How mothers parent their children with behavior disorders: Implications for unintentional injury risk

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Abstract

Introduction

This study was designed to test the role of parental supervision in explaining why children with behavior disorders have increased risk of unintentional injury.

Method

Children referred to a pediatric behavior disorders clinic and their mothers were unknowingly observed in a “hazard room” environment that housed several items that appeared dangerous but actually were altered to be safe.

Results

Mother and child behavior in the hazard room was correlated to parent-, teacher-, and observational-reports of children's externalizing behavior patterns, children's injury history, and mother's parenting styles. Maternal ignoring of children's dangerous behavior in the hazard room was the strongest correlate to children's injury history.

Conclusions

Poor parental supervision might serve as a mechanism to explain why children with behavior disorders, and those with oppositional behavior patterns in particular, have increased risk of unintentional injury.

Introduction

Unintentional injury is the leading cause of pediatric mortality, killing more children than the next 10 leading causes of death combined (National Safety Council, 2004). Clinicians and researchers have long hypothesized that children with behavior disorders are at elevated risk for unintentional injury compared to peers without behavior disorders (Davidson, 1987, Dunbar et al., 1939, Krall, 1953), and recent work confirms early hypotheses empirically using large, representative samples and sophisticated quantitative analyses (Brehaut et al., 2002, Rowe et al., 2004, Schwebel et al., 2002). Several critical issues concerning the link between behavior disorders and injury risk remain unresolved. Among the unresolved issues, and the focus of this study, is identification of particular mechanisms that might lead children with behavior disorders to have increased risk for injury.

DSM-IV lists injury risk as a trait associated with Attention-Deficit/Hyperactivity Disorder (ADHD; American Psychiatric Association, 1994), a link supported by some empirical work (Brehaut et al., 2002, DiScala et al., 1998, Swensen et al., 2004). In a review of hospital charts, DiScala and colleagues (DiScala et al., 1998) found children with ADHD had increased risk of pedestrian and bicycling injuries, as well as more severe overall injuries, when compared to their peers. In a population-based study of children in British Columbia, Brehaut and colleagues (Brehaut et al., 2002) found children treated with methylphenidate (and therefore likely to have ADHD symptomatology or diagnosis) had increased risk for injury in their history after controlling for known demographic mediators. Similar results have been reported with studies focused specifically on risk for burn injuries among children with ADHD (Mangus et al., 2004, Thomas et al., 2004) and risk for motor-vehicle crashes in adolescents and young adults with ADHD (Barkley et al., 1993, Barkley et al., 1996).

Other studies have found ADHD to have only modest (Davidson et al., 1988, Schwebel et al., 2002) or no (Byrne, Bawden, Beattie, & DeWolfe, 2003) relation to injury, and have suggested oppositional behavior and Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) diagnoses might predict unintentional injury risk better. In Schwebel and colleagues' work (2002), a sample of boys with behavior disorders had more injuries than a matched control group without behavior disorders. Within the group with behavior disorders, those with just ODD had a similar rate of injury to those boys with comorbid ODD and ADHD. Byrne and colleagues (2003) compared a group of preschoolers with ADHD and a matched control group. Although the group with ADHD exhibited more dangerous behavior patterns in a laboratory battery of parent-report, neuropsychological, and observational measures, a review of hospital records found no difference in injury rates between the two groups.

Despite accumulating evidence concerning the link between behavior disorders and injury risk, the mechanism through which children with behavior disorders might have increased risk for injury remains remarkably unexplored by researchers. Most attribute the increased risk to the specific symptoms associated with behavior disorders. Thus, children with ADHD are believed to have increased risk for injury due to their impulsive, hyperactive, and inattention behavior patterns (Davidson, 1987, Farmer & Peterson, 1995), while children with ODD or CD are believed to have increased risk due to their oppositional, noncompliant, and aggressive behavior patterns (Davidson, 1987).

An alternative explanation suggests children with behavior disorders might be at increased risk of unintentional injury due to poor parental supervision (Davidson, 1987, Rowe et al., 2004, Schwebel et al., 2002). Research with non-clinical samples suggests parenting style and adult supervision play central roles in children's safety (Morrongiello, 2005, Schwebel & Bounds, 2003, Schwebel et al., 2004). In fact, the quantity and quality of time parents spend with children apparently interacts with difficult child behavior patterns to create a situation whereby children at increased risk for injury due to hyperactive, impulsive, and oppositional behavior patterns have greatly reduced risk in the context of quality parenting (Schwebel et al., 2004). Unfortunately, for a number of reasons children with behavior disorders frequently have parents who fail to provide high-quality parental supervision (e.g., Denham et al., 2000, Sprich et al., 2000). An accumulating literature suggests mothers of children with behavior disorders have greater depression and hostility and low self-esteem, lower perceived social support, and marital dissatisfaction than children without behavior disorders (e.g., Johnston, 1996). Although the causality of parental dysfunction in children with behavior disorders is unclear — and may in fact be cyclical in the sense that aspects of parental dysfunction are a result rather than a cause of child dysfunction (Patterson, 1982) — the parental dysfunction that is common among children with behavior disorders may lead to poor parental supervision of those children, and poor parental supervision may lead to child injury risk.

The present study was designed to test three possible explanations for why children with behavior disorders might have increased risk for unintentional injury: (a) traits associated with ADHD such as impulsivity, hyperactivity, and inattention, which could cause children with behavior disorders to act in dangerous, impulsive, and inattentive ways near hazards; (b) traits associated with ODD such as oppositionality and noncompliance to safety rules, and aggression toward peers and siblings, which could cause children with behavior disorders to act in dangerous, aggressive, and noncompliant ways near hazards; and (c) poor parental supervision of children with behavior disorders near hazards. Given previous evidence, we hypothesized: (a) poor parental supervision would best explain injury risk among a sample of behavior disorders, (b) ODD symptoms would play a more modest role in explaining child injury risk, and (c) ADHD symptoms would play little, if any, role in explaining injury risk.

We tested our hypotheses using a methodological approach different than previous work on the topic. Previous work relied largely on retrospective review of hospital records or epidemiological data (e.g., Brehaut et al., 2002, Davidson et al., 1988, DiScala et al., 1998, Rowe et al., 2004, Swensen et al., 2004). Although such techniques are valuable, they do not permit careful analysis of the injury process (Peterson, Farmer, & Mori, 1987). To study the injury process, children with behavior disorders were recruited to enter an office room where they “waited” with their mothers for the experiment to start. In reality, the waiting room was an experimental manipulation — it was filled with objects that appeared to be hazardous but in reality were altered to be safe (Cataldo et al., 1992, Morrongiello & Dawber, 1998), and behavior in the room was videotaped and subsequently coded. Following a 15-minute session in the hazard room, parents completed a number of self-report and observational batteries.

Section snippets

Participants

Twenty-nine children referred consecutively for behavior disorders at a multidisciplinary university-based outpatient clinic comprised the sample. Exclusion criteria included IQ in moderate mental retardation range or lower, age over 11 or under 5, mother/mother-substitute not present at the appointment, and mother or child refusal to participate in the study. Approximately 15% of children were excluded for one or more of these reasons. The sample had a mean age of 8.35 years (SD = 1.73), and was

Results

Descriptive statistics for both the composite variables and the variables that comprised the composites are presented in Table 1. Each of the composite variables, as well as the PDI and maternal hazard room behavior variables that were not included in a composite, were correlated to children's age. No statistically significant correlations emerged (range of r = |.05| to |.25|). Similarly, tests were conducted to compare boys and girls on each of the composite variables as well as the PDI and

Discussion

This study was designed to study mechanisms that might explain the link between behavior disorders and risk for unintentional injury. As hypothesized, results suggest parental supervision may play the most critical role in explaining why children with behavior disorders have increased risk of unintentional injury: maternal ignoring of children's dangerous behavior was the strongest predictor of children's injury histories. ODD symptoms — including behaviors such as failure to follow rules — may

David C. Schwebel earned his B.A. from Yale University in 1994 and his M.A. and Ph.D. in clinical psychology from University of Iowa in 1996 and 2000, respectively. He is currently Associate Professor of Psychology at University of Alabama at Birmingham. Dr. Schwebel has published widely on psychological aspects of understanding and preventing children's unintentional injuries.

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    J. Bart Hodgens, Ph.D., is a Research Assistant Professor in the Department of Psychology at University of Alabama at Birmingham (UAB). He directs interdisciplinary clinics focusing on the evaluation and treatment of childhood behavior disorders and learning disabilities through the Sparks Civitan Clinics at UAB.

    Samantha Sterling graduated from the University of Alabama at Birmingham with a BS in Psychology. She is currently completing her masters degree in Applied Behavior Analysis at Florida State University. Her interests primarily involve children with developmental disabilities and behavior problems.

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