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Family stress and childhood accidents : a study of time relationship between stress-producing events… Boon, Joan Elizabeth 1965

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FAMILY STRESS AND CHILDHOOD ACCIDENTS A Study of Time R e l a t i o n s h i p between Stress-producing Events w i t h i n the Family and Childhood Accidents by JOAN ELIZABETH BOON FLORENCE YU SING KANE RACHEL MILDRED PAUL SHEILA GAYLE ROGERSON Thesis Submitted in P a r t i a l F u l f i l m e n t of the Requirements f o r the Degree of MASTER OF SOCIAL WORK in the School of S o c i a l Work Accepted as conforming to the standard required f o r the degree of Master of S o c i a l Work School of S o c i a l Work 1 9 6 5 The U n i v e r s i t y of B r i t i s h Columbia In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. School of Social Work The University of British Columbia, Vancouver 8, Canada. - v -ABSTRACT A d e s c r i p t i v e study of family s t r e s s and c h i l d h o o d accidents was c a r r i e d out as a group p r o j e c t , under the j o i n t auspices of the F a c u l t y of Medicine and the School of S o c i a l Work at The U n i v e r s i t y of B r i t i s h Columbia. It was designed as a behavioral approach to the p r e v e n t i o n of c h i l d h o o d a c c i d e n t s . The hypothesis developed and t e s t e d was: t h e r e is a s i g n i f i c a n t r e l a t i o n s h i p in t i m e , s p e c i f i c a l l y w i t h i n 30 days, between the occurrence of s t r e s s - p r o d u c i n g events in the family and accidents r e s u l t i n g in injury to one or more c h i l d r e n of that f a m i l y . A review of the l i t e r a t u r e i n d i c a t e s that accidents may be symptoms of d i s o r d e r in the f a m i l y . In keeping with the h o l i s t i c view of human b e h a v i o r , a broad, i n t e r r e l a t e d systems approach was u t i l i z e d , i n t e g r a t i n g the t h e o r i e s of r o l e and ego f u n c t i o n i n g as a conceptual framework to study the r e l a t i o n s h i p of p s y c h o s o c i a l f a c t o r s to a c c i d e n t s . The p o p u l a t i o n of f a m i l i e s of kO a c c i d e n t - r e p e a t e r c h i l d r e n was derived from an e a r l i e r e p i d e m i o l o g i c a l study of p e d e s t r i a n t r a f f i c a c -c i d e n t s i n v o l v i n g c h i l d r e n , undertaken by the Departments of Preventive Medicine and P e d i a t r i c s , The U n i v e r s i t y of B r i t i s h Columbia. The f a m i l -ies were interviewed and m a t e r i a l was c o l l e c t e d by means of research interviews based on an Interview Survey Guide which was s p e c i f i c a l l y d e v i s e d . The f i n d i n g s p o i n t up that the hypothesis was not v a l i d a t e d w i t h i n the narrow time p e r i o d of 30 days, and t h e r e were strong i n d i c a -t i o n s that i s o l a t e d s t r e s s was not r e l a t e d to the occurrence of c h i l d -hood a c c i d e n t s . However, in some of these f a m i l i e s prolonged s t r e s s f u l s i t u a t i o n s and m u l t i p l e accidents were found to c o i n c i d e . T h e r e f o r e , t h i s is one area which m e r i t s a f u t u r e study - p r o s p e c t i v e in n a t u r e . The c h a l l e n g e to s o c i a l work in such a s i g n i f i c a n t problem as c h i l d h o o d a c c i d e n t s is very apparent. The study c l e a r l y i n d i c a t e s the ways in which s o c i a l workers as members of community or agency i n t e r -d i s c i p l i n a r y teams, with t h e i r p a r t i c u l a r knowledge, a t t i t u d e s and s k i l l s can c o n t r i b u t e to accident p r e v e n t i o n . T h e i r e f f o r t s may be developed in the f o l l o w i n g a r e a s : d i r e c t family treatment, family l i f e e d u c a t i o n , c r e a t i o n and development of community r e s o u r c e s , encouragement of com-munity p a r t i c i p a t i o n and broader p u b l i c safety e d u c a t i o n . - i v -Acknowledgements The w r i t e r s are indebted to Miss Muriel C u n l i f f e , Professor of S o c i a l Work, who suggested the t o p i c and gave advice and guidance d u r i n g the course o f the study. They acknowledge g r a t e f u l l y the a s s i s t a n c e and encouragement o f Miss Eleanor B r a d l e y , who, p a r t i c u l a r l y in the f i n a l stages of the study, gave generously of her time and knowledge. The i n t e r e s t and support of Dr. J . R . Brummitt, Miss Eleanor Bradley and Miss Joan M o r i s o n , the p r o f e s s i o n a l s t a f f of the C h i l d Health Programme, under whose auspices t h i s study was undertaken j o i n t l y with the School of S o c i a l Work was i n v a l u a b l e . T h e i r thanks are a l s o extended t o Miss M. Beauchemin, Miss S. Cunningham and Miss S. Calthrop f o r w i l l i n g and competent s e c r e t a r i a l ass i s t a n c e . TABLE OF CONTENTS Chapter 1. Introduct ion Page A. Nature of the Problem: The e a r l i e r study. Accident occurrence. Accident causation The concept of accident proneness. Systems approach t o s t r e s s and a c c i d e n t s . Family r o l e performance and s t r e s s . I n d i v i d -ual ego f u n c t i o n i n g and s t r e s s . Focus of our study 2 B. Background of the Problem: Review of the l i t e r a t u r e 23 Chapter 2. D e f i n i t i o n s and Method Purpose. D e f i n i t i o n s : time p e r i o d , s t r e s s - p r o d u c i n g events, a c c i d e n t s , i d e n t i f i e d c h i l d and f a m i l y in current study. Method: s e t t i n g , f a m i l i e s , i n t e r v i e w , data c o l l e c t e d . General c o n s i d e r a t i o n s of the method 33 Chapter 3. Findings General c h a r a c t e r i s t i c s of a c c i d e n t - c h i l d r e n . Family p r o f i l e . S t ress f a c t o r s and a c c i d e n t s . General comments. C r i t i q u e of the Interview Survey Guide. Conclusion 45 Chapter 4 . Discussion of Findings and Summary Hypothesis i n v a l i d and reasons. Discussion of f i n d i n g s . Acute and chronic s t r e s s and a c c i d e n t s . The r o l e of s o c i a l work in accident p r e v e n t i o n : community p a r t i c i p a t i o n , f a m i l y l i f e education, c o n t i n u i n g p u b l i c education f o r accident prevention. Topic f o r f u r t h e r study. Conclusion 56 Appendices: A. A C l a s s i f i c a t i o n of Stress-producing Events B. A Conceptual Framework of P o s s i b l e Causal Factors in Accident Occurrence C. Covering L e t t e r to the Family Allowance D i v i s ion - i i i -TABLE OF CONTENTS, c o n t ' d . Appendices, c o n t ' d . Page D. Explanatory Le t te r E . Pos tsc r ip t F. Interview Survey Guide G. Bib l iography TABLES IN THE TEXT Table 1. Acute Stresses and Accidents 49 Table 2. Chronic Stresses and Accidents , 50 CHAPTER 1. INTRODUCTION A. Nature of the Problem In keeping with concern about the fact that accidents are one of the foremost causes of death and disablement in the world today, the four writers undertaking this group study enlist the cooperation of a group of citizens, namely parents, in one area of investigation which, it is hoped, will e l i c i t promising leads for future efforts in the human sciences to-ward the ultimate goal of accident prevention. The focus of this descrip-tive study, a joint project under the auspices of the Department of Prev-entive Medicine and the School of Social Work at The University of British Columbia, is upon the possible relationship in time between stress-produc-ing events in the family and the occurrence of childhood accidents. The writers' interest in family stress and childhood accidents was heightened by the results of an earlier research project carried out at The University of British Columbia. The Earlier Study A descriptive study carried out by the Child Health Programme of the Departments of Preventive Medicine and Pediatrics in the Faculty of Medicine of The University of British Columbia on 713 motor-vehicle accid-ents involving 7^ 9 child pedestrians In the City of Vancouver during a three year period from 1958 to I960,1 pointed up the fact that in the I960 1 Read, J.H., Bradley, E.J., Morison, J.D., Lewall, D. and Clarke, D.A, "The Epidemiology and Prevention of Traffic Accidents Involving Child. Pedestrians," Canadian Medical Association Journal. Vol. 89, October 5, 1963, pp. 687-701. 2 group there were 61 accident-repeater c h i l d r e n . It suggested that f u r t h e r study of these c h i l d r e n and t h e i r f a m i l i e s might y i e l d information regard-ing p o s s i b l e i d e n t i f i c a t i o n of s i t u a t i o n s i n v o l v i n g p o t e n t i a l accident v i c t i m s . Therefore the w r i t e r s planned t o approach the f a m i l i e s of these i d e n t i f i e d accident-repeater c h i l d r e n and seek t h e i r a s s i s t a n c e as sub-j e c t s i n the c u r r e n t study. A common c r i t i c i s m of accident research i s that much of i t involves r e p e t i t i o n of e a r l i e r p r o j e c t s , rather than u t i l -i z i n g previous f i n d i n g s . The w r i t e r s attempt t o avoid t h i s e r r o r . Accident Occurrence Evidence abounds t o a t t e s t the f a c t that accidents of a l l k i n d s , p a r t i c u l a r l y those o c c u r r i n g t o c h i l d r e n , c o n s t i t u t e a major cause of m o r b i d i t y and m o r t a l i t y i n the general p o p u l a t i o n today. Despite progres-s i v e p u b l i c enlightenment, i t i s seldom r e a l i z e d that " a c c i d e n t a l i n j u r y i s the leading cause of death during c h i l d h o o d , as w e l l as a most frequent cause of d i s a b i l i t y , " and that "more c h i l d r e n d i e each year from traumatic i n j u r i e s than from the next three l e a d i n g causes of death combined."' This statement i s borne out by innumerable s t a t i s t i c a l c o m p i l a t i o n s , such as that of the United States Safety C o u n c i l , which, in 1962, reported that in 1959, accidents claimed the l i v e s of 11,402 c h i l d r e n between the ages of one and fourteen y e a r s , w i t h the second le a d i n g cause of death, cancer, f o l l o w i n g f a r behind, w i t h 4,138 deaths. As reported in the previous study by Read et. a l _ . : 1 Meyer, Roger J . , R o e l o f s , H.A., Bluestone, J . and Redmond, S. " A c c i d -e n t a l Injury of Preschool C h i l d , " Journal of P e d i a t r i c s . V o l . 63, J u l y 1963, p. 95. 2 I b i d . , p. 97. - 3 -"Canada has always suffered from one of the world's highest accident f a t a l i t y rates, but the effects were formerly obscured by infective and contagious dis-eases which caused twice as many deaths. Today, there are over five times as many deaths from accidents as from infective and contagious diseases."' The earlier study, outlined various environmental conditions in the City of Vancouver affecting the occurrence of child pedestrian t r a f f i c accidents and noted that those conditions, "along with adult or parental factors and the amount of safety education the child had received, would, no doubt, appreciably influence his behavior in t r a f f i c . 1 1 It also stated that " i t was f e l t that...children, being influenced mainly by example, developed (the) same false sense of security toward the hazards of the road" as that exhibited by adult pedestrians and, perhaps, is "reinforced by the school safety patrol system, which protects the child at the danger-ous intersections on his way to and from school." These comments indicate the promising research approach which considers as possible causal factors the interaction between the accident victim and his physical and social environment. Accident Causation A common criticism of accident prevention efforts is that they are often hampered by inadequate knowledge about the causes of accidents. There has been a gradual change in philosophical approach to accidents, in which they are increasingly accepted to result from 'acts of Man,1 being as such subject to his control, and less believed to come about from 'acts 1 Read, J.H. et_aj_., op_. c i t . . p. 688. 2 Ibid., p. 689. -k-of God, ' or f a c t o r s uncont ro l l ab le by Man. Ear ly research into accident causat ion tended to focus on " i s o l a t e d t r a i t s such as react ion t ime, v i sua l a c u i t y , and se lec ted motor s k i l l s , " leading to l a r g e l y i n s i g n i f i c a n t r e s -u l t s , but "subsequent research located the crux of the accident problem in the broad area of personal adjustments ," ' leading to fur ther study by the s o c i a l sc iences and medic ine. Accident occurrence is now explained by many in terms of the m u l t i -causal i ty concept . Recent p u b l i c a t i o n s reviewing the 1 i te ra ture^ '^ have indicated the f a i l u r e of the segmental approaches and have shown that the ind iv idua l must be considered as an integrated whole. There fo re , the whole person in h is s i t u a t i o n must be s tud ied i f any sound attempt is to be made to assess c a u s a l i t y of a c c i d e n t s . Such a broad, i n t e r r e l a t e d , i n t e r d i s c i p -l i n a r y , systems approach to accidents is genera l ly recognized to be more r e a l i s t i c than the narrower theor ies employed in the p a s t . However, i t has been noted t h a t , whi le pursu i t of a s i n g l e causat ive f a c t o r may be s u f f i c -ient in e a s i l y i d e n t i f i a b l e c a s e s , the deeper, h o l i s t i c approach is required in order to deal with more complex accident r e l a t i o n s h i p s . ^ Increasing amounts of p u b l i c education and a lso inves t iga t ion of psychosocia l causal r e l a t i o n s h i p s are s t rong ly advocated. 1 Brody, Leon. "Psycho log ica l Aspects of Accident C a u s a t i o n , " Annual  Safety Education Review. American A s s o c i a t i o n f o r Hea l th , Physica l Educa-t i o n and Recrea t ion , 1963, Washington, D . C , p. 9 8 . 2 Damron, F r a z i e r . "Research in Home and Community S a f e t y , " Annual  Safety Education Review. American A s s o c i a t i o n fo r Hea l th , Physica l Educa-t i o n and Recrea t ion , 1 9 6 3 , Washington, D . C , p . kk. 3 Freeman, F . , Goshen, C E . and K ing , B .G . The Role of Human Factors in  Accident Prevent ion . U.S. Dept. of Hea l th , Education and Wel fare , Publ ic Health S e r v i c e , Washington, D . C , August 1, I960, p. 2 5 . k Rapoport, A . "Some Comments on Accident Research," Jacobs , H.H. et_ a l . . Behavioral Approaches to Accident Research. A s s o c i a t i o n f o r the Aid of C r i p p l e d C h i l d r e n , New York, 1961, p. 177. -5-The genesis o f c u r r e n t a c t i v i t y in accident research may be r e l a t -ed to the change in approach which developed when accidents came to be viewed through analogy with the t r a d i t i o n a l e p i d e m i o l o g i c a l p a t t e r n f o r research on d i s e a s e , i n v o l v i n g the presence of a s u s c e p t i b l e h o s t , an i n -c i t i n g agent, and a p r e d i s p o s i n g environment. It had been found that adeq-uate explanation of accidents r e q u i r e d c r e a t i v e t h i n k i n g and research s k i l l s from numerous d i s c i p l i n e s . The engineer used h i s knowledge and s k i l l s to c r e a t e a safe environment, the e p i d e m i o l o g i s t employed p r e v e n t -ive measures to reduce accident r i s k , and, of l a t e , the behavioral s c i e n t -ist has a p p l i e d h i s methods and t h e o r i e s to behavioral aspects of accident phenomena.^ For a comprehensive understanding o f the accident problem, it is necessary to c o n s i d e r a l l of the approaches. T h i s v i e w p o i n t , d e a l i n g with a l l of the f a c t o r s a f f e c t i n g human behavior unites many p o i n t s of view into a conceptual whole and t i e s in p a r t i c u l a r l y with the broad scope of the s o c i a l worker, who takes a h o l i s t i c approach to human b e h a v i o r , keeping in mind the innumerable i n t e r a c t i n g f a c t o r s in every human s i t u a -t i o n . It has been noted that " t h e behavioral aspects of accidents — such f a c t o r s as the c l i m a t e of the f a m i l y , the s o c i a l forces at work in the community, the values of the s o c i e t y as a whole — have r e c e i v e d much less o a t t e n t i o n than the p u r e l y t e c h n o l o g i c a l a s p e c t s . " T h i s would mean that a t t e n t i o n should be p a i d to events in the external s o c i a l environment which became i n t e r n a l i z e d by the c h i l d and may become s t r e s s - p r o d u c i n g . 1 Suchman, E . A . and S c h e r z e r , A . L . Current Research in Childhood A c -c i d e n t s . Research R e p r i n t , I960, A s s o c i a t i o n f o r the Aid of C r i p p l e d C h i l d -r e n , New York, p . v . 2 Jacobs, H . H . et, al. . Behavioral Approaches to Accident Research. A s s o c -i a t i o n f o r the A id of C r i p p l e d C h i l d r e n , New Y o r k , 1961, p . v . -6-The medical fields tend to specialize in physiological factors, including those which may be susceptible to the effects of stress, while in the soc-ial sciences, there has been increasing awareness of the part played by psychological and social factors. The Concept of Accident Proneness The concept of accident proneness has, for many years, existed as an explanation for "the possibility that certain individuals are predis-posed to accidents because of their mental makeup and, in fact, have more accidents than the average person."' The current, widely accepted point of view is that "the concept and the terminology describing the term are controversial, though it s t i l l continues, especially in industrial and 2 child research." As an alternative, the term accident-repeater is used, which is self-explanatory. It has been found that "research, plus math-ematical theory, now indicate that accident-repeaters are a relatively small population, account for a minor percentage of accidents, and indeed are a changing population." Thus, "in due time they tend to stabilize and relinquish membership in this special group, while previously "safe" indiv-iduals join for a period of time, (so that) the majority of accidents may 3 be attributed to the majority of the population." From these observations the term "accident prone" implies a rather fixed condition, whereas, the newer, and currently more popular term, "accident-repeater" has greater accuracy, in that it does not imply 1 Maclver, John. "Safety and Human Behavior," Jacobs, H.H. et a l . , Behavioral Approaches to Accident Research. Association for the Aid of Crippled Children, New York, 1961, p. 65. 2 Freeman, F. et_ al_., op_. c i t . , p. 26. 3 Brody, L., op_. c i t . , p. 98. -7-any more than i s o b j e c t i v e l y apparent through the occurrence of two or more accidents t o a p a r t i c u l a r i n d i v i d u a l . Yet, as some w r i t e r s have 1 2 noted, ' in many s i t u a t i o n s , an i n d i v i d u a l must have f a r many more than two accidents t o be s t a t i s t i c a l l y d i f f e r e n t from the mean, and so form part of the d i s t i n g u i s h a b l e small group which;is considered t o have more accidents than most people. Although people d i f f e r in t h e i r i n i t i a l l i a b i l i t y to accidents due t o personal f a c t o r s , t h e i r l i a b i l i t y could vary through time due t o the i n t e r a c t i o n of personal and environmental causes. It has been determined t h a t , whether o r not there e x i s t i n d i v i d u a l s who, in a given s i t u a t i o n , are more l i k e l y at a l l times t o incur an accident than t h e i r f e l l o w s exposed t o s i m i l a r r i s k , research i n t o the r o l e of "temporary a t t r i b u t e s of the i n d i v -idual such as worry, d i s t r a c t i o n , and i l l h e a l t h , and t h e i r e f f e c t on f a c t o r s such as f a t i g u e and v i g i l a n c e becomes meaningful."^ The idea has been discounted that a person i s "ac c i d e n t - p r o n e " merely because he has a c e r t a i n number of accidents over a c e r t a i n p e r i o d of time as a r e s u l t of being emotionally d i s t u r b e d . It has been suggested that a f a r b e t t e r term i s " a c c i d e n t - s u s c e p t i b i l i t y , " which "takes i n t o ac-count a l l the f a c t o r s which tend to predispose an i n d i v i d u a l t o accidents (or p r o t e c t him from them)." 1* The chance of having an accident i s r e l a t e d t o the p a r t i c u l a r environment in which a person l i v e s and the " i n d i v i d u a l d i f f e r e n c e s in personal adjustment, emotional and otherwise, as determined 1 Freeman, F. et al_. > 2EL» £•*•> P« 2&. 2 Read, J.H. et. a k , op. c i t . . p. 697. 3 Froggatt, Peter and Smiley, James A. "The Concept of Accident Prone-ness; A Review," B r i t i s h Journal of I n d u s t r i a l Medicine. V o l . 2, January 1964, p. 10. 4 Maclver, J . , op_. c i t . . p. 67. - 8 -by the efficiency of operation of a l l human factors." "There can be l i t t l e doubt that the injury is only the end-point of a developing sequence of behavior surrounding the accidental event... it is to be expected that the kind of conceptual approach taken to the accident phenomenon will have a profound effect upon the type of research 2 design used and the kind of data collected." Therefore, in this study the writers w i l l u t i l i z e a behavioral systems approach to accidents, em-ploying the theories of role and ego functioning to integrate personal and social factors. Systems Approach to Stress and Accidents The broad, interrelated, systems approach finds that: "Accidents have significance beyond themselves. They are always symptomatic of disorder in a particular dynamic system. The disorder may reside in the habits of an in-dividual or the customs of a community or the breakdown of a machine."3 In social work, general behavior systems theory is increasingly being accepted as an aid to psychodynamic understanding of the individual. "Systems are bounded regions in space-time, involving energy interchange among their parts, which are associated in functional relationships, and with their environments."^ General behavior systems theory deals with 1 Maclver, J., op_. c i t . . p. 67. 2 Suchman, E.A. "A Conceptual Analysis of the Accident Phenomenon," H.H. Jacobs et. aj_., Behavioral Approaches to Accident Research. Associa-tion for the Aid of Crippled Children, New York, 1961, p. 46. 3 Maclver, J., op_. c i t . . p. 71. 4 Miller, James G. "Toward a General Theory for the Behavioral Sciences," J.C. Coleman, Personality Dynamics and Effective Behavior. I960, Scott, Foresman and Company, Chicago, p. 433. - 9 -living systems, which are open systems, having important inputs and out-puts. Systems maintain steady states by negative feedback systems d i s t r i -buting information to sub-systems, such as defense mechanisms, to keep them in orderly balance and also in equilibrium with their environment. Variation might mean destruction. A range of s t a b i l i t y exists for any parameter or boundary, and beyond this range is stress and strain.^ A current view is that "individuals go through temporary states of instability and emotional stress which could make them more susceptible to 2 accidents." The number of writers accepting this view is increasing. Stress in the family can have great reverberations in a l l of the other areas of a person's l i f e . In the area of childhood accidents, numerous approaches have been taken in seeking preventive measures. Many earlier studies have suggested that familial events might be related to the occur-rence of injuries to children. Stress is an unavoidable element Of l i f e , which may arise from factors internal or external to the individual, or both. It has been defined as "usually the outcome of a struggle for the self-preservation (homeostasis) of parts in a whole,"^ and this has been found to be true of individual cells within man, man in society, and individual species in the whole animate world. Although everyone experiences stress a l l the time, what is harmful to one person is not necessarily so to another. In an effort to re-establish or maintain dynamic equilibrium, seen in a certain mode and level of social functioning, man tends to absorb stress situations 1 Mill er, J.G., op. c i t . . pp. 4 3 3 - 4 3 6 . 2 Freeman, F. et. al_., op., c i t . , p. 2 6 . 3 Selye, Hans. The Stress of Life. McGraw-Hill Book Company Inc., New York, 1 9 5 6 , p. 253. -10-through a v a r i e t y of defens ive and adapt ive responses, which have.been genera l ized a s M f i g h t " and f 1 i g h t . T h e s e mechanisms include r e p r e s s i o n , p r o j e c t i o n , suppress ion , r e s i s t a n c e , react ion format ion , r e s t i t u t i o n , and displacement . It is speculated that accidents occur as a r e s u l t of the f a i l u r e of such mechanisms to maintain the i n d i v i d u a l ' s e q u i l i b r i u m . When the f a m i l y , an open-ended system, receives s t r e s s , t h i s is t ransmit ted throughout, to the var ious members. Those with weak ego s t ruc tu res are unable to integrate the s t r e s s in order to maintain e q u i l -ibrium and so react to i t through behavior which may involve the occurrence of a c c i d e n t s . In a d isorganized f a m i l y , one member may take on the r o l e of a c c i d e n t - r e p e a t e r , to serve a purpose in s t a b i l i z i n g fami ly e q i u l i b r -ium. It is genera l ly accepted that p r e d i c t i o n of acc idents requires knowledge of the environmental accident p o t e n t i a l , the i n d i v i d u a l ' s aware-ness of environmental accident hazards, mot ivat ion toward accident preven-t i o n , and ind iv idua l r i s k - t a k i n g b e h a v i o r . ' S t ressors may g ive r i s e to temporary a c c i d e n t - s u s c e p t i b i l i t y in an i n d i v i d u a l ' s behavior through d i s -rupt ion of p h y s i o l o g i c a l , p h y s i c a l , p s y c h o l o g i c a l , s o c i a l , c u l t u r a l , or environmental e q u i l i b r i u m . Safety a t t i tudes may r e f l e c t the i n d i v i d u a l ' s b e l i e f that ' ' acc idents don' t happen to me," that everyone must look a f t e r h imse l f , or that accidents do not occur f requent ly enough to warrant s e r -ious concern . The chance combination of s i t u a t i o n a l f a c t o r s in a c e r t a i n way may or may not c rea te the c o r r e c t condi t ions f o r an accident to take p l a c e . Thus, at t imes , the c a r e l e s s person is p r o t e c t e d , whi le on other 1 Suchman, E . A . and Scherzer , A . L . , op_. c i t . . p . 7. - 11 -occasions he might, through coincidence, become an accident victim. It would seem that the three basic needs of affection, security, and self-esteem exert a direct influence upon the above mentioned behavior, and are apparent in the modes of expression unique to each individual per-sonality. It has been pointed out that, "when satisfaction of these needs is blocked, or over-done, accident potential increases, temporarily at least, (and) obviously involved are the origin and age of a 'condition;' compensating or adaptive processes; and the variety and duration of relev-2 ant environmental factors — a l l somewhat subject to chance." In the case of childhood accidents, it is particularly important to include con-sideration of the many interacting factors affecting the child's sense of security, his self-esteem, and the meeting of his affectional needs. The systems approach to stress and accident provides a unifying framework for studying social factors, conceptualized through role theory, and personal factors, viewed through the framework of ego functioning. Family Role Performance and Stress The concept of role is recognized as having particular value in our systems approach to the time relationship between stress-producing events within the family and childhood accidents. Therefore it will be discussed in some detail. In the social sciences.; and particularly in social work, the con-cept of role is widely employed to integrate the personal and social fac-tors underlying human behavior. Perlman, in an a r t i c l e looking at :i 1 Brody, L., op_. c i t . . p. 93. 2 Ibid., p. 99. -12-the implications of the concept of role for case workers, has defined role as "a person's organized pattern of actions and attitudes, fashioned by the position and function he is carrying in relation to one or more other persons.11 She further states that " i t is always a reciprocal inter-acting relationship and the family may be seen as a network of role-relat ionships."' To readily understand that role is a dynamic concept, and that change in one of its factors may alter an individual's or a group's social functioning, the components of social role are identified as: the inter-relatedness of a l l of a person's roles; the reciprocity of roles carried by various people in relation to each other; the role network, which in-cludes both the interrelated roles of the individual and the reciprocal role performance of those with whom he interacts; the range of role per-formance; role expectations or activities prescribed as appropriate for the role by the social norms, which must be accepted by individual and soc-iety; role perception, involving the way in which the role is viewed by the performer or the reciprocal person; and role performance modification, involving changes in role behavior. There are many factors in an individual's l i f e that may lower the performance of one or several roles as a result of affecting the function-ing of personality in any of its aspects. Because of the reciprocity of role behavior and the interrelatedness of roles, d i f f i c u l t i e s in role per-formance may create stress, which may further detract from role perform-1 Perlman, Helen H. "Family Diagnosis in Cases of Illness and Disabil-i t y , " Family-Centered Social Work in Illness and Disability: A Preventive  Approach. Monograph VI of Series "Social Work Practice in Medical Care and Rehabilitation Settings," 1961, National Association of Social Workers, New York, p. 11. -13-ance in the same area or in others. Therefore, prolonged or widespread stress in role functioning can result in extended role breakdown and even personality disorganization. It is speculated that accidents may be con- 1 sidered symptoms of an individual's inability to cope with personal or social stress. There are, however, various reasons for role impairment, which may be both a cause and an effect of stress, and i t is defined as "a situation of stress, which involves threat. 1 1' Three component elements of a stress situation have been found to consist of the following: the stress factor which threatens; the value which is threatened; and the reactions, individual and collective, to the threat. The reactions consist of "responses made by the individual with the goal of maintaining the level of social functioning which existed 2 prior to the occurrence of the stress." Responses to stress vary, depend-ing on the tolerance threshold, which includes somatic and ego capacity; nature, intensity and scope of stress; and the vulnerability of the factor affected by stress.^ Role support during stress through social contacts, professional or non-professional, is very influential to social function-ing, and its strategic timing might be utilized to bolster an individual's stress tolerance with the hope of limiting his susceptibility to accidents. Stressful conditions in terms of role theory have been outlined in terms of excessive or frustrating role expectations; unf u l f i l l e d , non-available, ambiguous, conflicting and incompatible roles; role transition, involving more than one person; and discontinuity in role sequence. As 1 Bernard, Jessie. Social Problems at Midcentury. Holt, Reinhart and Winston, New York, 1961, p. 70. 2 Boehm, Werner. The Social Casework Method in Social Work Education. Council on Social Work Education, New York, 1959, p. 108. 3 Loc. c i t . -14-modes of adaptation and adjustment to the above s t r e s s f u l c o n d i t i o n s , the f o l l o w i n g have been d e l i n e a t e d : role-abandonment, which may be a response to e x c e s s i v e , f r u s t r a t i n g , ambiguous, c o n f l i c t i n g o r incompatible expecta-t i o n s of another r o l e ; r o l e - i n n o v a t i o n , which responds t o the no n - e x i s t -ence of a r o l e in a given group; r o l e r e d i s t r i b u t i o n , which occurs in response to u n f u l f i l l e d r o l e s ; assumption of c u l t u r a l l y disapproved r o l e s , of which the causal f a c t o r s in s t r e s s f u l s i t u a t i o n s are not c l e a r l y under-stood; role.-conformity, in which p r e v i o u s l y h e l d , now ina p p r o p r i a t e r o l e -expectations are r i g i d l y adhered t o ; role-compartmentalization, i n v o l v i n g u t i l i z a t i o n of one set of r o l e - e x p e c t a t i o n s at a time in a s i t u a t i o n where incompatible r o l e c l u s t e r s are involved; r o l e - r e t r o g r e s s i o n , o f t e n a benefr i c i a l response to i l l n e s s ; and p a i r i n g w i t h a p r o f e s s i o n a l person in the human r e l a t i o n s f i e l d , such as a s o c i a l worker, in response to s t r e s s . ' The healthy f a m i l y today " i s not only the f o c a l p o i n t of f r u s t r a -t i o n s and tensions but a l s o the source f o r r e s o l v i n g f r u s t r a t i o n s and r e -l e a s i n g tens ions....Through i t s c a p a c i t y f o r sympathy, understanding, and u n l i m i t e d support, the f a m i l y r e h a b i l i t a t e s p e r s o n a l i t i e s bruised i n the course of c o m p e t i t i v e d a i l y l i v i n g . " S o l i d a r i t y i s an important aspect of l i f e in the f a m i l y , as a group. " I n a sense, the f a m i l y contains b u i l t -in problems of s o l i d a r i t y in that c h i l d r e n have t o be s o c i a l i z e d f o r indep-endent e x i s t e n c e o u t s i d e the f a m i l y . " ^ Numerous s t u d i e s have noted t h a t 1 Maas, Henry. "Behavioral Science Bases f o r a P r o f e s s i o n a l Education: The U n i f y i n g Conceptual Tool of C u l t u r a l Role," Proceedings of the I n t e r - d i s c i p l i n a r y Conference. 1959. Howard U n i v e r s i t y , Washington, D.C, pp. 11-22. 2 H i l l , Reuben. " S o c i a l Stresses on the Family: Generic Features of F a m i l i e s Under S t r e s s , " S o c i a l Casework. V o l . 39, February 1958, p. 140. 3 Cousins, A l b e r t N. "The F a i l u r e of Family S o l i d a r i t y , " The Family, eds. N.W. B e l l and E.F. Vogel, 1962, The Free Press, Glencoe, I l l i n o i s , p. 403. large f a m i l i e s are p a r t i c u l a r l y vulnerable to major c r i s e s , which have to be met through the s a c r i f i c e s of o l d e r c h i l d r e n and through united e f f o r t s 1 2 by the f a m i l y . ' It might be speculated that the absence of s o l i d a r i t y in the family perpetuates s t r e s s , disharmony and d i s e q u i l i b r i u m w i t h i n the l i f e systems of i t s members, e s p e c i a l l y c h i l d r e n , making them vulnerable to a v a r i e t y of a f f l i c t i o n s , depending upon i n d i v i d u a l c a p a c i t i e s f o r cop-ing with s t r e s s . Accidents might r e s u l t from behaviors employed in r e l i e v -ing the tension from such s t resses in the f a m i l y . On the other hand, a s t a b l e , secure home l i f e might well help a c h i l d to regain h is e q u i l i b r i u m l o s t , f o r example, through s t r e s s at s c h o o l . Factors conducive to good adjustment to c r i s i s have been found to be family a d a p t a b i l i t y ; family i n t e g r a t i o n ; a f f e c t i o n a l r e l a t i o n s among family members; good mar i ta l adjustment of husband and w i f e ; companionable p a r e n t - c h i l d r e l a t i o n s h i p s ; fami ly c o u n c i l type of contro l in d e c i s i o n -making; s o c i a l p a r t i c i p a t i o n of w i f e ; and previous successful experience with c r i s i s . P h y s i o l o g i c a l f a c t o r s , such as inherent c o n s t i t u t i o n a l l i m i t a t i o n s , s i c k n e s s , d i s a b i l i t y and the output and s t a t e of energy are very important determinants of s o c i a l f u n c t i o n i n g , as are environmental fac t ors — " t h e p h y s i c a l , s o c i a l and c u l t u r a l c o n d i t i o n s o u t s i d e man with which he constant ly in terac ts in the sense that he a f f e c t s them and they a f f e c t h i m . " In the s o c i a l environment of the i n d i v i d u a l there are many important f a c t o r s a f f e c t i n g adjustment to c r i s i s , which are sometimes o v e r -looked. These c o n s i s t of his s o c i a l s i t u a t i o n , people in his r o l e network; 1 Cousins , A.N., op. c i t . . p . 405. 2 H i l l , R . , OD_. c i t . . , p . 139. 3 I b i d . , p . 148 4 Boehm, W., op_. c i t . . p . 95. -16-h i s reference groups; the instrumental f a c t o r s a v a i l a b l e t o the i n d i v i d u a l in performance of h i s r o l e s ; the p r e v a i l i n g ideologies and norms in soc-i e t y as a whole or in p a r t ; economic, p o l i t i c a l , p h y s i c a l and t e c h n i c a l changes; s o c i e t a l i n d i f f e r e n c e or l a g in d e f i n i n g r o l e s of popu l a t i o n groups; and s o c i a l s t r a t i f i c a t i o n . ' The p r o f i l e of i n d i v i d u a l and f a m i l y adjustment a r i s i n g from c r i s i s i nvolves the broad stages of c r i s i s ; d i s o r g a n i z a t i o n ; recovery; and reorgan-2 i z a t i o n . F a m i l i e s tend t o be strengthened by s u c c e s s f u l l y coping w i t h 3 c r i s i s , whereas morale and s t r u c t u r e s u f f e r when defeat occurs in c r i s i s . "Hardships may be defined as those complications in a c r i s i s - p r e c i p i t a t i n g event which demand competencies from the f a m i l y which the event i t s e l f may have t e m p o r a r i l y paralyzed or made u n a v a i l a b l e . " i t has been found that "accident-proneness is d i s p r o p o r t i o n a t e l y high among i n d i v i d u a l s who la c k s e l f - c o n f i d e n c e and are c h a r a c t e r i z e d by a n x i e t y , " and f a m i l y c r i s i s - p r o n e -ness has s i m i l a r l y been r e l a t e d t o the d e f i n i t i o n of a s i t u a t i o n made by those involved.-*-The f a m i l y ' s d e f i n i t i o n of events determines whether or not the events become c r i s e s . C r i s i s - p r o v o k i n g events have been termed s t r e s s o r s . "Adjustment t o a c r i s i s that threatens the f a m i l y depends upon the adeq-uacy of r o l e performance of f a m i l y members, (and) p e r s o n a l i t y changes in members r e f l e c t the anxiety and f e e l i n g s of i n s e c u r i t y engendered by the 1 Boehm, W., op_. c i t . . p. 102. 2 H i l l , R., op_. c r t . , p. 146. 3 i b i d . , p. 141. 4 Loc. c i t . 5 I b i d . , p. 145. 6 I b i d . , p. 141. c r i s i s . " It is noted in the literature that problem or crisis-prone families are characterized by having insufficient resources for meeting c r i s i s . Crisis-prone families and multiproblem families have been found to have many similar i t i e s , and it has been suggested that crisis-proneness 2 runs in families as does accident-proneness. Family d i f f i c u l t i e s have been studied from a variety of viewpoints, which include the following: the source; effects upon the family configuration; type of event impinging upon the family; role conflict; and status change.^ It has been stated that the concept of social functioning "places on society the responsibility to do everything possible (within the bound-aries of reason and justice) to contribute to balanced living; it places on the individual the correlative responsibility to make use of these Zi offerings for the good of others as well as s e l f . " The concept of balance, which is continually being explored in social work practice and the behav-ioral, medical and social sciences, is increasingly being accepted as a vital factor in man's relations with other men. Psychological and physiol-ogical theories are emphasizing homeostasis or balance, and psychoanalytic theory postulates ego psychology, in which the ego is viewed as "the agent responsible for maintaining an ongoing reconciliation between the various forces that influence both overt and covert behavior; in so doing it acts as a balance-wheel for the whole of mental 1 ife.*' 1 H i l l , R., op_. c i t . . p. 147. 2 Ibid., p. 143. 3 Ibid., p. 147. 4 McCormick, Mary J. "The Role of Values in Social Functioning," Social  Casework. Vol. 42, February 1961, p. 70. 5 Ibid., p. 73. -18-In the f i e l d of accident research, as fnoother areas investigating the causes of human behavior, we must u t i l i z e a comprehensive multidiscip-1inary approach in studying the world's most complex and intricate creature — man. Individual Ego Functioning and Stress The rrationale to be followed by our research study"is that stress-producing events may have an impact upon the ego functioning of a child, causing established behavior controls to disappear, with the result that impulse takes over, rather than thinking through a situation and exercising self control. The theoretical approach followed by the Marcus group has been found to be very applicable to our study. They have considered the "mal-adjusted individual" to be "a type whose physiological and/or psychological mechanisms of defense f a i l to adapt adequately to a transient or chronic l i f e stress situation, who may then shift into the accident prone group, (and have said that) the probability of accidents diminishes with age, learning and improved physiological and psychological adaptation, up to maturity."' Freud, in his early writings developed a hypothesis as to why certain individuals might be more susceptible to accidents, namely that many apparent accidents of his patients were s e l f - i n f l i c t e d injuries, which, although apparently unintentional, were serving some need in a way not 2 necessarily recognized by the patient. This thesis has been modified and 1 Marcus, I.M., Wilson, W., Kraft, I., Swander, D., Southerland, F. and Schulhofer, E. "An Interdisciplinary Approach to Accident Patterns in Children," Monograph, Society for Research in Child Development. Serial No. 76, Vol. 25, I960, p. k, 2 ibid., p. 5. -19 -expanded throughout the y e a r s . The concept of adaptat ion is basic to the understanding of behav-iora l pat terns in the ind iv idua l with his internal f o r c e s , as he in terac ts with the environment. What is observed in a person 's behavior is the product of execution of the ego funct ions of percept ion or r e a l i t y - t e s t i n g , defense or adapta t ion , and i n t e g r a t i o n , expressed in the person 's s o c i a l f u n c t i o n i n g , which is a f fec ted both by f a c t o r s wi th in and ou ts ide the p e r -s o n a l i t y . Of the three forces in p e r s o n a l i t y — the i d , ego, and superego — the ego is that f o r c e which re la tes i n t e r n a l , i n s t i n c t u a l id impulses to e x t e r n a l , p r o h i b i t i v e , moral and s o c i a l values of the superego. The func t ion ing of the ego, which has both i n t e l l e c t u a l and emotional f a c t o r s , involves the expression of mot ivat ion or r e a l i t y - r e l a t e d s t r i v i n g , as well as the expression of c a p a c i t y . It is genera l ly accepted that parents should a lso be cons idered , when studying c h i l d r e n ' s behavior with t h e i r basic dependency upon t h e i r adult environment f o r p r o t e c t i o n , c a r e , nourishment, a f f e c t i o n , and mental s t i m u l a t i o n . The complex phenomenon of adaptat ion involves many f a c t o r s , such as " the i n d i v i d u a l ' s bas ic endowment, h is capac i ty to develop memory, p e r c e p t i o n s , judgment, a c t i v i t y t y p e , . . . a c t ions based on mental a c t i v i t y , such as defens ive or p r o t e c t i v e mechanisms, and the in tegra t i ve capac i ty when exper iencing f e e l i n g s , thoughts, and impulses toward motor a c t i o n , (as wel l as) problem-solv ing t e c h n i q u e s . " ' Th is adaptat ional ' e g o " f u n c -t i o n i n g develops from the rudimentary ad jus t i ve apparatus present in the i n f a n t , growing more complex and e f f e c t i v e with maturat ion. "The i n d i v l d -1 Marcus, I.M. et. aj_., OJD. c i t . . p. 40. -20-ual may react to a given s i t u a t i o n e i t h e r with p r e v i o u s l y developed modes of adaptat ion or by u t i l i z i n g a new p a t t e r n , (so) one may speak of ' r e g r e s -s i v e ' pat terns and ' p r o g r e s s i v e ' p a t t e r n s , the l a t t e r being cons is ten t with maturation and development." ' In the c h i l d , tension from fami ly s t r e s s leads him to behavior aimed at r e l i e f , which may, in i t s e l f , c rea te add i t iona l s t r e s s . In the dynamic whole of the p a r e n t - c h i l d r e l a t i o n s h i p , healthy and unhealthy r e -adjustments are c o n t i n u a l l y being made. Unhealthy new leve ls of e q u i l i b -rium c o n t r i b u t e to higher l eve ls of tension by i n t e r f e r i n g with the achievement of appropr ia te g o a l s . "The ever changing new l e v e l s of e q u i l i b r i u m should serve to a id in s u r v i v a l , r e l i e v e p a i n f u l t e n s i o n , and 2 permit p leasure experiences and u t i l i t y values in goal -d i r 'ected a c t i v i t y . " When tension i n h i b i t s a n t i c i p a t o r y mechanisms, r e a l i t y adaptat ion is weak-ened and s u r v i v a l value is decreased at the new level of e q u i l i b r i u m . Thus, there is greater l i k e l i h o o d that accidents w?11 take p l a c e . It is accepted that there are c o n s t i t u t i o n a l f a c t o r s in f luenc ing the i n d i v i d u a l ' s a b i l i t y to t o l e r a t e anxiety and react to s t i m u l i . Too, i t has been noted that neuromuscular e x c i t a b i l i t y is inf luenced by " c o n g e n i t a l , matura t iona l , and environmental f a c t o r s , of which parental a t t i tudes are e s p e c i a l l y important."^ C h i l d accidents are c l o s e l y a f fec ted by the p a r e n t - c h i l d r e l a t i o n -s h i p . Extreme a c t i v i t y pat terns of the c h i l d may make him d i f f i c u l t to s a t i s f y and so f r u s t r a t e both himself and h is parents in the establishment 1 Marcus, I.M. et. aj_., op_. c i t . , p. 40. 2 Loc . cj_t. 3 I b i d . , p . h\. -21-of a mutual r e l a t i o n s h i p , leading to fantasy and ideas of personal omni-potence. "The c h i l d who cannot e s t a b l i s h closeness w i t h h i s parents and who f a i l s t o master anxiety through i m i t a t i o n and i d e n t i f i c a t i o n w i t h h i s parents must r e l y more on k i n e s -t h e t i c i d e n t i f i c a t i o n and various motor a c t i v i t y p a t t e r n s . The more one r e l i e s on hyperactive motor discharge t o r e -e s t a b l i s h e q u i l i b r i u m , the more l i k e l y i t i s that the i n d i v i d u a l w i l l move i n t o s i t u a t i o n s which may provoke disapproval o r , i f overwhelming, lead i n t o dangerous s i t u a -t i o n s . In c o n t r a s t , the c h i l d w i t h a quiet a c t i v i t y p a t -t e r n seems t o r e - e s t a b l i s h e q u i l i b r i u m by a greater tend-ency to withdraw,"' It would seem t o be of p a r t i c u l a r s i g n i f i c a n c e that s t u d i e s on ch a r a c t e r disordered parents and t h e i r c h i l d r e n , and multiproblem f a m i l i e s , f r e q -u e n t l y encounter c h a r a c t e r i s t i c s such as those mentioned above, p o i n t i n g t o the broad systems of i n t e r r e l a t i n g i n t e r n a l and exte r n a l f a c t o r s i n -volved in any human s i t u a t i o n . A n t i c i p a t o r y thought processes developed through ego d i f f e r e n t i a -t i o n are "of utmost importance in achieving greater independence from im-mediate environmental s t i m u l a t i o n , " ^ Delay of a c t i v i t y through t r i a l thought processes i s less l i k e l y i n the i n d i v i d u a l who u t i l i z e s the prim-i t i v e defenses of immediate motor discharge. "Thus, a high a c t i v i t y p a t -t e r n i n t e r f e r e s w i t h the f u n c t i o n of higher order defenses, and the d i f -f e r e n t i a t i o n of r e a c t i o n p o s s i b i l i t i e s becomes more l i m i t e d , s e l e c t i v e c o n t r o l i s impaired, and the i n d i v i d u a l remains enslaved by h i s e a r l y s t i m u l u s - r e a c t i o n p a t t e r n . " A n x i e t y , which f u n c t i o n s s p e c i f i c a l l y t o 1 Marcus, I.M. e t aj_., op_. c i t . . p. 41. 2 Reiner, B. Simcox and Kaufman, I. Character Disorders in Parents of  Delinquents. Family S e r v i c e A s s o c i a t i o n of America, New York, 1959. 3 Marcus, I.M. et a l _ , , op_. c i t . , p. 41. 4 Loc. c i t . 22 alert a person to danger, has been described as an intellectual reaction geared to the fear of pain resulting from impending damage. Persistent attacks of anxiety, rationalized into morbid fears, have been viewed as "an interference with progressive ego adaptational mechanisms because, although no danger exists, the ego is exhausted by conflict, f l i g h t , and other mechanisms," and self-injurious actions have been seen "as a pain-eliminating response embodied in the 'riddance principle,' the wish to 'get it over with' by rushing into the feared situation or attacking the symbol to which fear is attached."' The foregoing theories reveal the importance of viewing human behavior in terms of a broad, systems approach and of ;uti1izing the con-cepts of role theory and ego functioning to integrate personal and social phenomena. Focus of Our Study The three established theories which have been discussed provide a framework through which family stress and childhood accidents may be studied, with the ultimate goal of accident prevention. The fact that many studies, in focusing on segments of human behavior, lose sight of the integral relationship of parts to the whole person, interacting with his physical and social environment, may account for frequent failure to carry results to the ultimate end of developing and applying remedial or preventive measures. In the case of our study, the prevention goal \hbpef.uHyf wi ,11 be furthered i f information is obtained which indicates that stress-producing events in families occur s i g n i f i c -1 Marcus, I.M. et. al_., op_„ c i t . . p. 42. - 2 3 -antly close in time to the occurrence of childhood accidents. In such a case, public education of hazards might lead to withdrawal from potentially dangerous situations, when a person is aware that he is adversely affected by stress. The Review of the Literature which follows indicates that, " a l l in a l l , research on childhood accidents suffers from the lack of any concept-ual framework to guide the collection, analysis, and interpretation of data,"' For this reason, recognizing the interaction between the child and his family situation, the previously mentioned concepts from systems theory, ego functioning, and role theory are being used. As a framework for our study, we have adapted a classification of stress-producing events, based on the theories which have been outlined in this chapter (See Append-ix A). B. Background of the Problem  Review of Literature In reviewing the literature, we shall confine ourselves to mater-ial related to the relationship in time between the occurrence of stress-producing family events and childhood accidents. Due to the limitations of both time and information for making an intensive review, the writers will necessarily be restricted to studies which are available and summar-ies by authorities on unavailable material. Owing to the variation of focus found in much research to date, and the paucity of information per-taining to the relationship between stress and the occurrence of accidents, it seems advisable to restrain ourselves from going too far afield in 1 Suchman, E.A. and Scherzer, A.L,, OD_. c i t . . p. 26. -24 -examining the mul t i tude of uncoordinated research s tud ies which have been done. There fore , we s h a l l attempt to consider the in te rac t ing f a c t o r s a f f e c t i n g the accident c h i l d in h is s i t u a t i o n as a dependent fami ly member ~ p h y s i c a l l y , p s y c h o l o g i c a l l y , emot iona l ly , s o c i a l l y and c u l t u r a l l y . With regard to i d e n t i f i c a t i o n of the a c c i d e n t - r e p e a t e r , Freeman et. a K have observed that inconsistent conc lus ions have resu l ted from "an enormous amount of research e f f o r t (which) has been d i rec ted toward i d e n t i f y i n g the c h a r a c t e r i s t i c s of the group f o r the purposes of s c r e e n -ing , r e h a b i l i t a t i n g , t r a n s f e r r i n g , r e t r a i n i n g , or simply 'understanding ' a c c i d e n t s . " ' A survey by Brody of r e s u l t s from psycho log ica l and medical examination, interviews and b iographica l analyses has suggested the f o l l o w -ing p r o f i l e of p e r s o n a l i t y t r a i t s of a c c i d e n t - r e p e a t e r s , not a l l of which are present n e c e s s a r i l y in each such i n d i v i d u a l : " 1 . Greater d i s t r a c t i b i 1 i t y than average. 2 . A tendency to act impu ls ive ly . 3 . A tendency to be a s o c i a l , nonconforming, aggress ive , and in to lerant of a u t h o r i t y . 4 . Emotional i n s t a b i l i t y , inc lud ing d i f f i c u l t y in t o l -e ra t ing tension and f r u s t r a t i o n . 5. An exaggerated not ion of a b i l i t y , unusual r i s k -tak ing and an unhealthy need to stand o u t . 6. In some c a s e s , a subconscious quest fo r a t tent ion or s a t i s f a c t i o n through s e l f - i n f l i c t e d I n j u r y . " 2 These t r a i t s must be seen in the context of the t o t a l unique p e r s o n a l i t y . It is genera l ly accepted that "an accident repeater in one area of a c t i v -i t y , (such as work) a l s o tends to have accidents in other areas (and) n e c e s s a r i l y , the occurrences and the consequences are mediated by the phys ica l c h a r a c t e r i s t i c s of the a c t i v i t y and other aspects of the f i e l d s . " 1 Freeman, F. et. a l_ . , op_. c i t . , p. 26. 2 Brody, L . , op_. c i t . , p . 98. 3 Loc . c i t . -25-For a thorough and conc ise review of e x i s t i n g mater ia l on c h i l d -hood a c c i d e n t s , the reader is re fer red to the recent work of Suchman and Scherzer . They have systematized c u r r e n t , uncoordinated research in chi ldhood a c c i d e n t s , under three main headings with numerous s u b - c l a s s -i f i c a t i o n s , which might be hypothesized as "causes ' * of accidents f o r fu ture research (See Appendix B ) . The main d i v i s i o n s in t h e i r c l a s s i f i c a -t i o n are the background of the c h i l d ; the fami ly background (both p a r e n t s ) ; and the environmental background, ' In view of these many p o s s i b l e causes of a c c i d e n t s , p lus many more, i t becomes apparent, p a r t i c u l a r l y when t h e i r combined e f f e c t s in any s i t u a t i o n are cons idered , that the task of d e t e r -mining the in f luence of one p a r t i c u l a r f a c t o r in causing an accident is almost overwhelming. It has been found that c e r t a i n f a c t o r s have received much more a t tent ion than others and, f o r the most p a r t , "coverage has been haphazard, most s tud ies simply making use of easy- to -get or a v a i l a b l e s t a t i s t i c s . " 2 3 Suchman and Scherzer , in t h e i r survey of s tudies of accidents as re la ted to the background of the c h i l d , have d iscussed h e r e d i t y , motor and verbal s k i l l s , phys ica l and s o c i a l growth and mental processes as s i g n i f i c a n t f a c t o r s . They have mentioned var ious emotional symptoms of interpersonal s t r e s s , such as c o n f l i c t , aggress ion , impulsive or u n r e f l e c t -ive behavior , i n s e c u r i t y , bossiness and puni t iveness in d o l l p l a y , s o l i c i t -a t ion of a f f e c t i o n , d i s r u p t i o n of harmonious group l i v i n g , daredevi l a t t i t -ude, easy arousal of emotional r e a c t i o n s , and a rude o r i n s u l t i n g a t t i t u d e to o t h e r s . The r e l a t i o n s h i p between unmet emotional needs and accidents 1 Suchman, E . A . and Scherzer , A . L . , OD,. c i t . . p. 13. 2 I b i d . , p . 14. 3 Loc . c i t . -26 -has been emphasized. A c c i d e n t - c h i l d r e n have been found to be immature and emotional ly uns tab le , to f e e l inadequate, to worry over phys ica l defects and to be h igh ly nervous and p h y s i c a l l y a c t i v e . Oedipal c o n f l i c t and sado-masochistic pat terns have been re la ted to a c c i d e n t s , and p e r s o n a l i t y c h a r a c t e r i s t i c s , g e n e r a l l y , have been suspected as a d e c i s i v e f a c t o r in a c c i d e n t s . S o c i a l l y , acceptance and status maintenance are important f a c t o r s which can include hazards. It is concluded that the c h i l d ' s emo-t i o n a l s t a t e is a s i g n i f i c a n t accident f a c t o r because i t may express i t -s e l f in p h y s i c a l behavior ; With regard to fami ly background, Suchman and Scherzer have found s t r i c t r e l i g i o u s upbr ing ing , low socio-jeconomic s t a t u s , inherent c o n s t i t u -t i o n a l or pred ispos ing f a c t o r s , and phys ica l and s o c i a l environments to be s i g n i f i c a n t f a c t o r s re la ted to occurrence of chi ldhood a c c i d e n t s . It has been noted that o f t e n , a c c i d e n t - c h i l d r e n come from larger f a m i l i e s and broken homes, and are l a te r in b i r t h order which might suggest that r o l e confusion or ro le lessness might be re la ted to the frequent emotional i n s t a b i l i t y of a c c i d e n t - c h i l d r e n . Among f a m i l i e s of a c c i d e n t - c h i l d r e n , a l c o h o l i s m , at least one a u t h o r i t a r i a n parent , s h i f t l e s s n e s s , and d i s r u p -t i v e acts are common, and geographic m o b i l i t y and crowded l i v i n g c o n d i -t ions are of ten found. The time of moving has been noted as a p a r t i c u l a r -ly high hazard p e r i o d . The phys ica l environment of a c c i d e n t - c h i l d r e n is genera l ly found to be p o o r . ' Accident s i t u a t i o n v a r i a b l e s have indicated that pre -school c h i l d r e n are u s u a l l y injured at home, gradual ly moving outs ide with age. 1 Suchman, E . A . and Scherzer , A . L . , op_. c i t . . p . 18. -27-Sources of injury include f a l l s , blows and crushes, cutt ing, p iercing, ingestion, poisons, burns, drowning, firearms, b i tes , scratches and attractive nuisances. Accidents frequently occurred in the afternoon and were associated with fatigue. Generally, it was found that childhood accidents occurred in July and August. Langford' and his group found accident-chiIdren to be less suc-cessful in avoiding environmental hazards of which they were aware; less concerned with injur ies, as were their parents; and less secure in family relationships, necessitating more so l ic i ta t ion of affection elsewhere than accident-free chi ldren. Of part icular note was the much higher incidence of accidents to the immediate family and close associates of the accident chi ldren. Of the accidents-children, three groups were distinguished. In the f i r s t , the children were overactive, restless and impulsive, liked by adults but not by peers, and were maladjusted in response to stress, be-coming impulsive and disorganized, not heeding danger s ignals , and getting into situations where accidents were inevitable. It was speculated that the accidents could well be unmotivated and the defect a developmental one in ego control mechanisms. The second group was characterized by immatur-i ty , lack of parental supervision, insistence by the chi ld on autonomy and self-determination, and competition in act iv i t ies with older children in a hazardous^, environment. In the third group were the children who viewed their homes as bleak and empty, had moderately severe conduct disorders before accidents, and later , after releasing pent-up rage and aggression, less resentful and rebel l ious, salvaging attention from mother when injured, 1 Langford, W.S. et aj_., "Pi lot Study of Childhood Accidents: Preliminary Report," Pediatr ics. Vol . 11, April 1953, pp. 405-415. -28-suggesting that accidents are motivated. Childhood accidents have been interpreted in a variety of ways by different writers. They have been considered by Melanie Klein to be suic-ide attempts with yet insufficient means,' and have been attributed by Ackerman and Chidester to the basic motives of hurting oneself out of guilt or symbolically hurting others out of revenge, or a combination of these, exhibited in reckless abandon in play resulting from considerable 2 unexpressed hatred and guilt feelings. Marked psychopathology, such as alcoholism, has been found in a large number of families of accident-child-ren and it has been noted that often, siblings have also been disturbed. The combination of sadistic father and passive, masochistic mother has appeared in a considerable number of cases and in young children, accid-ents have been interpreted by Fabian and Bender to represent inverted aggressive gestures directed at frustrating adults, often carried into 3 adult l i f e . Over-authority in the home has been related to pent-up ag-gression and resentment in the child. Among junior high school pupils, accident-repeaters have been found by Birnbach to excel' in physical fitness and strength tests and to be in better general health than accident-free students. However, their home, health and emotional adjustment has proven to be less adequate and 1 Klein, M., in Langford, W.S. et. aj_., "Pilot Study of Childhood Accid-ents: Preliminary Report," Pediatrics. Vol. 11, April 1953, p. 405. 2 Ackerman, N.W. and Chidester, L., ;.; Langford, W.S. et a]_., "Pilot Study of Childhood Accidents: Preliminary Report," Pediatrics. Vol. 11, April 1953, p. 405. 3 Fabian, A.A. and Bender, Lauretta. "Head injury in Children: Pre-disposing Factors," American Journal of Orthopsychiatry. Vol. 17, January 1947, pp. 68-79. 4 Marcus, I.M., et. a_L, op_. c i t . . p. 9. - 2 9 -they have been considered less industrious, dependable and adequate at school, reacting to the stress of adjustment demands with impulsive behavior and in general, being rebellious and unable to concentrate. Adjustment problems have also been found by Fuller to be prevalent among accident-repeater children of the nursery group, with injuries tending to decline sharply with increase in age.' A suggestive correlation has been noted between frequency of injury and exceptional physical strength, dare-devil attitudes to others, especially adults, and in g i r l s , tomboyishness, and it has been indicated by Fuller and Baune that, generally, less popul-2 ar children receive a greater number of injuries. Hospitalized, adult accidentsrepeaters have been found by Dunbar to exhibit some common characteristics, being carefree, sociable, well-liked people, but irresponsible toward their families and their work. Authoritarian figures have appeared to be a shared area of confl i c t , in which these accident-repeaters have sought autonomy and independence — when thwarted, reacting impulsively and aggressively, possibly leading to self-destruction in the depressed individual.^ It has been determined by Schulzinger that, among irresponsible and maladjusted people, a higher frequency of a l l types of accident has been apparent, and that, under emotional stress, almost anyone may temporarily become accident-prone.^ 1 Fuller, E.M. "Injury Prone Children," American Journal of Ortho- psychiatry. Vol. 18, October 1948, pp. 708-723. 2 Fuller, E.M. and Baune, H., Suchman, E.A. and Scherzer, A.L. Cur- rent Research in Childhood Accidents. Research Reprint, I960, Association for the Aid of Crippled Children, New York, p. 16. 3 Dunbar, F., in Marcus, I.M. et. aj_,, "An Interdisciplinary Approach to Accident Patterns in Children," Monograph: Society for Research in Child  Development. Serial No. 7 6 , Vol. 2 5 , I960, p. 6. 4 Schulzinger, M.S. The Accident Syndrome. C.C. Thomas, Springfield, 1956. -30-Accident'children have been found by Marcus and hfs group to give evidence of emotional problems to the same degree as enuretic children, and to have exhibited more activity before and after birth. Their responses have ap-peared to be more motor than cognitive and their parents have tended to be anxious, insecure and non-assertive.' A recent, interdisciplinary study by Meyer and his group, exploring certain child, family, and environmental factors associated with injuries has found that "each child appeared caught in a web of enclosing develop-mental and personal circumstances which progressively drew him toward the 2 injury studied." Acute hunger and extreme fatigue with far less parental supervision than usual were noted, as were hyperactivity, uncontrollability by parents, and inability to tolerate stress. More injured than uninjured control children had suffered early prolonged social deprivation from one or both parents through divorce or illness of parents or c h i l d . Parents of these children relied on explanation or punishment as primary preventive measures. It was illustrated that "stressful family l i f e factors were far more common in the 'accident' families studied than in the 'non-accident' comparison group, (and), the climate of stress in the home immediately pre-ceding the accident appeared to have influence in several ways: (A) Acutely stressful events appeared to reduce abruptly the quality of the child's protective human environment at a c r i t i c a l moment of sudden risk; family illness, sudden shifts in supervision, change of residence, and other c i r -cumstances appeared to produce hazardous conditions without protection; (B) Chronically stressful factors appeared to impede child rearing in most 1 Marcus, I.M. et al,,, op_. c i t . , pp. 1-51. 2 Meyer, R.J. et_ aj_., op_. c i t . . p. 96. -31-'accident 1 families studied, often in combination with acute stress." In the extended families (parents, siblings, grandparents, aunts and uncles) of injured children, previous accidental injury was found twice as frequently as in control families. Most severe injuries by far were sustained by chronically disordered families which functioned more as isolated individuals than as living units, in which family l i f e was perpetually disorganized and often beset by chronic medical and social problems. Less adequate attention was received by those children when injury occurred, and they were involved in more frequent past injuries than other "accident" or comparison children. Exposure to danger or pun-ishment were major safety measures before the child's injury. "Ninety-five per cent could have been prevented by modification of acute factors such as improved supervision during the most susceptible part of the day 2 when (the child) was reported to be most hungry, tired, or hyperactive." 3 k The results of various studies^' have indicated that accidents in children occur as an interplay of numerous factors, such as the devel-opmental level of the child, involving inexperience, immaturity, curiosity and coordination; and parental attitudes toward accident awareness and prevention. They have been generally adamant in advocating community arousal aimed at community action for accident prevention. In terms of the interrelated, intra- and interpersonal systems approach which we are employing in our study of the relationship in time 1 Meyer, R.J. et al,., op_. c i t . . p. 102. 2 Ibid., p. 103. 3 Loc. c i t . k McClave, CR. and Shaffer, T.E. "Accidents, Injuries and Children," Pediatric Clinics of North America. August 1957, W.B. Saunders Company, Philadelphia and London, pp. 635"°47. -32-between the occurrence of s t ress -p roduc ing events in the fami ly and a c c i d -ents to c h i l d members, the research f ind ings c i t e d above g ive s i g n i f i c a n c e to the whole broad context of our s tudy . The study which fo l lows is an attempt to i l l umina te one small a s -pect in the complicated r e l a t i o n s h i p between ind iv idua ls and s t r e s s — an inves t iga t ion of the r e l a t i o n s h i p in time between the occurrence of fami ly s t r e s s - p r o d u c i n g events and accidents to c h i l d members. With the frame-work o u t l i n e d in t h i s chapter , we s h a l l now move on to our small research p r o j e c t , which, i t is hoped, w i l l con t r ibu te s i g n i f i c a n t l y to the body of knowledge on chi ldhood accident p revent ion , desp i te i t s l i m i t a t i o n s . CHAPTER 2 . DEFINITIONS AND METHOD In the previous chapter a number of f a c t o r s , methods and approach-es were d i s c u s s e d , a l l having been the subjects of inves t iga t ions in the o v e r a l l study of accident p revent ion . The f ind ings of the study of Read et. aj_.' included ind ica t ions that s t ress -p roduc ing events were more f r e q -uent in f a m i l i e s in which there was a v i c t i m of a c h i l d pedestr ian t r a f f i c accident than in f a m i l i e s in which there had been no c h i l d r e n in such a c -c i d e n t s . S i m i l a r reports were d iscussed which confirmed or substant ia ted t h e i r f i n d i n g s and a lso suggested fu r ther leads with re ference to the p o s s i b i l i t y of the occurrence of acc idents as a symptom of d isorder in a system, in the f a m i l y , or in s o c i e t y . Impl ic i t in any d isorder of a system is the ex is tence of s t r e s s - p r o d u c i n g events and the responses to those events . Adaptat ion mechanisms of the fami ly ex is t in order to maintain fami ly homeostasis and insofar as mechanisms are funct iona l to handle the degree of s t r e s s f u l s i t u a t i o n , the fami ly w i l l adapt without undue d y s -f u n c t i o n . However, i f there is dysfunct ion to any degree, then i t is p o s s -i b l e f o r symptoms to appear, and i t may be found that these symptoms f o r some f a m i l i e s w i l l be a c c i d e n t s . 2 In cont ras t to the study of Read et aj_. of which t h i s is an ex-1 Read, J . H . e t . a l _ . , op_. c i t . . p . 12. 2 I b i d . , pp . 11-14. -34-tens ion, this study has excluded any assessment of feelings or attitudes on the part of accident-children or significant adults. No estimate was made of safe practices on the part of the accident-chiId or of the adults. Neither was there any estimate made of ego functioning as demonstrated, for example, by the perception of a hazard, the estimation of risk, the integration and execution of avoidance patterns, and adaptability. A. Purpose This present descriptive study' was undertaken by four investiga-tors with the purpose of testing the hypothesis that a significant rela-tionship exists in time, specifically 30 days, between the occurrence of stress-producing events within the family and accidents resulting in injury to one or more children of that family. B. Def ? n i t ions  Time Period The time period to determine the existence of a relationship be-tween stress-producing events and accidents was arbitrarily chosen to be 30 days -- that is, the 30 day period immediately prior to each of the described accidents. It was considered that the 30 day time period could be a reasonable time for a stressful event to have its impact and that anything occurring beyond that time was far removed from the event. The exact date of the total time period was determined by the date in I960 of the identifying child pedestrian t r a f f i c accident, selected 1 Kahn, Alfred J. "The Design of Research," V. Polansky, Norman A., ed. Social Work Research..3rd ed., University of Chicago Press, Chicago and London, p. 52. -35-from the study of Read et. al_. Therefore, a l l accidents which occurred In the two year period prior to, and a l l accidents after that date until Dec-ember 31, 1964, were included. Stress-producing Events Many events are known to be stress-producing to families.' The ones chosen for this study were discussed in Chapter 1 and are listed in Appendix A. in summary these are: additions to the family - birth of a sibling, remarriage of a parent, and a relative or boarder joining the household; loss of a family member-by death, illness or hospitalization; changes in marital status - divorce, separation or desertion; changes whereby a parent leaves the home - imprisonment, occupational reasons or the mother returns to work; changes in socio-economic status, either up-ward or downward; changes in place of dwelling; and accidents to other family members. Acc ident The definition of an accident has been the subject of much study by a number of investigators.2'3>**>5 T n e definition given by Arbous^ has been widely accepted: "... in a chain of events, each of which is planned 1 H i l l , R., op_. cjt.., p. 139. 2 iRead, J.H. et a]_., op_. c i t . . p. 3. 3 Froggatt, P. and Smiley, J.A., op_. c i t . , pp. 1-11. 4 Suchman, E.A. and Scherzer, A.L., op_. c i t . , :,. 5 S.uchmanfj.E.A,, op_. c i t . . p. 46. 6 Arbous, A.G. "Accident Statistics and the Concept of Accident Prone-ness. Part I. A C r i t i c a l Evaluation," Biometrics. Vol. 7, December 1951, p. 340; cited in Suchman, E.A. and Scherzer, A.L. Current Research in  Childhood Accidents. Research Reprint, I960, Association for the Aid of Crippled Children, New York. -36-or controlled, there occurs an unplanned event, which, being the result of some non-adjustive act on the part of the individual (variously caused), may or may not result in injury.... The resulting injury is a consequence of this unplanned event and does not in i t s e l f constitute the accident -it follows afterward. 1 1 The word "accident," as commonly used, refers to the occurrence of some injury or damage to a person or thing resulting from an unforeseen event. For such an injury or damage to be termed an accident, it partly depends on the personal bias of the reporter in his assessment. This as-sessment of an injury is based on its severity according to degree, such as, the cost in terms of loss of time, loss of money or in terms of pain. All such variables can introduce complications in the definition of an accident. In this study the definition which has been used is as follows: an accident is an injury received by a child which resulted from an unfore-seen event such as a f a l l , burn, poisoning, cut or motor-vehicle, and which required the attention of a doctor. Arbitrarily excluded were a l l injuries inflicted by other persons, those which resulted in death or were secondary to an organic disease or specific d i s a b i l i t y . Identified Child and Family in Current Study It was found by Read et aj_.' that a number of victims of pedestrian t r a f f i c accidents belonged to families in which there were a number of other types of accidents reported. Each child who was one of these victims of pedestrian t r a f f i c accidents has been called the identifying child, in 1 Read, J.H. et aj_., op_. c i t . , p. 11. -37-that the child has identified the families who have provided the research populat ion. The accident-chiId was any child belonging to the identified famil-ies who was under the age of 18 on December 31, 1964, and who was the v i c -tim of any type of accident between 1958 and December 31, 1964. Those persons considered to be members of the families were a l l children who were members of the household by lineal descent or by associa-tion, such as relatives, foster children or boarders, and a l l adult members of the family who were over the age of 18 on December 3 ' , 1964, who were resident in the house and ate meals together with the other members. C. Method; Steps following the selection of the families, based on the afore-mentioned definitions were: to locate and interview the families; to c o l -lect data based on an Interview Survey Guide; to assess the findings in light of the established hypothesis, to discuss implications of the find-ings relevant to accident prevention and to social work practice, and to suggest leads to further studies. Sett ing The Child Health Programme, Departments of Preventive Medicine and Pediatrics, Faculty of Medicine, The University of British Columbia, prov-ides a service as a model programme to other c l i n i c s for well child care, and f a c i l i t i e s for research and teaching in growth and development of children to other disciplines in the University. The f i l e s of the I960 study from which the writers selected their population were retained in the offices of the Child Health Programme. -38-Selection of Population These f i l e s were examined to select the families who had accident-repeater children. Sixty-one such families met the established c r i t e r i a of (1) having a child, under the age of 18 years on December 31» 1964, and who had been involved in a child pedestrian t r a f f i c accident in I960, and (2) having reported in I960 two or more accidents to any one or a l l of their children in the lifetime of the family. Location of Families It was possible to confirm or locate an alternate address for 43 of the 61 identified families. This was done by a search through the Vancouver City Directory and the Vancouver Telephone Directory. To locate the remaining 18 families, the cooperation of the Family Allowance Divis-ion, Victoria, B.C., was sought. As addresses of the families known to that agency are confidential and, therefore, cannot be released, a l i s t of the unlocated families with pertinent known st a t i s t i c a l information was sent to the Family Allowance Division, Victoria, B.C., with a covering letter (Appendix C). It was requested that, if addresses were known to that agency, they forward to the families an Explanatory Letter (Appendix D), together with a stamped return addressed postcard. In addition there was a post-script to the letter (Appendix E) in which the family was requested to enter their new address and telephone number on the card and return it by mai 1. From the l i s t of the 18 families sent to the Family Allowance Division, there were four who returned the postcards, one only giving an address within the Greater Vancouver Area, the other three being at too - 3 9 -great a distance for interviews to be feasible. The next step was to send Explanatory Letters (Appendix D) to the kk located families, describing briefly the purpose of the current study and requesting their repeated cooperation. Follow-up telephone calls were made to arrange interviews at times convenient to the interviewee and in-terviewer. Interview Of the kk located families, four refused to participate, leaving 40 for the study. Of these, 36 families were interviewed in person and four were interviewed by telephone. An Interview Survey Guide was drawn up as an aid to e l i c i t the information' needed in order to test the validity of the hypothesis (Ap-pendix F). Data Collected After completion of interviews, the material was collated and is presented in the following chapter. The characteristics derived from the results of the interviews, of the accident-children, family structure, stress-producing events, accidents, are described. A family p r o f i l e and comparison tables relating accidents to other factors within the specified time period were also drawn up and are elab-orated upon in the next chapter. Consideration was also given to the possibility of secondary findings resulting from the study, which might be a corollary of the primary focus. 1 Mass, Henry and Polansky, Norman A . "Collecting Original Data," Social Work Research. 3rd e d . , ed, Norman A . Polansky, 1963, University of Chicago Press, Chicago and London, p, 147, -40 -Various f a c t o r s re la ted to interviewing techniques w i l l now be d i s c u s s e d , cons idera t ion being given to the fac t that there were four persons conducting in terv iews. General Considerat ions of the Method The wr i te rs gave ithought to the matter of t e s t i n g the Interview Survey Guide p r i o r to i n i t i a t i n g the interview with the i d e n t i f i e d f a m i l -i e s . It was decided that p a r t l y f o r lack of time and p a r t l y that a l l interviews would be h igh ly i n d i v i d u a l i z e d , i n s u f f i c i e n t information would be gained to warrant tak ing the time requ i red . However, there was an awareness t h a t , with four in terv iewers , much v a r i a t i o n in technique would be present . The one common fea ture between interviewers was that each was to use techniques with which she , as an i n d i v i d u a l , f e l t most competent in respect to the p a r t i c u l a r f a m i l y . Various s k i l l s were c a l l e d f o r in order to obta in comparable i n -formation from d i f f e r e n t people with d i f f e r e n t needs and wants. Inter-viewing s k i l l s required the adaptat ion of techniques to each person . F l e x i b i l i t y in interviewing was encouraged. Although the Interview Survey Guide was fo l lowed , there was l i t t l e s t r u c t u r i n g of the interview other than that of f o c u s . A t t i tudes and f e e l i n g s about the type of information sought in t h i s d e s c r i p t i v e study were not to be e l i c i t e d , unless f a i l u r e to express them would lessen the a b i l i t y of the interviewee to r e c a l l the in format ion. Feel ings of anxiety about the purpose of the interview were a l l ayed by c l e a r statement of the purpose of the study by the in terv iewer . A statement of auspices and presenta t ion of c r e d e n t i a l s , as well as i n t r o -ductory and explanatory l e t t e r s by mail were useful means of prepar ing the interviewee. - 41 -The research interview has been d iscussed by F e l l in as being in d i s t i n c t contrast to the casework interv iew. It is a " f a c e - t o - f a c e verbal interchange in which one person , the interv iewer , attempts to e l i c i t i n -formation or expression of op in ion or b e l l e f from another person or p e r -sons. ' 1 ^ The method of conducting an interview is to a cons iderab le ex-tent determined by the purpose of that in terv iew, whether p r i m a r i l y f o r 2 information or to g ive h e l p , although most involve a combination of both . When the aim is to obta in information such as in a research type of i n t e r -view, in answering quest ions from a survey gu ide , the establishment of rapport is s t i l l important. Both an understanding of the c o n f i d e n t i a l i t y of the information and some understanding of the purpose of the interview were found to increase in teres t and w i l l i n g n e s s of the interviewee to p a r t i c i p a t e in the s tudy . An add i t iona l a id was an awareness t h a t , as opposed to the treatment interview where the aim is to help the i n t e r -viewee, the aim of t h i s research pro jec t is to the w e l l - b e i n g and safe ty of c h i l d r e n . As in any type of interview it is imperative that the interviewer understand the purpose of the interv iew, p a r t i c u l a r l y in t h i s s i t u a t i o n , where four interviewers were invo lved . Many of the answers required were those making r e l a t i o n s h i p s between events in which the person 's memory and a b i l i t y to r e c a l l was t e s t e d . Lines of accurate and f u l l r e c a l l were l a r g e l y inf luenced by the i n d i v i d u a l ' s s o c i a l o r g a n i z a t i o n , with i t s a c -1 F e l l i n , P h i l l i p . "The Standardized Interview in Soc ia l Work Research," S o c i a l Casework. V o l . 44, February 1963, p . 81. 2 G a r r e t t , Annet te . Interviewing; Its P r i n c i p l e s and Methods. Family S e r v i c e A s s o c i a t i o n of America, New York, 1942, p . 26. -42 -cepted scale of values. Bartlett speaks of social suggestion, which i s , in essence, the provision of that setting of interest, excitement and emotion which favors the development of specific images, and, secondly, by providing a persistent framework of institutions and customs which act as a schematic basis for constructive memory. Therefore, the interviewer, with this construct in mind, should adapt his techniques to some extent to the social background of the interviewee. For example, an immigrant to the country with limited f a c i l i t y with the language can be expected to have limited recall around areas which a native born Canadian would have good re c a l l . Social customs and value structure influence recall, such as dates related to schooling. A. person setting l i t t l e store on educa-tion and its institutions is likely to show a different recall to a family who places a high value on education. In this type of interview, where relationships between events are of the essence, significant periods in their lives can have greater or lesser value for re c a l l . A family that is concerned with health will find it easier to recall dates relative to health, in preference to a school starting date. A family with an inter-est in socio-economic status may preferentially recall dates relative to father's raise or lay-off. In our study, the order in which questions were asked was flex-ible in that relationships between events was being sought and therefore one event was used as a starting point to enable recall of other events. 1 Bartlett, Frederick Charles. "Social Influences on Individual Psycho-logical Processes," Readings in Social Psychology, eds. G.E. Swanson, T.M. Newcomb and E.L. Hartley et. al.., 1952, Henry Holt and Company, New York, p. 366. 2 Ibid., p. 368. - 43 -It was acknowledged that the a t t i t u d e of the interviewer could grea t ly in f luence the a t t i t u d e of the interviewee, i f a per functory ap-proach is taken with l i t t l e in te res t in the quest ion or purpose, a s i m i l -ar response and e f f o r t to r e c a l l past events may be had from the i n t e r -viewee. The content of the Interview Survey Guide i t s e l f , though s t ruc tured f o r the most p a r t , allowed f o r some f l e x i b i l i t y in content in that s i g n i f -icant serendip i tous mater ia l and f a c t s which the interviewee might cons ider relevant were cons idered . Allowance was made f o r " fu r ther comments and observat ions" - those which were considered to be worthy of note . Re la t ionship between two events does not n e c e s s a r i l y imply c a u s a -t i o n . What is sought in t h i s study is a cond i t ion under which c e r t a i n r e l a t i o n s h i p s p r e v a i l . The purpose of a l l d iagnos t ic or d e s c r i p t i v e s t u d i e s ' is to tes t an hypothes is . Insofar as an hypothesis is proven, c e r t a i n events may be p r e d i c t e d , thus br ing ing the event more under the cont ro l of man and thus preventab le . It is p o s s i b l e that an unknown i n t e r -vening v a r i a b l e may e x i s t between the dependent v a r i a b l e (accident) and the independent v a r i a b l e (s t ress-produc ing event ) . It is e s s e n t i a l when a sample or a t o t a l populat ion Is se lec ted f o r s tudy , such as in our s tudy , that a maximum number of that populat ion be l o c a t e d . In t h i s s i t u a t i o n , f o r example, one might ask what bias would be introduced by the exc lus ion of unava i lab le f a m i l i e s ; what are the c h a r -a c t e r i s t i c s of the unava i lab le f a m i l i e s ; and what skew would be introduced to the f i n d i n g s ? If the unava i lab le and unlocated f a m i l i e s c o n s i s t p r e -1 Kahn, A l f r e d J . "The Design of Research ," Soc ia l Work Research. 3rd e d . , e d . Norman A . Polansky, 1963, Un ive rs i t y of Chicago P r e s s , Chicago and London, p . 52. ponderantly of broken homes and the more t rans ien t members of the popu la -t i o n , i t is p o s s i b l e that our study is weighted in favor of more s t a b l e fami 1ies. . However, we should emphasize that a r e l a t i o n s h i p in time between the occurrence of accidents and s t r e s s - p r o d u c i n g events is under s tudy. Th is is not a comparison of f a m i l i e s , of a c c i d e n t s , or of s t r e s s events . Making an assumption that s t r e s s and a l l types of acc idents are u n i v e r -s a l l y d i s t r i b u t e d , i t would be v a l i d to exclude the unava i lab le f a m i l i e s without int roducing a bias into the r e s u l t s . On t h i s bas is the value in using m u l t i - a c c i d e n t f a m i l i e s is only that more accidents per interview are found, thus a l lowing a greater chance f o r exp lora t ion of the hypoth-es i s . In the next chapter we w i l l examine mater ia l obtained in the i n -te rv iews . CHAPTER 3. FINDINGS This chapter analyzes the data c o l l e c t e d on the 40 f a m i l i e s under s tudy , in which there were a t o t a l of 127 a c c i d e n t s . F i f t y - t h r e e (42%) of these accidents were i d e n t i f i e d as having some r e l a t i o n s h i p in time between a s t r e s s f u l event and an a c c i d e n t . However, there were only 19 (15%) of the t o t a l that occurred wi th in the 30 day time per iod as set down by the o r i g i n a l hypothes is . Th is was hardly s i g n i f i c a n t to v a l i d -ate the hypothes is . While the occurrence of a s t r e s s f u l s i t u a t i o n f o l -lowed s h o r t l y by an accident d id not show up in the a v a i l a b l e da ta , chron ic s t r e s s f u l s i t u a t i o n s , such as p e r s i s t e n t i l l n e s s or disablement to a parent or fami ly member ( e . g . s i b l i n g born a parap leg ic or mental ly retarded) d id produce s t resses in the l i f e of the c h i l d r e n . As t h i s was considered to be an important f i n d i n g , the s t r e s s data were c o l l a t e d a c -cord ing to acute and chronic s t r e s s e s . For the purpose of the s tudy , acute s t r e s s was def ined as those s t r e s s f u l events that have a d e f i n i t e t ime r e l a t i o n of 30 days to the o c -currence of a c c i d e n t s . Chronic s t r e s s was def ined as those prolonged s t r e s s f u l s i t u a t i o n s that were re la ted to a s e r i e s of accidents over the s i x year p e r i o d . General C h a r a c t e r i s t i c s of Accident Ch i ld ren Before analyz ing the s t r e s s f a c t o r s the general c h a r a c t e r i s t i c s of the a c c i d e n t - c h i l d r e n and t h e i r f a m i l i e s w i l l be determined. -46 -A c c i d e n t - c h i l d r e n : Of the 144 c h i l d r e n in the 40 f a m i l i e s , the populat ion of a c c i d e n t - c h i l d r e n under the age of 18 on December 31, 1964 was 63. Of these , 40 were boys and 23 were g i r l s . The g i r l to boy r a t i o was 1:1.6. The i r ages ranged from 5 to 18 y e a r s . The ages f o r boys at which time the accident occurred f e l l between 8 and 14 y e a r s , whereas the age f o r g i r l s was between 12 and 17. The accident range was from one to t e n , with an average of two accidents per c h i l d . The greatest concent ra -t i o n was one to three a c c i d e n t s . Of note was the f a c t that the greater percentage of acc idents occurred dur ing recreat ion ou ts ide the home, in the form of f a l l s , impacts or t r a f f i c ; , a c c i d e n t s . Family P r o f i l e The average s i z e of a Canadian fami ly is 3.5 c h i l d r e n , ' whereas in our study i t was 3 .7 . In other words, we found that 50% (20 f a m i l i e s ) had an average of 4.8 c h i l d r e n , and the remaining 50% (20 f a m i l i e s ) were below the average with 2.4 c h i l d r e n . F i f t y - f i v e percent (22 f a m i l i e s ) had not changed residence w i th in the s i x year p e r i o d ; 27.5% (11) had one move, and the remaining 17.5% (7) had more than one. There fore , change of res idence (average move was only 0.7 times dur ing the s i x year per iod) d id not appear to be one of the s t r e s s f u l f a c t o r s . The one exception was a fami ly that moved from one prov ince to another in which severa l accidents occurred to the c h i l d r e n both before and a f t e r the move. Ana lys is of the mar i ta l s ta tus of the parents showed that 92.5% 1 S c h l e s i n g e r , Benjamin. "Fami l i es of M i s f o r t u n e , " S o c i a l Problems:  A Canadian P r o f i l e , ed . Richard L a s k i n , 1964, McGraw-Hill Company, Inc . , New York, p . 288. - 47 -(37 f a m i l i e s ) of the parents were l i v i n g together; d i v o r c e , separat ion and remarriage had occurred in the remaining 7.5% (3 f a m i l i e s ) . In over ha l f of the f a m i l i e s s t u d i e d , the fa thers were e i t h e r p r o f e s s i o n a l s , businessmen, or s k i l l e d l abourers , the rest being made up of u n s k i l l e d labourers . Two fa thers of the l a t t e r group were unemployed at the time of the interview and one had died p r e v i o u s l y . The incomes were predominantly over $3»000 per annum. However, where the fa ther experienced frequent job f a i l u r e , i t c o n s t i t u t e d a s t r e s s -f u l s i t u a t i o n in the f a m i l y . Such a f i n d i n g was confirmed in a study under-taken by Reuben H i l l . ' F i f t y percent of the mothers were engaged in work outs ide the home, whi le only in a few cases d id they take up f u l l - t i m e employment; in most instances t h e i r work, such as house-c lean ing , was casual and i r regu la r in nature . Two other f i n d i n g s in our study were, the fa ther had had i l l n e s s of one kind or another more of ten than the rest of the f a m i l y . The average ages of the husband and wi fe were 40.7 and 41 years r e s p e c t i v e l y . In reviewing the above f i n d i n g s , the fami ly p r o f i l e was seen as one of s t a b i l i t y . That i s , a p r o f i l e of an "average s i z e d fami ly" where there was l imi ted change of res idence; moderate income; the fa ther was s t e a d i l y employed in a s k i l l e d occupat ion and there was l im i ted fami ly breakdown. Such s t a b i l i t y in f a m i l i e s of acc ident - repeaters was not borne out by the e a r l i e r study by Read et. aj[. They found a much higher percentage of fa thers employed as u n s k i l l e d workers; more f a m i l i e s had a lower yea r ly 1 H i l l , R. , op_. c i t . . pp . 139-150. 2 Read, J . H . et aj_., op_. c i t . . p p . 681-701. -48 -income; more fa thers were out of the home fo l lowing separat ion or d ivorce with mothers assuming the major r e s p o n s i b i l i t y f o r c h i l d - r e a r i n g ; and there were more r e l a t i v e s l i v i n g in the home. However, they too found that mothers more of ten worked outs ide the home. St ress Factors and Accidents The fo l low ing tab les show the acute and chron ic s t r e s s f u l events i d e n t i f i e d in those f a m i l i e s where there was a r e l a t i o n s h i p in time be-tween a s t r e s s f u l event and an a c c i d e n t . The age and sex of each a c c i d e n t -c h i l d and the types of acc idents were a l s o tabu la ted . Table 1 reveals that there were f a r less accidents (15 out of 40) that had any connect ion in time between an accident and a s t r e s s - p r o d u c i n g event . Table 2 shows that a predominant number of accidents (38 out of 45) occurred dur ing the per iod in which i d e n t i f i a b l e chron ic s t resses were present in the f a m i l i e s . Two of these f a m i l i e s had add i t iona l p r e c i p i t a t -ing s t r e s s e s . In one f a m i l y , the accident occurred on the day when the house underwent remodel l ing . During t h i s t ime, the mother was s u f f e r i n g from a prolonged i l l n e s s r e q u i r i n g frequent h o s p i t a l i z a t i o n p lus the fac t that the a c c i d e n t - c h i l d d id not l i k e s c h o o l . He developed stomach pain which was suspected to be symptomatic of a school phobia . In another fam-i l y , acc idents occurred on the day of a s i b l i n g ' s b i r thday and a l s o when the school term began. Concur ren t ly , the mother of ten changed j o b s . The whole fami ly attended mental heal th c l i n i c and the e ldest c h i l d in the fami ly assumed a good deal of home r e s p o n s i b i l i t y whi le the mother was employed as the breadwinner. A comparison of the fo l low ing two tab les po in ts up that an accum--49-Table 1. Acute Stresses and Accidents Acute Stress Acc ident -C h i l d Sex & Age Types of Accidents Fam-i 1 ies Types of St ress F a l l Motor Impact Cut Burn Others No. 1 I l lness of s i b l i n g B i r t h of s i b l i n g M(8) x / / / / / 2 R e l a t i v e v i s i t -ing M(9) / / X 3 I l lness of s i b l i n g M(14) F(17) X / 4 Mother s ta r ted working M(5) M.(8) / / / X 5 Mother s ta r ted working M(12) M(5) M(15) / / x / x / / / X / 6 Mother s ta r ted working F(16) X 7 House-moving M(12) M(10) / / / / X x / 8 Neighbourhood f i r e School s t a r t i n g M(7) F(13) X X / 9 Sports day M(10) F(12) / X X 10 S i b l i n g ' s b i r t h -day F(12) X Tota ls M 12 10 9 F 5 17 11 9 2 0 1 x Accidents connected with s t r e s s e s - 15 / Accidents not connected with s t resses - 25 -50 -Table 2. Chronic Stresses and Accidents Chronic Stress A c c i d e n t -C h i l d Sex & Age Types of Accidents Fam-11 les Types of St ress F a l l Motor Impact Cut Burn Others No. 1 Mother's i l l n e s s Acce lera ted c l a s s C h i l d assumed fami ly dut ies F(14) F(10) XX X X X 2 Retarded s i b l i n g F(17) M(16) M(15) F(12) F ( H ) X X XX X X X X X X xxxxxx X X 3 I l lness of mother M(14) M(12) X / x / / h House remodel-1 i n g * Frequent i l l n e s s in fami ly School phobia Mother 's i l l n e s s M(12) X X 5 School s t a r t i n g * S i b l i n g ' s b i r t h -day* Mother's job change Family attended M.H.C. M(14) M ( l l ) M(5) X X // / 6 Fa ther 's job f a i l u r e Parents ' quarrel wi th grand-parents M(12) M(8) X X X X - continued -51-Table 2, c o n t ' d . Chronic Stress A c c i d e n t -C h i l d Types of Accidents Fam-11 ies Types of St ress Sex & Age F a l l Motor Impact Cut Burn Others No. 7 Fa ther 's work i n j u r i e s S i b l i n g p a r a -p l e g i c S i b l i n g e p i l e p -t i c M(10) M(7) x X X 8 S i b l i n g ' s quar-r e l s with parents and subsequent marriage Mother's i l l n e s s M(14) XX / Tota ls M 13 8 17 F 5 10 15 7 2 1 10 x Accidents connected with s t resses - 38 / Accidents not connected with s t resses - 7 * P r e c i p i t a t i n g s t resses u l a t i o n of chron ic s t resses produced a higher ra te of a c c i d e n t s . The f i n d -ings revealed that mothers s t a r t i n g to work, and any prolonged i l l n e s s or disablement in the fami ly were s i g n i f i c a n t f a c t o r s causing e i t h e r acute or chronic s t r e s s at home, which appeared to resu l t in the occurrence of c h i l d -hood a c c i d e n t s . Further s a l i e n t f a c t o r s of the r e l a t i o n s h i p between accidents and s t r e s s e s w i l l be examined by comparing and con t ras t ing the patterns of two groups of f a m i l i e s , one with only one i d e n t i f y i n g accident and the other -52-with m u l t i p l e a c c i d e n t s . Within the s i x year per iod s t u d i e d , Group I with nine f a m i l i e s had only the i d e n t i f y i n g t r a f f i c a c c i d e n t s , whereas Group II with eight f a m i l -ies had f i v e or more a c c i d e n t s , the highest being 18 in one f a m i l y . The s i z e of fami ly was la rger in the second group in that h a l f of them had f i v e or more c h i l d r e n in each f a m i l y . The socio-economic status in both groups ranged from below $3,000 to above $6,000 per annum. Both groups had working mothers. The most s i g n i f i c a n t d i f f e r e n c e between the two groups of f a m i l i e s was that in Group I, in a l l except the two interviewed by t e l e -phone, the interviewers observed the fami ly to be c o n g e n i a l , re laxed , and there was good fami ly cohesion and i n t e r a c t i o n . In those eight f a m i l i e s with m u l t i p l e a c c i d e n t s , the s t resses p r e s -ent were e i t h e r chronic or acute . Evident s t resses were: a retarded c h i l d ; a c h i l d with a heart a i lment; a fa ther with frequent job f a i l u r e ; quarre ls between parents and grandparents; a l l c h i l d r e n were "slow l e a r n e r s ; " the whole fami ly at tending mental heal th c l i n i c with c h i l d r e n being nervous and ac t ing out ; c h i l d r e n were l e f t alone by parents and without proper s u p e r v i s i o n ; and the mother lack ing understanding of the c h i l d r e n ' s behav-i o r . Further exp lora t ion of the eight f ami l i es with m u l t i p l e accidents showed that f i v e of them had accidents center ing on one c h i l d in the fam-i l y . Moreover, a l l except one fami ly had had i d e n t i f i a b l e or accumulation of chron ic s t r e s s e s , e i ther with or without p r e c i p i t a t i n g s t r e s s - p r o d u c i n g events to t r i g g e r o f f a c c i d e n t s . To c i t e two examples: The f i r s t , a 15 year o ld boy who had had ten accidents during the f i v e - y e a r per iod from 1959-64. The mother descr ibed him as being " d o c i l e , awkward, with poor c o --53-o r d i n a t i o n . He is now 6'4" and is s t i l l growing," There was a t o t a l of eighteen accidents in t h i s f a m i l y , but the 15 year o l d boy had ten of them. The rest were d i s t r i b u t e d among h is four s i b l i n g s . The fa ther was a s k i l l e d labourer with over $6,000 per year as income. Mother was a housewife. There had been no moves or i l l n e s s in the f a m i l y . However, the youngest c h i l d , aged 8 , was found to be mental ly retarded at 18 months. The parents were t o l d that he would be a "mere vegetable" and were advised to p l a c e him in an i n s t i t u t i o n , but t h i s was re jected by the paren ts . The c h i l d r e n in t h i s fami ly were a l l very a c t i v e and a t h l e t i c , p a r t i c i p a t i n g in community c l u b s , and spent most of t h e i r time out of the house. The retarded c h i l d was the only one without an a c c i d e n t . The other c a s e , a boy of 8 years had had s i x a c c i d e n t s . He was the only one in the fami ly of f i v e c h i l d r e n with accidents which occurred between 1959-63. S ince the b i r t h of h is youngest s i b l i n g in A p r i l , 1963, he had not su f fe red an a c c i d e n t . The boy was s a i d to be very energet ic and received l i t t l e superv is ion from the mother, e s p e c i a l l y a f te r h is 11 year o ld s i s t e r was found to have heart t r o u b l e . She was an a c t i v e and h igh-s t rung g i r l r equ i r ing a lo t of mother's a t t e n t i o n . The f a t h e r , a s k i l l e d craf tsman, earned an average income. The housekeeping standard was below p a r . The mother expressed the op in ion that she was harassed with a large fami ly with a s i c k member and a c t i v e c h i l d r e n with whom to cope. The above two instances demonstrated c l e a r l y the r e l a t i o n s h i p be-tween accidents and s t r e s s e s . It was fu r ther noted that in these two cases the i l l n e s s of one c h i l d in the fami ly caused chron ic s t r e s s e s , wh i le another c h i l d appeared to take on most of the accidents in the fam-i l y . - 5 4 -General Comments The weakness of the r e t r o s p e c t i v e s tudy , a skewing of populat ion and l im i ted time span set down in the study w i l l be e laborated in the next chapter . In g e n e r a l , the response to the interviews was good, 95% (38 cases) cooperated w i l l i n g l y , and 5% (2) were e i t h e r ind i f f e ren t or uncooperat ive . There was overt r e s i s t a n c e in one case ; however, the interviewer was ab le to secure the e s s e n t i a l information a f t e r severa l wr i t ten notes and v i s i t s (the fami ly had no telephone in the house) . C r i t i q u e of the Interview Survey Guide (Appendix F) 1. Interviewer's frame of re fe rence: desp i te the fac t that these f i e l d interviews were pure ly for the purpose of e l i c i t i n g informat ion, the in terv iewers , because of t h e i r s o c i a l work t r a i n i n g , tended to do more than conduct research in terv iews. The use of the p r o f e s s i o n a l s k i l l to obta in information and help respondents to r e c a l l s i g n i f i c a n t f ac ts was ev ident . 2 . Accuracy of responses: although e f f o r t s were made to adhere to o b j e c t i v e s t r e s s f u l events , nonethe less , t h i s was a d i f f i c u l t area to ex-p l o r e , as inev i tab ly i t involved a t t i tudes and estimates which were found to lower the r e l i a b i l i t y of information obta ined . The mainstay of t h i s study depended a great deal on memory work spread over a long span of s i x y e a r s . This was very tax ing on the memory of the interv iewees, hence, i ts accuracy and complete r e c a l l was quest ionab le , e s p e c i a l l y when the time set down was only 30 days . Th is presented a d i f f i c u l t task f o r both interv iew-ers and interviewees. 3 . The ambiguity in phrasing questions may have e l i c i t e d d i f f e r e n t -55 -answers. The fo l low ing weaknesses were observed: The s e c t i o n under Mar i ta l S t a t u s : the quest ion regarding "Status of marriage of c u s t o d i a l parent , 1958, to another natural parent" ra ised some c o n f u s i o n . It would have been e a s i e r to s t a t e s imply : mar i ta l s ta tus of parents in 1958. The s e c t i o n under Socio-economic H is tory of the Fami ly: the terms "occupat ion" and "employment" a l s o contr ibuted to some misunderstanding because of the ambiguity . The s e c t i o n under Changes in Economic S ta tus : there could have been c l a r i f i c a t i o n of the use or non-use of the c o s t - o f - l i v i n g index, in order to determine the changes in economic s t a t u s . 4 . Some of the s ta ted defects in the Interview Survey Guidecould have been avoided by a p r e - t e s t of the questions posed. Those which d id not draw f o r t h cons is tent or d e f i n i t e responses could then have been r e v i s -e d . P r e - t e s t i n g provides not only a test of c l a r i t y of questions and of c o r r e c t i o n s of in te rpre ta t ion given by the interviewee, but i t a l s o a f fords the p o s s i b i l i t y of d i s c o v e r i n g new aspects of the study not an t ic ipa ted in the p lanning s tage . Cone 1 us ion The f ind ings of t h i s study pointed up an extension of the o r i g i n a l hypothesis which is that chronic s t resses in the fami ly are conducive to accidents in the c h i l d r e n . Further impl icat ions of t h i s f i n d i n g w i l l be dea l t with in the next chapter . CHAPTER k DISCUSSION OF FINDINGS AND SUMMARY This f i n a l chapter w i l l d iscuss the f ind ings and t h e i r impl icat ions f o r ch i ldhood accident prevent ion and f o r s o c i a l work p r a c t i c e . A . Hypothesis Inval id and Reasons The ana lys is of the data c o l l e c t e d indicates t h a t , in fo l lowing the se lec ted method, the wr i te rs f a i l e d to e s t a b l i s h the v a l i d i t y of the hypoth-e s i s : " that a s i g n i f i c a n t r e l a t i o n s h i p ex is ts in t ime, s p e c i f i c a l l y 30 days, between the occurrence of s t r e s s - p r o d u c i n g events wi th in the fami ly and accidents r e s u l t i n g in in jury to one or more c h i l d r e n of that f a m i l y . " In other words there was no c o n c l u s i v e evidence to say that one s t r e s s f u l event caused s u f f i c i e n t d i s o r g a n i z a t i o n to lower c o n t r o l s over the impulses of c h i l d r e n thereby causing a c c i d e n t s . There were a number of f a c t o r s which, in our o p i n i o n , contr ibuted to the negat ive r e s u l t . Those which appear to be of major importance are d iscussed below. The wr i te rs are aware of the l i m i t a t i o n s that the small number of cases p laced upon the c o n c l u s i o n s . The unavai labi l i ty of the t o t a l popu la -t i o n r e s u l t i n g in a s m a l l , s t a b l e group of hO f a m i l i e s to be interviewed, proved to be a l i m i t a t i o n . There was a skewing of populat ion in the s e l e c -t i o n of the sample, with only the r e l a t i v e l y " s t a b l e " f a m i l i e s being l o -cated and inc luded . It w i l l be r e c a l l e d that there is evidence in the l i t e r a t u r e that the parents in " s t a b l e " f a m i l i e s have stronger e g o - f u n c t i o n -ing . There fore , the c h i l d r e n of such " s t a b l e " f a m i l i e s might benef i t from -57-the example of t h e i r parents and, i f endowed with average i n t e l l i g e n c e , would have a po ten t ia l f o r adequate ego f u n c t i o n i n g . When s t resses t h r e a t -en these " s t a b l e " f a m i l i e s , the proper use of defense mechanisms by the c h i l d r e n would enable them to r e - e s t a b l i s h dynamic e q u i l i b r i u m . It is speculated that accidents occur when defense mechanisms f a i l to help c h i l d -ren regain t h e i r dynamic e q u i l i b r i u m . As mentioned in Chapter 1, when the f a m i l y , an open-ended system, experiences s t r e s s , t h i s is t ransmit ted throughout, to the var ious members. Those with the weak ego s t ruc tures are unable to in tegrate the s t r e s s in order to maintain e q u i l i b r i u m , and so react to i t through behavior which may involve the occurrence of a c c i d -en ts . While 21 f a m i l i e s of the t o t a l populat ion were unava i lab le fo r in terv iews, there was information on f i l e from the Read et a l . s tudy' which indicated cons iderab le i n s t a b i l i t y in these f a m i l i e s . They f requent ly changed res idence; fa thers were engaged in t rans ien t occupat ions; and some f a m i l i e s had compl icat ions such as d i v o r c e , separat ion and remarr iage. In order to obta in a representa t ive sample of f a m i l i e s of acc ident - repeater c h i l d r e n f o r any fo l low-up study these l a t t e r "unstab le" types of f a m i l i e s would need to be inc luded . In "unstab le" f a m i l i e s there might be more temporary s t r e s s e s of the ind iv idua l members such as worry, d i s t r a c t i o n and i l l h e a l t h . The i r e f f e c t on f a c t o r s such as f a t i g u e and v i g i l a n c e be-comes meaningful , and may resu l t in c h i l d r e n being s u s c e p t i b l e to a c c i d e n t s . S t ress in the fami ly can have great reverberat ions in a l l of the other areas of a person 's l i f e . As M i l l e r has s a i d , " i n d i v i d u a l s go through temporary s ta tes of i n s t a b i l i t y and emotional s t r e s s which could make them 1 Read, J . H . et aj_., op_. c i t . , pp . 1-127. -58-more s u s c e p t i b l e to a c c i d e n t s . " "Acc idents have s i g n i f i c a n c e beyond them-s e l v e s . They are always symptomatic of d isorder in a p a r t i c u l a r dynamic system. The d isorder may r e s i d e in the habi ts of an ind iv idua l or the 2 customs of a community or the breakdown of a machine." The weakness of a r e t r o s p e c t i v e study showed up qu i te markedly in t h i s p r o j e c t . A span of s i x y e a r s , with the time per iod between s t r e s s f u l events and accidents set down to be only 30 days , resu l ted in great d i f f i c -u l t y of r e c a l l by the respondents. Th is po in ts up the f a c t that any f u t u r e chi ldhood accident research s tudies should be p rospec t ive ones. Accept ing t h i s f a c t , one would conclude that p rospec t ive s tudies would be a more accurate way to obta in data on such a s i g n i f i c a n t s o c i a l problem as c h i l d -hood a c c i d e n t s . The var ious time per iods as s ta ted in the research design were found to be too r i g i d . It was impossible to obta in a complete accident pat tern f o r c h i l d r e n with a c u t - o f f date in 1958 cover ing a long span of s i x y e a r s . The same held t rue f o r the recording of s t r e s s - p r o d u c i n g events (within a 30-day time per iod) going back 25 months from the date of the I960 i d e n t i f y i n g pedest r ian t r a f f i c acc iden t , and coming forward u n t i l the end of 1964. The time per iod of 30 days fo r s t r e s s - p r o d u c i n g events , a r b i t -r a r i l y s e t , was too narrow, and going back over s i x years t h i s 30-day per iod was too s h o r t , thus c r e a t i n g d i f f i c u l t y to r e c a l l (that i s , r e l a t i n g s t r e s s -es and a c c i d e n t s ) . The gather ing of information about s t ress -p roduc ing events from parents only was recognized as a l i m i t a t i o n . For example, the school p e r -1 M i l l e r , J.G., op_. c i t . . pp . 433-^36. 2 Maclver , J . , op . c i t . . p. 71. -59-formance of the accident c h i l d r e n was not included on the ques t ionna i re . The main reason fo r not inc lud ing t h i s item and others invo lv ing e n v i r o n -ment was the l i m i t a t i o n of t ime. The w r i t e r s , t h e r e f o r e , b e l i e v e that in any fu ture s tud ies the school performance should be considered in order to obta in the o b j e c t i v e viewpoint of the teacher in the t o t a l eva luat ion of the impact of s t r e s s upon the accident c h i l d r e n . For example, there might be cons iderab le s t r e s s in the school s i t u a t i o n such as a c c e l e r a t i o n or re tardat ion and var ious other p o s s i b l e s t r e s s e s . It a l s o would be va luable to have knowledge of the accident c h i l d ' s p e r s o n a l i t y , h is r e l a -t i o n s h i p s with peers and a d u l t s , and h is a t t i tudes towards s a f e t y . B. D iscuss ion of Findings Table 1 ind icates that only a small number of acute s t resses were re la ted in time to a c c i d e n t s . Recognizing the in te rac t ion between the c h i l d and h is fami ly s i t u a t i o n , and in order to iden t i f y the s p e c i f i c s t r e s s -producing events the concepts from systems theory,ego f u n c t i o n i n g , and r o l e theory were used (Appendix A ) . In so do ing , nine s t r e s s f u l events were i d e n t i f i e d , as occur r ing wi th in the 30-day p e r i o d . To i l l u s t r a t e our ap-p l i c a t i o n of the theor ies used, these nine acute s t resses are examined a c -cord ing to the r o l e theory . " I l l n e s s of s i b l i n g " means r o l e changes and r o l e impairment f o r the i l l fami ly member and might involve r o l e realignment f o r other fami ly members. " B i r t h of s i b l i n g " involves add i t ion of a r o l e to the fami ly r o l e network, with loss of r o l e to a s i b l i n g , and consequent adaptations through-o u t . A " r e l a t ive v i s i t ing" represents an add i t iona l r o l e in the household. "Mother s t a r t s to work" represents c r e a t i o n of a new r o l e , with r e c i p r o c a l realignment of ro les of other fami ly members. When a fami ly chances i ts -60-residence a l l fami ly members take on new r o l e networks and they have adjustments to make to a new environment. Th is has been found to be a time when c h i l d r e n are more vu lnerable to a c c i d e n t s . A "neighbourhood f i r e " creates an environmental change, and might be qu i te s t r e s s f u l to a s e n s i t -ive c h i l d , there fore hampering the funct ion of h is ego. "School s t a r t i n g " is both a r o l e change and a new r o l e f o r the c h i l d . "School Events (Sports  Day)" means a temporary r o l e change or a change in status f o r the c h i l d f o r that p a r t i c u l a r day. " S i b l i n g ' s b i r thday" is a demotion in r o l e or temporary change in status in that the a c c i d e n t - c h i l d is not important f o r that day. Many e a r l i e r s tud ies have suggested that such f a m i l i a l events might be re la ted to the occurrence of i n j u r i e s to c h i l d r e n . While numbers were not considered s i g n i f i c a n t , we were impressed with the c h i l d ' s accident being re la ted in time to when a "mother s ta r ted to work." It is known that an added r o l e f o r mother cou ld a l t e r the whole fami ly c o n s t e l l a t i o n . There could a lso be u n a v a i l a b i l i t y of r o l e or r o l e abandonment r e s u l t i n g in lack of superv is ion for the c h i l d r e n leading to a c c i d e n t s . If the mother s ta r ted to work because the fa ther was unemployed t h i s reversal of ro les could become s t r e s s - p r o d u c i n g f o r the c h i l d r e n . The above d i s c u s s i o n c l e a r l y indicates that the hypothesis is i n -v a l i d . However, a f te r c o l l a t i n g the data the wr i te rs found that there were chronic s t r e s s s i t u a t i o n s or the accumulation of s t r e s s - p r o d u c i n g events in the f a m i l i e s which appeared to be re la ted in some way to accidents of c h i l d r e n . Th is observat ion might be considered as an extension of the hypothesis and may have s u f f i c i e n t s i g n i f i c a n c e to warrant a fo l low-up study to be o u t l i n e d at the conc lus ion of t h i s chapter . Every time there is a r o l e s h i f t in the f a m i l y , there is some s t r e s s on the members. The fami ly member with a weak ego may be unable to adapt to -61-the s t r e s s , and i f he cannot r e - e s t a b l i s h e q u i l i b r i u m and more s t resses accumulate, there may be d i s i n t e g r a t i o n of h is ego func t ion ing leading to accident s u s c e p t i b i l i t y . The wr i te rs were impressed with the many chronic s t resses upon eight f a m i l i e s who had m u l t i p l e accidents to c h i l d r e n (that i s , f a m i l i e s with f i v e orcmore a c c i d e n t s ) . A l l these f a m i l i e s had some chronic s t resses (Table 2 ) . For purposes of treatment, the s o c i a l worker would analyze the s t r e s s - p r o d u c i n g events and chron ic s t r e s s fac to rs in these f a m i l i e s . Wherever p o s s i b l e , fami ly treatment would involve he lp ing a l l fami ly mem-bers together to r e l i e v e t h e i r anx ie t ies through appropr ia te s o c i a l work techniques and help them gain an awareness of and p o s i t i v e a t t i tudes towards sa fe ty and accident p revent ion . Role support in times of s t r e s s would be s t rong ly advocated. While not numerical ly s i g n i f i c a n t , there were three of the eight f a m i l i e s in which there was a d isab led c h i l d causing chron ic s t r e s s which appeared to lead to another c h i l d in the fami ly having m u l t i p l e a c c i d e n t s . Review of the l i t e r a t u r e (Chapter 1) supports the theory that there is a r e l a t i o n s h i p between unmet emotional needs and a c c i d e n t s , and that a c c i d -e n t - c h i l d r e n have been found to be immature and emotional ly unstab le . The mother with a d isab led c h i l d may s u f f e r ro le - impairment , and be unable to meet the emotional needs of her other c h i l d r e n . Th is suggests that the theory of the m u l t i p l e accident c h i l d as the "scapegoat" might a lso be appl ied in these three c a s e s , in that the m u l t i p l e accident c h i l d has the r o l e of a "problem c a r r i e r " (having a c c i d -e n t s ) . It is analagous to . . . "from the point of view of the f a m i l y , the primary func t ion of scapegoating is that i t permits the fami ly to maintain -62-i ts s o l i d a r i t y . " The scapegoating mechanism is immediately funct iona l f o r the fami ly as a group but dysfunct iona l fo r the emotional heal th of the c h i l d and fo r h is adjustment ou ts ide the fami ly of o r i e n t a t i o n . The fami ly scapegoat w i l l f ee l s t rong fami ly pressure which creates c o n s i d e r -able c o n f l i c t s f o r him. Once he has been se lec ted there is a c i r c u l a r react ion which tends to perpetuate h is r o l e assignment. The c h i l d may take on many of the c h a r a c t e r i s t i c s which parents d i s l i k e in themselves and each o t h e r , and he becomes a symbo l ica l l y appropr ia te object on which to focus t h e i r own a n x i e t i e s . The parents thus pro jec t t h e i r own d i f f i c -u l t i e s and problems onto the c h i l d and in dea l ing with them as the c h i l d ' s problems (accidents) rather than t h e i r own. In a d d i t i o n , there is a p o s s -i b i l i t y of secondary g r a t i f i c a t i o n f o r the accident c h i l d in the form of s p e c i a l a t ten t ion and exemption from c e r t a i n r e s p o n s i b i l i t i e s as compensa-t i o n f o r h is acceptance of the scapegoat r o l e . There is a l s o a p o s s i b i l i t y of the c h i l d ' s i d e n t i f i c a t i o n with an acc ident - repeater parent . The above exempl i f ies the prolonged s t r e s s found in the f a m i l i e s under study which, in our o p i n i o n , warrants an extension of the hypothesis f o r s tudy . C. The Role of S o c i a l Work in Accident Prevention S o c i a l Assessment and Treatment of Family Re la t ionships S ince s o c i a l workers have a s p e c i a l i z e d knowledge of the dynamic in te rac t ions wi th in the nuclear fami ly (which may r e s u l t in i l l n e s s or a c -c i d e n t ) , they can o f f e r t h e i r s k i l l s in treatment s e r v i c e s to f a m i l i e s 1 Voge l , E . F . and B e l l , Norman, W. "The Emotional ly Disturbed C h i l d as The Family Scapegoat ," The Fami ly , eds . Norman W. Be l l and E . F . V o g e l , 1962, The Free P r e s s , Glencoe, I l l i n o i s , p . 395. -63 -undergoing chronic s t r e s s , such as ind iv idua l casework s e r v i c e and fami ly group interviewing,, The l a t t e r method has been developed by var ious p s y c h i a t r i s t s and s o c i a l workers from 1953 onward. It is being used by s o c i a l workers in a v a r i e t y of ways. With some there is f l e x i b i l i t y , and treatment may, at one point in the c a s e , include a l l members of the f a m i l y , and at another, var ious members. Whereas, with others a l l members of the nuclear fami ly must be involved throughout the to ta l p r o c e s s . Some s o c i a l workers have found the approach def ined by Be l l as the method most approp-r i a t e . "Fami ly group therapy is an e f f o r t to e f f e c t behavioural and a t t i t u d i n a l changes wi th in a t o t a l fami ly through a a s e r i e s of conferences attended by the pa ren ts , the c h i l d r e n 9 years of age and o l d e r , and the t h e r a p i s t . . . the fami ly is the unit to be t r e a t e d . . . the problem fo r which the fami ly is accepted f o r treatment is to be thought of as a problem of the f a m i l y , not as a problem of the c h i l d . . . . F u n c t i o n a l l y , then the symptom is thought of as a product of a d i s r u p t i o n in fami ly i n t e r a c t i o n , most usua l ly a breakdown in i n t r a - f a m i l y communication, not as the product of i n t r a - p s y c h i c c o n f l i c t s . " ' There are many ways of working with a f a m i l y . There fore , the r a t i o n a l e f o r the method se lec ted must be based on sound s o c i a l a s s e s s -ment which includes the use of the three aforementioned theor ies of systems, r o l e and ego f u n c t i o n i n g . Some of these f a c t o r s are mentioned in the e labora t ion on chronic s t resses noted in the f a m i l i e s under s tudy. Community P a r t i c i p a t i o n In add i t ion to d i r e c t s e r v i c e to f a m i l i e s in accident p reven t ion , s o c i a l workers have a r e s p o n s i b i l i t y - to iden t i f y the s o c i a l needs of such 1 B e l l , John E . "Family Group Therapy," Publ ic Health Monograph No. 64. 1961, U.S. Dept. of Hea l th , Education and Wel fare , Washington, D . C , p . 4 . -64 -fami l i e s as re la ted to s t r e s s f u l events and acc iden ts ; to make known the gaps in s e r v i c e and to g ive leadership in the development of prevent ive community s e r v i c e s . Examples of such community p a r t i c i p a t i o n f o l l o w . The "Working Mother" was found to be a p a r t i c u l a r l y s t r e s s f u l event . There fo re , in order to help young c h i l d r e n who are deprived of t h e i r mothers who are working during the daytime, the p ro fess ion of s o c i a l work has a r e s p o n s i b i l i t y to fu r ther the c r e a t i o n of more agencies such as day care c e n t e r s . There would be provided not only day care fo r the p r e -school c h i l d , but a lso a f t e r - s c h o o l programs f o r the school age c h i l d . Such r e s p o n s i b i l i t y is based on the c o n v i c t i o n that good day care has value fo r c h i l d r e n of a l l ages and t h e i r f a m i l i e s . Programs that can p r o v -ide a c h i l d with a bas is f o r wider learn ing and expression can lessen s t r e s s and help to increase ego f u n c t i o n i n g . There fore , s o c i a l workers should take leadership in encouraging more day care centers (with improved standards in programming and teaching) fo r young c h i l d r e n of working mothers. Leadership should a l s o encourage e x i s t i n g community agencies to prov ide necessary a f t e r - s c h o o l programs, or take steps to organize other a l t e r n a t i v e a f t e r - s c h o o l programs, such as using the present neighbourhood f a c i l i t i e s f o r the school age c h i l d . In the survey of married women workers by the Canadian Federal Department of Labour' many working mothers of small school -age c h i l d r e n c l e a r l y indicated they welcomed some p l a c e where t h e i r c h i l d r e n could go a f t e r school to spend the time u n t i l the mother's return from work. 1 Ottawa, Dept. of Labour, "Marr ied Women Workers: The Home S i t u a t i o n , " Canadian S o c i e t y , eds. Bernard P. B l i s h e n , Frank E. Jones, Kaspar D. Naegele and John Por te r , 1964, Macmillan Company of Canada, Toronto, pp. 150-154. -65 -Family L i f e Education S o c i a l workers have a r e s p o n s i b i l i t y to encourage and organize c lasses in fami ly l i f e educat ion . In these c lasses var ious p r o f e s s i o n a l s such as a doc tor , m i n i s t e r , s o c i a l worker and banker could be given an op-por tun i ty to ins t ruc t parents and fu ture parents regarding the many facets of fami ly l i v i n g , inc lud ing p o s i t i v e parental a t t i tudes with f i r m , kind d i s c i p l i n e of c h i l d r e n , and in p a r t i c u l a r , the r o l e of parents in safe ty education fo r t h e i r c h i l d r e n . Parents should be made aware of the growth and development and l i m i t a t i o n s of c h i l d r e n at d i f f e r e n t ages. These c l a s s e s might be h e l d , f o r ins tance , in community c e n t e r s , neighbourhood houses, or at the loca l Y .W.C .A . or Y . M . C . A . The p r o f e s s i o n a l s o c i a l worker in these c l a s s e s would emphasize education fo r wholesome s o c i a l func t ion ing by the ind iv idua l wi th in the dynamic nuclear fami ly group. For example, r o l e has been def ined "as a g o a l - d i r e c t e d pat tern or sequence of acts t a i l o r e d by the c u l t u r a l process fo r the t ransact ions a person may car ry out in a s o c i a l group or s i t u a t i o n . " The range of fami ly ro les such as those of husband and w i f e , fa ther and mother, son and daughter, brother and s i s t e r could be explained and d i s -cussed . A l s o included in the d i s c u s s i o n s could be the i n e v i t a b l e s t resses in a fami ly and the necessary realignment of ro les ( for example, i f mother s t a r t s to work), r o l e performance, and r o l e expectat ions in order to main-t a i n fami ly e q u i l i b r i u m . Role support dur ing s t r e s s is very i n f l u e n t i a l to s o c i a l f u n c t i o n i n g . Its u t i l i z a t i o n at the s t r a t e g i c t ime to b o l s t e r an i n d i v i d u a l ' s s t r e s s to le rance with the hope of l i m i t i n g h is s u s c e p t i b i l i t y 1 S p i e g e l , J . P . "The Resolut ion of Role C o n f l i c t Within the Fami ly , " The Fami ly , eds . Norman W. B e l l and E . F . Voge l , 1962, The Free P r e s s , G len -c o e , 111inois , p. 363. -66-to accidents is most important. Accidents w i l l not n e c e s s a r i l y be the symptom f o r a l l f a m i l i e s , but i t would be important to acquaint f a m i l i e s with resources f o r treatment when necessary . The importance of parental a t t i tudes and guidance in c h i l d development should be inc luded , po in t ing out in p a r t i c u l a r the parents ' r e s p o n s i b i l i t y in the prevent ion of a c c i d -ents to c h i l d r e n . Cont inuing Publ ic Education f o r Accident Prevention A cont inu ing educational program fo r f a m i l i e s regarding accident prevent ion f o r c h i l d r e n is a n e c e s s i t y . The mass media such as r a d i o , t e l e v i s i o n and the newspapers have already been used with some s u c c e s s . The pro fess ions can p lay an important r o l e in sa fe ty educat ion . Take, f o r example, the Well C h i l d Care C l i n i c s where phys ic ians and c h i l d heal th personnel should take every opportuni ty to inform and counsel parents r e -garding accident prevent ion at each stage of development. S o c i a l workers, in t h e i r contacts with ind iv idua ls and groups should take an equa l ly r e s -p o n s i b l e r o l e in safe ty educat ion . Safety education being taught in kindergarten and schools should be given high p r i o r i t y . Major emphasis on programs appropr ia te , not only to the c h i l d at h is p a r t i c u l a r stage of development, but a l s o to parents in P . T . A . and other parent groups, should prov ide a medium f o r teaching parent safe ty consc iousness . The B r i t i s h Columbia Safety Counci l publ ishes educat ional l i t e r a -tu re on accident p reven t ion . A l l across Canada May 2nd, I965 has been dec lared by the Federal Government as " C h i l d - S a f e t y Day." It is hoped that t h i s p u b l i c i t y may resu l t in an aroused community so that we s h a l l get com-munity ac t ion towards the prevent ion of chi ldhood a c c i d e n t s . - 67 -D. Topic f o r Further Study As a resu l t of the observat ions and f ind ings the wr i te rs have found that there are many areas which could be explored in fu ture s t u d i e s . One such s tudy, p rospec t ive in nature , might be set up with the fo l lowing hypothes is : in a fami ly where chronic fami ly s t r e s s develops some c h i l d in the fami ly may become the bearer of that s t r e s s by having a c c i d e n t s . Th is might be developed by choosing a sample of f a m i l i e s in the C i t y of Vancouver who have one or more d isab led c h i l d r e n l i v i n g at home. They could be interviewed on a regular basis f o r a time per iod of f i v e years from a s t a r t i n g date . Accidents to a l l c h i l d r e n would be recorded with relevant d e t a i l s . Family h i s t o r i e s could be obta ined , as wel l as a l l p e r t -inent environmental d a t a . E . Cone 1us ion "Acc identa l in jury is the leading cause of death during chi ldhood as wel l as a most frequent cause of d i s a b i l i t y . " ' There is much study and research to be done in the f i e l d of c h i l d -hood accident prevent ion to which s o c i a l workers have a c o n t r i b u t i o n to make. They can use t h e i r knowledge to assess the s t ress -p roduc ing events upon fam-i l i e s . The s k i l l s in casework, groupwork and community organ iza t ion can be a p p l i e d . Treatment on a prevent ive leve l is provided by reaching out to promote a bet ter s o c i a l and emotional c l imate in which the c h i l d and his fami ly may f u n c t i o n . D i rect s e r v i c e a s s i s t s f a m i l i e s when s t r e s s - p r o d u c i n g events o c c u r . S o c i a l workers can g ive leadership in fami ly l i f e education and the 1 Meyer, R . J . et. aj_., op_. c i t . . p . 9 5 . -68-c r e a t i o n of necessary s o c i a l s e r v i c e s . Soc ia l workers have a c o n t r i b u t i o n to make in the i n t e r - d i s c i p l i n a r y "team" approach to prevent ion of a c c i d -ents to c h i l d r e n . -69-APPENDIX A A C l a s s i f i c a t i o n of S t ress-Produc ing Events: Based on a systems ap-proach to s o c i a l and personal f a c t o r s embodied in the concepts of ro]e and ego f u n c t i o n i n g . I. Loss of Member: - Death o f : c h i l d spouse parent member of household fami ly pet member of extended fami ly neighbour c l o s e fami ly f r i e n d - H o s p i t a l i z a t i o n o f : c h i l d parent member of household - Separat ion of parent from fami ly because o f : armed s e r v i c e s occupat ional t rave l (part - t ime absence) deser t ion 11. Add i t ion to the Household o f : c h i l d new parent extended fami ly member other III. Role Changes: - Change i n : socio-economic status promot ions demot ions loss of employment - Change by: i l l n e s s of fami ly member h o s p i t a l i z a t i o n fo r m e d i c a l , mental or add i t iona l reasons imprisonment of fami ly member involvement with p o l i c e and court i l l e g i t i m a c y or unwanted pregnancy runaway other -70-APPENDIX A. cont'd. IV. Environmental Changes: family dwelling place child's a c t i v i t i e s , school, playmates f i r e s , floods, hurricanes V. Fights between Parents Adapted from H i l l , Reuben. "Social Stresses on the Family: Generic Feat-ures of Families Under Stress," Social Casework. Vol. 39, February 1958, pp. 139-150. - 71 -APPENDIX B A Conceptual Framework of P o s s i b l e Causal Factors in Accident Occur-rence. " A . Background of the c h i l d 1. Heredity 2 . Physica l f a c t o r s a . Body growth, s t r u c t u r e , and funct ion b. Age c . Sex 3. Mental f a c t o r s k. Emotional f a c t o r s a . A t t i tudes and values b. Personal adjustment c . St ress f a c t o r s 5. Pe rsona l i t y t r a i t s 6. Habits and a c t i v i t i e s 7. A c t i v i t y on incidence of accident 8. S o c i a l f a c t o r s a . Re la t ionsh ips with peers b. Supervisor 9 . General heal th s ta tus and accident h i s t o r y B. The fami ly background (both parents) 1. Race 2 . R e l i g i o n 3. E t h n i c i t y and c u l t u r a l background k. Socio-economic s ta tus 5. Family composit ion and age s t r u c t u r e 6. Mar i ta l and fami ly r e l a t i o n s h i p s 7. C h i l d - r e a r i n g p r a c t i c e s 8. A t t i tudes of fami ly members 9 . Length of res idence in area 10. Geographical m o b i l i t y 11. L i v i n g cond i t ions a . Crowding b. Community f a c t o r s 12. Health status and accident h i s t o r y C . The environmental background 1. Physica l environment a . Geographical loca t ion b. Topography c . Rural -urban areas 2. Technologica l environment a . Housing i . Design and cons t ruc t ion i i . Maintenance i i i . Appl iances and equipment i v . Furnishings b. Area outs ide the dwel l ing - 7 2 -APPENDIX B. c o n t ' d . C . The environmental background, c o n t ' d . 3 . Accident s i t u a t i o n va r iab les a . Locat ion b. Agent of accident c . Condi t ions at time of accident i . Time . i i . Weather and s e a s o n . " 1 Suchman, E . A . and Scherzer , A . L . , op_. c i t . , p. 13 -73-APPENDIX C Covering Let te r to Family Allowance D i v i s i o n November 27, 1964. Mr. W. R. Bone, Regional D i r e c t o r , Family Allowance D i v i s i o n , Dear Mr. Bone: The Department of Prevent ive Medicine and the School of Soc ia l Work at the Un ive rs i t y of B r i t i s h Columbia are j o i n t l y p lanning a r e s -earch study on f a m i l i e s of acc ident - repeater c h i l d r e n in the Vancouver a rea . The sample of s i x t y - o n e fami l i es has been i d e n t i f i e d from a former epidemiological study into pedestr ian t r a f f i c accidents invo lv -ing Vancouver c h i l d r e n undertaken by the U . B . C . C h i l d Health Programme in I960. We are unable to loca te the homes of eighteen of our "acc ident c h i l d r e n " in the Vancouver D i r e c t o r y , and are enc los ing a l i s t g iv ing I960 information f o r each c h i l d . If your records ind ica te where and with whom these eighteen are present ly l i v i n g , we would be very g ra te -f u l i f you would forward our l e t t e r s (copy of which is enclosed) in the stamped envelopes. Thank you very much fo r your coopera t ion . Yours t r u l y , E n d s J , R. Brummitt, M.D. , D i rec tor -74-T H E UNIVERSITY OF BRITISH COLUMBIA VANCOUVER 8, CANADA APPENDIX D CHILD HEALTH PROGRAMME l i n t n 9t l o A l i ROOM 209. W E S B R O O K BUILDING lNOVettlDer C-Z> > J - V C t f * Dear In I960 the Department of P r e v e n t i v e Medicine, UBC c a r r i e d out a r e s e a r c h study on t r a f f i c a c c i d e n t s i n v o l v i n g c h i l d p e d e s t r i a n s up to the age of l b years. The purpose of t h a t study was to determine some of the causes of c h i l d p e d e s t r i a n ^ t r a f f i c a c c i d e n t s and to Introduce p r e v e n t i v e means to reduce t h i s growing p u b l i c h e a l t h problem. At that time you cooperated i n the r e s e a r c h study which was of great help i n i d e n t i f y i n g a number of c a u s a t i v e f a c t o r s i n v o l v e d i n such a c c i d e n t s . Now we wish to explore i n g r e a t e r d e t a i l f u r t h e r p a r t i c u l a r events w i t h i n the f a m i l i e s o f those a c c i d e n t v i c t i m s to d i s c o v e r whether any r e l a t i o n e x i s t s i n time between them and oth e r types o f a c c i d e n t s which may have occurred before o r s i n c e . This new study x^rill be done by the School of S o c i a l Work i n c o o p e r a t i o n w i t h the Department of Pr e v e n t i v e Medicine.'. I t i s planned t h a t members of the r e s e a r c h team w i l l meet wit h members of the f a m i l i e s concerned i n o r d e r to complete a ques-t i o n n a i r e which we hope w i l l add to our knowledge of a c c i d e n t causat i o n . As before a l l i n f o r m a t i o n i d e n t i f i a b l e to p a r t i c u l a r f a m i l i e s w i l l be t r e a t e d by the study group as c o n f i d e n t i a l although the c o n c l u s i o n s w i l l be used to enlarge f u r t h e r ^ p u b l i c and r e s e a r c h knowledge r e l a t e d t o a c c i d e n t p r e v e n t i o n . We would be most g r a t e f u l f o r your f u r t h e r c o o p e r a t i o n i n t h i s c u r r e n t phase of the study, and a member of the study group w i l l telephone you i n t h i s regard w i t h i n t e n days. At the same time, a mutually convenient time f o r a v i s i t , w i t h i n the next few months, w i t h members of your f a m i l y can be d i s c u s s e d . Yours t r u l y , . J . -jr." Brummltt, M»D;., D i r e c t o r , C h i l d H e a l t h Programme* (Miss) M u r i e l C u n l i f f e , P r o f e s s o r , School nf S o c i a l Work. -75-APPEND1X E P .S . The Family Allowance o f f i c e in V i c t o r i a has k ind ly forward-ed t h i s l e t t e r to you. As we are s t i l l unaware of your present address, we would be most gra te fu l i f you would k ind ly f i l l in the enclosed p o s t - c a r d and mail i t to us so that we may contact you aga in . -76-APPEND1X F University of British Columbia - Child Health Programme C a 8 e * A STUDY OF FAMILIES OF ACCIDENT-REPEATER CHILDREN IN VANCOUVER Q U E S T I O N N A I R E (Interview Survey Guide) Date of Interview.. Name of Social Worker... Interviewee: [ ( Mother j j Mother & Father j* [ Father j j Other Part I. Identifying Information: a) Family name b) Identifying Child: (l)Name (£) Address..... (3) Sex Male Female c) Date of pedestrian t r a f f i c accident (1960) Part II. History of Family Structure a) Father's name Date of birth.. Father's address ............................................. Phone No, b) Mother'8 name • Date of birth Mother's address •••••••••• Phone No, c) Children: Name Sex Date of birth In home Left Home - date Day Mth Yr Age n #3 #4 #5 #6 d) Other Household Members: Name Sex Status i n house Relationship Birthdate Entered Left -77-APPENDIX F. cont'd. p a g e t w o Part III. Socio-economic Histpry of Family a) Father's Occupation. Any changes of occupation and/or employment 1958-1964: Date Occupation Date Employment • • • b) Mother's Occupation Any changes 1958 to 1964: Date Occupation c) Economic Status of Family, taking into consideration total income from a l l sources between 1958 and 1964: Above average ($6000 + ) Average ($3000 - $6000) d) Changes in Economic Status, 1958-1964: | | No change ) Upward • Downward Below average (under $3000) Fluctuating Part IV. History of Marital Status a) Status of marriage of custodial parent, 1958, to other natural parent: b) Any changes between 1958 and 1964: Day Month Year Absence of one spouse -Reason: Desertion Separation Divorce Death Remarriage -78-APPENDIX F. CONT'D p a g e t h r e e Part V. History of Family Mobility, 1958-1964 a) Date of f i r s t accident: Address at time of f i r s t accident: b) Dates of any subsequent move(s): Day Month Year Address Part VI. History of Family Health, 1958-1964 Note any significant physical and/or mental illness requiring hospitalization or causing d i s a b i l i t y to any of household members: Name Illness or Disability Date -79-APPENDIX F. cont'd. p a g e f o u r Part VII. History of Accidents to Children in Household (under 18 years on December 31,196* when medical attention required-from I ub8-l ub4: Enter name of child and date of accident in appropriate square: Location of Accident F a l l Accidents Burns Poison s = Cuts Impact Motor Vehicle Other (1) Home (2) School -(3) Recreation (4) Traffic (5) Other Part VIII. Further comments and observations: -So* APPENDIX G Bibliography BOOKS Bernard, Jessie. Social Problems at Midcentury. Holt, Reinhart and Win-ston, New York, 1961. Boehm, Werner. The Social Casework Method in Social Work Education. Coun-c i l on Social Work Education, New York, 1959. Bossard, James S. and Boll, Eleanor, S. The Large Family System. Univer-sity of Pennsylvania Press, Philadelphia, 1956. Coleman, James C. Personality Dynamics and Effective Behavior. Scott, Foresman and Company, Chicago, I960. Erikson, Erik H. Childhood and Society. 2nd ed., W.W. Norton and Company, New York, 1963. Garrett, Annette. Interviewing;, Its Principles and Methods. Family Serv-ice Association of America, New York, 19^2. Halsey, Maxwell N., ed. Accident Prevention: The Role of Physicians and Public Health Workers. The Blakiston Division, McGraw-Hill Book Company Inc., New York, 1961. Polansky, Norman A., ed. Social Work Research. 3rd ed., University of Chicago Press, Chicago and London, 1963. Reiner, B. Simcox and Kaufman, I. Character Disorders in Parents of Bel?n- quents. Family Service Association of America, New York, 1959. Schulzinger, M.S. The Accident Syndrome. C.C. Thomas, Springfield, 1956. Selye, Hans. The Stress of Life. McGraw-Hill Book Company Inc., New York, 1956. JOURNALS. PAMPHLETS. ARTICLES American Association for Health, Physical Education and Research, Annual  Safety Education Review. 1963, Washington, D.C. Bartlett, Frederick Charles. "Social Influences on Individual Psycholog-ical Processes," Readings in Social Psychology, eds. G.E. Swanson, T.M. Newcomb and E.L. Hartley et. a]_., 1952, Henry Holt and Comp-any, New York, pp. 362-369. Cousins, Albert N. "The Failure of Family Solidarity," The Family, eds. Norman W, Bell and Ezra F. Vogel, 1962, The Free Press, Glencoe, 111inois, pp. 403-416. Fabian, A.A. and Bender, Lauretta. "Head Injury in Children: Predisposing Factors," American Journal of Orthopsychiatry, Vol. 17, January 1947, pp. 68-79. Fell in, P h i l l i p . "The Standardized Interview in Social Work Research," Social Casework. Vol. 44, February 1963, pp. 81-85. Francis, Roy G. "The Nutty Other: A Prologomania to Research," Pacific  Sociological Review, Vol. 3 , Spring I960, pp. 41-44. Froggatt, Peter and Smiley, James A. "The Concept of Accident Proneness; A Review," British Journal of Industrial Medicine, Vol. 2 , Jan-uary 1964, pp. 1-11. Fuller, E.M. "Injury Prone Children," American Journal of Orthopsychiatry. Vol. 18, October 1948, pp. 708-723. Haddon, Wm., Suchman, E.A. and Klein, David. "Toward a Science of Accident Research," Traffic Safety Research Review, Vol. 8, September 1964, pp. 66-73. H i l l , Reuben. "Social Stresses on the Family: Generic Features of Families Under Stress," Social Casework, Vol. 39, February 1958, pp. 139-150. Jacobs, H.H., Suchman, E.A., Fox, B.H., Gibson, J.J., Alpenfels, E.J., Hayes, A.B., Freedman, A.M., Foote, N.N., Bronfenbrenner, U., Asch, S.E., Co t t r e l l , L.S., Clausen, J.A. and Rapoport, A. Be- Havioral Approaches to Accident Research. Association for the Aid of Crippled Children, New York, 1961. Keddy, J. Arthur. "Accidents in Childhood: A Report on 17,141 Accidents," Canadian Medical Association Journal. Vol. 91, September 26, 1964, pp. 675-680. Langford, W.S., Gilder, Rodman, Wilking, V.N., Genn, M.M. and S h e r r i l l , W.H. "Pilot Study of Childhood Accidents: Preliminary Report," Pediat- r i c s , Vol. 11, April 1953, pp. 405-415. McClave, C.R. and Shaffer, Thos. E. "Accidents, Injuries and Children," Pediatric Clinics of North America. August 1957, W.B. Saunders Company, Philadelphia and London, pp. 635-647. McCormick, Mary J. "The Role of Values in Social Functioning," Social Case- work, Vol. 42, February 1961, pp. 70-78. ' 8 2 -Maas, Henry. "Behavioral Sc ience Bases fo r a Profess iona l Educat ion: The Uni fy ing Conceptual Tool of Cu l tu ra l R o l e , " Proceedings of the  I n t e r d i s c i p l i n a r y Conference. 1959, Howard.Universi ty , Washing-t o n , D . C , pp. 11-22. Marcus, I .M., W i l s o n , W., K r a f t , I., Swander, D. , Souther land, F. and Schu lhofe r , E . "An I n t e r d i s c i p l i n a r y Approach to Accident Pat -terns in C h i l d r e n , " Monograph: Society fo r Research in C h i l d  Development. S e r i a l No. 76, V o l . 25, I960, pp . 1-51. Meyer, Carol H. " I n d i v i d u a l i z i n g the Mult iproblem Fami ly , " Soc ia l Case- work. V o l . 44, May 1963, pp . 267-272. Meyer, Roger J . , R o e l o f s , H . A . , B luestone, J . and Redmond, S . "Acc identa l Injury of Preschool C h i l d , " Journal of P e d i a t r i c s . V o l . 63, July 1963, pp . 95-105. Ottawa, Dept. of Labour, "Married Women Workers: The Home S i t u a t i o n , " Can- adian S o c i e t y , eds . Bernard P. B l i s h e n , Frank E . Jones, Kaspar D. Naegele and John P o r t e r , 1964, Macmillan Company of Canada, Toronto , pp . 146-154. Perlman, Helen H. "Family Diagnosis in Cases of I l lness and D i s a b i l i t y , " Family-Centered Soc ia l Work in;. I l lness and D i s a b i l i t y : A Prevent- ive Approach. Monograph VI of " S o c i a l Work P r a c t i c e in Medical Care and R e h a b i l i t a t i o n S e t t i n g s , " 1961, National A s s o c i a t i o n of S o c i a l Workers, New York, pp . 7"20. Read, J . H . "Acc idents and Poisons in C h i l d h o o d , " Mimeographed paper , 1959. Read, J . H . , Brad ley , E . J . , Mor ison, J . D . , L e w a l l , D. and C l a r k e , D.A. "The Epidemiology and Prevention of T r a f f i c Accidents Involving C h i l d P e d e s t r i a n s , " Canadian Medical A s s o c i a t i o n J o u r n a l . V o l . 89 , October 5 , 1963, pp . 687-701. S c h l e s i n g e r , Benjamin. "Fami l i es of M is fo r tune , " S o c i a l Problems: A Canad- ian P r o f i l e , ed . Richard L a s k i n , 1964, McGraw-Hill Company, Inc . , New York, pp . 284-290. Suchman, E . A . and Scherzer , A . L . Current Research in Childhood A c c i d e n t s . Research Repr in t , I960, A s s o c i a t i o n fo r the A id of Cr ipp led C h i l d -ren , New York. S p i e g e l , John P. "The Resolut ion of Role C o n f l i c t Within the Fami ly , " The  Fami ly , eds. Norman W. Be l l and Ezra F. Voge l , 1962, The Free P r e s s , Glencoe, I l l i n o i s , pp . 361-381. V o g e l , Ezra F. and B e l l , Norman W. "The Emotional ly Disturbed C h i l d as the Family Scapegoat ," The Fami ly . eds. Norman W. Be l l and Ezra F. V o g e l , 1962, The Free P r e s s , Glencoe, I l l i n o i s , p p . 382-397. W i l l i a m s , N. " T r a f f i c Accidents - Epidemiology and Medical Aspects of P r e v e n t i o n , " Canadian Medical A s s o c i a t i o n J o u r n a l . V o l . 90, May 9, 1964, pp . 1099-1104. REPORTS B e l l , John E . "Family Group Therapy," Publ ic Health Monograph. No. 64. 1961, U .S . Dept. of Hea l th , Education and Wel fare , Washington, D.C. Freeman, F . , Goshen, C E . and K ing , B .G. The Role of Human Factors in A c - c ident Prevent ion . U .S . Dept. of Hea l th , Education and Wel fare , Pub l ic Health S e r v i c e , Washington, D . C , August 1, I960. 

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