Determination of Injury Risks and Safety Measures Taken by Mothers of Children With an Intellectual Disability and Autism Spectrum Disorder Hatice Yıldırım Sarı, PhD, RN, Alev Girli, PhD, Semra Ozturk Ozgonenel, PhD, and Helen Rowley, MD Hatice Yıldırım Sarı, PhD, RN, is an Associate Professor at Health Science Faculty, Nursing Department, Izmir Katip Celebi University, ˙I zmir, Turkey, Alev Girli, PhD, is a Psychologist at Education Faculty, Special Training Department, Dokuz Eylul University, ˙I zmir, Turkey, Semra Ozturk Ozgonenel, PhD, is a Psychologist at Cagdas Isık Special Training Center, ˙I zmir, Turkey, and Helen Rowley, MD, is a Foundation Year Doctor at the University of Leicester, Leicester, UK.
Search terms: Autism, injury, intellectual disability Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: The purpose of the study is to determine the injury risk behaviors and home safety measures in children with an intellectual disability or autism spectrum disorder. METHOD: The study sample included mothers of 100 children between the ages of 2 and 12 years. FINDINGS: There was a significant difference between the home safety measures and the children’s ages, the birth order of the children, and the mother’s and father’s ages. There was not a significant relationship between the children’s ages, diagnosis, and Injury Behavior Checklist (IBC). There is a positive correlation between the total score of the Home Safety Measures Control List and IBC. ÖZET AMAÇ: Bu aras¸tırmanın amacı zihinsel yetersizlig ˘ i olan veya otizmi olan çocukların yaralanma riskli davranıs¸larını ve ebeveynlerinin ev güvenlik önlemlerini belirlemektir. YÖNTEM: Aras¸tırmanın örneklemi 2–12 yas¸lar arasında 100 çocug ˘ un annesinden olus¸maktadır. BULGULAR: Ev güvenlik önlemleri ile çocukların yas¸ları, çocug ˘ un ailenin kaçıncı çocug ˘ u oldug ˘ u ve anne ve baba yas¸ı arasında anlamlı ilis¸ki saptanmıs¸tır. Çocug ˘ un yas¸ı, tanısı ve Yaralanma Riskli Davranıs¸lar Listesi skorları arasında anlamlı ilis¸ki saptanmamıs¸tır. Yaralanma Riskli Davranıs¸lar ve Ev Güvenlik Önlemleri puanları arasında pozitif yönde korelasyon bulunmaktadır.
Accidents and injuries pose a serious public health threat for children. Childhood injuries not only cause death or disabilities but also pose a serious problem in terms of the cost (financial, emotional, and social) incurred (Dal Santo, Goodman, Glik, & Jackson, 2004). According to Peden et al. (2008), in developed countries, approximately 20,000 children lose their lives each year due to accidents and injuries. In developing countries, however, approximately one million children under the age of 15 die each year due to unexpected injuries (Peden et al., 2008). There was a relationship between childhood injuries and variables such as child age, gender, and family socioeconomic status. Boys experience approximately 70% more accidents and injuries when compared with girls (Peden et al., 2008). Children of unemployed mothers
© 2015 NANDA International, Inc. International Journal of Nursing Knowledge Volume 27, No. 2, April 2016
are at a higher risk of injury. Additionally, behavioral characteristics of children older than 2.5 years are associated with an increased risk of injury (Dal Santo et al., 2004). In several studies conducted in Turkey, it has been demonstrated that families’ knowledge regarding the prevention of accidents is insufficient, making children more vulnerable to accidents (Erkal, 2010; ˙I nanç, Baysal, Cos¸gun, Tavilog ˘ lu, & Ünivar, 2008; Yıldırım, 2010). Disability and Frequency of Injuries Recent studies indicate that children with intellectual disability (ID) are at a higher risk of injury (Lee, Harrington, Chang, & Connors, 2008; Xiang, Stallones, Chen, Hostetler, & Kelleher, 2005). Brenner et al. (2013) conducted research
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Determination of Injury Risks and Safety Measures using 2006–2007 National Electronic System Surveillance data and determined that children with learning disabilities experienced injuries 1.57 times more often than children with other disabilities. Lee et al. (2008) showed that the incidence of injuries is two to three times higher in children with autism, attention deficit hyperactivity disorder, and psychopathology than in children with no disabilities. In a retrospective study of schoolchildren with and without disabilities, it was noted that children with disabilities were exposed to injuries twice as often compared with children without disabilities (Ramirez, Fillmore, Chen, & Peek-Asa, 2010). According to a study conducted in Greece, of the children admitted to hospital due to injuries, 2.3% had motor or sensory insufficiency (Petridou et al., 2003), where falls are more common in children with a preexisting disability. In addition, the place of residence, immigration status, and cold months (winter) have been found to be factors associated with injury in children with disabilities (Petridou et al., 2003). The American Association on Intellectual and Developmental Disabilities (2010) described that “ID is a disability characterized by significant limitations both in intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior, which covers a range of everyday social and practical skills. This disability originates before the age of 18” (http://aaidd.org/). Cognitive limitations in children with an ID are among the factors that increase their risk of injuries (Limbos, Ramirez, Park, Peek-Asa, & Kraus, 2004; Ramirez, Peek-Asa, & Kraus, 2004; Rowe, Maughan, & Goodman, 2004; Sherrard, Tonge, & Ozanne-Smith, 2001; Slayter et al., 2006). According to the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), “[p]eople with Autism Spectrum Disorder (ASD) tend to have communication deficits, such as responding inappropriately in conversations, misreading nonverbal interactions, or having difficulty building friendships appropriate to their age. In addition, people with ASD may be overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items. The symptoms of people with ASD will fall on a continuum, with some individuals showing mild symptoms and others having more severe symptoms.” ID and ASD frequently coexist. Cavalari and Romancyzk (2012) stated that in children with an ASD diagnosis, there was an increase in risk-taking behaviors, such as running into the road. Furthermore, severe injuries were more frequent, and there was a positive correlation with the severity of ASD symptoms and the frequency of injuries. Richards, Oliver, Nelson, and Moss (2012) reported that self-injurious behavior is more common in children with impulsivity, hyperactivity, and negative emotions, but less common in children with better skills and speaking ability. The Injury Behavior Checklist (IBC; Speltz, Gonzales, Sulzbadner, & Quan, 1990) is often used to determine the risk of injury in 2- to 5-year-old children without disability. Potts et al. (1997) found that the IBC could be extended in its use for children between the ages of 2 and 9. The
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H. Yıldırım Sarı et al. review of the literature revealed that the IBC had been used in children with ID (Cavalari and Romancyzk 2012). Moreover, Rowe and Maughan (2009) used the IBC to determine the level of “risk-taking” in children with mental health problems.
Home Safety Measures According to Ug ˘ ur (2004), “the best way to deal with accidents and problems arising from accidents is to avoid the accidents.” In order to avoid accidents, education should be provided, physical environmental arrangements and appropriate legal regulations should be put into practice, and compliance with these laws should be ensured (Ug ˘ ur, 2004). Home safety measures implemented by parents have been proven to be effective in preventing childhood injuries (Kendrick et al., 2013). It is reported that families often consider safety in specific areas, such as smoke alarms, fire exit plan, stair gates, electrical outlet covers, storage of medicines, and cleaning materials (Kendrick et al., 2013). Ug ˘ ur states that the child’s developmental stage and individual needs must be considered when planning and adjusting home safety measures regarding number of floors, the location of windows, balconies, garage, swimming pool, yard, and fences around the yard, in addition to the materials that should be used for the stairs and railings, lighting, flooring, and household goods. Children with ID have either behavioral deficiencies or excesses, which necessitate further training on safety measures (Dixon, Bergstrom, Smith, & Tarbox, 2010). No studies on injury-related characteristics of children with ASD or ID have been conducted in Turkey. Research on training on safety measures for children with ID and their families is very limited (Batu, Ergenekon, Erbas, & Akmanoglu, 2004).
Aim This study was planned to determine the incidence of injury risk behaviors and home safety measures and the relationship between sociodemographic variables in children with ID or ASD.
Research Questions 1. What are the home safety measures taken for children with ID or ASD? 2. Is there a relationship between the home safety measures and sociodemographic variables of children and families? 3. What is the incidence of injury risk behavior among children with ID or ASD? 4. Is there a relationship between injury risk behavior and sociodemographic variables of children?
H. Yıldırım Sarı et al.
Determination of Injury Risks and Safety Measures
Methods
demographic information about the child and questions about the child’s characteristics associated with increased risk of injuries.
The study was designed as a descriptive study. Approval was taken for study from the ˙I zmir Katip Celebi University Ethics Committee in 2012. Families were informed about the research, their written and verbal consent was obtained, and only the families volunteering to participate were included in the study.
List of home safety measures. In the study, a list of home safety measures prepared by Yıldırım (2010) was used. It contains home safety measures for children aged 1–4 years. In this study, 36 questions from the list developed by Yıldırım were used. Before these 36 questions were used, five experts, specializing in the field of education, ASD, or ID, were consulted and their opinions were obtained about the list. This list includes 36 questions regarding the measures to be taken at home in order to ensure children’s safety. Families were asked to mark “yes” if the measure was already taken and “no” if that measure was not taken. The questionnaire including the list of home safety measures was marked accordingly; 1 point was given to each “yes” answer and 0 point to each “no” answer. The lowest possible score of the safety measures list is 0 and the highest possible score is 36. To implement the list, the permission was obtained from Yıldırım.
Design
Study Setting and Participants The study was conducted with two special training courses. The reason why this special training course was preferred is that it gave training to students not only from the city where they are located but also from the neighboring cities and towns, and included students with different socioeconomic levels. Of the students attending both branches of the course (in total 279 children), 71.3% (n = 199) were male, and 59.8% (n = 167) were diagnosed with autism and 40.2% (n = 112) with ID. The mothers of children with an ID or ASD between the ages of 2 and 12 were included in the study. During the study, 100 mothers were surveyed. Families who gave their consent to participate in the study, and whose children had ID or ASD, were between 2 and 12 years old, and were able to walk, were included in the study. Families who did not consent to participate in the study and families whose children had physical disabilities and prevent them from being able to move were excluded from the study. In Turkey, the definitive diagnosis of children with suspected ASD or ID is made after they are thoroughly examined by child neurologists, child psychiatrists, and clinical psychologists working in hospitals or university hospitals specializing in child health. In order to achieve diagnosis, young children are given developmental assessment tests, and older children when necessary are given intelligence tests. Children diagnosed with ASD or ID are referred to a training center so they can benefit from special education and guidance services provided by the center. In the training center, the child receives a training program in accordance with his/her diagnosis and developmental level. All of the children included in the sample of this research were first evaluated and then diagnosed with ASD or ID by a child psychiatrist, neurologist, and clinical psychologist. Measures Family demographic information form. It is prepared by the researchers and contains information about the mother, father, and family. The form also includes questions on how often and when mothers supervise their children. Child demographic information. The form is prepared by the researchers and is based on literature. It contains
IBC. In the study, the “Injury Behavior Checklist” developed by Speltz et al. in 1990 was used. The IBC, which has 24 items, is a 5-point Likert-type scale used to determine preschool (2–5 years of age) children’s injury risk behaviors. The checklist is filled in by taking into account the behaviors displayed by the child within the last 6 months. The lowest and highest possible scores to be obtained from the checklist are 0 and 96, respectively. Whereas a total score of 48 and above suggests a high risk for injury behavior, a score of less than 48 indicates a low risk for injury behavior (Speltz et al., 1990). The internal consistency coefficient of the original scale was α = .87 (Speltz et al., 1990), and the Turkish version of the scale was found to be α = .87 (Uysal, Ergül, & Ardahan, 2008). To implement the scale, the permission was obtained from Uysal. In our investigation, the Cronbach’s alpha coefficient was determined as .89. Procedure Children were accompanied by their family members when they came to the special training center. While the child was having a one-to-one lesson with the special education teacher, the child’s family members stayed in the waiting room, they were informed about the study, and then the data were collected from them through face-to-face interviews. Data Analysis In the study, p < .05 was considered significant. The relationship among the list of home safety measures, IBC scale, and sociodemographic variables was examined with the chi-square test, analysis of variance test, Kruskal–Wallis H test, and t-test. The Cronbach’s alpha analysis of the IBC scale was conducted.
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Determination of Injury Risks and Safety Measures Results As can be seen in Table 1, ages of children included in this study varied between 2 and 12, with a mean age of 7.8 ± 2.88. Seventy-five percent of the children were boys, 67.3% had a diagnosis of ASD, and 62% were the first child in the family. Twenty-one of the children included in this study had not only a disability but also a chronic disease requiring medication (see Table 1 for details). Of these 21 children with a chronic condition, 10 had a neurological system-related disease (epilepsy), three had a psychiatric disease, three had a respiratory disease, one had an endocrine disease, one had an immune condition, one had a cardiac disease, one had a urinary tract disease, and one had a metabolic disease. Twenty-one percent of the children taking medication took Risperdal. Seventy percent of the children taking medication were diagnosed with ASD. Of the children, 7% were hyperactive, 25% were active, and 68% had normal activity level. Of those with ASD, 37% could not speak or were echolalic. Fifteen percent of the children were identified as high-functioning. The sociodemographic characteristics of parents are shown in Table 2. Research question 1: What are the home safety measures taken for children with ID or ASD?
H. Yıldırım Sarı et al. ations, for example, when the mothers did housework, when someone else accompanied the child, or while the child was studying, playing on the computer, or watching TV. As can be seen in Table 3, while 92% of the families stated that lighting in their homes was sufficient, only 13% of them stated that there was a fire escape in their homes. Research question 2: Is there a relationship between the home safety measures and sociodemographic variables of children and families? The questionnaire including the list of home safety measures was marked accordingly; 1 point was given to each “yes” answer and 0 points to each “no” answer. The lowest possible score of the safety measures list is 0 and the highest possible score is 36. We compared mean scores of the safety measures list with sociodemographic variables. As can be seen in Table 4, a significant relationship was determined between the lower age of children and the higher safety measures taken at home (t = 2.706, p < .05). If the child is the firstborn, mothers take higher safety measures (t = 1.724, p < .05). Safety measures taken at
Table 2. Sociodemographic Characteristics of Parents Characteristics total: 100
The mothers were asked how often they supervised their children. According to their statements, 89% supervised their children continuously, 7% sometimes, and 4% rarely. The mothers did not supervise their children in some situ-
Table 1. Demographic Information of the Children Included in the Study Characteristics total: 100 Age (years) (mean: 7.8 ± 2.88 (min: 2, max: 12) 2–6 7–12 Gender Female Male Disability Autism spectrum disorder Intellectual disability Birth order First Second Third Additional information Additional chronic condition No additional conditions On medication Not on medication Orthopedic condition present No orthopedic condition present Wheelchair user Non-wheelchair user
98
Number
%
44 56
44.0 56.0
25 75
25 75
70 34
67.3 32.7
62 33 5
62.0 33.0 5.0
21 79 47 53 4 96 0 100
21.0 79.0 47.0 53.0 4.0 96.0 0 100.0
Mother’s age (years) (mean: 36.6 ± 6.0, min: 23, max: 50) 23–32 33–42 43–50 Mother’s job status Employment Unemployment Mother’s education Not educated Primary school High school University Father’s age (years) (mean: 40.3 ± 5.5, min: 30, max: 52) 30–40 41–52 Father’s job status Employment Unemployment Father’s education Primary school High school University Birth order One child Two children Three children Have an another child with a disability Do not have another child with a disability Economic status Low income Middle income High income
Number
%
28 56 16
28.0 56.0 16.0
38 62
38.0 62.0
1 25 24 50
1.0 25.0 24.0 50.0
47 51
48.0 52.0
93 6
93.9 6.1
22 21 55
22.4 21.4 56.1
40 52 8 2 98
40.0 52.0 8.0 2.0 98.0
13 74 13
13.0 74.0 13.0
H. Yıldırım Sarı et al.
Determination of Injury Risks and Safety Measures
Table 3. Distribution of Home Safety Measures Measures (N = 100) 1. Kitchen and bathroom floors are not slippery or wet. 2. There are no small items or loose cables likely to cause falls while walking. 3. Sharp-edged or angular objects and furniture are covered with cotton or sponge. 4. Items like matches, lighters, and candles are kept out of the reach of children. 5. Cleaning agents, disinfectants, poisonous products, and cosmetic products are kept in their own boxes or storage lockers out of reach of children. 6. No table cloth is laid over the kitchen table or the cloth is attached on the table. 7. Knives and other sharp objects are kept out of reach of children or stored in cupboards. 8. Medicines and vitamins are stored in boxes or in lockers out of the reach of children. 9. Electrical outlets have a safety lock. 10. There are safety mechanisms used to adjust the width between window railings and how wide windows are opened. 11. The width between the balcony railings is suitable enough so that children’s feet or heads do not get stuck. 12. Bars of the balcony are thick enough, and prevent children from climbing. 13. There is sufficient lighting (75- or above watt light bulbs). 14. No water is stored in bathtubs or bucket-like containers. 15. Electrical equipment (radio, hair dryer, etc.) is not plugged in, is away from water, and out of the reach of children. 16. There are no furniture or objects in front of the window. 17. The child’s mattress fits the bed. 18. The width between the bars of the bed rails is no more than 6 cm. 19. Plants likely to cause harm are out of the reach of children. 20. Toys do not have small, detachable parts likely to cause choking. 21. Toys do not have sharp edges or rope-like thin and long parts. 22. There are no toys like guns, pop guns, darts, or ejection toys among the child’s toys. 23. The furniture or heavy objects likely to topple are fixed onto the floor. 24. Rugs, carpets, and runners do not slide. 25. There is a barrier to prevent the child from touching objects like the heater, stove, etc. 26. Wardrobes can also be opened from inside. 27. No heavy objects are placed on the cabinets, wardrobes, or cupboards. 28. The front door of the house or balcony doors cannot be easily opened by children. 29. There is a fire extinguisher ready to use at home. 30. There is a first aid kit/medicine cabinet at home. 31. First aid kits/medicine cabinets are locked and placed high enough for children not to reach. 32. The numbers of emergency services are either recorded in every phone in the house or printed as a list near the phone. 33. There is an emergency plan. 34. There is fire escape at home. 35. There are handrails on both sides of the stairs. 36. There is a fire and smoke detector at home.
Age 2–6 years Yes/No
Age 7–12 years Yes/No
Total Yes/No
Analysis
38/6 37/7
44/12 45/11
82/18 82/18
p > .05 p > .05
16/28
10/46
26/74
χ2 = 4.386 p < .05
40/4
38/18
78/22
χ2 = 7.630 p < .05
33/11
35/21
68/32
p > .05
24/20
28/28
52/48
p > .05
35/9
33/23
68/32
χ2 = 4.813 p < .05
36/8
36/20
72/28
χ2 = 3.757 p < .05
16/28 23/21
14/42 29/27
30/70 52/48
p > .05 p > .05
39/5
41/15
80/20
χ2 = 3.663 p < .05
30/14
31/25
61/39
42/2 38/6 42/2
50/6 42/14 41/15
92/8 80/20 83/17
p > .05 p > .05 χ2 = 8.638 p < .05
25/19 41/3 34/10
25/31 47/9 40/16
50/50 88/12 74/26
p > .05 p > .05 p > .05
35/9
39/17
74/26
p > .05
32/12
40/16
72/28
p > .05
35/9
39/17
74/26
p > .05
41/3
44/12
85/12
χ2 = 4.125 p > .05
33/11
25/31
58/42
χ2 = 9.321 p < .05
35/9 27/17
42/14 19/37
77/23 46/54
p > .05 χ2 = 7.466 p < .05
29/15 37/7
35/21 39/17
64/36 76/24
p > .05 p > .05
32/12
30/26
62/38
χ2 = 3.838 p < .05
12/32 30/14 28/16
9/47 39/17 33/23
21/79 69/31 61/39
p > .05 p > .05 p > .05
16/28
20/36
36/64
p > .05
16/28 6/38 11/33 8/36
23/33 7/49 12/44 8/48
39/61 13/87 23/77 16/84
p p p p
p > .05
> > > >
.05 .05 .05 .05
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H. Yıldırım Sarı et al.
Table 4. Comparison of Sociodemographic Variables With the Scores Obtained From the List of Home Safety Measures Home Safety Measures Control List point Variables Gender Girl (n = 25) Boy (n = 75) Age 2–6 years (n = 44) 7–12 years (n = 56) Number of child First child (n = 62) Second and third child (n = 38) Mother’s age 23–32 years (n = 28)a 33–42 years (n = 56)b 43–52 years (n = 16)c Mother’s education Primary school (n = 25)a High school (n = 24)b University (n = 50)c Father’s age 30–40 years (n = 47) 40–49 years (n = 51)
SS
Analyses
p
21.9 21.8
7.1 6.9
t = −.033
p > .05
23.9 20.2
5.7 7.4
t = 2.706
p < .05
22.7 20.3
6.2 7.9
t = 1.724
p < .05
24.6 22.3 15.6
6.4 6.1 7.5
KWH = 14.978 c < b,a*
.001
19.4 23.7 22.1
8.9 6.8 5.8
KWH = 2.696
p > .05
23.6 20.0
7.1 6.6
t = 2.608
p < .05
X
*Mother’s age and control list Bonferroni results: (43–52 age and 23–32 age mean difference −9.04464, p = .000), (43–52 age and 33–42 age mean difference −6.68750, p = .001). KWH, Kruskal-Wallis H test.
home were also noted to vary depending on the mother’s age. This difference is related with the fact that mothers aged between 43 and 52 had lower safety measure scores (Kruskal-Wallis H = 14.978, p < .05) (Table 4). There was a significant difference between the age of the fathers and their home safety measure scores, where the highest scores were of fathers aged 30–40 (t = 2.608, p < .05). No significant relationship was detected between home safety measures taken at home and the fathers’ education levels and economic status. No significant difference was detected between highfunctioning and non-high-functioning children in terms of home safety measures. There were significant differences between children who are able to speak (n = 63) and who are not able to speak (n = 37) in terms of the following safety measures: “Items such as matches, lighters, candles are kept out of the reach of children” (chi-square: 4.285, p < .05). “The furniture or heavy objects likely to topple are fixed onto the floor” (chi-square: 5.832, p < .05). Wardrobes can also be opened from inside (chi-square: 5.990, p < .05). The numbers of emergency services are either recorded in every phone in the house or as a printed list near the phone (chi-square: 4.075, p < .05). There were significant differences between active children (n = 32) and children with normal activity (n = 68) in terms of the following safety measures: “The furniture or heavy objects likely to topple are fixed onto the floor” (chi-
100
square: 5.832, p < .05). Wardrobes can also be opened from inside (chi-square: 5.990, p < .05). The numbers of emergency services are either recorded in every phone in the house or printed as a list near the phone (chi-square: 4.075, p < .05). There is a positive correlation between the total score of the Home Safety Measures Control List and IBC (Pearson correlation .21, p < .05). Research question 3: What is the incidence of injury risk behavior among children with ID or ASD? It was determined that of the children, 7% were very active at home, 25% were active at home, 21% had interest in electrical devices, for example lighters and matches, where 32% showed interest in kitchen gadgets. Six percent of the children displayed a behavior of inserting objects such as chickpeas and peanuts up their nose, and 12% exhibited a behavior of playing with sharp objects, such as knives and scissors, which were likely to pose danger to themselves. As can be seen in Table 5, 65.7% (n = 46) of the children enjoyed jumping on furniture, beds, seats, or other objects, whereas 52.9% (n = 37) tried to explore the environment they were not allowed to be in, and 44.3% (n = 31) fall down. The mean IBC score was 44.62 ± 1.22. While 61.4% (n = 43) of the children did not have a risk of injury, 38.6% (n = 27) had an increased risk.
H. Yıldırım Sarı et al.
Determination of Injury Risks and Safety Measures
Table 5. Injury Behavior Characteristics of Children Never and rarely
Sometimes
Often
Injury Behavior Checklist (N = 70, children ages 2–9 years)
n
%
n
%
n
%
n
%
1. Runs out into the street 2. Jumps off furniture or other structures 3. Jumps down stairs 4. Rides bike in unsafe areas 5. Runs or bumps into things 6. Falls down 7. Plays with fire 8. Puts fingers or objects near appliances or outlets 9. Leaves the house without permission 10. Refuses to use seat belt or to stay seated in car 11. Plays with sharp objects 12. Pulls/pushes over furniture or heavy objects 13. Falls out window or downstairs 14. Puts objects or nonfood items in mouth 15. Gets scratches, scrapes, and bruises during play 16. Takes chances on playground equipment 17. Tries to climb on top of furniture or cabinets 18. Stands on chairs 19. Explores places that are off limits 20. Gets into dangerous substances 21. Plays carelessly or recklessly 22. Comes into contact with hot objects 23. Behaves carelessly in or around water hazards 24. Teases and/or approaches unfamiliar animals
40 24 47 64 45 39 63 64 66 58 62 60 63 52 55 57 51 41 33 68 46 64 53 48
57.1 34.3 67.1 91.4 64.3 55.7 90.0 91.4 94.3 82.9 88.6 85.7 90.0 74.3 78.6 81.4 72.9 58.6 47.1 97.1 65.7 91.4 75.7 68.6
15 21 15 3 14 25 7 4 4 7 6 7 7 11 13 12 13 17 21 2 17 6 12 13
21.4 30 21.4 4.3 20.0 35.7 10.0 5.7 5.7 10.0 8.6 10.0 10.0 15.7 18.6 17.1 18.6 24.3 30.0 2.9 24.3 8.6 17.1 18.6
8 16 6 0 6 3 0 1 0 1 2 2 0 4 2 1 5 10 4 0 6 0 3 6
11.4 22.9 8.6 0 8.6 4.3 0 1.4 0 1.4 2.9 2.9 0 5.7 2.9 1.4 7.1 14.3 5.7 0 8.6 0 4.3 8.6
7 9 2 3 5 3 0 1 0 4 0 1 0 3 0 0 1 2 12 0 1 0 2 3
10.0 12.9 2.9 4.3 7.1 4.3 0 1.4 0 5.7 0 1.4 0 4.3 0 0 1.4 2.9 17.1 0 1.4 0 2.9 4.3
Research question 4: Is there a relationship between injury risk behavior and sociodemographic variables of children? The IBC score was 46.5 ± 11.7 for children aged 2–6 years and 40.11 ± 11.3 for children aged 7–12 years. There were significant differences between the two groups (t = 2.664, p < .05). While the IBC score was 47.63 ± 12.9 for the active children, it was 40.76 ± 10.8 for the children with the normal activity level. The difference between the two groups was significant (t = 2.699, p = .008). There were no significant differences between the high-functioning and non-highfunctioning children, and children who are able to speak and children who are not able to speak, in terms of IBC scores. Discussion Home Safety Measures As seen in Table 3, the lowest levels of safety measures were observed in the following areas: presence of fire escape, fire and smoke detector, handrails on both sides of the stairs, electrical outlets with a safety lock, sharp-edged or angular objects, and furniture covered with cotton or sponge. Of these measures, fire escapes and smoke detectors are not among the widely used structural arrangements in houses; thus, families may not have taken these measures. However, home safety is very important when
Always
considering prevention of childhood injuries (Kendrick, Barlow, Hampshire, Polnay, & Stewart-Brown, 2007). According to the fire regulations in Turkey, smoke detectors are an obligation for high buildings. Fire escapes are necessary for the buildings higher than four stories (Turkey Regulation on Fire Protection of Buildings, 2009). It was observed that security measures were taken more at homes where children were hyperactive or active. It is especially important to provide training on home security measures for the mothers of these children. In our study, 89 (89%) mothers stated that they constantly supervised their children. Similarly, Gallagher, Reifsnider, and Gill (2009) reported that mothers supervised their children closely or stayed with the children in order to prevent them from being injured. Home safety measures were compared with yes/no responses for age group by chi-square analysis in Table 3. According to this analysis, more mothers who have children 7–12 years of age were not undertaking home safety measures. Our study revealed that more safety measures were taken at homes where parents had younger children (Table 4). Our findings also revealed that 38.6% of the children were at an increased risk of injury. Of the home accident-related deaths of children under the age of 18 years that occurred in Turkey between 1996 and 2000, the highest incidence was observed in children between the ages of 0 and 3 years (Mahmut, Sunay, Emre, & Gürol, 2005). Accidents are more common in younger age groups; therefore, the mothers of young children who take more
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Determination of Injury Risks and Safety Measures safety measures are normal. According to the results of a study, the incidence of injury in children with a disability decreases as they grow older (Petridou et al., 2003). In addition, developmental age rather than chronological age should be taken into consideration when safety measures at home are arranged (Gaebler-Spira & Thornton, 2002). According to a report by Peden et al. (2008), sociodemographic variables, such as economic status, mother’s age, mother’s education, single parent, family type, and the number of children, are directly associated with childhood injuries (Peden et al., 2008). According to our results, parents who had their first child and were younger took more safety measures (Table 4). Erkal (2010) found that educated mothers and young mothers took more safety measures at home. However, contrary to this, there are other studies indicating that younger mothers are a significant risk factor for injury (˙I nanç et al., 2008). According to our findings, there is no significant relationship between the economic status of the family and taking safety measures at home. However, researchers have found that the children of unemployed mothers were more prone to injuries compared with the children of mothers with higher economic status (Dal Santo et al., 2004; Erkal, 2010).
H. Yıldırım Sarı et al. dren who had ASD also had ID; however, we did not have any data related with comorbidity of ASD and ID. This ASD and ID comorbidity can also affect child injury behavior. However, no comparison based on the diagnoses of ASD and ID was made. In future studies, it would be useful to conduct investigations based on diagnosis and the degree of the disability. In addition, it was determined that 47% (n = 47) of the children in our study took medication. No significant relationship was determined between the children’s injury risk behaviors and medicine use. Conclusion In this study, we demonstrated that 89% (n = 89) of the mothers constantly supervised their children. There was a significant difference between the safety measures taken at home and the children’s age and the birth order of the child. There was a significant relationship between the safety measures taken at home and the mother’s age and the father’s age. It was determined that more active children and young children have a higher risk for injury. There is a significant correlation between IBC and home safety measures.
Injury Risk Behavior According to our findings, of the children in the study, 65.7% exhibited the risky behavior of jumping off furniture or other structures, whereas 52.9% exhibited the risky behavior of exploring places that are prohibited. The IBC scores of active and hyperactive children were higher than those with normal activity levels. One of the common symptoms in children with autistic spectrum disorder is sensory difference. Due to their sensory differences in vision, hearing, taste, touch, and motion, children with ASD tend to look for specific solutions to sensory stimuli. Desire to act is more intense among children who are less sensitive to motion than among other children. In addition, children with ID or children with autism do not have much opportunity to play or do physical activities with their peers in places such as playgrounds, schools, and parks, which could contribute to these children’s desire to be more active and sometimes to do uncontrolled movements at home. According to our findings, the families of the children who exhibited behaviors of exploring prohibited places took safety measures. For example, the width between the balcony railings was narrow enough to prevent children’s feet or heads from getting stuck. Some studies reported that children diagnosed with ASD displayed risk-taking behavior more frequently, and that they experienced serious injuries more often (Cavalari & Romancyzk, 2012; Richards et al., 2012). It was also reported that in children having impulsivity, hyperactivity, and negative emotions, self-injurious behavior was more prevalent. Furthermore, children who had better skills or were able to express themselves displayed self-injurious behaviors less frequently (Richards et al., 2012). In our study, some chil-
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Implications for Nursing Practice Based on these results, it can be recommended that families of children with ASD or ID should regularly be trained about home safety measures. Providing first aid training for families would be advantageous. The comparison between children with ID or ASD and other children in terms of injury risk behaviors should also be investigated. In addition, comparative studies can be planned to determine whether there is a difference between the families of children with ID or ASD and the families of other children when the use of safety measures is assessed. Studies with large samples can be conducted to determine injury risk analysis between factors such as age, diagnosis, activity, ability to speak, and high-functioning ASD. Limitations The limitation of the study is that the study lacked a control group. The questionnaires, especially the injury frequency questionnaire, were answered by a small number of families. However, since the number of the participants in our study was not sufficient, it was not possible to compare the subgroups in the ASD or ID groups in terms of their conditions being mild, moderate, or severe. Reliability and validity studies of the Home Safety Measures List used in this study were not conducted. The social desirability effect must be considered as a limitation since the data were gathered through face-to-face interviews, thereby potentially influencing the results where negative behaviors are underreported.
H. Yıldırım Sarı et al. References American Association on Intellectual and Developmental Disabilities. (2010). Definition of intellectual disability. Retrieved from http://aaidd .org/intellectual-disability/definition/faqs-on-intellectual-disability# .UpMjddLIYUY American Psychiatric Association. (2013). Autism spectrum disorder. In Diagnostic and statistical manual of mental disorders (5th ed.). Retrieved from http://www.dsm5.org/Documents/Autism%20Spectrum %20Disorder%20Fact%20Sheet.pdf Batu, S., Ergenekon, Y., Erbas, D., & Akmanoglu, N. (2004). Teaching pedestrian skills to individuals with developmental disabilities. Journal of Behavioral Education, 13(3), 147–164. Brenner, R. A., Taneja, G. S., Schroeder, T. J., Trumble, A. C., Moyer, P. M., & Louis, G. M. B. (2013). Unintentional injuries among youth with developmental disabilities in the United States, 2006–2007. International Journal of Injury Control and Safety Promotion, 20(3), 259–265. doi:10.1080/17457300.2012.696662 Cavalari, R. N., & Romancyzk, R. G. (2012). Caregiver perspectives on unintentional injury risk in children with an autism spectrum disorder. Journal of Pediatric Nursing, 27(6), 632–641. doi:10.1016/j.pedn.2011.07.013 Dal Santo, J. A., Goodman, R. M., Glik, D. G., & Jackson, K. (2004). Childhood unintentional injuries: Factors predicting injury. Risk among preschoolers. Journal of Pediatric Psychology, 29(4), 273–283. doi:10.1093/jpepsy/ jsh029 Dixon, D. R., Bergstrom, R., Smith, M. N., & Tarbox, J. (2010). A review of research on procedures for teaching safety skills to persons with developmental disabilities. Research in Developmental Disabilities, 31(5), 985– 994. doi:10.1016/j.ridd.2010.03.007 Erkal, S. (2010). Identification of the number of home accidents per year involving children in the 0–6 age group and the measures taken by mothers to prevent home accidents. Turkish Journal of Pediatrics, 52(2), 150–157. Gaebler-Spira, D., & Thornton, L. S. (2002). Injury prevention for children with disabilities. Physical Medicine and Rehabilitation Clinics of North America, 13(4), 891–906. Gallagher, A. M. R., Reifsnider, E., & Gill, S. (2009). Home-based injury prevention practices used by mothers of Mexican descent living in San Antonio, TX. Public Health Nursing, 26(2), 114–123. doi:10.1111/j.15251446.2009.00762.x ˙I nanç, D. Ç., Baysal, S. U., Cos¸gun, L., Tavilog ˘lu, K., & Ünivar, E. (2008). Injury control in childhood: Family’s attitude and safety counseling. Türk Pediatri Ars¸ivi, 43(4), 84–88. Kendrick, D., Barlow, J., Hampshire, A., Polnay, L., & Stewart-Brown, S. (2007). Parenting interventions for the prevention of unintentional injuries in childhood. Cochrane Database of Systematic Reviews, 17(4), Art. No.: CD006020. Kendrick, D., Mulvaney, C. A., Ye, L., Stevens, T., Mytton, J. A., & Stewart-Brown, S. (2013). Parenting interventions for the prevention of unintentional injuries in childhood. Cochrane Database of Systematic Reviews, (3), Art. No.: CD006020. doi:10.1002/14651858.CD006020 .pub3 Lee, L., Harrington, R. A., Chang, J. J., & Connors, S. L. (2008). Increased risk of injury in children with developmental disabilities. Research in Developmental Disabilities, 29(3), 247–255. doi:10.1016/j.ridd.2007.05.002 Limbos, M. A., Ramirez, M., Park, L. S., Peek-Asa, C., & Kraus, J. F. (2004). Injuries to the head among children enrolled in special education. Archives of Pediatrics & Adolescent Medicine, 158(11), 1057–1061. doi:10.1001/archpedi.158.11.1057 Mahmut, A., Sunay, Y. M., Emre, A., & Gürol, C. (2005). Infant and adolescent deaths due to home accidents in ˙I stanbul. Turkish Journal of Pediatrics, 47(2), 141–149.
Determination of Injury Risks and Safety Measures Peden, M., Oyegbite, K., Ozanne-Smith, J., Hyder, A. A., Branche, C., Fazlur Rahman, A. K. M., . . . Bartolomeos, K. (2008). World health report on child injury prevention. World Health Organization. Retrieved from http://www.unicef.org/eapro/World_report.pdf Petridou, A., Kedikoglou, S., Andrie, E., Farmakakis, T., Tsiga, A., Angelopoulos, M., . . . Trichopoulos, D. (2003). Injuries among disabled children: A study from Greece. Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention, 9, 226–230. doi:10.1136/ip.9.3.226 Potts, R., Martinez, I. G., Dedmon, A., Schwarz, L., Diliio, D., & Swisher, L. (1997). Brief report: Cross validation of the injury behavior checklist in a school age sample. Journal of Pediatric Psychology, 22(4), 533–540. Ramirez, M., Fillmore, E., Chen, A., & Peek-Asa, C. (2010). A comparison of school injuries between children with and without disabilities. Academic Pediatrics, 10(5), 317–322. Ramirez, M., Peek-Asa, C., & Kraus, J. F. (2004). Disability and risk of school related injury. Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention, 10(1), 21–26. doi:10.1136/ ip.2003.002865 Richards, C., Oliver, C., Nelson, L., & Moss, J. (2012). Self-injurious behaviour in individuals with autism spectrum disorder and intellectual disability. Journal of Intellectual Disability Research, 56(5), 476–489. doi:10.1111/ j.1365-2788.2012.01537.x Rowe, R., & Maughan, B. (2009). The role of risk-taking and errors in children’s liability to unintentional injury. Accident; Analysis and Prevention, 41, 670–675. Rowe, R., Maughan, B., & Goodman, R. (2004). Childhood psychiatric disorder and unintentional injury: Findings from a national cohort study. Journal of Pediatric Psychology, 29(2), 119–130. doi:10.1093/jpepsy/jsh015 Sherrard, J., Tonge, B. J., & Ozanne-Smith, J. (2001). Injury in young people with intellectual disability: Descriptive epidemiology. Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention, 7(1), 56–61. doi:10.1136/ip.7.1.56 Slayter, E. M., Garnick, D. W., Kubisiak, J. M., Bishop, C. E., Gilden, D. M., & Hakim, R. B. (2006). Injury prevalence among children and adolescents with mental retardation. Mental Retardation, 44, 212–223. Speltz, M. L., Gonzales, N., Sulzbadner, S., & Quan, L. (1990). Assessment of injury risk in young children: A preliminary study of the injury behavior checklist. Journal of Pediatric Psychology, 15, 373–383. doi:10.1093/ jpepsy/15.3.373 Turkey Regulation on Fire Protection of Buildings. (2009). Türkiye binaların yangından korunması hakkında yönetmelik. Retrieved from http:// www.sanayi.gov.tr/Files/Mevzuat/yangin-yonetmeligi-20042010141550 .pdf Ug ˘ur, S. B. (2004). Yaralanma Kontrolü (Ya da Haddon Matriksi). Klinik Çocuk Forumu, 4(2), 55–61. Uysal, A., Ergül, S ¸ ., & Ardahan, M. (2008). Injury risk for preschool children (Okul öncesi çocuklarda yaralanma riski). Ege University Nursing Faculty Journal (Ege Üniversitesi Hems¸irelik Yüksekokulu Dergisi), 24(3), 105– 114. Xiang, H., Stallones, L., Chen, G., Hostetler, S. G., & Kelleher, K. (2005). Non fatal injuries among US children with disabling conditions. American Journal of Public Health, 95(11), 1970–1975. doi:10.2105/AJPH.2004 .057505 Yıldırım, N. (2010). The determination of risks factors for home accidents among children in the one to four years old period and the effectiveness of nursing interventions based on social learning theory on decreasing these risk factors (Doctorate Thesis). Hacettepe University, Institute of Health Sciences, Program of Public Health Nursing, Ankara.
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Search terms: Autism, injury, intellectual disability Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: The purpose of the study is to determine the injury risk behaviors and home safety measures in children with an intellectual disability or autism spectrum disorder. METHOD: The study sample included mothers of 100 children between the ages of 2 and 12 years. FINDINGS: There was a significant difference between the home safety measures and the children’s ages, the birth order of the children, and the mother’s and father’s ages. There was not a significant relationship between the children’s ages, diagnosis, and Injury Behavior Checklist (IBC). There is a positive correlation between the total score of the Home Safety Measures Control List and IBC. ÖZET AMAÇ: Bu aras¸tırmanın amacı zihinsel yetersizlig ˘ i olan veya otizmi olan çocukların yaralanma riskli davranıs¸larını ve ebeveynlerinin ev güvenlik önlemlerini belirlemektir. YÖNTEM: Aras¸tırmanın örneklemi 2–12 yas¸lar arasında 100 çocug ˘ un annesinden olus¸maktadır. BULGULAR: Ev güvenlik önlemleri ile çocukların yas¸ları, çocug ˘ un ailenin kaçıncı çocug ˘ u oldug ˘ u ve anne ve baba yas¸ı arasında anlamlı ilis¸ki saptanmıs¸tır. Çocug ˘ un yas¸ı, tanısı ve Yaralanma Riskli Davranıs¸lar Listesi skorları arasında anlamlı ilis¸ki saptanmamıs¸tır. Yaralanma Riskli Davranıs¸lar ve Ev Güvenlik Önlemleri puanları arasında pozitif yönde korelasyon bulunmaktadır.
Accidents and injuries pose a serious public health threat for children. Childhood injuries not only cause death or disabilities but also pose a serious problem in terms of the cost (financial, emotional, and social) incurred (Dal Santo, Goodman, Glik, & Jackson, 2004). According to Peden et al. (2008), in developed countries, approximately 20,000 children lose their lives each year due to accidents and injuries. In developing countries, however, approximately one million children under the age of 15 die each year due to unexpected injuries (Peden et al., 2008). There was a relationship between childhood injuries and variables such as child age, gender, and family socioeconomic status. Boys experience approximately 70% more accidents and injuries when compared with girls (Peden et al., 2008). Children of unemployed mothers
© 2015 NANDA International, Inc. International Journal of Nursing Knowledge Volume 27, No. 2, April 2016
are at a higher risk of injury. Additionally, behavioral characteristics of children older than 2.5 years are associated with an increased risk of injury (Dal Santo et al., 2004). In several studies conducted in Turkey, it has been demonstrated that families’ knowledge regarding the prevention of accidents is insufficient, making children more vulnerable to accidents (Erkal, 2010; ˙I nanç, Baysal, Cos¸gun, Tavilog ˘ lu, & Ünivar, 2008; Yıldırım, 2010). Disability and Frequency of Injuries Recent studies indicate that children with intellectual disability (ID) are at a higher risk of injury (Lee, Harrington, Chang, & Connors, 2008; Xiang, Stallones, Chen, Hostetler, & Kelleher, 2005). Brenner et al. (2013) conducted research
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Determination of Injury Risks and Safety Measures using 2006–2007 National Electronic System Surveillance data and determined that children with learning disabilities experienced injuries 1.57 times more often than children with other disabilities. Lee et al. (2008) showed that the incidence of injuries is two to three times higher in children with autism, attention deficit hyperactivity disorder, and psychopathology than in children with no disabilities. In a retrospective study of schoolchildren with and without disabilities, it was noted that children with disabilities were exposed to injuries twice as often compared with children without disabilities (Ramirez, Fillmore, Chen, & Peek-Asa, 2010). According to a study conducted in Greece, of the children admitted to hospital due to injuries, 2.3% had motor or sensory insufficiency (Petridou et al., 2003), where falls are more common in children with a preexisting disability. In addition, the place of residence, immigration status, and cold months (winter) have been found to be factors associated with injury in children with disabilities (Petridou et al., 2003). The American Association on Intellectual and Developmental Disabilities (2010) described that “ID is a disability characterized by significant limitations both in intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior, which covers a range of everyday social and practical skills. This disability originates before the age of 18” (http://aaidd.org/). Cognitive limitations in children with an ID are among the factors that increase their risk of injuries (Limbos, Ramirez, Park, Peek-Asa, & Kraus, 2004; Ramirez, Peek-Asa, & Kraus, 2004; Rowe, Maughan, & Goodman, 2004; Sherrard, Tonge, & Ozanne-Smith, 2001; Slayter et al., 2006). According to the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), “[p]eople with Autism Spectrum Disorder (ASD) tend to have communication deficits, such as responding inappropriately in conversations, misreading nonverbal interactions, or having difficulty building friendships appropriate to their age. In addition, people with ASD may be overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items. The symptoms of people with ASD will fall on a continuum, with some individuals showing mild symptoms and others having more severe symptoms.” ID and ASD frequently coexist. Cavalari and Romancyzk (2012) stated that in children with an ASD diagnosis, there was an increase in risk-taking behaviors, such as running into the road. Furthermore, severe injuries were more frequent, and there was a positive correlation with the severity of ASD symptoms and the frequency of injuries. Richards, Oliver, Nelson, and Moss (2012) reported that self-injurious behavior is more common in children with impulsivity, hyperactivity, and negative emotions, but less common in children with better skills and speaking ability. The Injury Behavior Checklist (IBC; Speltz, Gonzales, Sulzbadner, & Quan, 1990) is often used to determine the risk of injury in 2- to 5-year-old children without disability. Potts et al. (1997) found that the IBC could be extended in its use for children between the ages of 2 and 9. The
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H. Yıldırım Sarı et al. review of the literature revealed that the IBC had been used in children with ID (Cavalari and Romancyzk 2012). Moreover, Rowe and Maughan (2009) used the IBC to determine the level of “risk-taking” in children with mental health problems.
Home Safety Measures According to Ug ˘ ur (2004), “the best way to deal with accidents and problems arising from accidents is to avoid the accidents.” In order to avoid accidents, education should be provided, physical environmental arrangements and appropriate legal regulations should be put into practice, and compliance with these laws should be ensured (Ug ˘ ur, 2004). Home safety measures implemented by parents have been proven to be effective in preventing childhood injuries (Kendrick et al., 2013). It is reported that families often consider safety in specific areas, such as smoke alarms, fire exit plan, stair gates, electrical outlet covers, storage of medicines, and cleaning materials (Kendrick et al., 2013). Ug ˘ ur states that the child’s developmental stage and individual needs must be considered when planning and adjusting home safety measures regarding number of floors, the location of windows, balconies, garage, swimming pool, yard, and fences around the yard, in addition to the materials that should be used for the stairs and railings, lighting, flooring, and household goods. Children with ID have either behavioral deficiencies or excesses, which necessitate further training on safety measures (Dixon, Bergstrom, Smith, & Tarbox, 2010). No studies on injury-related characteristics of children with ASD or ID have been conducted in Turkey. Research on training on safety measures for children with ID and their families is very limited (Batu, Ergenekon, Erbas, & Akmanoglu, 2004).
Aim This study was planned to determine the incidence of injury risk behaviors and home safety measures and the relationship between sociodemographic variables in children with ID or ASD.
Research Questions 1. What are the home safety measures taken for children with ID or ASD? 2. Is there a relationship between the home safety measures and sociodemographic variables of children and families? 3. What is the incidence of injury risk behavior among children with ID or ASD? 4. Is there a relationship between injury risk behavior and sociodemographic variables of children?
H. Yıldırım Sarı et al.
Determination of Injury Risks and Safety Measures
Methods
demographic information about the child and questions about the child’s characteristics associated with increased risk of injuries.
The study was designed as a descriptive study. Approval was taken for study from the ˙I zmir Katip Celebi University Ethics Committee in 2012. Families were informed about the research, their written and verbal consent was obtained, and only the families volunteering to participate were included in the study.
List of home safety measures. In the study, a list of home safety measures prepared by Yıldırım (2010) was used. It contains home safety measures for children aged 1–4 years. In this study, 36 questions from the list developed by Yıldırım were used. Before these 36 questions were used, five experts, specializing in the field of education, ASD, or ID, were consulted and their opinions were obtained about the list. This list includes 36 questions regarding the measures to be taken at home in order to ensure children’s safety. Families were asked to mark “yes” if the measure was already taken and “no” if that measure was not taken. The questionnaire including the list of home safety measures was marked accordingly; 1 point was given to each “yes” answer and 0 point to each “no” answer. The lowest possible score of the safety measures list is 0 and the highest possible score is 36. To implement the list, the permission was obtained from Yıldırım.
Design
Study Setting and Participants The study was conducted with two special training courses. The reason why this special training course was preferred is that it gave training to students not only from the city where they are located but also from the neighboring cities and towns, and included students with different socioeconomic levels. Of the students attending both branches of the course (in total 279 children), 71.3% (n = 199) were male, and 59.8% (n = 167) were diagnosed with autism and 40.2% (n = 112) with ID. The mothers of children with an ID or ASD between the ages of 2 and 12 were included in the study. During the study, 100 mothers were surveyed. Families who gave their consent to participate in the study, and whose children had ID or ASD, were between 2 and 12 years old, and were able to walk, were included in the study. Families who did not consent to participate in the study and families whose children had physical disabilities and prevent them from being able to move were excluded from the study. In Turkey, the definitive diagnosis of children with suspected ASD or ID is made after they are thoroughly examined by child neurologists, child psychiatrists, and clinical psychologists working in hospitals or university hospitals specializing in child health. In order to achieve diagnosis, young children are given developmental assessment tests, and older children when necessary are given intelligence tests. Children diagnosed with ASD or ID are referred to a training center so they can benefit from special education and guidance services provided by the center. In the training center, the child receives a training program in accordance with his/her diagnosis and developmental level. All of the children included in the sample of this research were first evaluated and then diagnosed with ASD or ID by a child psychiatrist, neurologist, and clinical psychologist. Measures Family demographic information form. It is prepared by the researchers and contains information about the mother, father, and family. The form also includes questions on how often and when mothers supervise their children. Child demographic information. The form is prepared by the researchers and is based on literature. It contains
IBC. In the study, the “Injury Behavior Checklist” developed by Speltz et al. in 1990 was used. The IBC, which has 24 items, is a 5-point Likert-type scale used to determine preschool (2–5 years of age) children’s injury risk behaviors. The checklist is filled in by taking into account the behaviors displayed by the child within the last 6 months. The lowest and highest possible scores to be obtained from the checklist are 0 and 96, respectively. Whereas a total score of 48 and above suggests a high risk for injury behavior, a score of less than 48 indicates a low risk for injury behavior (Speltz et al., 1990). The internal consistency coefficient of the original scale was α = .87 (Speltz et al., 1990), and the Turkish version of the scale was found to be α = .87 (Uysal, Ergül, & Ardahan, 2008). To implement the scale, the permission was obtained from Uysal. In our investigation, the Cronbach’s alpha coefficient was determined as .89. Procedure Children were accompanied by their family members when they came to the special training center. While the child was having a one-to-one lesson with the special education teacher, the child’s family members stayed in the waiting room, they were informed about the study, and then the data were collected from them through face-to-face interviews. Data Analysis In the study, p < .05 was considered significant. The relationship among the list of home safety measures, IBC scale, and sociodemographic variables was examined with the chi-square test, analysis of variance test, Kruskal–Wallis H test, and t-test. The Cronbach’s alpha analysis of the IBC scale was conducted.
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Determination of Injury Risks and Safety Measures Results As can be seen in Table 1, ages of children included in this study varied between 2 and 12, with a mean age of 7.8 ± 2.88. Seventy-five percent of the children were boys, 67.3% had a diagnosis of ASD, and 62% were the first child in the family. Twenty-one of the children included in this study had not only a disability but also a chronic disease requiring medication (see Table 1 for details). Of these 21 children with a chronic condition, 10 had a neurological system-related disease (epilepsy), three had a psychiatric disease, three had a respiratory disease, one had an endocrine disease, one had an immune condition, one had a cardiac disease, one had a urinary tract disease, and one had a metabolic disease. Twenty-one percent of the children taking medication took Risperdal. Seventy percent of the children taking medication were diagnosed with ASD. Of the children, 7% were hyperactive, 25% were active, and 68% had normal activity level. Of those with ASD, 37% could not speak or were echolalic. Fifteen percent of the children were identified as high-functioning. The sociodemographic characteristics of parents are shown in Table 2. Research question 1: What are the home safety measures taken for children with ID or ASD?
H. Yıldırım Sarı et al. ations, for example, when the mothers did housework, when someone else accompanied the child, or while the child was studying, playing on the computer, or watching TV. As can be seen in Table 3, while 92% of the families stated that lighting in their homes was sufficient, only 13% of them stated that there was a fire escape in their homes. Research question 2: Is there a relationship between the home safety measures and sociodemographic variables of children and families? The questionnaire including the list of home safety measures was marked accordingly; 1 point was given to each “yes” answer and 0 points to each “no” answer. The lowest possible score of the safety measures list is 0 and the highest possible score is 36. We compared mean scores of the safety measures list with sociodemographic variables. As can be seen in Table 4, a significant relationship was determined between the lower age of children and the higher safety measures taken at home (t = 2.706, p < .05). If the child is the firstborn, mothers take higher safety measures (t = 1.724, p < .05). Safety measures taken at
Table 2. Sociodemographic Characteristics of Parents Characteristics total: 100
The mothers were asked how often they supervised their children. According to their statements, 89% supervised their children continuously, 7% sometimes, and 4% rarely. The mothers did not supervise their children in some situ-
Table 1. Demographic Information of the Children Included in the Study Characteristics total: 100 Age (years) (mean: 7.8 ± 2.88 (min: 2, max: 12) 2–6 7–12 Gender Female Male Disability Autism spectrum disorder Intellectual disability Birth order First Second Third Additional information Additional chronic condition No additional conditions On medication Not on medication Orthopedic condition present No orthopedic condition present Wheelchair user Non-wheelchair user
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Number
%
44 56
44.0 56.0
25 75
25 75
70 34
67.3 32.7
62 33 5
62.0 33.0 5.0
21 79 47 53 4 96 0 100
21.0 79.0 47.0 53.0 4.0 96.0 0 100.0
Mother’s age (years) (mean: 36.6 ± 6.0, min: 23, max: 50) 23–32 33–42 43–50 Mother’s job status Employment Unemployment Mother’s education Not educated Primary school High school University Father’s age (years) (mean: 40.3 ± 5.5, min: 30, max: 52) 30–40 41–52 Father’s job status Employment Unemployment Father’s education Primary school High school University Birth order One child Two children Three children Have an another child with a disability Do not have another child with a disability Economic status Low income Middle income High income
Number
%
28 56 16
28.0 56.0 16.0
38 62
38.0 62.0
1 25 24 50
1.0 25.0 24.0 50.0
47 51
48.0 52.0
93 6
93.9 6.1
22 21 55
22.4 21.4 56.1
40 52 8 2 98
40.0 52.0 8.0 2.0 98.0
13 74 13
13.0 74.0 13.0
H. Yıldırım Sarı et al.
Determination of Injury Risks and Safety Measures
Table 3. Distribution of Home Safety Measures Measures (N = 100) 1. Kitchen and bathroom floors are not slippery or wet. 2. There are no small items or loose cables likely to cause falls while walking. 3. Sharp-edged or angular objects and furniture are covered with cotton or sponge. 4. Items like matches, lighters, and candles are kept out of the reach of children. 5. Cleaning agents, disinfectants, poisonous products, and cosmetic products are kept in their own boxes or storage lockers out of reach of children. 6. No table cloth is laid over the kitchen table or the cloth is attached on the table. 7. Knives and other sharp objects are kept out of reach of children or stored in cupboards. 8. Medicines and vitamins are stored in boxes or in lockers out of the reach of children. 9. Electrical outlets have a safety lock. 10. There are safety mechanisms used to adjust the width between window railings and how wide windows are opened. 11. The width between the balcony railings is suitable enough so that children’s feet or heads do not get stuck. 12. Bars of the balcony are thick enough, and prevent children from climbing. 13. There is sufficient lighting (75- or above watt light bulbs). 14. No water is stored in bathtubs or bucket-like containers. 15. Electrical equipment (radio, hair dryer, etc.) is not plugged in, is away from water, and out of the reach of children. 16. There are no furniture or objects in front of the window. 17. The child’s mattress fits the bed. 18. The width between the bars of the bed rails is no more than 6 cm. 19. Plants likely to cause harm are out of the reach of children. 20. Toys do not have small, detachable parts likely to cause choking. 21. Toys do not have sharp edges or rope-like thin and long parts. 22. There are no toys like guns, pop guns, darts, or ejection toys among the child’s toys. 23. The furniture or heavy objects likely to topple are fixed onto the floor. 24. Rugs, carpets, and runners do not slide. 25. There is a barrier to prevent the child from touching objects like the heater, stove, etc. 26. Wardrobes can also be opened from inside. 27. No heavy objects are placed on the cabinets, wardrobes, or cupboards. 28. The front door of the house or balcony doors cannot be easily opened by children. 29. There is a fire extinguisher ready to use at home. 30. There is a first aid kit/medicine cabinet at home. 31. First aid kits/medicine cabinets are locked and placed high enough for children not to reach. 32. The numbers of emergency services are either recorded in every phone in the house or printed as a list near the phone. 33. There is an emergency plan. 34. There is fire escape at home. 35. There are handrails on both sides of the stairs. 36. There is a fire and smoke detector at home.
Age 2–6 years Yes/No
Age 7–12 years Yes/No
Total Yes/No
Analysis
38/6 37/7
44/12 45/11
82/18 82/18
p > .05 p > .05
16/28
10/46
26/74
χ2 = 4.386 p < .05
40/4
38/18
78/22
χ2 = 7.630 p < .05
33/11
35/21
68/32
p > .05
24/20
28/28
52/48
p > .05
35/9
33/23
68/32
χ2 = 4.813 p < .05
36/8
36/20
72/28
χ2 = 3.757 p < .05
16/28 23/21
14/42 29/27
30/70 52/48
p > .05 p > .05
39/5
41/15
80/20
χ2 = 3.663 p < .05
30/14
31/25
61/39
42/2 38/6 42/2
50/6 42/14 41/15
92/8 80/20 83/17
p > .05 p > .05 χ2 = 8.638 p < .05
25/19 41/3 34/10
25/31 47/9 40/16
50/50 88/12 74/26
p > .05 p > .05 p > .05
35/9
39/17
74/26
p > .05
32/12
40/16
72/28
p > .05
35/9
39/17
74/26
p > .05
41/3
44/12
85/12
χ2 = 4.125 p > .05
33/11
25/31
58/42
χ2 = 9.321 p < .05
35/9 27/17
42/14 19/37
77/23 46/54
p > .05 χ2 = 7.466 p < .05
29/15 37/7
35/21 39/17
64/36 76/24
p > .05 p > .05
32/12
30/26
62/38
χ2 = 3.838 p < .05
12/32 30/14 28/16
9/47 39/17 33/23
21/79 69/31 61/39
p > .05 p > .05 p > .05
16/28
20/36
36/64
p > .05
16/28 6/38 11/33 8/36
23/33 7/49 12/44 8/48
39/61 13/87 23/77 16/84
p p p p
p > .05
> > > >
.05 .05 .05 .05
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Determination of Injury Risks and Safety Measures
H. Yıldırım Sarı et al.
Table 4. Comparison of Sociodemographic Variables With the Scores Obtained From the List of Home Safety Measures Home Safety Measures Control List point Variables Gender Girl (n = 25) Boy (n = 75) Age 2–6 years (n = 44) 7–12 years (n = 56) Number of child First child (n = 62) Second and third child (n = 38) Mother’s age 23–32 years (n = 28)a 33–42 years (n = 56)b 43–52 years (n = 16)c Mother’s education Primary school (n = 25)a High school (n = 24)b University (n = 50)c Father’s age 30–40 years (n = 47) 40–49 years (n = 51)
SS
Analyses
p
21.9 21.8
7.1 6.9
t = −.033
p > .05
23.9 20.2
5.7 7.4
t = 2.706
p < .05
22.7 20.3
6.2 7.9
t = 1.724
p < .05
24.6 22.3 15.6
6.4 6.1 7.5
KWH = 14.978 c < b,a*
.001
19.4 23.7 22.1
8.9 6.8 5.8
KWH = 2.696
p > .05
23.6 20.0
7.1 6.6
t = 2.608
p < .05
X
*Mother’s age and control list Bonferroni results: (43–52 age and 23–32 age mean difference −9.04464, p = .000), (43–52 age and 33–42 age mean difference −6.68750, p = .001). KWH, Kruskal-Wallis H test.
home were also noted to vary depending on the mother’s age. This difference is related with the fact that mothers aged between 43 and 52 had lower safety measure scores (Kruskal-Wallis H = 14.978, p < .05) (Table 4). There was a significant difference between the age of the fathers and their home safety measure scores, where the highest scores were of fathers aged 30–40 (t = 2.608, p < .05). No significant relationship was detected between home safety measures taken at home and the fathers’ education levels and economic status. No significant difference was detected between highfunctioning and non-high-functioning children in terms of home safety measures. There were significant differences between children who are able to speak (n = 63) and who are not able to speak (n = 37) in terms of the following safety measures: “Items such as matches, lighters, candles are kept out of the reach of children” (chi-square: 4.285, p < .05). “The furniture or heavy objects likely to topple are fixed onto the floor” (chi-square: 5.832, p < .05). Wardrobes can also be opened from inside (chi-square: 5.990, p < .05). The numbers of emergency services are either recorded in every phone in the house or as a printed list near the phone (chi-square: 4.075, p < .05). There were significant differences between active children (n = 32) and children with normal activity (n = 68) in terms of the following safety measures: “The furniture or heavy objects likely to topple are fixed onto the floor” (chi-
100
square: 5.832, p < .05). Wardrobes can also be opened from inside (chi-square: 5.990, p < .05). The numbers of emergency services are either recorded in every phone in the house or printed as a list near the phone (chi-square: 4.075, p < .05). There is a positive correlation between the total score of the Home Safety Measures Control List and IBC (Pearson correlation .21, p < .05). Research question 3: What is the incidence of injury risk behavior among children with ID or ASD? It was determined that of the children, 7% were very active at home, 25% were active at home, 21% had interest in electrical devices, for example lighters and matches, where 32% showed interest in kitchen gadgets. Six percent of the children displayed a behavior of inserting objects such as chickpeas and peanuts up their nose, and 12% exhibited a behavior of playing with sharp objects, such as knives and scissors, which were likely to pose danger to themselves. As can be seen in Table 5, 65.7% (n = 46) of the children enjoyed jumping on furniture, beds, seats, or other objects, whereas 52.9% (n = 37) tried to explore the environment they were not allowed to be in, and 44.3% (n = 31) fall down. The mean IBC score was 44.62 ± 1.22. While 61.4% (n = 43) of the children did not have a risk of injury, 38.6% (n = 27) had an increased risk.
H. Yıldırım Sarı et al.
Determination of Injury Risks and Safety Measures
Table 5. Injury Behavior Characteristics of Children Never and rarely
Sometimes
Often
Injury Behavior Checklist (N = 70, children ages 2–9 years)
n
%
n
%
n
%
n
%
1. Runs out into the street 2. Jumps off furniture or other structures 3. Jumps down stairs 4. Rides bike in unsafe areas 5. Runs or bumps into things 6. Falls down 7. Plays with fire 8. Puts fingers or objects near appliances or outlets 9. Leaves the house without permission 10. Refuses to use seat belt or to stay seated in car 11. Plays with sharp objects 12. Pulls/pushes over furniture or heavy objects 13. Falls out window or downstairs 14. Puts objects or nonfood items in mouth 15. Gets scratches, scrapes, and bruises during play 16. Takes chances on playground equipment 17. Tries to climb on top of furniture or cabinets 18. Stands on chairs 19. Explores places that are off limits 20. Gets into dangerous substances 21. Plays carelessly or recklessly 22. Comes into contact with hot objects 23. Behaves carelessly in or around water hazards 24. Teases and/or approaches unfamiliar animals
40 24 47 64 45 39 63 64 66 58 62 60 63 52 55 57 51 41 33 68 46 64 53 48
57.1 34.3 67.1 91.4 64.3 55.7 90.0 91.4 94.3 82.9 88.6 85.7 90.0 74.3 78.6 81.4 72.9 58.6 47.1 97.1 65.7 91.4 75.7 68.6
15 21 15 3 14 25 7 4 4 7 6 7 7 11 13 12 13 17 21 2 17 6 12 13
21.4 30 21.4 4.3 20.0 35.7 10.0 5.7 5.7 10.0 8.6 10.0 10.0 15.7 18.6 17.1 18.6 24.3 30.0 2.9 24.3 8.6 17.1 18.6
8 16 6 0 6 3 0 1 0 1 2 2 0 4 2 1 5 10 4 0 6 0 3 6
11.4 22.9 8.6 0 8.6 4.3 0 1.4 0 1.4 2.9 2.9 0 5.7 2.9 1.4 7.1 14.3 5.7 0 8.6 0 4.3 8.6
7 9 2 3 5 3 0 1 0 4 0 1 0 3 0 0 1 2 12 0 1 0 2 3
10.0 12.9 2.9 4.3 7.1 4.3 0 1.4 0 5.7 0 1.4 0 4.3 0 0 1.4 2.9 17.1 0 1.4 0 2.9 4.3
Research question 4: Is there a relationship between injury risk behavior and sociodemographic variables of children? The IBC score was 46.5 ± 11.7 for children aged 2–6 years and 40.11 ± 11.3 for children aged 7–12 years. There were significant differences between the two groups (t = 2.664, p < .05). While the IBC score was 47.63 ± 12.9 for the active children, it was 40.76 ± 10.8 for the children with the normal activity level. The difference between the two groups was significant (t = 2.699, p = .008). There were no significant differences between the high-functioning and non-highfunctioning children, and children who are able to speak and children who are not able to speak, in terms of IBC scores. Discussion Home Safety Measures As seen in Table 3, the lowest levels of safety measures were observed in the following areas: presence of fire escape, fire and smoke detector, handrails on both sides of the stairs, electrical outlets with a safety lock, sharp-edged or angular objects, and furniture covered with cotton or sponge. Of these measures, fire escapes and smoke detectors are not among the widely used structural arrangements in houses; thus, families may not have taken these measures. However, home safety is very important when
Always
considering prevention of childhood injuries (Kendrick, Barlow, Hampshire, Polnay, & Stewart-Brown, 2007). According to the fire regulations in Turkey, smoke detectors are an obligation for high buildings. Fire escapes are necessary for the buildings higher than four stories (Turkey Regulation on Fire Protection of Buildings, 2009). It was observed that security measures were taken more at homes where children were hyperactive or active. It is especially important to provide training on home security measures for the mothers of these children. In our study, 89 (89%) mothers stated that they constantly supervised their children. Similarly, Gallagher, Reifsnider, and Gill (2009) reported that mothers supervised their children closely or stayed with the children in order to prevent them from being injured. Home safety measures were compared with yes/no responses for age group by chi-square analysis in Table 3. According to this analysis, more mothers who have children 7–12 years of age were not undertaking home safety measures. Our study revealed that more safety measures were taken at homes where parents had younger children (Table 4). Our findings also revealed that 38.6% of the children were at an increased risk of injury. Of the home accident-related deaths of children under the age of 18 years that occurred in Turkey between 1996 and 2000, the highest incidence was observed in children between the ages of 0 and 3 years (Mahmut, Sunay, Emre, & Gürol, 2005). Accidents are more common in younger age groups; therefore, the mothers of young children who take more
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Determination of Injury Risks and Safety Measures safety measures are normal. According to the results of a study, the incidence of injury in children with a disability decreases as they grow older (Petridou et al., 2003). In addition, developmental age rather than chronological age should be taken into consideration when safety measures at home are arranged (Gaebler-Spira & Thornton, 2002). According to a report by Peden et al. (2008), sociodemographic variables, such as economic status, mother’s age, mother’s education, single parent, family type, and the number of children, are directly associated with childhood injuries (Peden et al., 2008). According to our results, parents who had their first child and were younger took more safety measures (Table 4). Erkal (2010) found that educated mothers and young mothers took more safety measures at home. However, contrary to this, there are other studies indicating that younger mothers are a significant risk factor for injury (˙I nanç et al., 2008). According to our findings, there is no significant relationship between the economic status of the family and taking safety measures at home. However, researchers have found that the children of unemployed mothers were more prone to injuries compared with the children of mothers with higher economic status (Dal Santo et al., 2004; Erkal, 2010).
H. Yıldırım Sarı et al. dren who had ASD also had ID; however, we did not have any data related with comorbidity of ASD and ID. This ASD and ID comorbidity can also affect child injury behavior. However, no comparison based on the diagnoses of ASD and ID was made. In future studies, it would be useful to conduct investigations based on diagnosis and the degree of the disability. In addition, it was determined that 47% (n = 47) of the children in our study took medication. No significant relationship was determined between the children’s injury risk behaviors and medicine use. Conclusion In this study, we demonstrated that 89% (n = 89) of the mothers constantly supervised their children. There was a significant difference between the safety measures taken at home and the children’s age and the birth order of the child. There was a significant relationship between the safety measures taken at home and the mother’s age and the father’s age. It was determined that more active children and young children have a higher risk for injury. There is a significant correlation between IBC and home safety measures.
Injury Risk Behavior According to our findings, of the children in the study, 65.7% exhibited the risky behavior of jumping off furniture or other structures, whereas 52.9% exhibited the risky behavior of exploring places that are prohibited. The IBC scores of active and hyperactive children were higher than those with normal activity levels. One of the common symptoms in children with autistic spectrum disorder is sensory difference. Due to their sensory differences in vision, hearing, taste, touch, and motion, children with ASD tend to look for specific solutions to sensory stimuli. Desire to act is more intense among children who are less sensitive to motion than among other children. In addition, children with ID or children with autism do not have much opportunity to play or do physical activities with their peers in places such as playgrounds, schools, and parks, which could contribute to these children’s desire to be more active and sometimes to do uncontrolled movements at home. According to our findings, the families of the children who exhibited behaviors of exploring prohibited places took safety measures. For example, the width between the balcony railings was narrow enough to prevent children’s feet or heads from getting stuck. Some studies reported that children diagnosed with ASD displayed risk-taking behavior more frequently, and that they experienced serious injuries more often (Cavalari & Romancyzk, 2012; Richards et al., 2012). It was also reported that in children having impulsivity, hyperactivity, and negative emotions, self-injurious behavior was more prevalent. Furthermore, children who had better skills or were able to express themselves displayed self-injurious behaviors less frequently (Richards et al., 2012). In our study, some chil-
102
Implications for Nursing Practice Based on these results, it can be recommended that families of children with ASD or ID should regularly be trained about home safety measures. Providing first aid training for families would be advantageous. The comparison between children with ID or ASD and other children in terms of injury risk behaviors should also be investigated. In addition, comparative studies can be planned to determine whether there is a difference between the families of children with ID or ASD and the families of other children when the use of safety measures is assessed. Studies with large samples can be conducted to determine injury risk analysis between factors such as age, diagnosis, activity, ability to speak, and high-functioning ASD. Limitations The limitation of the study is that the study lacked a control group. The questionnaires, especially the injury frequency questionnaire, were answered by a small number of families. However, since the number of the participants in our study was not sufficient, it was not possible to compare the subgroups in the ASD or ID groups in terms of their conditions being mild, moderate, or severe. Reliability and validity studies of the Home Safety Measures List used in this study were not conducted. The social desirability effect must be considered as a limitation since the data were gathered through face-to-face interviews, thereby potentially influencing the results where negative behaviors are underreported.
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