Applied Science, Faculty of
Medicine, Faculty of
Other UBC
Non UBC
Architecture and Landscape Architecture (SALA), School of
Pediatrics, Department of
Population and Public Health (SPPH), School of
DSpace
Brussoni M, Brunelle S, Pike I, et alCan child injury prevention include healthy risk promotion?Injury Prevention 2015;21:344-347.
B.C. Injury Research and Prevention Unit
Brussoni, Mariana
Brunelle, Sara
Pike, Ian, 1958-
Sandseter, Ellen Beate Hansen
Herrington, Susan
Turner, Heather
Belair, Scott
Logan, Louise
Fuselli, Pamela
Ball, David J.
To reflect on the role of risk-taking and risky play in child development and consider recommendations for the injury prevention field, a symposium was held prior to the November 2013 Canadian Injury Prevention and Safety Promotion Conference. Delegates heard from Canadian and international researchers, practitioners and play safety experts on child development, play space design and playground safety, provision of recreation, and legal and societal perceptions of risk and hazard. The presenters provided multidisciplinary evidence and perspectives indicating the potential negative effect on children's development of approaches to injury prevention that prioritise safety and limit children's opportunities for risky play. Delegates considered the state of the field of injury prevention and whether alternative approaches were warranted. Each presenter prepared a discussion paper to provide the opportunity for dialogue beyond attendees at the symposium. The resulting discussion papers provide a unique opportunity to consider and learn from multiple perspectives in order to develop a path forward.
Can child injury prevention include healthy riskpromotion?Mariana Brussoni,1 Sara Brunelle,2 Ian Pike,1 Ellen Beate Hansen Sandseter,3Susan Herrington,2 Heather Turner,4 Scott Belair,5 Louise Logan,6 Pamela Fuselli,6David J Ball7▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/injuryprev-2014-041241).For numbered affiliations seeend of article.Correspondence toDr Mariana Brussoni,Department of Pediatrics,University of British Columbia,BC Injury Research andPrevention Unit, Room F511,4480 Oak Street, Vancouver,BC, V6H 3V4 Canada;mbrussoni@cw.bc.caReceived 19 March 2014Revised 2 December 2014Accepted 8 December 2014Published Online First22 December 2014To cite: Brussoni M,Brunelle S, Pike I, et al. InjPrev 2015;21:344–347.ABSTRACTTo reflect on the role of risk-taking and risky play in childdevelopment and consider recommendations for the injuryprevention field, a symposium was held prior to theNovember 2013 Canadian Injury Prevention and SafetyPromotion Conference. Delegates heard from Canadianand international researchers, practitioners and play safetyexperts on child development, play space design andplayground safety, provision of recreation, and legal andsocietal perceptions of risk and hazard. The presentersprovided multidisciplinary evidence and perspectivesindicating the potential negative effect on children’sdevelopment of approaches to injury prevention thatprioritise safety and limit children’s opportunities for riskyplay. Delegates considered the state of the field of injuryprevention and whether alternative approaches werewarranted. Each presenter prepared a discussion paper toprovide the opportunity for dialogue beyond attendees atthe symposium. The resulting discussion papers provide aunique opportunity to consider and learn from multipleperspectives in order to develop a path forward.RISKY PLAY SYMPOSIUMA symposium was held prior to the November 2013Canadian Injury Prevention and Safety PromotionConference in Montreal, Canada, in order to reflecton the role of risk-taking and risky play in childdevelopment and consider recommendations for theinjury prevention field. Canadian and internationalpresenters included researchers, practitioners andplay safety experts, who discussed child develop-ment, play space design and playground safety, pro-vision of recreation, and legal and societalperceptions of risk and hazard. Herein we provide asummary of the discussion occurring at the sympo-sium, providing an overview of the arguments madeby each presenter and reflection on the state of theresearch evidence and implications for injury pre-vention practice. Links are provided to presenters’full submission to provide readers the opportunityto view complete arguments. Most presenters wereCanadian and reflected on the Canadian landscape.However, the issues discussed are common to manydeveloped nations, such as the USA, the UK andAustralia.1–3 Nations such as Norway and Finlandlead the way in child-centric approaches to childdevelopment and injury prevention that can act asmodels for other jurisdictions.4 5INTRODUCTIONIn the middle of the twentieth century, injury pre-vention became increasingly recognised as aprofession within the mandate of public health.6This resulted in important gains in reducing injurymorbidity and mortality rates. A key contributor tothese successes was epidemiological research thatidentified social, individual and environmental riskfactors for injuries.6 With identification of patternscame the development of prevention strategies todiminish risk factors.7Over the years, the injury prevention field hasbecome increasingly multidisciplinary, expandingfrom its roots in epidemiology to incorporate behav-ioural science perspectives.8 This has proven particu-larly fruitful for child injury prevention as it haspromoted understanding of the developing child andchildren’s particular vulnerabilities. To encouragecontinued advancement of the field and to ensurethat injury prevention efforts are grounded inbroader, more holistic understandings of health andwell-being, particularly for children, it is importantto encourage inclusion of a larger list of disciplines.The need for injury prevention to expand its dis-ciplinary base becomes readily apparent when consid-ering children’s risk-taking through risky play. Riskyplay is thrilling and exciting forms of play that mayinclude the possibility of physical injury. Sandseterand Kennair9 have further categorised it into play atheight, speed, near dangerous elements (eg, water,fire), with dangerous tools, and where there is thepotential for disappearing or getting lost.DEVELOPMENTAL BENEFITS OF RISKY PLAYEllen Sandseter, a Norwegian early childhood educa-tion researcher, discusses the developmental benefitsof risky play and cites evidence suggesting that thereare good reasons for encouraging, rather than limit-ing, children’s opportunities for risk-taking and riskyplay (see online supplement 1). These include pro-moting physical activity, independence, cognitive andsocial development, and reducing mental illness andlearning difficulties.10–12 Notably, risky play alsohelps children learn risk perception and managementskills, which are important in developing understand-ing of how to navigate risks and avoid injuries.9 11Sandseter describes children’s naturally progressivethrill-seeking, which promotes gradual mastery ofchallenges and realistic risk perception. She also high-lights the potential antiphobic effects of risky play,helping children to become accustomed to and copewith stimuli that could otherwise elicit anxiety (eg,heights).Despite the developmental benefits of risky play,many well-intentioned injury prevention efforts arefocused on limiting precisely these kinds ofOpen AccessScan to access morefree content344 Brussoni M, et al. Inj Prev 2015;21:344–347. doi:10.1136/injuryprev-2014-041241Special feature on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from exposures for children, which are treated as safety hazards.Thus far, there has been little recognition of the distinctionbetween hazard and risk in the injury prevention field. Risks(situations in which a child can recognise and evaluate the chal-lenge and decide on a course of action) have been equated withhazards (a source of harm that is not obvious to the child, suchthat the potential for injury is hidden).1 13 For example, climb-ing a tall slide is a risk, whereas a hazard would be that the slideis not properly anchored and could topple with the child’sweight. Confusing risk with hazard has made it more challen-ging to recognise the benefits of risk. Indeed, through varioussafety standards, playground designs, rules and supervision prac-tices, we have restricted children’s access to risky play opportun-ities to such an extent that we might be harming theirdevelopment.1 9 14PARENTING AND SOCIETAL PERCEPTIONS OF RISKPsychological and public health research has largely been basedon the assumption that people seek to avoid risks and voluntaryrisk-taking results from faulty cognitive appraisals, lack ofunderstanding or a personality flaw.15 Yet, a large body of litera-ture documenting voluntary risk-taking, including among chil-dren, suggests that it is normal, pervasive and developmentallynecessary.16–20The basic childhood need for risky play appears to be at oddswith several shifts in social attitudes that have intersected toheighten awareness of and concerns regarding risks, not just ofpublic health professionals, but at a broader societal level.2 21These shifts are evident in approaches to parenting that areprominent in Western society today. Sociologists have illustratedhow perceptions of childhood have transitioned over time suchthat children in modern society are positioned as precious andneeding the highest possible degree of parents’ attention andcaregiving.22 23 These trends coincide with a move towards neo-liberal political structures that shift a greater portion of theburden of responsibility for ensuring personal well-being fromthe state onto individuals.24 The result is a push towards ‘inten-sive parenting’ where parents (primarily mothers) are encour-aged to become experts on optimal parenting strategies, andchild health and development so as to ensure that their childrenachieve their full potential.23 25 26 These beliefs regardingacceptable parenting are coupled with a pervasive societal pushto control and manage risks, particularly for children, who areperceived as highly vulnerable and threatened by numerousperils, of which injury is a prominent one.21 27With injuries representing the leading cause of death for chil-dren in developed nations,28 concerns about safety are under-standable. However, how parents’ safety concerns manifest inpreventive action are not necessarily productive for healthy childdevelopment or for injury prevention. Many parents’ primarysafety concerns relate to abduction and exposure to traffic.29–31Prominent preventive strategies (that are also consistent with‘intensive parenting’) include limiting children’s unsupervisedoutdoor play and chauffeuring children to and from a series oforganised activities.31–33 Attempts to deviate from this parentingmodel can be met with sanctioning from other parents or eventhe police.25 34 Ironically, these strategies increase the injuryproblem by reducing ‘eyes on the street’ and by increasingtraffic.35 36 The current ‘backseat generation’ has markedly feweroutdoor risky play opportunities and access to natural play spacescompared with previous generations.30 32 37–39Parents’ observed behaviours are in stark contrast to theirexpressed wishes for their children’s play opportunities andexperiences.40 Brussoni and colleagues have interviewed manyparents about their approach to children’s risk engagement andinjury prevention.41–43 When asked to recall their childhoodplayscape, many parents graphically describe unsupervisedadventures in woods, ditches, fields, and so on, where they didnot return home until meal times. Frequently, their next obser-vation is a lament that their children do not have the opportun-ity to experience such unfettered play, often because oflimitations they place in the interest of safety.PLAYGROUND SAFETY STANDARDS AND CHILDREN’SPLAY SPACE DESIGNSocietal concerns about risk minimisation and the vulnerabilityof children2 44 are physically manifest in safety standards forchildren’s play spaces and equipment, and the resulting play-ground structures (eg, Canadian Standards Association’s (CSA)standards CAN/CSA-Z614-14).45 Standards advocate stringentinjury control measures that help ensure playgrounds are hazardfree. However, some standards have been adopted without con-sideration of the cost. Ball46 highlights that the push forimpact-absorbing surfaces has come at great economic cost,resulted in a poverty of play opportunities and effectively pro-hibited exploration of risk, with no noticeable benefit to redu-cing deaths and serious injuries—already very rare events. SusanHerrington, a landscape architect and children’s play spacedesign researcher in Canada, notes in her paper (see online sup-plement 2) that these standards are created by organisations pri-marily concerned with engineering and manufacturing, resultingin technical standards that do not consider the developmentalbenefits of risk-taking. She points to misinformation to play-ground designers regarding the safety levels of design elements,such as surfacing, narrowing design opportunities to a checklistof do’s and don’ts and resulting in the ubiquitous KFC (kit,fence, carpet) playgrounds. Herrington cites her research inchildcare centres showing how the KFC playgrounds have verylimited play value and could developmentally disadvantage chil-dren. Instead of being an ideal forum to encourage and supportdevelopmentally beneficial risky play for children, playgroundshave become less than suitable places for these opportunities.Scott Belair, certified playground inspector and member ofthe CSA Z614 technical committee for play equipment, raisesconcerns regarding playground design and standards as a practi-tioner and a father (see online supplement 4). He comments onthe expansion of CSA standards in the last 25 years, tripling inlength, despite the rarity of serious injuries and deaths. Changesinclude recommendations leading to lowering the height ofstructures, standardising the width of stair treads and railings,prohibiting use of natural (grass and earth) surfacing andincreasing non-encroachment zones.47 48 Belair highlights thelack of excitement of play opportunities and makes severalrecommendations for playground design that incorporateSandseter’s definition of risky play.BUBBLE-WRAPPED RECREATIONHeather Turner, the director of recreation and arts in NorthVancouver, British Columbia, reflects on 35 years of municipalparks and recreation experience in her paper (see online supple-ment 3). She provides the history of the provision of municipalrecreation services, illustrating how shifting priorities and cul-tural norms have influenced resources and approaches to recre-ation services. Turner points to a change from providing arenasfor free play to what she terms ‘bubble-wrapped recreation’, fol-lowed by more recent efforts to provide challenging and adven-turous activities that support child development—efforts thatBrussoni M, et al. Inj Prev 2015;21:344–347. doi:10.1136/injuryprev-2014-041241 345Special feature on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from she perceives need to continue in order to find a reasonable andbalanced approach that builds healthy communities.PUBLIC POLICY PERSPECTIVELouise Logan, president and chief executive officer of ParachuteCanada, and Pamela Fuselli, Parachute’s vice president of govern-ment and stakeholder relations, provide an overview of Canadianpolicy and legal statutes relevant to playground safety (see onlinesupplement 5). They point to the patchwork of statutes, stan-dards, regulations and duties governing playground safety inCanada, such as the duty of care to ensure reasonable safety on aproperty. Logan and Fuselli note that CSA standards are volun-tary, but in practice many jurisdictions insist on their adherencein the interest of minimising injury and litigation.48 Interestingly,they found few examples of case law resulting from playgroundinjuries. This seems incommensurate with the fear of litigationthat is a dominant force for limiting risky play opportunities.Overall, Logan and Fuselli find the Canadian approach to publicpolicy one that ’supports a strong focus on child safety, and legalrisk mitigation’, and does not consider negative impacts on childdevelopment. They encourage debate to identify guiding princi-ples that promote stimulating and safe lives.RISK–BENEFIT ASSESSMENTDavid Ball, a risk management researcher and advisor to theUK’s Play Safety Forum, describes playgrounds as ‘oases ofsafety’ in his paper (see online supplement 6). He describesattempts in the UK to shift policy and the Play Safety Forum’sManaging Risk in Play Provision position statement49 and imple-mentation guide50 that promote a risk–benefit assessment modelthat considers not only hazards but the developmental benefitsof risk taking. Recognising the multidisciplinary aspect of chil-dren’s play and play space design, Ball provides numerousrecommendations tailored to different practitioners.THE STATE OF THE EVIDENCELacking in the research literature on child development and riskyplay are studies using gold standard research methods, such asrandomised controlled trials. The bulk of the evidence comesfrom qualitative and quantitative research with methodologicalconcerns common to research undertaken in community settings.For example, Hüttenmoser12 compared developmental outcomesfor children living in surroundings where they were permitted toplay freely outdoors without adult supervision with socio-economically similar children in neighbourhoods where parentsdid not allow unsupervised outdoor play due to perceived trafficsafety concerns. His findings indicated significantly better motorskills, social behaviour, independence and conflict resolution inchildren with ready access to opportunities for outdoor unsuper-vised play opportunities. However, his research design was notable to control for pre-existing differences between the familiesthat might have influenced the results.Expansion of the evidence base to systematically investigatelinkages and key hypotheses is necessary. The existing multidis-ciplinary evidence and years of practitioner experience stronglysuggest that children need risky play opportunities to promotedevelopment and to develop the risk management skills neededto keep themselves safe. Necessary next steps include systematicreviews to appraise and synthesise the current state of the evi-dence, improved play-related injury surveillance that includesdata on exposure (number of children playing and amount oftime spent at play), and highly controlled and rigorous researchthat can systematically investigate this hypothesis, while remain-ing relevant to real-world settings. Recent research provides anexample of innovative research exploring this issue. One studyexamined whether children’s reaction times in detecting riskschanged after a multiweek intervention promoting risky playactivities.51 Results indicated that compared with a controlgroup, the intervention group showed significant reduction inreaction time on a risk perception test, and their teachers ratedan increase in self-esteem and a decrease in conflict sensitivity.TOWARDS A CULTURE OF REASONABLENESSDespite the variety of presenters at the symposium and thevastly different disciplines and backgrounds they represented, allcame to the same conclusion: the injury prevention status quo,which prioritises safety above all else, is not reasonable oracceptable. The challenge is to broaden the focus and committo a child-centric approach—one that includes not only the miti-gation of injury but also optimal child development, whichnecessitates exposure to competence-appropriate risky play in ahazard-free play space. The injury prevention field is at animportant juncture, with an opportunity for critical analysis ofcommonly held assumptions that can promote a cultural shiftand epistemological growth. Fruitful discussion has alreadyoccurred debating the need to prevent all injuries or whethersome injuries are acceptable.52–55 There is a pressing need toexpand these discussions to consider the difference between riskand hazard and the importance of risk for healthy child devel-opment. The alternative is to drift into the dangerous realm ofunreasonableness. Instead, we have the opportunity to act as acatalyst for societal change and promote a culture of reasonable-ness with the health and well-being of children at its centre.Author affiliations1Department of Pediatrics, University of British Columbia, BC Injury Research andPrevention Unit, Vancouver, British Columbia, Canada2School of Architecture and Landscape Architecture, University of British Columbia,Vancouver, British Columbia, Canada3Queen Maud University College of Early Childhood Education, Trondheim, Norway4North Vancouver Recreation and Culture Commission, North Vancouver, BritishColumbia, Canada5Reliable Reporting, Toronto, Ontario, Canada6Parachute, Toronto, Ontario, Canada7Middlesex University, London, UKAcknowledgements This paper is based on a symposium held in November2013, prior to the Canadian Injury Prevention and Safety Promotion Conference. Thesymposium was made possible by grant funding from the Canadian Institutes ofHealth Research (grant # TIR-104028). The authors thank the reviewers for theirthoughtful comments on previous versions of this paper. Career support for MB isprovided by a Michael Smith Foundation for Health Research (MSFHR) scholar awardand a British Columbia Child and Family Research Institute salary award. Careersupport for IP is provided by a British Columbia Child and Family Research Institute(CFRI) salary award.Contributors MB and IP planned the symposium that the papers stem from. MBwrote the introductory paper with assistance in drafting and revising from IP and SB.EBHS is the sole author of ‘Developmental benefits of children’s risky play’. SH is thesole author of ‘Rewriting the ground rules for outdoor play spaces’. HT is the soleauthor of ‘Bubble-wrapped recreation—have fun but don’t get hurt’. SB is the soleauthor of ‘Children risk to risk’. LL and PF are the authors of ‘Risky play, injuryprevention and child development—public policy perspective’. DJB is the sole authorof ‘Risk management and risk–benefit assessment’. All authors approved the finalversion that was submitted for review. Each author is a guarantor for their ownpaper, and MB is responsible for the overall content as a guarantor.Competing interests None.Provenance and peer review Not commissioned; externally peer reviewed.Open Access This is an Open Access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-NC 4.0) license, whichpermits others to distribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided the original work isproperly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/346 Brussoni M, et al. Inj Prev 2015;21:344–347. doi:10.1136/injuryprev-2014-041241Special feature on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from REFERENCES1 Brussoni M, Olsen LL, Pike I, et al. Risky play and children’s safety: Balancingpriorities for optimal child development. Int J Environ Res Public Health2012;9:3134–8.2 Ball DJ, Ball-King L. Public safety and risk assessment. New York, NY: Routledge,2011.3 Little H, Eager D. Risk, challenge and safety: implications for play quality andplayground design. Eur Early Child Educ Res J 2010;18:497–513.4 Markkula J, Öörni E. Providing a safe environment for our children and youngpeople: Finland’s national action plan for injury prevention among children andyouth. Helsinki: 2010. http://www.thl.fi/thl-client/pdfs/bcda07c2-aa23-4faa-a59d-55a60fdc6764 (accessed 28 Oct 2013).5 Sandseter EBH, Little H, Wyver S. Do theory and pedagogy have an impact onprovisions for outdoor learning? A comparison of approaches in Australia andNorway. J Adventure Educ Outdoor Learn 2012;12:167–82.6 Green J. From accidents to risk: public health and preventable injury. Heal Risk Soc1999;1:25–39.7 Martinez R. Injury control: a primer for physicians. Ann Emerg Med 1990;19:72–7.8 Gielen AC, Sleet DA. Injury prevention and behavior. In: Gielen AC, Sleet DA,DiClemente RJ, eds. Injury and violence prevention: behavioral science theories,methods and applications. San Francisco, CA: Jossey-Bass, 2006:1–16.9 Sandseter EBH, Kennair LEO. Children’s risky play from an evolutionary perspective:the anti-phobic effects of thrilling experiences. Evol Psychol 2011;9:257–84.10 Sandseter EBH. Restrictive safety or unsafe freedom? Norwegian ECEC practitioners’perceptions and practices concerning children’s risky play. Child Care Pract2012;18:83–101.11 Gill T. No fear: growing up in a risk averse society. London: Calouste GulbenkianFoundation, 2007.12 Hüttenmoser M. Children and their living surroundings: Empirical investigation intothe significance of living surroundings for the everyday life and development ofchildren. Child Environ 1995;12:403–13.13 Wallach F. Playground safety: what did we do wrong? Park Recreat 1992;27:52–7.14 Hart R. Containing children: some lessons on planning for play from New York City.Environ Urban 2002;14:135–48.15 Zinn JO. Social theories of risk and uncertainty: An introduction. Singapore:Blackwell Publishing, 2008.16 Green J. Risk and the construction of social identity: children’s talk about accidents.Sociol Heal Illn 1997;19:457–79.17 Lupton D, Tulloch J. “Life would be pretty dull without risk”: voluntary risk-takingand its pleasures. Health Risk Soc 2002;4:113–24.18 Lyng S. Edgework: a social psychological analysis of voluntary risk taking. Am JSociol 1990;95:851–86.19 Christensen P, Mikkelsen MR. Jumping off and being careful: children’s strategies ofrisk management in everyday life. Sociol Heal Illn 2008;30:112–30.20 Hansen EB, Breivik G. Sensation seeking as a predictor of positive and negative riskbehaviour among adolescents. Pers Individ Dif 2001;30:627–40.21 Beck U. Risk society: towards a new modernity. London: Sage, 1992.22 Zelizer VAR. Pricing the priceless child: The changing social value of children.New York, NY: Basic Books, 1985.23 Einboden R, Rudge T, Varcoe C. Producing children in the 21st century: a criticaldiscourse analysis of the science and techniques of monitoring early childdevelopment. Health 2013;17:549–66.24 Foucault M. Governmentality. In: Burchell G, Gordon C, Miller P., eds. The foucaulteffect: studies in governmentality. Chicago: University of Chicago Press, 1991;307.25 Shirani F, Henwood K, Coltart C. Meeting the challenges of intensive parentingculture: gender, risk management and the moral parent. Sociology 2012;46:25–40.26 Wall G. Mothers’ experiences with intensive parenting and brain developmentdiscourse. Womens Stud Int Forum 2010;33:253–63.27 Douglas M. Risk as a forensic resource. Daedalus 1990;119:1–16.28 Peden M, Oyegbite K, Ozanne-Smith J, et al. World report on child injuryprevention. Geneva: World Health Organization Press, 2008.29 Valentine G. “Oh yes I can.” “Oh no you can’t”: children and parents’understandings of kids’ competence to negotiate public space safely. Antipode1997;29:65–89.30 Clements R. An investigation of the status of outdoor play. Contemp Issues EarlyChild 2004;5:68–80.31 Carver A, Timperio A, Crawford D. Playing it safe: The influence of neighbourhoodsafety on children’s physical activity—a review. Heal Place 2008;14:217–27.32 Malone K. The bubble-wrap generation: children growing up in walled gardens.Environ Educ Res 2007;13:513–27.33 Jago R, Thompson JL, Page AS, et al. Licence to be active: parental concerns and10-11-year-old children’s ability to be independently physically active. J PublicHealth 2009;31:472–7.34 CBC Radio. Free range parenting. 2013. http://www.cbc.ca/player/Radio/Local+Shows/British+Columbia/On+The+Island/ID/2362092477/?page=4 (accessed 30Sep 2013).35 Jacobs J. The death and life of great American cities. New York, NY: Vintage Books,1961.36 Johnson GD, Lu X. Neighborhood-level built environment and social characteristicsassociated with serious childhood motor vehicle occupant injuries. Health Place2011;17:902–10.37 Hofferth SL. Changes in American children’s time—1997 to 2003. Electron Int JTime Use Res 2009;6:26–47.38 Karsten L. It all used to be better? Different generations on continuity and changein urban children’s daily use of space. Child Geogr 2005;3:275–90.39 Gaster S. Urban children’s access to their neighborhood: Changes over threegenerations. Environ Behav 1991;23:70–85.40 Niehues AN, Bundy A, Broom A, et al. Everyday uncertainties: reframingperceptions of risk in outdoor free play. J Adventure Educ Outdoor Learn2013;13:223–37.41 Brussoni M, Olsen LL. Striking a balance between risk and protection: fathersattitudes and practices towards child injury prevention. J Dev Behav Pediatr2011;32:491–8.42 Brussoni M, Olsen LL, Creighton G, et al. Heterosexual gender relations in andaround childhood risk and safety. Qual Health Res 2013;23:1388–98.43 Brussoni M, Olsen L. The perils of overprotective parenting: Fathers’ perspectivesexplored. Child Care Health Dev 2013;39:237–45.44 Ball DJ, Ball-King L. Safety management and public spaces: restoring balance.Risk Anal 2013;33:763–71.45 Canadian Standards Association. CAN/CSA-Z614-14—Children’s playspaces andequipment. 5th edn. Toronto, ON: Canadian Standards Association, 2014.46 Ball DJ. Policy issues and risk-benefit trade-offs of “safer surfacing” for children’splaygrounds. Accid Anal Prev 2004;36:661–70.47 Canadian Playground Safety Institute. Comparison Table of CSA Z614 StandardRequirements. http://www.cpsionline.ca/UserFiles/File/EN/sitePdfs/trainingCPSI/StandardsComparisonChart-2007-03-29.pdf (accessed 11 Oct 2013).48 Herrington S, Nicholls J. Outdoor play spaces in Canada: the safety dance ofstandards as policy. Crit Soc Policy 2007;27:128–38.49 Play Safety Forum. Managing risk in play provision: a position statement. London:Play England, 2008.50 Ball DJ, Gill T, Spiegal B. Managing risk in play provision: implementation guide.London: Play England, 2012.51 Bertrands E, Lavrysen A. Facilitating risk perception and competence in youngchildren. European Early Childhood Education Research Association Conference.Crete, Greece: EECERA, 2014.52 Molcho M, Pickett W. Some thoughts about “acceptable” and “non-acceptable”childhood injuries. Inj Prev 2011;17:147–8.53 Rivara F. Counterpoint: minor injuries may not be all that minor. Inj Prev2011;17:149–50.54 Pless IB. On preventing all injuries. Inj Prev 2012;18:285–6.55 Langley J, Cryer C. A consideration of severity is sufficient to focus our preventionefforts. Inj Prev 2012;18:73–4.Dangerous trampolinesLarge inflatable toys may qualify as a newish hazard, but trampolines have long been knownto be dangerous for children. The number of such injuries is steadily increasing despite newsafety measures. Part of the problem may be due to the sense of false security provided bynetted enclosures resulting in less parental supervision. It is also likely that the rise is due toincreased exposure as a result of the growing popularity of trampolines. (Noted by IBP)Brussoni M, et al. Inj Prev 2015;21:344–347. doi:10.1136/injuryprev-2014-041241 347Special feature on January 2, 2021 by guest. Protected by copyright.http://injuryprevention.bmj.com/Inj Prev: first published as 10.1136/injuryprev-2014-041241 on 22 December 2014. Downloaded from Page 1 of 3SUPPLEMENT 1Injury Prevention Quite a few researchers have documented how children are active explorers, often both seeking and preferring risky play that may involve physical risk-taking activities and play where the ability to fight and physical strength are tested.[1–6] In one of the classic works on animal and human play, Aldis [7] points out that much of children’s play is related to fear, and that young children actively seek out the thrills of fearful situations such as swinging and jumping from high places. Both observations of children’s expressions in play[8] and interviews with children about their motives for engaging in risky play,[9] indicate that the ambiguity of experiences in risky play is the central point in children’s motivation for engaging in this kind of play. Sandseter’s[3,9] study showed that the primary motivation for the children to engage in risky play was the pleasant emotions it would give them as they gained a higher level of arousal and mastered risks they did not think they would dare. To achieve these experiences, they had several arousal-increasing strategies they incorporated in their play, such as intentionally increasing the height and speed of their play, acting more rashly, choosing more risky strategies of action and seeking to balance on the border of fear. Risk-taking in play includes both fear and excitement and this ambiguous feeling is what children seek in their play.[3,5,7,10–12] WHAT DO CHILDREN LEARN THROUGH RISKY PLAY?One of the benefits of children’s engagement in risky play is the “lessons for life” that they unconsciously learn while practicing handling risks. Risky play, as several researchers argue, is a way for children to enhance their risk mastery skills. Children approach the world around them through play; they are driven by curiosity and a need for excitement; they rehearse handling real-life risky situations through risky play; and they discover what is safe and not.[4,13–16] From a risk-theory perspective, this means that children gain a realistic notion of the objective risk in the situation.[13] Boyesen[17] states that in order for a child to “learn” how to master a risky situation, s/he will need to somehow approach the situation, and thereby increase the risk. This is similar to the argument proposed by Ball[1] and Stutz,[18] who emphasize the importance of letting children develop a sound sense of risk through taking risks in play. In a similar vein, a study investigating play providers’ views of children’s risky play in the UK reported that enabling children to test their abilities, develop skills for use in the wider world and learn about the real consequences of risk-taking were the most important benefits of risks and challenge in play.[19] Aldis[7] exemplifies how children progressively encounter risky play and seek out thrills in a gradual manner, which allows them to master the challenges involved. In this way, their subjective perception of the risk becomes more realistic. Through risky play, children prepare for handling real risks and dangers – it is a serious risk-management exercise.[13]The benefits of risky play involving activities related to height and speed, such as sliding, swinging, climbing and bike riding, may be relevant to learning about one’s ecology, exploring the environment[20] and practicing and enhancing different motor/physical skills for developing muscle strength, endurance and skeletal quality.[21–25] All physical practice and training might be relevant for the developing child. These kinds of play also involve training related to perceptual competencies, such as depth-, form-, shape-, size-, and movement perception,[26] and general spatial-orientation abilities.[20]Children venturing out on their own away from the surveillance of caretakers is a way of exploring one’s world and becoming at home in it.[4] Bjorklund and Pellegrini[20] similarly argue that children come to know their environment through continuously exploring new areas and objects. It seems that children attain enhanced familiarity and competence about their environment, its potentials and its dangers through exploring its features.[20] Rough-and-tumble play also involves great physical and motor stimulation.[21–25] Another possible function of rough-and-tumble play is to enhance social competence through affiliation with peers, social signaling, as well as good managing and dominance skills within the peer group.[23,24] It also provides for practice of complex social skills, such as bargaining, manipulating and redefining situations.[27,28] ANTI-PHOBIC EFFECTS OF RISKY PLAYAnother recently described evolutionary function of children’s risky play refers to the anti-phobic effect such play may have.[29] This suggested function of children’s risky play Can child injury prevention include health risk promotion?ARTICLE1Queen Maud University College of Early Childhood Education, Trondheim, NorwayDevelopmental benefits of children’s risky playEllen Beate Hansen Sandseter1Developmental benefits of children’s risky play — Supplement 1, Ellen Beate Hansen SandseterPage 2 of 3is based on research suggesting that several human fears and phobias, such as fear of heights, fear of water and separation anxiety, appear naturally at a developmentally relevant age as a part of the child’s maturation due to interplay between genes and the environment, yet vanish again due to a natural interaction with the relevant environment and the anxious stimulus as part of normal development.[30,31] Research on fear of heights has shown that sustaining injury due to falls both before age five and between ages five and nine is associated with the absence of fear of heights at age eighteen.[32] Thus, risky play with great heights may provide a desensitizing or habituating experience, resulting in less fear of heights later in life.[29] Similarly, research on separation anxiety shows that the number of separation experiences before age nine correlates negatively with separation anxiety symptoms at age eighteen,[33] and research on fear of water has concluded that there is no relationship between experiencing water trauma before age nine and the symptoms of water fear at age eighteen.[34] These findings suggest that risky play, where children separate from their caretakers by exploring new and unknown areas and play near and in water, may also have habituating effects on the innate fears of separation and water.[29] As such, Sandseter and Kennair[29] suggest that one important aspect of risky play is the anti-phobic effect of exposure to typical anxiety-eliciting stimuli and contexts, in combination with positive emotions (thrills, excitement and fearful joy) and relatively safe situations. The children learn to cope with and no longer to fear potentially dangerous situations.WHERE WE OUGHT TO GO/CALL FOR ACTIONUnderstanding of why and when children engage in risky behavior is important, particularly if such behavior in the long run is beneficial to their normal development. It seems that risky behavior is maintained despite adults’ attempts to make children’s environments relatively risk free. From both a safety perspective, as well as from a normal psychological developmental perspective, understanding the function of risky play and the different psychological mechanisms and motivational systems involved is important. In practice we should outline the balance between safety requirements and children’s needs and opportunities to play freely in challenging, stimulating and developing environments. The balancing act of letting children explore and take risks while still keeping them safe from fatal and serious injuries is not easy. The safety legislation on children’s play environments and the recent growing safety concerns among parents and caretakers should not result in restricting children from engaging in risky and challenging play activities. Rather, caregivers and supervisors should let children encounter risks and challenges within a relatively safe play setting,[4] even though one would have to take this important knowledge at the risk of some minor injuries. Children should be able to engage in challenging play, adjusted to each individual’s sense of risk and urge for exhilaration, and preschool staff, teachers and parents should be encouraged to support and maybe even inspire this. Play environments are also important for children’s opportunity to engage in risky play.[35] At playgrounds and play environments, one must consider both the risks and the developmental benefits of letting children face the risks.[1] A preoccupation with strict surveillance and restrictions of risky play would hinder the children from positive mastery experiences such as fun, enjoyment, high arousal, excitement, thrill, pride, achievement and healthy self-esteem.[12–14,16] Paradoxically, risk-avoidance puts children at greater risk because they may miss out on important developmental benefits.[1,4,13–18] Through risky play, children prepare themselves to handle “real risks and dangers,” it is “serious risk-management exercise.”[13]Children’s safety is important and severe injuries or death must be avoided. However, the benefits of risky play should be highlighted and brought forward as a natural part of the play safety discussion.REFERENCES1. Ball DJ. Playgrounds - risks, benefits and choices. Report No. CRR 2002/426. London, England: 2002. http://www.hse.gov.uk/research/crr_htm/2002/crr02426.htm2. Readdick CA, Park JJ. Achieving Great Heights: The Climbing Child. Young Child 1997;53:14–9.3. Sandseter EBH. Scaryfunny: A qualitative study of risky play among preschool children. 2010.http://ntnu.diva-portal.org/smash/record.jsf?pid=diva2:322544 (accessed 11 Oct2013).4. Smith SJ. Risk and our pedagogical relation to children: On the playground and beyond. Albany, NY: State University of New York Press 1998. 5. Stephenson A. Physical risk-taking: Dangerous or endangered? Early Years 2003;23:35–43. 6. Stine S. Landscapes for learning: Creating outdoor environments for children and youth. New York, NY: John Wiley & Sons 1997. 7. Aldis O. Play fighting. New York, NY: Academic Press 1975. 8. Sandseter EBH. Children’s expressions of exhilaration and fear in risky play. Contemp Issues Early Child 2009;10:92–106.9. Sandseter EBH. “It tickles in my tummy!”: understanding children’s risk-taking in play through reversal theory. J Early Child Res 2010;8:67–88. doi:10.1177/1476718X0934539310. Cook SC. The perception of physical risk by children and the fear/exhilaration response. University of Missouri-Columbia 1993;:220.11. Cook S, Peterson L, DiLillo D. Fear and exhilaration in response to risk: An extension of a model of injury risk in a real-world context. Behav Ther 1999;30:5–15.12. Coster D, Gleeve J. Give us a go! Children and young people’s Developmental benefits of children’s risky play — Supplement 1, Ellen Beate Hansen SandseterPage 3 of 3views on play and risk-taking. London, England: 2008. http://www.playday.org.uk/media/2667/give_us_a_go___children_and_young_peoples_views_on_play_and_risk_taking.pdf13. Adams J. Risk. London, England: Routledge 1995. 14. Apter MJ. Danger: Our quest for excitement. Oxford: Oneworld 2007. 15. Gill T. No fear: Growing up in a risk averse society. London, England: : Calouste Gulbenkian Foundation 2007. 16. Sutton-Smith B. The ambiguity of play. Cambridge, MA: Harvard University Press 2001. 17. Boyesen M. Den truende tryggheten. 1997.18. Stutz E. Playground Safety: Proceedings of the 1995 International Conference. In: Christiansen ML, ed. Playground safety: Proceedings of the 1995 International Conference of Playground Safety. Pennsylvania: Penn State University. Center for Hospitality, Tourism & Recreation Research 1995. 19. Greatorex P. Risk and play: Play providers’ experience and views on adventurous play. London, England: 2008. http://www.playday.org.uk/media/2670/risk_and_play___play_providers’_experience_and_views_on_adventurous_play.pdf20. Bjorklund DF, Pellegrini AD. The origins of human nature: Evolutionary developmental psychology. Washington, DC: American Psychological Association 2002. 21. Bjorklund DF, Pellegrini AD. Child development and evolutionary psychology. Child Dev 2000;71:1687–708.22. Byers JA, Walker C. Refining the motor training hypothesis for the evolution of play. Am Nat 1995;146:25. 23. Humphreys AP, Smith PK. Rough and tumble, friendship, and dominance in schoolchildren: Evidence for continuity and change with age. Child Dev 1987;58:201–12. 24. Pellegrini AD, Smith PK. Physical activity play: The nature and function of a neglected aspect of playing. Child Dev 1998;69:577–98.25. Bekoff M, Byers J. A critical reanalysis of the ontogeny and phylogeny of mammalian social and locomotor play: An ethological hornet’s nest. In: Immelmann K, Barlow G, Petrinovich WL, et al., eds. Behavioral development: The Bielefeld interdisciplinary Project. Cambridge, England: Cambridge University Press 1981. 296–337.26. Rakison DH. Infant perception and cognition: An evolutionary perspective on early learning. In: Origins of the social mind: Evolutionary psychology and child development. New York, NY: Guilford Press 2005. 317–53.27. Flinn M V., Ward C V. Ontogeny and evolution of the social child. In: Ellis BJ, Bjorklund DF, eds. Origins of the social mind: Evolutionary psychology and child development. New York, NY: Guilford Press 2005. 19–44.28. Smith PK. Does play matter? Functional and evolutionary aspects of animal and human play. Behav Brain Sci 1982;5:139–55. 29. Sandseter EBH, Kennair LEO. Children’s risky play from an evolutionary perspective: The anti-phobic effects of thrilling experiences. Evol Psychol 2011;9:257–84.30. Poulton R, Menzies RG. Fears born and bred: toward a more inclusive theory of fear acquisition. Behav Res Ther 2002;40:197–208.31. Poulton R, Menzies RG. Non-associative fear acquisition: a review of the evidence from retrospective and longitudinal research. Behav Res Ther 2002;40:127–49.32. Poulton R, Davies S, Menzies RG, et al. Evidence for a non-associative model of the acquisition of a fear of heights. Behav Res Ther 1998;36:537–44.33. Poulton R, J. Milne B, Craske MG, et al. A longitudinal study of the etiology of separation anxiety. Behav Res Ther 2001;39:1395–410.34. Poulton R, Menzies RG, Craske MG, et al. Water trauma and swimming experiences up to age 9 and fear of water at age 18: a longitudinal study. Behav Res Ther 1999;37:39–48.35. Sandseter EBH. Affordances for risky play in preschool: The importance of features in the play environment. Early Child Educ J 2009;36:439–46. Page 1 of 3SUPPLEMENT 2Injury Prevention Are we protecting our children too much while at play? From the perspective of most professional landscape architects in North America this is a tricky question to answer. Playgrounds are the sites of frequent litigation and professional liability insurance coverage must extend to specialty areas related to playground safety, along with skate park design, and soil testing. The fear of litigation dictates design, unfortunately, and skews the focus of the design process of most play spaces from adventure and challenge to safety and protection. This situation reflects a larger societal belief that children are in danger and are in need of our protection, and it has been documented in much of the literature concerning children’s health and public space over the past six years.[1–6] This nuanced understanding of the role of risk in children’s development in relation to the design of outdoor play spaces seldom makes its way to debates in landscape architecture. Rather discussions in the professional literature emphasize the need to demonstrate due diligence to safety in the selection of equipment and fall surfaces.In an effort to show due diligence to children’s safety professional designers rely on safety guidelines and standards sold by organizations, such as the Canadian Standards Association (CSA) and the American Society for Testing, Materials (ASTM) International. These organizations sell guides to the technical requirements for the design of outdoor play spaces (as well as the manufacture/construction, installation, maintenance, and inspection of them). This scope leaves little room to consider the benefits of risk-taking for a developing child—a consideration that should be factored into a playground’s design. It is not the purview of these organizations to do so as the writers of these technical documents are typically engineers and manufacturers. However, municipalities often tie funding for playground construction and renovation to the use of these technical guides. The consideration of the benefits of age appropriate risk-taking is not undertaken, as the conformance to technical standards and products become the primary focus of design.Particularly troubling are discussions among landscape architects and designers themselves regarding the safety of particular materials and equipment is often presented as a quick checklist of “dos and don’ts,” with some materials and standards promoted as “fail-safe” approaches to the design of children’s outdoor play spaces. A case in point is impact-absorbing surfaces, like rubber around play structures. In a 2011 article on playground design by an American landscape architect, he advises readers that, “safety surfacing will cushion falls so that emergency-room visits are not needed.”[7] Not to pick on this particular author (who most likely has the best of intentions) but the statement is indicative of the misinformation provided to and by landscape architects about playground safety and design. The safety surfacing that the author refers to is rubber, poured-in-place or tiles. It is tested, designed, and marketed to landscape architects for applications in children’s outdoor play spaces. Yet no material can guarantee the elimination of trips to the emergency room. Moreover, the exact contribution that this surfacing makes to children’s injury prevention is debated among epidemiologists and engineers. Davidson et al.[8] modeled energy flow within the wrist when impacting two playground surfaces – rubber and bark. They found that rubber surfacing returned more energy to the wrist than bark surfacing, increasing likelihood of fracture. Ball[9] found that while impact-absorbing surfaces, such as rubber tiles, were installed throughout the UK between 1981-1999, there were few cost-benefits to justify their expense, and there has been no apparent trend in playground injury cases since the surfacing was installed. This is an important consideration because outdoor play spaces have limited sources of funding, and the cost associated with implementing expensive surfacing will take funds away from other parts of the design. So while impact-absorbing surfaces’ contribution to injury prevention is debatable, the promotion of its use in the literature in landscape architecture continues.These uncertainties about the safety of particular materials also contribute to the narrowing of the palette of play surfaces and structures designed across North America and in the UK. Impact-absorbing surfaces account for the carpet in what Woolley and Lowe[10] call the KFC (Kit, Fence, Carpet) playground design style commonly found throughout the UK. KFC playgrounds are ubiquitous in Canada too. Impact-absorbing surfaces featured prominently in my own analysis of sixteen outdoor play spaces at licensed childcare centres in the city of Vancouver, British Columbia. Of the sixteen centres studied, eight contained primarily rubber matting as Can child injury prevention include health risk promotion?ARTICLE1School of Architecture and Landscape Architecture, University of British Columbia, Vancouver, BC, CanadaRewriting the ground rules for outdoor play spacesSusan Herrington1Rewriting the ground rules for outdoor play spaces — Supplement 2, Susan HerringtonPage 2 of 3surfacing for the play space.[11] We also found that impact-absorbing surfaces had little or no play value compared with sand or other loose material. During focused interviews with early childhood educators working at these centers, it was noted that the rubber could not be manipulated by the children. They also revealed that they were very aware of how expensive the rubber was, and that sand combined with sun and water eroded its surface. As a result they spent a good deal of time keeping sand away from this expensive surfacing.[12] Wooley and Lowe[10] also found that the KFC playgrounds they studied in the UK failed in providing manipulation and interaction with the environment. In short, substituting sand for rubber surfacing removes a valuable play element from the play space, especially for young children. Play structures are another case in point, and represent the kit in KFC. Kits are fixed play structures. Although they provide little change over time, and do not offer the manipulation that loose parts offer, they are typically selected for playgrounds designed by landscape architects. With increased concern for safety on most Canadian playgrounds, these fixed structures have become lower and some research suggests that they are not as challenging or thrilling. In our interviews with the Early Childhood Educators working in the centres studied in Vancouver, 57 percent wished there were more challenging equipment and play structures in their outdoor play spaces.[13] This may account for why we found that children were playing on the play equipment in these centres only 13% of their play time.[11] In Cincinnati, Ohio researchers conducting nine focus groups with 49 early childhood educators at 34 childcare centres for preschoolers found that injury prevention on the playground was one of the three barriers to physical activity (finance and focus on academics were the other two barriers).[14] Several participants discussed how overly strict standards had rendered climbers unchallenging and uninteresting to the children, thus diminishing opportunities for physical activity. The new play equipment was thought to be safer, but children quickly mastered it and it became uninteresting to the children. “To keep it challenging teachers noted that children would start to use the equipment in (unsafe) ways for which it was not intended.”[14] Sadly, this could potentially increase the number of injuries in play spaces that were designed with the intention of mitigating injuries. Regarding litigation, landscape architects should consider the fact that lawsuits are argued based on children’s developmental interest–that they enter adulthood without disadvantage.[15,16] If a landscape architect’s design or planning of a playground or specification of playground equipment causes a developmental disadvantage in a child using the playground then he or she can be found negligent.[17] Yet, could landscape architects be negligent in providing developmentally supportive play spaces? Are KFC playgrounds with their carpets and kits developmentally disadvantaging children, especially play spaces used on a daily basis on schools grounds and childcare centres? If so, landscape architects and designers should collaborate with researchers in child development and injury prevention to better understand the relationship between risk-taking, child development, and the design of outdoor play spaces. Landscape architects need more holistic guidance on how to balance risk benefits and safety in their design of play spaces. The UK Play Safety Forum’s Managing Risk in Play Provision: Implementation Guide[18] offers play providers a unique guide to strike this balance. This document gives a comprehensive description of risk-benefit assessments for the multi-faceted questions one must ask during the planning and design for an outdoor play space, as well as case studies. It could certainly provide a template for a Canadian version.In conclusion, landscape architects are currently working with limited information regarding the relationship between child development, risk-taking, and the design of outdoor play spaces. Information on this relationship tends to be taken from guidelines that are often focused on the engineering aspects of the playground features and materials. Since funding is often tied to the design’s conformance to these guidelines, speculation beyond their requirements seldom happens. This limited knowledge has also had the unfortunate consequences of reducing much of the discussion about play space design amongst landscape architects to checklists that in some instance are based on unsubstantiated facts. To move forward, we need to cut across disciplinary boundaries—between landscape architecture, child development, and injury prevention—and adopt a holistic approach to the design of children’s outdoor play spaces. We need to rewrite the ground rules for design to help children engage with the environment rather than only protecting them from it.REFERENCES1. Gill T. No fear: Growing up in a risk averse society. London, England: : Calouste Gulbenkian Foundation 2007. 2. Little H, Eager D. Risk, challenge and safety: Implications for play quality and playground design. Eur Early Child Educ Res J 2010;18:497–513. 3. Sandseter EBH, Kennair LEO. Children’s risky play from an evolutionary perspective: The anti-phobic effects of thrilling experiences. Evol Psychol 2011;9:257–84.4. Brussoni M, Olsen LL, Pike I, et al. Risky play and children’s safety: Balancing priorities for optimal child development. Int J Environ Res Public Health 2012;9:3134–8.5. Ball DJ, Ball-King L. Safety management and public spaces: Restoring balance. Risk Anal 2013;33:763–71. 6. Lester S, Russell W. Play for a change - Play, policy and practice: A review of contemporary perspectives. London, Rewriting the ground rules for outdoor play spaces — Supplement 2, Susan HerringtonPage 3 of 3England: 2008. http://www.playengland.org.uk/resources/play-for-a-change-play,-policy-and-practice-a-review-of-contemporary-perspectives.aspx7. Schoenthal T. Creating chemistry. Effectively mixing design and equipment for playground safety. Landsc Archit Bus 2011;:18–21.8. Davidson PL, Wilson SJ, Chalmers DJ, et al. Analysis of energy flow during playground surface impacts. J Appl Biomech 2012.9. Ball DJ. Policy issues and risk-benefit trade-offs of “safer surfacing” for children’s playgrounds. Accid Anal Prev 2004;36:661–70. 10. Woolley H, Lowe A. Exploring the relationship between design approach and play value of outdoor play spaces. Landsc Res 2013;38:53–74. doi:10.1080/01426397.2011.64043211. Herrington S, Lesmeister C, Nicholls J, et al. Seven C’s: An informational guide to young children’s outdoor play spaces. Vancouver: : Consortium for Health, Intervention, Learning and Development (CHILD) 2007. http://www.wstcoast.org/playspaces/outsidecriteria/7Cs.pdf12. Herrington S, Nicholls J. Outdoor play spaces in Canada: The safety dance of standards as policy. Crit Soc Policy 2007;27:128–38. doi:10.1177/026101830707221013. Herrington S. Perspectives from the ground: Early Childhood Educators’ perceptions of outdoor play spaces at child care centers. Child Youth Environ 2008;13:64–87.14. Copeland KA, Sherman SN, Kendeigh CA, et al. Societal values and policies may curtail preschool children’s physical activity in child care centers. Pediatrics 2012;129:265–74. 15. Archard D. Children: Rights and childhood. 2nd ed. London, England: Routledge 2004. 16. Herrington S. Rights of passage - rites to play: Landscapes for children at the turn of the Centuries. In: Egoz S, Makhzoumi J, Pungetti G, eds. The Right to landscape: Contesting landscape and human rights. London, England: Ashgate Publishing 2011. 113–23.17. Schatz S. Regulation of landscape architecture and the protection of health, safety and welfare. Washington, DC: 2003. http://www.asla.org/uploadedFiles/CMS/Government_Affairs/Member_Advocacy_Tools/PHSW-FINAL.pdf18. Ball DJ, Gill T, Spiegal B. Managing risk in play provision: Implementation guide. London: Play England 2012. http://www.playengland.org.uk/resources/managing-risk-in-play-provision-implementation-guide.aspx Page 1 of 2SUPPLEMENT 3Injury Prevention As a recreation practitioner who deals with the issues of risk and play on the front-line, I have had my share of experiences related to balancing facilities and programs for both risk-averse and risk-seeking community members. My goal is to provide a snapshot of the historically complex interaction between public recreation and risk, and how changes in demand – be it away from, or toward risky play have impacted municipal recreation services. The origin of the Parks and Recreation movement in the early 1900s was largely in the provision of free and open park spaces for the aesthetic enjoyment of residents and visitors. These were simpler times and little time was spent considering potential risks in these spaces. Later, this work evolved into the development and management of swimming places (both outdoor and indoor), tennis courts, and new community halls to supplement churches and schools as venues for dances and community events. At that time, few resources were put into formalized recreation programs and services, and individuals took responsibility for their own leisure time. Our role was to build it and let them come. During this period, when government was considered “owned by the people” – it was almost unthinkable to take legal action against government for an injury incurred while playing in a park or facility; therefore little attention was paid to the mitigation of risk, and patrons were largely responsible for their own safety.The 1950s, 60s and 70s were different times. Unstructured play was the norm for most children, playing games like scrub and kick-the-can with no adult supervision or cell phone contact. I was fortunate to spend every summer at a lake where our “main beach” had a raft, dock, slide and – the best of all – a home-crafted metal two level diving tower with planks on two sides where I learned to dive into water that was about 10 feet deep. Although I suspect the village council of the day was aware that these features brought risk of injury and they were open to litigation, the amenities made the beach area incredibly popular for locals and visitors. This period; late 1950s to 1970s – brought some changes to the Parks and Recreation sector. During these years we were primarily seen as providers of recreation spaces - swimming pools, ice arenas, curling clubs, parks, and rather modest community centres. While more ‘managed’ or ‘organized’ recreation programs were emerging, the trend of free, unsupervised and unmitigated play remained most popular. We continued to be mainly facilitators, providing space where people could connect with each other and engage with recreation however they chose. Being safe continued to mostly be the responsibility of the patron – and while I do not suggest that this was a better time to be a child, there is a lot to be said for free play, and the associated learning that took place. I suggest that during that time, risk management was a notion for municipalities in their provision of recreation services, but not a great focus.In the 1980s and 90s, taxpayer investment in public recreation increased as we built many facilities. We went wild in the playground department; constructing adventure and creative playgrounds that promised to foster creativity, innovation and ingenuity. We built many community recreation centres and sport specific facilities and switched from being primarily facility providers to both facility and program providers. This was a significant change sparked by consumer demand. Residents began to request recreation programs for two primary reasons. Firstly, recreation was increasingly recognized as an important tool in positive childhood development and we developed programs and services that would maximize this development. Secondly, related more directly to risk-aversion, was parental pressures and demands. The style of parenting that dominated in the 1990s was characterized by high fear, high control and low risk. Due to fear of ‘what could happen’, parents were over-protective and over-scheduled their children. We, as recreation service providers, mirrored these trends in our practices. The pressure to remove risky play elements, such as my beloved diving tower, came from risk-averse parents, insurance providers, Council members and administrators. We developed rules and regulations, ramped up our supervision of programs held in padded gyms and tore down playgrounds that were too high and too hard. We closed diving boards during public swimming sessions, removed ropes, slides, platforms and other fun elements. We resisted the growing demand for skate parks in response to public fears that they would be havens for delinquent youth to swear, do drugs and no doubt hurt themselves. We replaced swings, monkey bars and adventure playground components with static elements, brightly coloured to Can child injury prevention include health risk promotion?ARTICLE1North Vancouver Recreation Commission, North Vancouver, BC, CanadaBubble-wrapped recreation – have fun but don’t get hurt!Heather Turner1Bubble-wrapped recreation – have fun but don’t get hurt! — Supplement 3, Heather TurnerPage 2 of 2make them look attractive; distracting parents and children from the fact that they were not that much fun. We closed outdoor paddling pools, introduced waiver forms, criminal record checks for staff and risk management manuals. A good example of this is my childhood beach which today has only a dock; no raft, slide or tower - all removed because the village could not afford the escalating insurance costs and the council was not prepared to take the chance of a potential lawsuit.For the last 2 to 3 decades, our society has been so afraid of what “might” happen that children no longer bike through their neighbourhood, let alone to soccer practice or a friend’s house. According to Active Healthy Kids Canada, only 25 to 35% of Canadian children and youth walk, bike or wheel to school – 65 to 75% are driven.[1] In addition to the health issues arising from this inactivity, over-protecting children impacts their ability to assess bad situations, take physical risk, learn from the consequences of taking such risks, and to problem solve. My colleagues and I are passionate about the physical, social, emotional and cognitive benefits of play and recreation to participants and espouse the public good that the community at large derives from quality recreation. We aim to facilitate the healthy development of children, although I suggest that we got a bit side-tracked in the past 10 to 20 years in trying to appease parental fears and by becoming overly focused on mitigating risk. We did benefit from parental fears of children playing outside unsupervised; our program registrations increased as parents sought safe indoor, supervised recreation programs. Most municipalities are now experiencing shifts in demand and either plateaus or decreases in participation in traditional registered programs. There appears to be a renewed increase in spontaneous activities and risky recreation and sport. We are now seeing the young adults that were over-protected children in the 1990s craving activities that are thrilling. While municipalities are not usually the providers of these of high-risk activities, they have an impact on the Councils and staff as the demand for, and concerns around these activities increase and collide. In my community, we have recently dealt with two matters directly related to such risk and recreation. Firstly, we have been wrestling with the impact of the popular longboarding trend. There is pressure from the public to ban the activity and pressure from participants and their parents to allow it. This balancing act is challenging because both those for and those against have good points. While longboarding is prohibited on certain streets, as with many banned activities, enforcement is a problem and fines are rare. Municipalities face a dilemma of wanting people to be safe but struggling with the ability to regulate. A second example is an examination of the question of helmet use in ice arenas. Several viewpoints were expressed; that helmets should be mandatory for all, or for those under 16, while others expressed concern that teenagers would stop participating if helmets were required. We conducted research into the frequency of arena incidents, the probability of helmets preventing serious injury and the age of participants who typically participated in public skating. Our ultimate decision was to require helmets in registered programs and for instructors and supervisors on ice, and to encourage helmet use, but not to make them mandatory for all. We made this choice to ensure that we did not counter our primary objective – to attract youth to public skating sessions and to get them active. Our challenge is to find the right balance between satisfying the legitimate concerns of risk managers and the public while meeting the recreation needs of risk-seeking parents and youth. When presented with the opportunity to offer circus programs in which participants fly high on silks and trapezes and pedal on unicycles, we jumped at it. In the 1990s we would have been too scared to try. We need to continue to move away from focusing too much on bubble-wrapped recreation – towards smartly and courageously providing new, innovative and physically challenging activities in support of healthy child development.I wonder if in a few years we may begin to see that the parents (those who were over-protected in the 1990s) want different childhood experiences for their offspring; one with more adventure and risk-taking. Perhaps the pendulum that swung from personal responsibility for recreation to government provided; from outdoor to indoor and from risk-averse to managed acceptable risk will swing back to somewhere in the middle. Risk in recreation is unavoidable and incidents will happen. Our goal must be to understand and meet the needs of our residents and address the expectations and fears of the risk-averse and risk-seeking in a reasonable, balanced way that protects both the participants and the municipalities. We need to understand parental fears and concerns and respond to them, but do that with our ultimate goal in mind; to build healthy individuals, families and communities.REFERENCES1. Active Healthy Kids Canada. Is active play extinct? 2012 Active Healthy Kids Canada report card on physical activity for children and youth. Active Healthy Kids Canada 2012.Page 1 of 3SUPPLEMENT 4Injury Prevention As I sit near the playground at my 5-year-old son’s school, I see parents and teachers struggle to prevent children from going up the spiral slide to the highest platform on the playground. It seems twice as many children want to climb up the spiral slide as those that wish to sit down on their bums and descend the slide “as intended.” The reality is that it is normal for a child to want to climb up a slide when after the first few “intended use” turns, it loses its excitement. They are only doing what they are naturally wired to do – challenging themselves. We are told that new play equipment designs are built for safety. But have playgrounds actually become any safer? Or are they just boring pieces of equipment that encourage kids to play elsewhere other than at the play space and therefore evade injury statistics? Many playgrounds have been stripped of fun and excitement for thrill-seeking kids, all as a result of litigation concerns, risk managers, parents, various pieces of legislation and playground safety standards. But, after all the playground removals we have heard about, read about or been involved with, have new playgrounds really become safer? Will this trend continue? Should more risk be re-introduced to the childhood play experience? Surely, exposure to some risk makes kids more comfortable with it.The Executive Director of the U.S. Alliance for Childhood, Joan Almon, says, “Give [children] some genuine risk and they quickly learn what their limits are, and then they expand their limits.”[1] The problem is that if children never encounter even tiny or age appropriate risks, they never develop common sense in dealing with risk and challenge.[1] In the schoolyard, at a standard play space or elsewhere, how can we learn how fast is “too fast” unless we have experienced or witnessed “too fast”? How do children learn to fall from a playground structure safely unless they have experienced or witnessed a fall?Some municipalities in Canada limit the height of equipment to 1.8 meters (6 feet). No doubt this will help reduce the chance of an injury from falls, especially considering that very few children will get excited about going to the park. What if for every kid who avoids breaking a leg from a playground fall, a million more never develop the muscles to do a chin-up, the endurance to play a game of tag, or the ability to analyze risk and learn about consequences?[1] This problem, at times, goes well beyond playground safety standards. Some schools or school boards have outlawed ball playing, tag and other running games, while others only allow running around the perimeter of the yard and not anywhere in the middle due to the chance of a collision between runners.[1] In addition, some schools have optional outdoor recess and sometimes physical education class is not a requirement. Risk limitation can encourage children to find alternative uses for play equipment (for example the common game grounders in which the children climb the outer periphery of the play equipment without touching the ground). If the intent is to reduce injuries from falls, could we not provide the same height, but provide more enclosure and/or better resiliency of the protective surfacing on the playground to make it safer, but still fun? Canadian hospitalization rates due to playground injuries have dropped significantly from 35 per 100,000 in 1994/95 to 25 per 100,000 in 2011/12.[2] This might be due, in part, to increased compliance with the playground safety standard. Originally published in 1990 by the Canadian Standards Association (CSA), the standard includes recommendations for manufacturing, installation and inspection of play spaces as well as requirements for design (e.g. playground surfacing, equipment height, spacing between climber rungs).[3] Since the initial set of safety standards was published, we have seen it grow from 52 pages in the 1990 edition, to 165 pages in 2014, even though public playgrounds account for an average of less than 1 fatality per year in Canada, much rarer than death by lightning strike.[4–6] Canada is not alone in expanding its regulations. The same scenario is evidenced in other parts of the world, including the United States.The limitations of standards might be reflected in recent hospitalization statistics showing an upswing in playground injuries from 2007/8 to 2011/12, as reported in a CBC news article.[7] Playground designer Adam Bienenstock, raises the issue of play space surfacing (personal communication, Adam Bienenstock, October 1, 2013): when testing adherence to the recommendations for surfacing, the current gold standard for measuring impact is the surface impact test from the fall height of the installed equipment. This test is designed to prevent head injuries and is not intended to provide Can child injury prevention include health risk promotion?ARTICLE1Phrase used by Joan Almon, Executive Director of the U.S. Alliance for Childhood.[12]2Reliable Reporting, Toronto, ON, Canada“Children rise to risk”1Scott Belair2“Children rise to risk” — Supplement 4, Scott BelairPage 2 of 3any measure of injury reduction other than head injury. Commonly used surfacing, such as rubber, may comply with the standard and adequately prevent head injuries, while contributing to the increased incidence of specific bone fractures.[8] Another limitation of the playground standard identified by Bienenstock is that it was not written to provide guidance for risk and play in nature. ‘Time in Nature’ is now an indicator in the Active Healthy Kids Canada Report Card.[9] There is growing evidence that the emotional, physical, and intellectual development of our children improves through increased contact with nature, while at the same time reduces bullying, injury rates, vandalism, and aggressive behaviors.[10] For natural playgrounds, less stringent standards might improve child development outcomes.Some of the world’s most creative playgrounds and playground designers are located in Scandinavia and Germany. Many believe that early playgrounds evolved from children having a great time playing in the rubble of bombed out buildings (as compared to local play spaces). Following the war, many play space designers started with the concept of the adventure playground,[11] with the understanding of what children wanted in a play space (adventure, thrill seeking, changing play environment, creativity – often with loose parts, hiding play places, etc.) and then tried to add a modicum of safety. Playground safety standards ought to be based on the hazard rather than prescriptive text. For example, in a majority of playground safety standards, climber rungs need to be 30 cm or less in distance apart. This spacing is based on the maximum distance a younger user can climb. The result is that these climbers are not challenging to our older users. What if, instead of a specific dimension, playground standards told designers to ensure climber rungs were spaced appropriately for the age group they were designed for? We might see slanted climber rungs. The idea of the slant is to make them closer together on one side and therefore easier, yet the other side of the climber might have significantly greater spacing as a challenge for older users. Children could choose the appropriate spot for themselves. This would allow play space designers to be more creative, provided the hazards are addressed and/or mitigated. In new playground design, no one wants to create spaces that lead to children getting hurt. But there are ways to give children a sense of excitement without risking serious injuries. For instance, designers can provide climbing to thrill seeking heights of 6 to 8 metres, while limiting direct falls to the surfacing to manageable heights of 70 cm or less. These types of more exciting playgrounds are already commonplace in Europe and the movement is starting to spread to North America. The general concept is to incorporate hills, embankments, landscape features and climbing equipment to form a pyramid or hill shape with play elements extending at various heights and lengths from a central point. The central masts are often only accessible through small cracks that adults dare not go!Many parents, designers, and manufacturers of equipment would like to see risky elements of choice (e.g. monkey bars, suspension bridges, zip lines, hill slides, etc.) be available in play spaces, but not hidden hazards (e.g. faulty or damaged equipment, near structural failure, equipment improperly spaced, etc.).If we focused on the following areas from a hazard removal-based perspective, we could open the door to more creative designs:1. Heights – Do provide graduated challenge and indicate age appropriateness or difficulty levels. Do not provide great height without adequate fall protection (i.e. cushioned surfacing) and/or appropriate enclosure devices.2. Speed – Do provide sliding, swinging, and motion activities where children control the speed and movement of equipment. Do not provide uncontrolled speed.3. Tools – Do allow children to make a child-constructed playground or alter the look of a part, to indeed make it their park. Do not provide dangerous tools (such as saws, axes, ropes).4. Visibility / Supervision – Do allow children over age 3 years to have some freedom without an adult (this can be done by trimming lower levels of shrubs for foot visibility, mesh enclosures so that children can have their space, provide fencing around the play space for containment, etc.). Do not design a space where children can get lost or disappear from supervision. Do not put elements too close together to inhibit flow of movement throughout the play space, or inhibit fall protection.5. Dangerous Elements – Do not allow cliffs, deep or icy water, fire pits, etc. in a play space.6. Entanglement / Entrapment – Do not allow equipment joints that could entangle cloth or entrap all or part of a child’s body.Following that, a play space should be regularly inspected and maintained for obvious hazards (broken, vandalized components, significant wearing / decay, etc.). After that, we should let designers have the flexibility to be creative and add new stimuli to play spaces. And finally…let kids play and be kids!“Children rise to risk” — Supplement 4, Scott BelairPage 3 of 3REFERENCES1. Skenazy L. Free range kids: Giving our children the freedom we had without going nuts with worry. San Francisco: : Jossey-Bass 2009. 2. Canadian Institute for Health Information. National Trauma Registry Minimum Data Set, 1994-1995 to 2011-2012. 2013.3. Canadian Standards Association. CAN/CSA-Z614-14 - Children’s playspaces and equipment. 5th ed. Toronto, ON: Canadian Standards Association 2014. 4. Fuselli P, Yanchar NL. Preventing playground injuries. Paediatr Child Health 2012;17:328–30.5. Safe Kids Canada. Child & youth unintentional injury: 10 years in review. Toronto: 2007. http://www.mhp.gov.on.ca/en/prevention/injury-prevention/skc_injuries.pdf6. Mills B, Unrau D, Parkinson C, et al. Assessment of lightning-related fatality and injury risk in Canada. Nat Hazards 2008;47:157–83. doi:10.1007/s11069-007-9204-47. CBC News. Playground equipment involved in rising number of injuries. 2013.http://www.cbc.ca/news/playground-equipment-involved-in-rising-number-of-injuries-1.1858497 (accessed 30 Sep2013).8. Howard AW, Macarthur C, Rothman L, et al. School playground surfacing and arm fractures in children: a cluster randomized trial comparing sand to wood chip surfaces. PLoS Med 2009;6:e1000195. 9. Active Healthy Kids Canada. Are we driving our kids to unhealthy habits? Toronto, ON: 2013. http://www.activehealthykids.ca/ReportCard/2013ReportCard.aspx10. UNICEF. The state of the world’s children 2012. New York, NY: 2012. http://www.unicef.org/sowc2012/fullreport.php (accessed 11 Oct2013).11. Kozlovsky R. Adventure playgrounds and postwar reconstruction. In: Gutman M, Coninck-Smith N de, eds. Designing modern childhoods: History, space and the material culture of children: An international reader. New Brunswick, NJ: : Rutgers University Press 2008. 12. Skenazy L. The war on children’s playgrounds. Salon. 2010.http://www.salon.com/2010/05/18/war_on_childrens_playgrounds/ (accessed 19 Mar2014). Page 1 of 3SUPPLEMENT 5Risky play, injury prevention & child development – public policy perspectiveLouise Logan & Pamela Fuselli1Injury Prevention 1. INTRODUCTIONAccording to the Canadian Institute for Health Information, more than 28,000 children are injured on playgrounds across Canada every year.[1] Approximately 10% of these injuries result in hospitalization. The Canadian Pediatric Society notes that children five to nine years of age have the highest risk of injury.[2] Falls are the leading cause of injury, and the types of injury sustained include head injuries, fractures, internal injuries, dislocation, and amputation. The fact that children’s play and playgrounds can result in injury, even serious injury and death, is not news. Nor is the idea that measures should be put in place to prevent injuries and keep children safe from harm. Rather, the question under consideration is whether the measures put in place to keep play spaces safe also support optimal child development and health.Balancing the need to provide environments where children can develop, and at the same time avoid injury raises important public policy issues. In this paper, we will briefly explore the current public policy landscape in Canada as it relates to children’s play spaces, and touch on policy considerations that have been identified in Canada as relevant to striking the “right balance” in the context of children’s play spaces.2. CURRENT PUBLIC POLICY LANDSCAPESafety on playgrounds and equipment in Canada is governed by a patchwork of statutes, standards, provincial regulations, and duties at common law. 2.1 LegislationRelevant statutory provisions can be found in provincial occupier liability statutes, which set out the general duty of care an occupier owes to persons coming on the premises. In general terms, an occupier owes a duty to take reasonable care in the circumstances, such as outlined in the Ontario’s Occupier Liability Act (RSO 1990, c. 0.2).[3] In Alberta, the Occupier Liability Act also includes provisions specific to children (RSA 2000, c. 0-4, s. 13) and provides that, in certain circumstances, the occupier owes a duty to take reasonable care to see children will be reasonably safe from danger. In determining whether the duty of care has been discharged, consideration will be given to the age of the child, the ability of the child to appreciate the danger, and the relative burden on the occupier of eliminating the burden.Provincial education statutes set out the duties of teachers and principals to maintain proper order and discipline, and to attend to the health and comfort of students.2.3 StandardsThe Canadian Standards Association has developed a nationally recognized standard under CAN/CSA-Z614 “Children’s Playspaces and Equipment”.[4] Its purpose is “to promote and encourage the provision and use of playspaces that are well-designed, well-maintained, innovative, and challenging, and, in so doing, contribute to the development of healthy children in the broadest sense of the word.”The CSA Standard provides detailed information about materials, installation, strength of the equipment, surfacing, inspection, maintenance, performance requirements, access onto and off of equipment, play space layout and specifications for each type of equipment.First issued in 1990 and last reaffirmed in 2012, this standard is not law, but it is widely used and referred to as the minimum acceptable standard that should be voluntarily complied with. The Standard applies to public use play spaces and play equipment found in schools, parks, childcare facilities, institutions, multiple family dwellings, private resort and recreation developments, restaurants and other areas of public use. It does not apply to home playgrounds.Some jurisdictions have adopted this standard in regulation, policies, and guidelines. Quebec has made Z614 mandatory for daycare operators by referencing Z614 directly in their Education Childcare Regulation under the Educational Childcare Act. In Ontario, childcare settings that are licensed by the Ministry are inspected for compliance with the Z614 as a condition of licensure. 2.3 Case LawEducators have a well-established common law duty to students. The leading case on this point is Myers v. Peel County Board of Education (1981), 123 D. L.R. (3d) [1981] 2 S.C.R. 21, which went to the Supreme Court of Canada. According to the courts, school authorities must conduct Can child injury prevention include health risk promotion?ARTICLE1Parachute, Toronto, ON, CanadaRisky play, injury prevention & child development - public policy perspective — Supplement 5, Louise Logan & Pamela FuselliPage 2 of 3themselves in the same manner as a “careful or prudent parent”, which includes a duty to guard against inherent and foreseeable elements of risk in the activities of the students.[5] The application of the standard of care in individual cases is dependent on the facts of the case, and takes into account a variety of factors such as: the type of activity being undertaken, the location where the injury occurred, the age of the students, the condition of the equipment, and the number of students being supervised. Interestingly, although the statistics indicate that there are lots of cases of children being injured, there is relatively little Canadian case law related to playgrounds. This does not, however, diminish the importance of legal duties, standards of care, and the risk of legal action as a policy driver. 3. DISCUSSIONSandseter and Kennair[6] state that: “In modern western society there is a growing focus on the safety of children in all areas, including situations involving playing. An exaggerated safety focus on children’s play is problematic because while on the one hand children should avoid injuries, on the other hand they might need challenges and varied stimulation to develop normally, both physically and mentally.” Similar themes and concerns are explored in the 2012 paper by Brussoni et al[7] which raises important questions about the impact of restrictions on children’s outdoor risky play on child development and health, and proposes a new paradigm that includes a balancing of risky play and children’s safety. In this section we briefly explore to what extent Canadian public policy balances playground safety with the need to provide stimulating play environments. We also consider whether the current standard of care could accommodate consideration of additional factors such as the importance of thrilling experiences to healthy child development.3.1 Public Policy FocusIt is interesting to consider whether Canada’s current public policy environment reflects an “exaggerated safety focus” when it comes to children’s playgrounds and spaces. Canada does have a nationally recognized standard for playground equipment and play spaces. The standard is voluntary, but one that has been relied on and incorporated by reference to become, in some contexts, a de facto minimum. But does having a standard necessarily imply an exaggerated focus on safety such that harm may result? The one does not necessarily flow from the other, and it is worth remembering that in addition to focusing on safety, the standard also explicitly recognizes the need for “innovative” and “challenging” play spaces that support healthy child development in the “broadest sense of the word”. (The question of whether or not it successfully achieves this balance, or whether its implementation and enforcement have contributed to or detracted from the achievement of this balance is beyond the scope of this paper.)Nonetheless, public policy debate on this matter does reflect a strong emphasis on the need to keep vulnerable children safe from harm. This is evident in the debate on a motion brought before the Ontario legislature relating to the CSA standards. The motion sought to have the standard recognized by the government of Ontario as the appropriate safety standards for playground equipment bought and sold in Ontario, and to urge all Ontario municipalities, school boards, childcare centres, and other provincially funded agencies to use playground equipment to adhere to the national standard when buying playground equipment. The motion was debated against a backdrop of a tragic death of a young boy who was strangled by a loop in a rope attached to playground equipment at a condominium complex.The debate on the motion was relatively brief, focusing on the tragic event, the incidence of injury and death, and the credibility of the CSA guideline. There was some discussion about the need to reduce the costs of insurance and liability for property owners, and concern over the impact of the additional costs of meeting the standards. The legislators stated their belief that: “What we must do is ensure that the chances of children getting seriously injured are reduced as much as possible.”[8]A similar focus can be seen in the implementation of playground safety policy in Ontario schools. The focus in this context is on risk management and harm reduction through the application of principles that “systematically identify, prioritize and address the issues related to CSA standard compliance and playground equipment safety.”[9] Insurance costs and the risk of legal action are dominant considerations, and appear to be a driving principle behind much of the dialogue and policy development process in school boards, daycares and municipalities.When there is a consideration of the balancing of interests, the public debate on play space relies heavily on the traditional regulatory equation in the safety context: the relative need for protection versus the relative cost or burden of eliminating danger or hazards. An economic cost-benefit analysis is a standard consideration in the regulation of occupational health and safety and environmental protection, and a mandatory economic analysis of the impact of proposed regulations is fast becoming the norm.A clear example of this equation in the context of child safety can be found in the Alberta Occupiers Liability Act, which states that in determining whether the duty of care to a child has been discharged consideration shall be given to: the age of the child, the child’s ability to appreciate danger, Risky play, injury prevention & child development - public policy perspective — Supplement 5, Louise Logan & Pamela FuselliPage 3 of 3and the burden on the occupier of eliminating the danger or protecting the child from the danger as compared to the risk of the danger to the child.3.2 Standard of Care – the Careful and Prudent Parent?When assessing negligence, the case law in Canada does not refer to the benefits of risky play or a balancing of priorities. However, it may be worth considering whether the current standard of a “careful and prudent parent” could conceivably incorporate a broader set of considerations such as whether an injury occurred in the course of age appropriate risky play. The standard is not one of “safety perfection” and as such it may be able to hold considerations such as whether a “careful and prudent parent” would encourage their child to engage in “thrilling experiences” that support normal development. 4. CONCLUSION We started with the question of whether the public policy measures in place in Canada to keep play spaces safe support optimal child development and health, and how Canada has balanced the need to provide environments where children can develop and at the same time avoid injury.Based on our preliminary review of the landscape, current public policy supports a strong focus on child safety, and legal risk mitigation. It does not address the balancing of risky play and child development, or explicitly consider whether public policy that has a strong safety focus may have secondary, negative impacts on child development. The Canadian approach contrasts starkly with the explicit principles underlying public policy in at least one leading jurisdiction: Finland. The Finnish national action plan for injury prevention among children and youth published in the fall of 2009 includes guidelines for long term injury prevention for children and young people under the age of 25. The action plan explicitly states that safety, health and stimulation are the core elements of the future, and the vision is of Finnish children and young people living stimulating and safe lives.[10] Brussoni et al.,[7] cite similar emerging examples in the UK.In our view, there is an opportunity to draw the debate into the public realm in Canada, explicitly identify the guiding principles, and shine a light on this important public policy issue.REFERENCES1. CBC News. Playground equipment involved in rising number of injuries. 2013.http://www.cbc.ca/news/playground-equipment-involved-in-rising-number-of-injuries-1.1858497 (accessed 30 Sep2013).2. Fuselli P, Yanchar NL. Preventing playground injuries. Paediatr Child Health 2012;17:328–30.3. Government of Ontario. Occupiers’ Liability Act, R.S.O. 1990, c. O.2. Canada: 1990. http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90o02_e.htm (accessed 11 Mar2014).4. Canadian Standards Association. CAN/CSA-Z614-14 - Children’s playspaces and equipment. 5th ed. Toronto, ON: Canadian Standards Association 2014. 5. Mackesy Smye. Playgrounds and structures: Liability of school boards and municipalities. Hamilton, ON: 2013. http://www.mackesysmye.com/wp-content/uploads/2013/04/Playgrounds_and_Structures_liability_of_school_boards_and_municipalities.pdf6. Sandseter EBH, Kennair LEO. Children’s risky play from an evolutionary perspective: The anti-phobic effects of thrilling experiences. Evol Psychol 2011;9:257–84.7. Brussoni M, Olsen LL, Pike I, et al. Risky play and children’s safety: Balancing priorities for optimal child development. Int J Environ Res Public Health 2012;9:3134–8.8. Ontario Legislative Assembly. Official report of debates (Hansard). 1993. 9. Ontario School Boards’ Insurance Exchange. Risk management at a glance for Ontario Schools: Playground safety. 2013.http://osbie.on.ca/risk-management/at-a-glance/playground-safety.aspx (accessed 28 Oct2013).10. Markkula J, Öörni E. Providing a safe environment for our children and young people: Finland’s national action plan for injury prevention among children and youth. Helsinki: 2010. http://www.thl.fi/thl-client/pdfs/bcda07c2-aa23-4faa-a59d-55a60fdc6764 (accessed 28 Oct2013). Page 1 of 3SUPPLEMENT 6Risk management and risk-benefit assessmentDavid J. Ball1Injury Prevention INTRODUCTIONThis statement is written in the context of children’s play, a topic of professional interest which for me commenced in 1986 and has continued with no slackening of pace to occupy a part of my life that otherwise might have been devoted to such things as climate change and nuclear waste. Some people regard play as relatively unimportant on the scale of threats faced by the human race, but I do not share that view. I believe that ‘play,’ however interpreted, is an essential part of life regardless of one’s age and whether it is recognised or acknowledged or not, and that without it things would rapidly deteriorate. Not everyone shares this view. For instance, as an adviser to the UK’s Play Safety Forum (PSF), I am aware that of late the Forum has been in deep discussion with various influential agencies about the role of play. During one meeting, which was focused upon play equipment safety standards, a question was posed about the age of children who were being protected. The answer, after modest hesitation, was ‘about 7 or 8 years.’ This answer was no surprise but a confirmation of an earlier suspicion. I think there is a tendency, when contemplating play, to think only of the very young. But I also believe this amounts to a serious oversight. Teenagers (and much older folks) need opportunity to play for, to paraphrase the Bard, ‘all the world’s a playground,’ and were one to design all equipment with just toddlers in mind, then others would find it mindlessly tame and so lose out on valuable life experiences.WORLDVIEWS IN ISOLATIONIt could be said that the above separation of view is an example of persons marching to different tunes, not necessarily deliberately, but perhaps more through a certain containment of thought processes, which in turn may be a consequence of different professional cultures and work practices. It is not by any means the only example of the co-existence of parallel universes of thought.[1]Many research papers on the safety of playgrounds, for instance, commence with a stream of statistics implying that play is dangerous and in need of urgent intervention. What is often missing is some means of putting the injury rate on playgrounds into perspective. If you do that, by factoring in exposure (how many children play and for how long), a very different picture begins to emerge.[2] Playgrounds start to look more like oases of safety than locations of carnage, which is pretty remarkable considering all of the antics in which players engage.[3]Nonetheless, in Britain, the injury prevention movement has had a major influence since the 1990s, if not earlier, and its impacts have been felt in numerous areas of public life, including play provision.[4] Not all of these impacts have been considered beneficial, and some have even been ridiculed, such that the British Government is now part-way through a major review of health and safety regulation[5] with the current intention of identifying:“areas where further reforms are needed to create a modern, simplified, risk-based framework for health and safety in Great Britain.”[6]Within this ministerial statement the words ‘risk-based framework’ are worthy of contemplation, for they pinpoint a further dichotomy. Although English safety law requires all reasonable interventions to be made, where reasonableness is predicated on a trade-off between the benefits of a safety measure versus its cost and difficulty of implementation, there have been signs of a hazard-based mentality creeping in, first in the workplace and then spreading to encapsulate public life, sometimes including play. The hazard-based approach essentially revolves around the identification of hazards, such as a wooden swing seat or an unprotected drop, and tries to eliminate or remediate them. In contrast, a risk-based approach would also commence by identifying hazards, but would then assess the likelihood of harm (the risk) prior to deciding what if any interventions were reasonable in the circumstances. It is clearly the Government’s intention that the hazard-based approach is generally to be shunned, but in practice it remains widespread.The words ‘in the circumstances’ are also deeply salient because they, in turn, pinpoint another rift, perhaps the most important of all. The numerous debates in the UK play community over recent decades have, above all, been concerned that the benefits of play have been sidelined and should be factored into decisions about the reasonableness, or otherwise, of proposed safety interventions. The simple Can child injury prevention include health risk promotion?ARTICLE1Middlesex University, London, UKRisk management and risk-benefit assessment — Supplement 6, David J. BallPage 2 of 3reason is that safety interventions may lessen benefits. The PSF has marshaled this difficult line of thought in the following policy position, which has been endorsed inter alia by the Government and the safety regulator:“Children need and want to take risks when they play. Play provision aims to respond to these needs and wishes by offering children stimulating, challenging environments for exploring and developing their abilities. In doing this, play provision aims to manage the level of risk so that children are not exposed to unacceptable risks of death or serious injury.”[7]This position is, of course, radically different from that of hazard-based control and injury minimisation. Exposure to some risk is here seen as one of the purposes of play provision rather than something to be eliminated, even including some risk of serious consequence. From this has emerged the idea that play situations should be subject to a new form of risk assessment, namely, risk-benefit assessment. So, in thinking about what interventions are reasonable ‘in the circumstances,’ consideration would need to be given to the circumstances of play including its objectives.This, I should say, may appear radical on the one hand but at the same time it is common sense. Life, on reflection, is about trade-offs in which we accept certain risks in exchange for associated benefits.[8] It is seldom about the selection of one priority, such as injury reduction, and its single-minded pursuit without regard for other factors that may be important.EMERGING EVIDENCE OF THE IMPORTANCE OF PLAYInjury statistics are relatively easy to collect but hard evidence of play benefits less so, for obvious reason. Gradually, though, research in social sciences is beginning to identify the importance of play. Benefits are legion including developmental opportunities;[9] opportunities to experience challenge;[10] the chance to learn from mistakes;[11] encounters with the natural world;[12] reductions in psychopathology and neuroticism;[13] and opportunities to foster citizenship and community.[14]IMPLICATIONS FOR THE PATH AHEADIn most industrialised countries systems of risk assessment and play safety inspection have been devised, coupled with the publication of advisory standards on play equipment safety. The history described here raises serious and complex issues for those involved: » For the health and safety community, it needs to be realised that injury control measures at some point impinge adversely upon health and that that point has likely already been passed. More benefit may be realised more easily by focusing less on injury prevention, and more upon other health benefits (whether physical, psychological or social) of varied and stimulating play provision » For the risk assessment community, recognition needs to be given to the essential difference between factory space and public space including play space. While it may be appropriate to minimise risk of injury in factories, public life has other valued objectives which require recognition beyond lip service » For standards setters, the trade-off between risk and benefit needs to be fairly acknowledged and this further requires a more inclusive process in which the play community has a greater involvement than historically has been the case » In addition, standards setters need to contemplate whether a) equipment standards should be more strongly age-related and b) where the boundary lies between legitimate territory for standards and territory which should be occupied by local community play providers » For play safety inspectors, conventional forms of industry-derived risk assessment are no longer appropriate as benefits of play need to be factored in to the consideration of what is reasonable. In turn, this implies that the next generation of safety inspectors needs to have expertise in both benefits and risks and how these may be weighed one against the other » Local community play providers need to be more proactive in monitoring the benefits and risks of their play provision. These things are neither delegable, nor predictable given that the recipe of children and young people, plus equipment, plus the environment is a complex systemCONCLUSIONSIt need not be said that all professional communities, whether involved in injury control, play provision, equipment manufacture, or risk management, care about the welfare of children. All do, but what is apparently missing is an agreed agenda for bringing this about, and different actors continue to sail their own course, passing each other like proverbial ships in the night, or sometimes worse - strafing the perceived ‘enemy’ with passing fire. In the interest of the welfare of children and young people, the communities they live in, and society at large, these largely disciplinary and professional barriers need to be breached and a more reflective approach taken.Risk management and risk-benefit assessment — Supplement 6, David J. BallPage 3 of 3REFERENCES1. Ball DJ. Ships in the night and the quest for safety. J Inj Control Saf Promot 2000;7:83–96.2. Ball DJ, Gill T, Spiegal B. Managing risk in play provision: Implementation guide. London: Play England 2012. http://www.playengland.org.uk/resources/managing-risk-in-play-provision-implementation-guide.aspx3. Ball DJ. Playgrounds - risks, benefits and choices. Report No. CRR 2002/426. London, England: 2002. http://www.hse.gov.uk/research/crr_htm/2002/crr02426.htm4. Ball DJ, Ball-King L. Safety management and public spaces: Restoring balance. Risk Anal 2013;33:763–71. 5. Löfstedt R. Reclaiming health and safety for all: An independent review of health and safety legislation. London, England: 2011. http://www.official-documents.gov.uk/document/cm82/8219/8219.pdf6. Hoban M. A progress report on implementation of health and safety reforms. London, England: 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/92634/progress-report-health-safety-reforms-feb-2013.pdf7. Play Safety Forum. Managing risk in play provision: A position statement. London: Play England 2008. 8. Graham JD, Wiener JB. Risk vs. risk: Tradeoffs in protecting health and the environment. Cambridge, MA: Harvard University Press 1995. 9. Brussoni M, Olsen LL, Pike I, et al. Risky play and children’s safety: Balancing priorities for optimal child development. Int J Environ Res Public Health 2012;9:3134–8.10. Herrington S, Nicholls J. Outdoor play spaces in Canada: The safety dance of standards as policy. Crit Soc Policy 2007;27:128–38. 11. Christensen P, Mikkelsen MR. Jumping off and being careful: Children’s strategies of risk management in everyday life. Sociol Heal Illn 2008;30:112–30. 12. Louv R. Last child in the woods: Saving our children from Nature-Deficit Disorder. Chapel Hill, NC: Algonquin Books 2008. 13. Sandseter EBH, Kennair LEO. Children’s risky play from an evolutionary perspective: The anti-phobic effects of thrilling experiences. Evol Psychol 2011;9:257–84.14. Peterson GT. “Playgrounds which would never happen now, because they’d be far too dangerous”: Risk, childhood development and radical sites of theatre practice. Res Drama Educ J Appl Theatr Perform 2011;16:385–402.
Article
eng
Reviewed
Vancouver : University of British Columbia Library
Injury Prevention
Attribution-NonCommercial-NoDerivatives 4.0 International
Faculty
Researcher
Graduate
Children and youth (0-19)
Injury policy and prevention
Outdoor/risky play
Can child injury prevention include healthy risk promotion?
Text