developmental factors childhood - injury prevention

Injury Prevention 1996; 2: 228-236

REVIEW ARTICLE

Developmental risk factors for childhoodpedestrian injuries

Richard A Schieber, Nancy J Thompson

'The automobile is the naturalpredator of the child' Burton H Harris, MD

Pedestrian injuries remain a significant publichealth problem for children.' In 1992 in theUnited States, more than 600 children youngerthan 16 years of age died2 and an estimated31 000 were non-fatally injured3 from pedest-rian injuries. In that country, pedestrianinjuries account for 6 30o of childhoodfatalities from all causes between 1-14 years,and 9-30o of deaths from all causes in childrenbetween 5 and 9 years, the highest risk group inchildhood.2 The childhood annual pedestriandeath rate in other industrialized nations issimilar: Australia 3 1,4 New Zealand 3 0,5 andthe United Kingdom 2 46 deaths per 100 000persons between 1 and 14 years old.Why are children, especially young children,

at such high risk? Childhood pedestrianinjuries result from a highly complex interac-tion of many possible factors.7 A full analysiswould include risk factors related to the child,the driver, and the environment (table). In thisreview we consider only one aspect of theproblem: the developmental attributes affectingthe behavior of children that make them morelikely to be struck by a vehicle. We address the

Somefactors associated with child pedestrian injuries

Factors related to the childStage of development, behavior, and cognition

Short attention spanIrregular walking speedPropensity for midblock dart-outs

Anatomic development and physical attributes5886Relatively short stature (more difficult to see and be seen)Use of reflective clothesSudden appearance in the roadway

Social environmentEffect of others on crossing behavior87

Crossing guardsParent or other accompanying adultOlder sibling or peer

Adverse family factors38 88PovertyCrowdingPlacement in the care of local authorities

Factors related to the driverInfluence of seeing a child in or near the roadway89-9Use of alcohol'9Driver fatigue92Factors related to the environmentType of road93Driveway, parking lot, freeway, major or minor

arterial road, collector road, local streetLayout of road94Traffic signals and traffic islandsAdverse traffic conditions

Traffic density and vehicle speed7 95-98Home and neighborhood characteristics98Roadside parkinzVehicle design99 oo

Inclement weatherDarkness'o'

normal developmental stages of children, howchildren of various ages behave in traffic, whattasks and skills are needed to negotiate trafficsuccessfully and which are deficient, and theeffectiveness of school based methods intendedto correct such deficiencies.

Stages of cognitive and psychosocialdevelopment: relationship to risk ofpedestrian injuryYoung children are, by their nature, more atrisk than most adults in traffic. They are likelyto be exposed to traffic threats that exceed theircognitive, developmental, behavioral, physical,and sensory abilities.8 Development occurscontinuously, rather than discretely in steps.The age at which a certain stage is reachedvaries among children, as may their abilities atthe outset of any stage. Because injuries arereported and tabulated according to a chrono-logic rather than developmental scale, relatinginjury risk to stage of development is difficult,yet is valuable to consider. Most work related tothe cognitive development of children isfounded on the developmental theory of JeanPiaget.9 He described four stages of develop-ment that were based on a child's ability tosolve mental problems from infancy throughadolescence: sensorimotor intelligence,preoperational, concrete operational, and for-mal operational stages.

SENSORIMOTOR INTELLIGENCE STAGEThis first stage extends from birth to about 18months, during which time the infant buildsconcepts by interacting with the environment.Responses that were originally based on ins-tinct become shaped by acquisition ofknowledge concerning properties of objects inthe environment. For example, if a mobile ismore interesting to infants after they make itmove, they will touch it more often. Infantsbegin to perceive themselves as causal agents,and eventually learn to behave in a mannerneeded to achieve their desired outcome.

Epidemiologic studies note that young child-ren are at increased risk of pedestrian injuries indriveways'° and other relatively protectedareas. Two factors contribute to this risk. First,children may be drawn toward, rather thanaway from, moving vehicles. Second, infantshave not yet fully developed the concept ofobject permanence - that an object still existseven though it has been moved out of sight. To

National Center forInjury Prevention andControl, Centers forDisease Control andPrevention (CDC), USPublic Health Service,US Department ofHealth and HumanServices, Atlanta,Georgia, USA

Correspondence to:Dr Richard A Schieber,DUIP/NCIPC/CDC, 4770Buford Highway NE,Mailstop K-63, Atlanta,GA 30341, USA.

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Childhood pedestrian injuries

an infant, then, a vehicle parked in the garagemay not exist if it cannot be seen from wherethe infant sits in the driveway, or if it is locatedbeyond a blind bend in the road. Fortunately,object permanence in children begins toemerge slightly before they begin to walk.

PREOPERATIONAL STAGEThe second stage of development described byPiaget spans from about 18 months to 7 years.Such children acquire symbolic operations,including the ability to imitate in the absence ofa model, form mental images, draw and playsymbolically, and use language. These enhancethe ability to fantasize, allowing children toescape the immediate environment andexperience new events. During this time, motorskills expand, including running and jumping.The capacity for fantasy and increasedlocomotor skills broaden the child's range ofexpression. For example, a child may playsimultaneously the role of fireman, fire truck,hose, ladder, engine, siren, burning building,and the occupants of the building."I Suchenhanced activity, in concert with a separationfrom reality and its attendant restrictions,places the child at increased risk of pedestrianinjuries, for how can a soaring airplane beconcerned with where the road begins?

Early studies reported that children in thepreoperational stage could not depart fromtheir own point ofview (egocentric thinking).'2In the child's view, the world centers on him, soifhe can see himself, the world also can see him.For this reason, preschool children may havedifficulty imagining that a driver cannot seethem standing between parked cars. Similarly,children see no need to assess traffic beforerunning across the street, because, from theirpoint of view, the environment exists to servethem. Early studies also reported that childrenat this stage used only the most fundamentalsystems to classify an object (rigid thinking).For example, a preschool child presented withtwo clay balls of equal mass will recognize thatthey have equal amounts of clay, if they areboth shaped as spheres. However, if one isflattened, the preoperational child will think ithas more clay because it has a larger cir-cumference, since size is a fundamental meansof classification for children of this age. Usingthis rigid system of classification, a child mayperceive all wide streets as dangerous, but allnarrow streets as safe, because size is the onlybasis for classification.More recent theory uses a 'constructivist'

approach to understanding cognitive develop-ment. In this approach, humans are 'activeprocessors of information who construct theirown reality . . . through active physical andmental manipulation of the environment.'13Witness that the properational child can, infact, have more than one perspective if the cuesprovided are familiar.'4 For example, childrenbetween ages 2 and 5 were able to take the per-spective of familiar Sesame Street charactersrather than their own. 15 With appropriateprompts, then, it may be possible to enhanceyoung children's ability to evaluate whether a

driver can see them. They correctly organizeknowledge into categories based on a variety ofcriteria, but these categories are based on whatis practical, rather than what is logical.'6 Ratherthan centering on one characteristic, they usecues, such as a set of painted white lines on astreet, to generalize and thus define a categorycalled 'a safe place to cross'. Categories arelearned hierarchically; basic level categories arelearned first (for example, car), while subor-dinate categories (for example, make) andsuperordinate categories (for example, trans-portation) are developed later. The child canmake sophisticated distinctions among cate-gories, but their developmental order mustprogress in proper sequence. For example, achild must learn to distinguish 'road' from'non-road' before she can distinguish a high-way from a dead-end street. Until the pre-operational child learns the full breadth ofcategories in this hierarchy, the capacity tolearn safe pedestrian behavior is limited.

Several other developmental features make itdifficult to train the preoperational child to dealwith traffic successfully. Cause and effect donot exist, so children at this stage cannotcomprehend that their actions have demons-trable consequences. They tend to center theirattention on one characteristic, to the exclusionofother features that are often more important.A child may be more interested in the color ofan onrushing car rather than its speed orproximity. Finally, the preschool child distortsfacts to create a personal reality. For example, achild playing a game may incorporate an ap-proaching car into his game, or think that he hasthe magical power the stop the vehicle.

CONCRETE OPERATIONAL STAGEThe third stage spans from about 7 years toadolescence. Attention has been focused onthree of the conceptual skills such childrenacquire- skills of conservation, classification,and combination. Conservation, the ability todetermine, for example, that the same amountof clay is present whether it exists as a ball orpancake, is now established. Classificationskills are structured according to principles oflogic. During the concrete operational stage,children will form a hypothesis and use it toguide their classification system until it fails, atwhich point they will form a new hypothesis.Such skills greatly enhance the ability to iden-tify dangerous situations. However, perfor-mance is inconsistent while these skills aredeveloping. Similarly, the child who can clas-sify well in one dimension may have difficultyclassifying in another dimension. For example,a child may be able to conserve the mass of theclay objects, but not be able to transfer thisconcept to their weight. Difficulty arises whendealing with complex or combinatorial situa-tions, which require simultaneous processingof more than one feature. Thus, a child mayhave difficulty determining whether it is safe tocross the street between two parked cars(learned as dangerous) when the cars arelocated on a crosswalk (learned as safe).The concept of proportions begins to

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develop only at the end of the concrete opera-tional stage. This has several ramifications.First, because probability is a form of a propor-tion, most children in this third stage will notbe able to distinguish between a low and a highprobability event, and thus cannot understandrisk. Second, an event that results from theconfluence of several factors (for example, a carcareering off a bridge, with failure of a safetybelt to unlatch and consequent trapping of theoccupant, resulting in drowning) may be con-sidered just as likely to occur as one that resultsfrom one factor (for example, a child killed bystepping in front of a moving bus).

FORMAL OPERATIONAL STAGEThe final stage of cognitive development beginsin adolescence. For the first time, youths canthink abstractly about events not previouslyexperienced or even contemplated. Theirdecisions can now be based on simultaneousconsideration of two or more variables. Interms of pedestrian skills, it now becomespossible to judge both the speed and thedistance of an oncoming car. Behavior is nowviewed as the initiation of a chain of events,rather than the occurrence of a single,immediate outcome. As in the previous stage,these cognitive characteristics develop slowly,and are manifested inconsistently at first.

Interaction of psychosocial and cognitivedevelopmentAspects of psychosocial development and cog-nitive development occur in tandem and mayinteract to modify the risk of injury. Forexample, acquisition of self control (impulsecontrol) is a hallmark of the toddler'spsychosocial development. This helps reducethe risk associated with increased locomotionand fantasy. Likewise, the rigid understandingof, and adherence to, rules by children in theearly phase of the concrete operational stagemay enhance their safety as their pedestriandomain broadens from home to neighborhoodand school. However, rigid adherence to rulesdoes not always lead to greater safety, becauseinability to generalize from a specific circums-tance addressed by the rule to other somewhatsimilar situations not specifically addressedmay put young children at greater risk whenthey encounter a new circumstance. Too, theaggressive, outgoing, defiant behaviorstereotypical of 3 year old male toddlers likelyincreases their risk of pedestrian injury byemboldening them.'718 Later, during the mid-dle phase of the concrete operational stage,children characteristically enjoy undertakingdangerous adventures with friends. However,this phase may occur before the concept ofproportions (risk) is acquired, leading them totake risks they cannot gauge and to conse-quences they do not expect.

How do children behave in real traffic?Children may be injured while standing, walk-ing, or playing on the sidewalk or curb,'9

driveway,1° or street.'o However, mostbehavioral studies have examined crossing thestreet, because this is the activity associatedwith most injuries.2' This task can be dividedinto two phases, precrossing and crossing.Development is especially relevant to the pre-crossing phase, including selection of themoment to cross, which involves observation,perception, judgment, and decision, and selec-tion of the site to cross.22

Early data concerning street crossing skillswere obtained by observing elementary schoolchildren crossing near schools.23 Before enter-ing traffic, only 40" 0ofAmerican children wereobserved to search to the left, fewer than 3000to the right, and 50°, behind. Fewer than 350wstopped at the curb before crossing, and 2000,stepped into danger. About 15-20%U did notcross within the crosswalk area, and 1000played in the street while crossing. About 30(0ran across the street. Grayson noted that 3900of child pedestrian casualties in the UnitedKingdom had not looked at all before crossing,and another 2100 had looked but not recog-nized an imminent threat before crossing.24The crossing behaviour of children appears

to differ substantially from that of adults.25Adults base crossing decision on the best timeto cross, while children base it on the best placeto cross. In one study, most children preferredto cross the street where a traffic island waslocated, presumably because it simplified thetask by dividing it in half. However, adultsseldom preferred to cross at that site, perhapsbecause it might take longer to cross. Adultsbegin observing and judging traffic long beforereaching the curb, which enables them tohesitate less at the curb. They then crossdiagonally at midblock, following closelybehind the last vehicle that passes them. Thismaximizes the gap distance to the next oncom-ing vehicle. Those children who do observetraffic before crossing tend to stop at the curb atmidblock before assessing traffic, which in-creases curb delay. They then cross the road atright angles to the curb, preferring the shortestdistance to the shortest time. The adult patternis adopted by children by 11-12 years of age.The adult pattern, although more efficient,probably increases exposure to traffic becauseof the additional time spent in the roadway.

What necessary traffic skills do childrenlack at various ages?Precrossing skills include planning the route,detecting traffic, making a judgment about itsthreat, and making a decision about whetherand how to cross. Crossings skills principallyinvolve motor development and continuousfeedback about decisions made. In consideringthe following studies, the reader should becognizant of several facts. First, experimentalstudies, such as those discussed below in whichchildren are presented with a real or simulatedroadway, assume that the child looks for trafficand recognizes traffic after seeing it. In fact,however, fewer than 40°!, ofthe children struckdo both.26 Second, simulated studies or perfor-mance tests supervised by adults may not instill

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the anxiety or confusion that may occur in realtraffic, thus overestimating the child's ability toperform. Third, most experimental studies donot present complex threats that are morerealistic, such as several vehicles travelling atdifferent speeds or in different directions.These are likely to be even more difficult for thechild to judge.

PLANNING A ROUTEPlanning a safe route is difficult for youngchildren up to 9 years old. Even then, there maybe some problems in finding a safe place tocross a road. Younger children favor the mostdirect route over seeking the safest places tocross. Accordingly, the young child may crossin midblock at right angles to the curb, butcross an intersection diagonally rather thanperforming a two part right angle crossing.

DETECTING TRAFFICDetecting traffic requires sensory acuity andcorrect processing of sensory information.Because the automobile is a moving stimulus,detection requires a search strategy. The abilityto search systematically begins during the con-crete operational stage, but is not reliablypresent until the end of this stage, about age 11.To detect traffic, most pedestrians use visual

and auditory cues. Visual perception incor-porates visual acuity, scanning ability, use offull visual fields, and color perception. Visualacuity is well developed by 6 months of life,27 2but children may have tunnel vision and thusbe unable to process information from theirperipheral fields of vision.29 The short statureand lower eye level position of young childrenmay further limit their field ofview. The abilityto abstract color as a property begins at about 3years of age. Between 3 and 6 years, color ispreferred over form as a basis of categorization,after which color becomes subordinate.A' Theability to match by color does not necessarilysignify an ability to identify colors,3' which maybe important when teaching young children todiscriminate traffic signals. Older children,however, use color beneficially. Under experi-mental conditions, search times of 7-12 yearold were substantially reduced when color cueswere introduced.32The ability to scan effectively is poorly

developed in young children.33 When childrenbetween 3 and 6 years of age were presented apicture, the youngest children fixated on itscenter with very little eye movement. Whenthey were later asked whether they recognized apicture, they made large visual sweeps beyondits boundaries. With increasing age, however,they progressively fixated on fewer features,used fewer eye movements, had shorter searchtimes, and misidentified less often. The dura-tion of fixation also decreased with age, sug-gesting that older children process visual in-formation more quickly.3'

Sounds can provide vital clues in traffic,including tire or engine noises made by anoncoming vehicle and skidding tires or a honk-ing horn indicating impending danger. Six year

olds appear to be substantially less able thanadults to detect the simulated direction of anoncoming vehicle.35 Sensitivity to sound maydepend on age, increasing through age 12 anddeclining thereafter.36 Children with deficienthearing or visual acuity may be more likely tosustain a pedestrian injury than those withnormal sensory acuity,37 although anotherstudy refutes this.38 Even the brain hemi-spheres may differ in the accuracy with whichthey process sound signals received from theirdesignated ear on the contralateral side. Itappears that the right ear/left brain combina-tion performs better in this regard than the leftear/right brain in young children.39

PROCESSING SENSORY INPUTOnce traffic is seen or heard, it must be heeded.The first step is to recognize its importance.Young children cannot rapidly identify anddiscard irrelevant, distracting cues. Before thestage of formal operations, children lack theability to concurrently process more than onefeature of a situation. Young children morereadily attend to incidental aspects of a visualfield during scanning, especially if it is new,surprising, or something with which the childis emotionally involved."42 Before age 5, con-trol of attention is almost lacking; after that,irrelevant information is not always ignored.Before age 6, children may not have an auto-matic search plan. Children 6-7 years of agecan learn which situations call for a planned,systematic search, but they may not focussufficiently to conduct this search until they areabout 11 years old.4345 Such developmentallynormal attention deficits cause the youngschool age child to be unreliable in traffic.

MAKING CORRECT JUDGMENTS ABOUT TRAF-FIC THREATSCrossing decisions include whether or not toenter the roadway, the place to cross, the pathto take, how fast to travel, and how the drivermight react. A sound decision on whether toenter the roadway should be based upon recall(experience) and monitoring of the trafficdetected, including the distance, speed, andanticipated direction ofvehicles and the oppor-tunities provided by various gaps in traffic. Thetime that has elapsed while making the decisionalso needs to be incorporated. Successful cross-ing performance also requires reliable estima-tion of the pedestrian's walking speed, peakcapabilities, and distance to the other side oftheroad or a traffic island. Integrating all theseaspects is difficult for the child, especially oneinexperienced in traffic, and result in a longerdecision making time. In fact, a 5 year oldrequires about twice as long to reach a pedest-rian decision as an adult.'& This leaves even lesstime to execute an imperfectly planned cross-ing.

Vehicle distanceBefore the concrete operational stage begins atabout 7 years, the child's system of

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classification is based on familiar and obvioustraits such as size. Assessment of distancedepends in part on comparing the size of thevehicle to objects located near to and far fromthe observer, using the memory of the absolutesize of a vehicle from previous encounters.Unfortunately, children have a limited abilityto correctly retain the true size of an object('size constancy') as it is moved farther fromthem, with the limit of accuracy reached atabout 60 feet.47 Vinje48 suggested that thePiagetian concept of overconstancy49 may bepartly responsible: the mind interprets a smallobject located nearby as having the same size asa larger object farther away, and consequently,the distances from the observer are erroneouslyconsidered to be equal. This overestimates thedistance between the child and the smallerobject, putting the child at imminent risk.Adults tend to underestimate actual distances,which may be partly protective.50 Comparedwith adults, children vary more in their deter-minations of distance, and children make suchdeterminations less efficiently.5'

Vehicle movementUntil age 8, it is difficult for a child to process allthe information needed to determine whether avehicle is moving. The concept of motion isassociated with a more fundamental category ofclassification, size, and is assessed by makingrepeated estimates of vehicle size relative toother objects. Since young children havedifficulty estimating size, their assessment ofvehicle movement is unreliable.

Vehicle speedThe concept of speed is even more complexbecause it incorporates the ratio of distance perunit of time. Piaget believed that the child'sconcept of movement and speed is closelyrelated to his concept of time, which begins inthe earliest (sensorimotor) stage but is notcomplete until the concrete operational stage(7-11 years).52 Because children in thepreoperational stage have not mastered theability to assess distance or time, accuratedeterminations of speed are well beyond theircapability. Furthermore, their assessment oftheir own walking speed used to cross the roadis influenced by fantasy, for example thinking 'Iam as fast as a jet'. Even though concreteoperational children have begun to consider theconcept of distance, and their assessment is lesslikely to be affected by fantasy, they are still notproficient in dealing with combinatorialclassification of more than one attribute, suchas distance and time. The concept of a ratio orproportion is thus beyond their reach. Forseveral reasons, then, the determination ofspeed is not reliable until the last stage.

Piaget's theory of children's skills has beenvalidated by studies demonstrating that untilthe age of 8, young children do not assess speedwell. Children younger than 8 believe thatwhichever vehicle passes more objects is travel-ing faster, regardless of the time needed to doso.53 Fast speeds are more difficult to correctlyascertain than slow or medium speeds, even for

older children. Children may suppose thatcompact cars inherently travel faster than big-ger, quiet cars.54 Even at age 9, only 750O" ofchildren could correctly judge which of twotrains traveled faster, given identical startingand stopping times but different routes ofdiffering lengths.55 The misbeliefs about speedare compounded by the absence of a referencebase of likely motor vehicle speeds. In onestudy only about 600", of children 4- 7 years oldeven knew what speed to expect from variousvehicles.56

Gap acceptanceGap acceptance refers to the pedestrian's viewofwhether there is sufficient time to safely crossthe road and avoid a collision with the nextoncoming car. This judgment takes intoaccount vehicle distance, roadway width, vehi-cle speed, and walking speed. Too short a gapacceptance results in a 'tight fit', either ascrossing begins or ends. Accepting too long agap results in rejecti-ng valid (missed) oppor-tunities. Children's abilities in gap assessmenthave been studied by showing them videorecordings of approaching vehicles, by using a'pretend road' adjacent to but protected from areal road, and by unobtrusively observing realcrossings. In general, young children err inboth directions: compared with adults, child-ren miss more opportunities and have more'tight fits' as they enter the roadway.57

Impulse control is an important feature ofgap acceptance. Young children have difficultysuppressing sudden impulses and are likely torun into the road, appearing suddenly withoutwarning.5859 In one series, the midblock dart-out was the leading cause of pedestrian injuries,constituting 2400 of all pedestrian injuries.About 90')O of these dart-outs occurred inchildren younger than 14 years.2' Between 5and 7 years, the child learns to suppress the firstimpulse, in favor of a later response.60

Anticipating driver behaviorCompounding young children's limitations inassessing traffic is the child's inability toanticipate driver behavior or to evaluate theirown role in communicating their intent todrivers. While current research suggests thatyoung children can adopt a perspective otherthan their own, this appears to be limited to theperspective of familiar others. Because the roleof driver and often the person driving areunfamiliar to the child, young children cannotanticipate driver actions very well. Moreover,only in adolescence do youths begin to under-stand that their own behavior can initiate achain of events. Therefore, younger childrendo not assess very well the importance of theirown role in making the driver aware of theirpresence. The egocentricity of school age (oryounger) children also makes it difficult forthem to imagine that the driver might beunaware of their presence. The situation isfurther exacerbated by the propensity forimpulsive behavior in young children. Whilestriving for self control begins at age 2, it is notconsistently effective before age 6 or 7.

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CausalityThe young child's understanding of causalityin social relationships is age dependent. Forexample, they may believe that adults willalways be kind to them, and therefore, thatdrivers will be able to stop instantly if neces-sary. Magical thinking may lead them to conc-

lude that nothing bad will happen to them, or

that bad things can be avoided by such simplemeans as crossing one's fingers.6' True rationalcausality does not appear until age 7 or 862 andnot until adolescence can youths consider theirown legitimate role in the causal chain.

Crossing the streetA child's ambulatory ability is related to motordevelopment. At age 3, most children walkautomatically, can run, jump from a height of1-5 feet, and have fairly good balance. Duringthe next year, the child acquires a steady pace

and gait and can walk backwards.63 By 5 years,

the child can start efficiently and stop quickly,can negotiate sharp corners, and becomes moregraceful and strong.' Because these motorskills develop fairly early in life, they do notseem to impede a child's ability to negotiatetraffic after the sensorimotor stage.

Developmental considerations whenteaching pedestrian skillsSeveral general educational approaches exist,including: teaching traffic safety by havingchildren memorize a short poem or list of rules;using audiovisual aids, print, and electronicmedia; using table top or other indoor demons-trations; using miniature street simulations('traffic gardens' and 'safety towns'), and real,yet protected, traffic situations, such as a 'pre-tend road'. Several authors have reviewed theeffectiveness of these methods, though fewprograms have been carefully evaluated.65"

Obeying rules is an age dependent pheno-menon. Because preoperational children haveso many difficulties making traffic relateddecisions, their decisions are principally rulebased. Their personal safety depends on learn-ing and strictly obeying crossing guidelines,such as 'only cross when an adult or crossingguard determines that it is safe for you to do so.'However, rules may not be understood or

remembered when needed. For example,young children may interpret literally the state-ment 'cross only with an adult or a crossingguard present', concluding that the presence ofa crossing guard is sufficient for them to cross

the street, even if his back is turned. Rules mustbe stated in a way that the child can compre-hend through speech or reading. Negative andpassive sentences are difficult for children lessthan 8 years to understand. Even 'left' and'right' may be confused in traffic situationsuntil about age 9.35 In an evaluation of thepopular six line British Green Cross Code,20% of children tested misread or did not readat all,67 or did not heed68 the rules, which were

written at grade 3-4 Flesch-Kincaid readinglevel (about the same as a Hemingway shortstory).69 Even if these rules were understood,

they only cover rudimentary crossing skills, notthose of complex traffic.Another problem is the inflexibility with

which young children (generally before age 10),follow rules. This could endanger childrenfaced with a new traffic situation. When aninflexible view of rules is combined with thenormal egocentric view of young children, achild may 'logically' conclude that walking in apedestrian crossing zone renders him magicallysafe from all harm. For example, children 5-6years old taught the Green Cross Code did notknow its purpose, but would repeat the wordswhen crossing as a talisman to ward off cars.70

Classroom posters and other printed materialare often used in pedestrian education. How-ever, the limited attention of young children,combined with their difficulty in selectingrelevant cues, suggests that the effectiveness ofsuch materials may be limited. In one study,less than 10% of children could remember thecontent of the poster, and after a single lesson,only about one fourth of children 7 years oryounger could recall the safety points illus-trated.7' In another study, classroom teachingusing a table top model was not substantiallyeffective.72 Audiovisual aids may not be veryeffective either; one research team observed nopre/post difference in stopping behavior after afilm was shown to children in grades 4-6.73Finally, several studies indicate that, althoughclassroom education may improve knowledgeof pedestrian safety issues, it does not changechildren's behavior.74 75 The poor ability ofyoung children to generalize from the class-room to the street, or their inability to thinkabstractly, further limits the potential successof classroom teaching.

Studies of simulated traffic, such as trafficgardens or safety towns, note a general lack ofeffectiveness.76 The method may be superior toclassroom education for some, but not for otherchildren. In one study, no long range, benefitwas demonstrated.77Some data suggest that some children can

achieve better road crossing skills withspecialized, practical training using real trafficsituations.78 One such method used was apretend road, a stretch of pavement locatedparallel and adjacent to a real road but pro-tected from it by a barrier. Several studiessuggest that, using a pretend road, elementaryschool children can be taught to judge gaps atnearly adult levels.79 For example, themechanics and purpose of a two way pretendroad was taught to 5 year old children, who thenused it to achieve roadway crossing competenceat a level similar to that of older children.80

ConclusionsPedestrian safety is a complex problem. For ayoung child, the act of crossing a street is aconscious, problem solving situation, with eachcircumstance appearing to be unique. Is a childready and able to acquire the necessary skillsthrough education or training, or should theseapproaches be made secondary to effortsdesigned to change driver behavior, adultsupervision, or the roadway environment? It

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appears that certain elements can be taughtsuccessfully, albeit with great educationaleffort; the pretend road is a good example ofthis. The question still remains, should pedes-trian safety be a primary focus ofinjury preven-tion education?

Several factors should be considered in an-swering this question. First, statistical com-parisons between intervention and controlgroups generally do not take into account theabsolute level ofperformance achieved, which iscritical. Two examples demonstrate this well.A study of roadway crossing techniques in 5year olds noted that table top educationresulted in improvements that were statisticallyequal to those of real traffic education, but theperformance level achieved by the groups usingthe two methods was poor. At best, only 44% ofeither group chose a 'safe' or 'more safe'method of crossing.8' Another study noted thatyoung children improved their crossing abilityat intersections, so that nearly 75% performedin a safe (albeit minimally so) manner afterinstruction, compared with less than 20% ofthe control group. Again, is this proportionhigh enough for safety?82 Because the momen-tum of a motor vehicle weighing 1000 kg andtravelling at 50 kph is one thousand timesgreater than that of a young child weighing10 kg and traveling at 5 kph, any collision canresult in a serious or fatal injury. Accordingly,collisions must be stringently avoided. Animprovement in outcome from education orany other countermeasure is insufficient if itleaves one in four children at risk, even if it isstatistically significant.

Second, outcome studies thus far have notdetermined whether children behave the sameunder supervised test conditions as they wouldwhen observed unobtrusively. For example,pretend roads seem to be a promising methodof training young children to cross even twoway streets successfully. However, does thispermanently increase their vigilance andreduce their normal lapses in attention? Thisrequires further investigation.A developmental perspective suggests that

traditional pedestrian traffic education haslimited value for young elementary schoolchild-ren, and that most efforts targeting this age groupshould be directed towards improving the road-way, vehicles, drivers, and adult supervision.However, this does not preclude the impor-tance of educating or training the child. Asnoted, pedestrian injury has many causes, andchild behavior may be amenable to educationand training. Those behavioral aspectsamenable to improvement are worth tackling,but, to be useful, the education and trainingprovided must be based on the child'sdevelopmental stage and consequent ability tocomprehend and incorporate such information.Meanwhile, developmental experts, especi-

ally educational psychologists and behavioralscientists, should be encouraged to participatein developing new techniques that might im-prove pedestrian behavior of young children.For example, virtual reality computer pro-grams could be developed to allow repetitious,individualized, staged instruction of dealing

with traffic threats using a personal computer.They also should be encouraged to conductmore observational studies of real life crossingpatterns of children at various ages, cultures,and urban and rural settings, to determine thesocial norm of young children walking to andfrom school and at play. This might indicatecircumstances where an adult, rather than anolder sibling, needs to supervise the youngchild. Because very young children cannot betaught effectively how to deal with traffic,urban planners and traffic engineers should beencouaged to develop safer residential com-munities by restricting vehicular access andslowing traffic, and to discourage playing in thestreet by introducing safe playgrounds.83Adult supervision, however, remains a prin-

cipal solution for young children. Parents andchild safety advocates should promote betterparent assessment of children's capabilities,and more adult supervision of child pedestrianbehavior, during the grade school years.84 Thisis particularly important because the ages atgreatest risk coincide with the period whenparents are most likely to overestimate theirchildren's pedestrian skills.85 All such effortsshould be undertaken with developmentalcharacteristics of children in mind. The age atwhich adults should permit children to crossthe road independently is related to manyfactors, including especially the type of road-way, traffic density, visibility of children at theroadside, and their developmental stage. Theparent should not assume that, because a childcan cross some streets under some conditions,that he or she is ready for independent(unsupervised) walking. Instead, the parentshould either ensure adult supervision, orestablish rules to indicate which path(s) thechild may take on commonly traveled routesand which streets may be crossed independ-ently. In our opinion, as a rough guide, daytimecrossing of low traffic residential streetsfamiliar to the child should be supervised untilabout age 7 or 8. Busy streets with several trafficlanes and a signalized crosswalk could benegotiated independently by most children atabout 12 years. Road crossing of major arteriesshould be supervised until adolescence.

In summary, the child's developmental stagedictates how he or she views and responds tovehicular traffic. Pedestrian training andeducation must fit the fundamental frameworkof the child's thinking to be effective. Becausecertain aspects of training are not within thereach of toddlers and preschool children,environmental countermeasures and adultsupervision must be relied upon. Awareness ofthe stages of child development and theirimpact on pedestrian skills should help parents,educators, and injury prevention experts pro-tect child pedestrians better.

We thank David Sleet, PhD, for his thoughtful review of thismanuscript.

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DWI charges and severity of injuryA study abstracted in Inroads - the Quarterly Bulletin of the AAAM (winter 1996) andoriginally published in the Annals of Emergency Medicine (1996; 27: 66-72) concludes thatinjured alcohol-impaired drivers who require at least emergency treatment are infrequentlycharged with DWI, and that, the more severe the injury, the less likely a DWI charge.

Not drunk?A driver in Montreal who ran a red light, killing one passenger in another car and severelyinjuring another, claimed not to be drunk. He refused a blood sample, claiming he had 'felthot and then blacked out' thus causing the 'accident'.

Passing strangeI admit, it seems strange for a journal editor to be excerpting material from another'sabstracts, but Jan Shield's Child Safety News is so good it is hard to resist. In the March 1996issue, she includes a paper called 'Making reading easier' which I urge all our authors to readand take to heart (Archives ofDisease in Childhood 1996; 74: 180-2). As well, I was struck bythe wide range of 'mainstream' journals publishing child injury papers: the BM7,Developmental and Behavioral Pediatrics, Pediatrics, Archives of Pediatrics and AdolescentMedicine,JAMA, the Medical Journal of Australia, to name but a few. Equally importantare the smaller journals that also need to be considered: Children's Environments, Journal ofTrauma, Pediatric Annals, Journal of Burn Care and Rehabilitation, Annals of EmergencyMedicine, Journal of Public Health Medicine; these are but a few examples.

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