Insurance Institute for Highway Safety, 2008).

Use the chart below to counsel adolescent patients and their parents on bicycle safety.

TEEN BICYCLE SAFETY COUNSELING GUIDELINES
Make sure all bike parts are working properly and that the wheels are inflated and that the brakes work.
Always wear a bicycle helmet. The helmet should fit snugly and not move from side to side. The front of the helmet should be approximately one inch above the eyebrows, and the chinstrap should be buckled snugly.
When riding a bicycle, always wear a helmet that meets or exceeds the safety standards developed by Snell, ANSI (American National Standards Institute), and/or ASTM (American Society for Testing and Materials).
Always wear bright colors when riding a bicycle, and avoid riding at night. If you have to ride at night, wear something that reflects light. Make sure you have reflectors on the front and rear of your bike and that your headlight is on. Bicycles are considered vehicles, and bicyclists must obey the same rules as motorists.
Ride single file and with the flow of traffic, never against it.
Follow all traffic signs, signals, and lane markings.
Before you enter any street or intersection, check for traffic by looking left-right-left.
When turning left or right, always look behind you for a break in traffic, then signal before making the turn. Watch out for left- or right-turning traffic.
Stay out of drivers' blind spots and use appropriate hand signals.

Chart of counseling guidelines for bicycle safety adapted with permission from the ThinkFirst National Injury Prevention Foundation’s webpage for teen bicycle safety (n.d.).

About Sports Safety

Sports are an important factor for youth fitness and self-esteem. Young athletes, however, are not small adults. Their bones, muscles, tendons, and ligaments are still growing, making them more prone to injury. In particular, contact sports have inherent dangers that put young athletes at special risk for severe injuries. More than half of the 7 million sports and recreation-related injuries that occur each year are sustained by those between ages 5 and 24 (CDC, 2009). Even with proper safety equipment and rigorous training, youngsters are still at risk for severe injuries to the neck, spinal cord, and growth plates.

In an eleven-year study on high school sports-related concussions (Lincoln et al., 2011), researchers found football, lacrosse, and soccer to be the riskiest sports for boys. Soccer, lacrosse, and basketball were the riskiest sports for girls. However, according to researchers, “concussion detection, treatment, and prevention should not be limited to those sports traditionally associated with concussion risk.”

Additionally, high climatic heat stress may place young athletes at an increased risk for heat-related illness and in rare cases, death. In a revised policy statement on climatic heat stress and exercising youth (2011), the AAP states that heat illness from exertion is usually preventable. According to the AAP, “special consideration, preparation, modifications, and monitoring are essential when children and adolescents are engaging in sports or other vigorous physical activities in warm-to-hot weather.”

Click this link to the AAP’s Pediatrics website to download the entire revised policy statement, “Climatic Heat Stress and Exercising Children and Adolescents,” which includes new guidelines for safeguarding against heat-related illness.

Use the chart below to counsel adolescent patients and their parents on sports injury prevention. The counseling guidelines are adapted from the AAP’s 2010 Sports Injury Prevention Tip Sheet and “Climatic Heat Stress and Exercising Children and Adolescents” policy statement.

SPORTS SAFETY COUNSELING GUIDELINES
Wear the right gear. This includes appropriate and properly fitting protective equipment, such as pads (neck, shoulder, elbow, chest, knee, shin), helmets, mouthpieces, face guards, protective cups, and/or eyewear.
Strengthen muscles with conditioning exercises.
Increase flexibility with stretching before and after games.
Use the proper technique.
Take breaks.
Play safe. Strict rules should be enforced.
Stop the activity if there is pain.
Avoid heat injury by allowing children to gradually adapt to physical activity in the heat and making time for and encouraging sufficient fluid intake before, during, and after exercise.
Modify activity as needed given the heat and limitations of individual athletes.
Provide rest periods of at least two hours between same-day contests in warm-to-hot weather.
Limit participation of children who have had a recent illness or have other risk factors that would reduce exercise-heat tolerance.

Chart of counseling guidelines for sports injury prevention adapted with permission from the American

Academy of Pediatrics (2010 Sports Injury Prevention Tip Sheet and Climatic Heat Stress and Exercising Children and Adolescents policy statement).

About Water Safety

Water sports and recreation are popular and fun forms of youth fitness. However, certain risk factors place adolescents at risk for unintentional water-related injuries and drowning. According to the CDC (2010), most drowning among youth over 15-years-old occurs in natural water settings. Additionally, alcohol use is involved in up to half of adolescent and adult deaths associated with water recreation and about one in five reported boating fatalities. For those with seizure disorders, drowning is the most common cause of unintentional injury death.

Use the chart below to counsel adolescent patients and their parents about water-related injury and drowning prevention.

WATER SAFETY COUNSELING GUIDELINES
Always swim with a buddy.
Avoid drinking alcohol before or during swimming, boating, or water skiing. Do not drink alcohol while supervising children.
Learn to swim.
Learn CPR. Your CPR skills could make a difference in someone’s life.
Do not use air-filled or foam toys, such as “water wings,” “noodles,” or inner-tubes in place of life jackets (personal flotation devices).
Know the local weather conditions and forecast before swimming or boating in natural-water areas.
Use U.S. Coast Guard-approved life jackets when boating.
Know the meaning of and obey warnings represented by colored beach flags.
Watch for dangerous waves and signs of rip currents (for example, water that is discolored and choppy, foamy, or filled with debris and moving in a channel away from shore). If you are caught in a rip current, swim parallel to shore; once free of the current, swim toward shore.

Chart of counseling guidelines for teen water safety adapted with permission from Unintentional Drowning: Fact Sheet (National Center for Injury Prevention and Control, CDC, 2010).

Unintentional Injury Advocacy

Health-care providers can be effective advocates for injury prevention at local, state, and national levels. The participation and support of pediatricians nationwide were important factors in the now-universal infant car safety seat legislation as well as the expectation of child safety seat use as a social norm (TIPP, n.d.). Advocacy at the local level may include working with community resources that have a major influence on children, such as the school system, park district, Head Start, child-care centers, organizations such as the YMCA, and local media.

In Oski’s Pediatrics: Principles and Practice (McMillan, J., Feigin, R.D., DeAngelis, C.D., & Jones, Jr., M.D., 2006), the authors warn, “when health-care providers remain silent on injury issues, the community may mistakenly assume that injury is not a matter of health” (p. 146).

Safe Kids USA provides materials for community advocacy. Additionally, local Safe Kids Coalitions in all fifty states offer health-care providers valuable opportunities to get involved. Click this link to Safe Kids USA to see a listing of Safe Kids Coalitions in Texas.

Case Study: Motor Vehicle Crashes and Teenage Drivers

John is a 16-year-old who recently got his driver license. He wants to celebrate with his friends at a party this weekend. He and his friends exchange several texts over the next few days to finalize plans. While discussing his plans with his parents, he informs them that there will be no alcohol at this party and that he will be responsible for driving his four best friends there and back.

Question A: Which of the following is true about risk factors associated with teenagers like John and motor vehicle crashes?

Sorry, this answer is not the correct answer.
In 2006, the motor vehicle death rate for male drivers and passengers ages 15 to 19 was almost twice that of their female counterparts (CDC, 2010).

This is part of correct answer F.
The presence of teen passengers increases the crash risk of unsupervised teen drivers. This risk increases with the number of teen passengers (CDC, 2010). Additionally, the presence of male teenage passengers increases the likelihood of risky driving behavior.

This is part of correct answer F.
Text messaging while driving is becoming as dangerous as drinking and driving in terms of inhibiting a teen’s driving abilities. Cell phone use accounts for 2,600 vehicle fatalities and 300,000 collisions annually (SADD/Liberty Mutual, 2007).

This is part of correct answer F.
Teens are more likely than older drivers to underestimate dangerous situations or not be able to recognize hazardous situations (CDC, 2010).

Sorry, this answer is incorrect.

This answer is correct.
See answers b), c), and d) for explanation.

Question 2: Which of the following may help to reduce the number of motor vehicle crashes involving teenage drivers?

Sorry, this is not the correct answer.
Teens who drive with other teens are more likely to be distracted. Distracted driving can increase the chance of a motor vehicle crash.

Sorry, this is not the correct answer.
At all levels of blood alcohol concentration, the risk of involvement in a motor vehicle crash is greater for teens than for older drivers.

This answer is correct.
In 2008, half of teen deaths from motor vehicle crashes occurred between 3 p.m. and midnight, and 56 percent occurred on Friday, Saturday, or Sunday. While not yet tested, when parents control a teen’s nighttime and weekend driving, they may help reduce the risk of teen deaths from motor vehicle crashes.

Sorry, this is not the correct answer.

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