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Bite injuries at a day care center
Early Childhood Research Quarterly, 4, 89-96 (1989)
Bite Injuries at a Day Care Center Hope C. Solomons College of Nursing, The University of Iowa Richard Elardo College of Education, The University of Iowa Over a 42-month period, 66 of 133 children at a university day care center received 224 bites, three of them by insects. Most bites were inflicted by other children, but nearly 20070 were secondary to falls. Toddlers 13 to 24 months of age were bitten most frequently. Most bites occurred mid-morning, randomly throughout the week, and most commonly in September. Suggestions are made for decreasing children's aggressive biting in group care. Biting is a problem in child care centers; children bite each other as well as their adult caretakers. Although child care workers frequently complain about the problem, only three published studies of children's accidents and injuries in day care or preschool settings mentioned bites. In a universitybased day care center, bites ranked after falls and collisions as the third leading cause of injuries (Elardo, Solomons, & Snider, 1987; Solomons, Lakin, Snider, & Paredes-Rojas, 1982). Over 40 years ago bites among a group of preschool children were less common, but they accounted for 6°7o of injuries to boys and 3070 to girls (Fuller, 1948). The only paper that focused specifically on biting among normal children in a day care center used epidemiological statistical analyses to determine the rate of biting (Garrard, Leland, & Smith, 1988). Rate was defined as the number of events (children with h u m a n bites) divided by the total number of children at risk (inferred from financial records to determine the number of days of enrollment for each child in the center and whether full time or part time). There were no sex differences, but rate of biting varied by age, with toddlers most likely to be bitten. O f 224 children, 104 (46070) received one or more human bites. According to Marr, Beck, and Lugo (1979), " H u m a n bites are a serious medical and surgical problem. A wide range of secondary consequences have been documented in the medical literature, including deformity, amputation, infection, transmission of disease agents, and psychosexual aberrations (p. Correspondence and requests for reprints should be sent to Hope C. Solomons, Professor Emerita, College of Nursing, The University of Iowa, Iowa City, IA, 52242. 89
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514). They analyzed 892 bites reported to the New York City Department of Health over one year. The ages of victims ranged from infancy through old age; little information existed about the biters. Bite marks have been used in forensic investigations to provide information about the biter. In a review of 67 cases, Vale and Noguchi (1983) reported that bites "occurred primarily in sex-related crimes, child abuse cases, and cases involving other types of physical altercations" (p. 61). Among children sheltered in Las Vegas juvenile care facilities, 17 of 1,100 showed signs of bite-mark abuse, an incidence of 1,545 among 100,000 population; this was far higher than previously reported statistics on child abuse and neglect for that community (Rawson, Koot, Martin, Jackson, Novosel, Richardson, & Bender, 1984). The body areas most frequently bitten were the upper limbs (Garrard et al., in press; Marr et al., 1979; Vale & Noguchi, 1983) and the head and neck (Rawson et al., 1984). From a bacteriologic perspective, human bites can be more virulent than those from animals, and infection is common (Peeples, Boswick, & Scott, 1980). In addition to a variety of pathogens (Rest & Goldstein, 1985), primary syphilis has been transmitted following a human bite (Fiumara & Exner, 1981). Although the AIDS virus has been cultured from saliva (Groopman et al., 1984), to date we have found no information that the AIDS virus has been transmitted by human bites (Schechter et al., 1986). Nevertheless, one AIDS carrier was convicted of assault with a deadly and dangerous weapon after he bit two people ("Aids Carrier," 1987). The number of young AIDSaffected children in hospital day care, who like many children occasionally bite, is of concern to health care workers (A. Cratoxa, personal communication, May 26, 1987). From the child development and pediatric literature, studies on biting include aversive procedures (Matson & Ollendick, 1976) and behavior modification (McGuire, 1977) to eliminate biting others and to control self-inflicted biting (Luiselli, Helfen, Colozzi, Donellon, & Pemberton, 1978). Studies also include reports of aggressive, biting children who may themselves be victims of child abuse and are capable of causing severe injury or death (Adelson, 1972; Schmitz & ten Bensel, 1980). The purpose of this study is to review the incidence of bites among the 1,324 accidents reported earlier (Elardo et al., 1987) to examine in more detail how bites varied by age, sex, body part injured, cause of injury, season of the year, and time of day. On the basis of our review of the literature and our own experience as psychologists, we also offer suggestions for intervention with the biting child and the victim.
METHODOLOG Y Subjects Subjects were 133 normal children, ranging in age from 2 to 80 months, 69 boys and 64 girls, who attended the Early Childhood Education Center at
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the University of Iowa. The median age was 38 months, and the typical child remained enrolled at the center for approximately two years. Most children were from white, middle-class, two-parent households, although admissions were encouraged from both single- and two-parent families in which both parents were employed or in school.
Consent Procedures and Setting At the time of admission, parents signed forms that permitted their children's records to be used in research. As Elardo et al. (1987) stated, "Congruent with the mission of the university, the goals of the center were to provide service to children and their families, education for university students in a variety of majors, and a facility for research in child development" (p. 62). The day care center was located in a former laboratory school building with well-equipped, spacious rooms, kitchen facilities, nurse's office, and administrative suite. Outdoor play areas overlooked the scenic Iowa River. O f the 5 head teachers, 2 had master's degrees in early childhood education; the others had bachelor's degrees. The assistant teachers were graduate students. High quality group day care was provided for 70 to 75 children each semester. All children attended the center full time, except for the 5-year-old kindergartners, who arrived for lunch and the afternoon program after attending public school in the morning. The ratio of teaching staff to children usually provided more adults than the ratios required by the state of Iowa because of the unpaid student teachers who were not counted as official caretakers. Our group sizes and numbers of paid teachers were: Infant and toddler room, 12 children, 3 adults; 2-year-old room, 10 children, 2 adults; 3-year-old room, 18 children, 3 adults; 4-year-old room, 18 children, 2 adults; 5-year-old room, 15 children, 1 adult. Instrument A one-page " R e p o r t of Accident" was completed by a staff member each time a child had an injury such as a scrape, bump, bruise, or bleeding, or had prolonged crying which staff believed was serious enough to require documentation. Space was provided on each accident sheet for the following information: child's name, date, time, description of the accident, nature of the injury, treatment, and whether the parents were notified and what they were told. Procedure Data for this analysis were obtained from 1,324 accidents that occurred over a 42-month period (Elardo et al., 1987), after which the center closed because of university financial exigencies. Each accident sheet was reviewed anew, and 224 accidents were classified as bites, defined as injury to soft tissue caused by human or animal teeth or an insect sting. This number includes 23 more bites than were reported initially (Elardo et al., 1987). Most
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of these were accidents in which children fell and inadvertently bit themselves; these had been classified earlier as falls rather than bites. Demographic information on each child and the accident reports were coded for computer analysis. Of the 1,324 accident reports, 38 were not dated, so only 1,286 records were used to determine day of the week, month of the year, and age of the child; and 42 did not include time of day, so only 1,282 records were used for this purpose. To calculate the number of bites for each age group, the number of bites was divided by the average number of children per age enrolled each semester. The number of children varied according to age group, so results are presented as averages.
RESULTS Of the 133 children studied over a 42-month period, 66 (49.6O7o) suffered 224 bites. For those children who had been bitten, the mean number was 3.4 bites, the mode was one. One very active child who had the greatest number of bites (16) also had the largest number of non-bite accidents (55).
Timing The 42-month span of this study covered three and one-half calendar years. The average number of bites per month was greatest in September and lowest in the summer months. The frequency of bites did not vary significantly over the five weekdays. Through the course of the morning, the frequency of bites increased to a peak between 10 a.m. and noon, then declined through the afternoon nap time. In contrast with non-bite accidents (Elardo et al., 1987), the frequency of bites was low throughout the afternoon (Figure 1.).
Age Differences The average number of accidents per age rather than the total is reported because the numbers of children of each age were not equal (Table 1). Toddlers of 13 to 24 months were most likely to be bitten ( X ' = 2 4 . 7 8 , 5 df, p < .001); the frequency of bites was significantly lower for older children.
Injury and Treatment All bites were treated by washing, applying ice, and comforting; according to the accident report forms, only four bites actually broke the skin. Parents were rarely notified, since the injuries were not serious.
Sex Differences Of the 66 children bitten, 35 were boys and 31 were girls. The boys received 108 bites and the girls 116. Sex differences were not statistically significant.
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20.5 20 a0 °
m
nn o
15 10
¢)
5
(D 13-
0
7-8 9 A.M.
10 11 12
1 2 P.M. Time of Day
Figure 1. Table 1.
Percentage of bites by time of day.
Average Number of Bites for Each Age Group
Age in Months
2-12 13-24 25-36 37--48 49-60 61 +
8 4 - 5 Unknown
Number of Children Per Age Each Semester
Average Number of Bites Per Age Group
4a 8a 10 18 18 15
1.0 11. I 6.4 2.4 .8 .2
Note. Chi square=24.8, 5 df, p < .001.
" These two age groups shared the same classroom. Cause
O f the 224 bites, 171 (76.3070) were delivered b y a n o t h e r child, 44 (19.6070) were self-induced, a n d 3 (1.3070) were caused by an insect. In 6 cases (2.7070), it was not clear whether a n o t h e r p e r s o n or the child was at fault. T h e r e p o r t f o r m s generally read, for e x a m p l e , " B i t t e n on right h a n d b y a n o t h e r c h i l d " a n d rarely i n d i c a t e d the t y p e o f d i s p u t e that p r o b a b l y p r e c e d e d the a t t a c k . F o r t y - t h r e e bites were s e c o n d a r y to falls, a n d one child bit h i m s e l f out o f rage a n d f r u s t r a t i o n .
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Table 2.
Solomons and Elardo Body Part Bitten
Body PaN Head, neck, face Trunk Upper limbs Lower limbs
Percentage of Injuries 27.0 7.3 63.7 2.0
Body Part Injured As shown in Table 2, most bites were to the fingers, hands, and arms (63.7), followed by bites to the head area (27.0). Of those to the head, neck, and face, two-thirds were to the mouth region, an indication of the number of bites that followed falls.
DISCUSSION According to our results and those of Garrard et al. (1988), nearly half of the children in clay care received human bites. Toddlers, defined as 13 to 24 months in our study and 16 to 30 months in theirs, were the age group most likely to be bitten. A weakness in both investigations is that no data were available for the perpetrators. However, since the centers used in both studies were segregated by age, with infants and toddlers in this sample sharing a room, it is highly probable that the biters were in the same age group as the bitten. Some day care centers use multiage groupings, and we do not know whether these data would generalize to those settings. As reported in the medical literature (Mart et al., 1979; Vale & Noguchi, 1983) and in the Garrard et al. (1988) day care paper, the upper limbs were the body areas with the greatest number of bites. The most typical biting incident involved instrumental aggression, defined as aggression aimed toward the achievement of nonaggressive goals (Feshbach, 1970, p. 161) such as "retrieval of an object, territory or privilege" (Hartup, 1974, p. 338). Instrumental aggression is distinguished--not always easily--from hostile aggression, in which the aggressive act is directed toward an object or another person. The frequency of biting was greatest during September, the start of the academic year and the peak month for new admissions to the day care center. Some children need to learn to socialize with their peers and to comply with their teachers' expectations of appropriate behavior. Toddlers lack the reasoning ability and verbal skills that older children have developed for handling conflicts. Furthermore, the young toddler risks bite injury due to awkward motor coordination; 43 bites occurred after children fell or tripped and bit themselves. The earlier speculation that bites may have been due to
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"teething children chomping on anything or a n y o n e " (Solomons et al., 1982) now seems incredibly naive. We see two main avenues for decreasing the frequency of biting in child care centers. First, reduce the need for instrumental aggression by assuring an adequate supply of interesting curriculum materials. At the Early Childhood Education Center, for example, only one wagon was available for the toddlers, and disputes were frequent. The frustrated teacher declared, " W e can't have a wagon a n y m o r e ! " Another teacher, however, suggested providing a second wagon. When this was done, aggressive behavior decreased significantly. Second, anticipate trouble, intervene, and redirect children to other activities. Staff vigilance is crucial to minimize all types of aggressive responses. Nevertheless, even with staff vigilance and enough interesting materials, it is unlikely that biting and other acts of aggression will be eliminated among groups of young children. Further suggestions for reducing these problems are derived from the National Day Care study (Ruopp, Travers, & Goodrich, 1980). The researchers recommended adult-child ratios appropriate for the children's ages, (1:4 for children under 3 years, 1:7 for preschoolers between 3 and 5), with groups limited to twice the number of children recommended per adult, that is, no larger than 8 for children under 2, and a m a x i m u m of 12 for youngsters between 2 and 3 years of age. A further finding was that staff members who had formal training in child development were more likely to be found in higher quality programs. We would recommend in-service continuing education for staff members on a variety of topics, including management of aggression. When biting occurs, we believe more attention should be given to the child bitten than to the biter; do not reinforce biting behavior. Take the biter by the hand and place him or her in a time-out chair, saying firmly, " N o biting is allowed. You hurt So-and-so and made him c r y . " Do not lecture at that time or you may reinforce the biter with your attention. The bite victim should be comforted and the wound examined and cleaned. If the skin is broken, further treatment may be necessary. Soon after the incident, an accident report should be completed. Extinction and punishment are two approaches that we are reluctant to recommend for use by staff members in child care programs. If staff members ignore biting behavior in an attempt to extinguish it, the biter is likely to be doubly reinforced by gaining the disputed toy and seeing the victim in tears. Punishment of biters can take the form of retribution, that is, a bite for a bite, spanking the biter, or the use of aversive substances such as soap, bitter mouthwash, or lemon juice. Since we believe it is inadvisable for children to model aggressive behavior, we advise caretakers to refrain from such disciplinary methods. Moreover, it is against the law to use physical punishment in most child care centers.
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Despite the potential for severe harm from human bites, as documented in the medical literature, the injuries from bites in our study and that of Garrard et al. (1988) were not serious. Nevertheless, biting behavior is a source of concern for child care workers and anguish for the victims.
REFERENCES Adelson, L. (1972). The battering child. Journal of the American Medical Association, 222, 159-161. AIDS carrier convicted of assault. (1987, June 25).Iowa Cio' Press Citizen. Elardo, R., Solomons, H.C., & Snider, B.C. (1987). An analysis of accidents at a day care center. American Journal of Orthopsychiatry, 57, 60-65. Feshbach, S. (1970). Aggression. In P,H. Mussen (Ed.), Carmichael's manual of child psychology, (Vol. 2, pp. 159-259). New York: Wiley. Fiumara, N.J., & Exner, J.H. (1981). Primary syphilis following a human bite. Sexually Transmitted Diseases, 8. 21-22. Fuller, E.M. (1948). Injury-prone children. American Journal of Orthopsychiatry, 18, 708723. Garrard, J., Leland, N., & Smith, D.K. (1988). Epidemiology of human bites to children in a day care center. American Journal of Diseases of Children, 142, 643-650. Groopman, J.E., Salahuddin, S.Z., Sarngadharan, M.D., Markham, P.D., Gonda, M., Sliski, A., & Gallo, R.C. (1984). HTLV-III in saliva of people with AIDS related complex and healthy homosexual men at risk for AIDS. Science, 226, 447-449. Hartup, W.W. (1974). Aggression in childhood: Developmental perspectives. American Psychologist, 29, 336-341. Luiselli, J.K., Helfen, C.S., Colozzi, G., Donellon, S. & Pemberton, B. (1978). Controlling self-inflicted biting of a retarded child by the differential reinforcement of other behavior. Psychological Reports, 42, 435--438. Marr, J.S., Beck, A.M., & Lugo, J.A., Jr. (1979). An epidemiologic study of the human bite. Public Health Reports, 94, 514-521. Matson, J.L., & Ollendick, T.H. (1976). Elimination of low frequency biting. Behavior Therapy, 7, 410-412. McGuire, P.F. (1977). Debbie won't stop biting her playmates: Behavior modification in family medicine. Journal of the Maine Medical Association, 68, 267-268. Peeples, E., Boswick, J.A., Jr., & Scott, F.A, (1980). Wounds of the hand contaminated by human or animal saliva. Journal of Trauma, 20, 383-389. Rawson, R.D., Koot, A., Martin, C., Jackson, J., Novosel, S., Richardson, A., & Bender, T. (1984). Incidence of bite marks in a selected juvenile population: A preliminary report. Journal of Forensic Science, 29, 254-259. Rest, J.G., & Goldstein, E.J.C. (1985). Management of human and animal bite wounds. Emergency Medicine Clinics of North America, 3. 117-126. Ruopp, R., Travers, J., & Goodrich, C. (1980). Report of the National Day Care Study. Cambridge, MA: Abt Associates. Schechter, M.T., Boyko, W.J., Douglas, B., Maynard, M., Willoughby, B., McLeod, A., & Craib, K.J.P. (1986). Can HTLV-II1 be transmitted orally? Lancet, (February 15), 379. Schmitz, K., & ten Bensel, R.W. (1980). The biting child syndrome. Child Abuse and Neglect, 4, 285-288. Solomons, H.C., Lakin, J.A., Snider, B.C., & Paredes-Rojas, R.R. (1982). Is day care safe for children? Accident records reviewed. Children's Health Care, 10, 90-93. Vale, G.L., & Noguchi, T.T. (1983). Anatomical distribution of human bite marks in a series of 67 cases. Journal of Forensic Sciences, 28, 61-69.
Bite Injuries at a Day Care Center Hope C. Solomons College of Nursing, The University of Iowa Richard Elardo College of Education, The University of Iowa Over a 42-month period, 66 of 133 children at a university day care center received 224 bites, three of them by insects. Most bites were inflicted by other children, but nearly 20070 were secondary to falls. Toddlers 13 to 24 months of age were bitten most frequently. Most bites occurred mid-morning, randomly throughout the week, and most commonly in September. Suggestions are made for decreasing children's aggressive biting in group care. Biting is a problem in child care centers; children bite each other as well as their adult caretakers. Although child care workers frequently complain about the problem, only three published studies of children's accidents and injuries in day care or preschool settings mentioned bites. In a universitybased day care center, bites ranked after falls and collisions as the third leading cause of injuries (Elardo, Solomons, & Snider, 1987; Solomons, Lakin, Snider, & Paredes-Rojas, 1982). Over 40 years ago bites among a group of preschool children were less common, but they accounted for 6°7o of injuries to boys and 3070 to girls (Fuller, 1948). The only paper that focused specifically on biting among normal children in a day care center used epidemiological statistical analyses to determine the rate of biting (Garrard, Leland, & Smith, 1988). Rate was defined as the number of events (children with h u m a n bites) divided by the total number of children at risk (inferred from financial records to determine the number of days of enrollment for each child in the center and whether full time or part time). There were no sex differences, but rate of biting varied by age, with toddlers most likely to be bitten. O f 224 children, 104 (46070) received one or more human bites. According to Marr, Beck, and Lugo (1979), " H u m a n bites are a serious medical and surgical problem. A wide range of secondary consequences have been documented in the medical literature, including deformity, amputation, infection, transmission of disease agents, and psychosexual aberrations (p. Correspondence and requests for reprints should be sent to Hope C. Solomons, Professor Emerita, College of Nursing, The University of Iowa, Iowa City, IA, 52242. 89
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514). They analyzed 892 bites reported to the New York City Department of Health over one year. The ages of victims ranged from infancy through old age; little information existed about the biters. Bite marks have been used in forensic investigations to provide information about the biter. In a review of 67 cases, Vale and Noguchi (1983) reported that bites "occurred primarily in sex-related crimes, child abuse cases, and cases involving other types of physical altercations" (p. 61). Among children sheltered in Las Vegas juvenile care facilities, 17 of 1,100 showed signs of bite-mark abuse, an incidence of 1,545 among 100,000 population; this was far higher than previously reported statistics on child abuse and neglect for that community (Rawson, Koot, Martin, Jackson, Novosel, Richardson, & Bender, 1984). The body areas most frequently bitten were the upper limbs (Garrard et al., in press; Marr et al., 1979; Vale & Noguchi, 1983) and the head and neck (Rawson et al., 1984). From a bacteriologic perspective, human bites can be more virulent than those from animals, and infection is common (Peeples, Boswick, & Scott, 1980). In addition to a variety of pathogens (Rest & Goldstein, 1985), primary syphilis has been transmitted following a human bite (Fiumara & Exner, 1981). Although the AIDS virus has been cultured from saliva (Groopman et al., 1984), to date we have found no information that the AIDS virus has been transmitted by human bites (Schechter et al., 1986). Nevertheless, one AIDS carrier was convicted of assault with a deadly and dangerous weapon after he bit two people ("Aids Carrier," 1987). The number of young AIDSaffected children in hospital day care, who like many children occasionally bite, is of concern to health care workers (A. Cratoxa, personal communication, May 26, 1987). From the child development and pediatric literature, studies on biting include aversive procedures (Matson & Ollendick, 1976) and behavior modification (McGuire, 1977) to eliminate biting others and to control self-inflicted biting (Luiselli, Helfen, Colozzi, Donellon, & Pemberton, 1978). Studies also include reports of aggressive, biting children who may themselves be victims of child abuse and are capable of causing severe injury or death (Adelson, 1972; Schmitz & ten Bensel, 1980). The purpose of this study is to review the incidence of bites among the 1,324 accidents reported earlier (Elardo et al., 1987) to examine in more detail how bites varied by age, sex, body part injured, cause of injury, season of the year, and time of day. On the basis of our review of the literature and our own experience as psychologists, we also offer suggestions for intervention with the biting child and the victim.
METHODOLOG Y Subjects Subjects were 133 normal children, ranging in age from 2 to 80 months, 69 boys and 64 girls, who attended the Early Childhood Education Center at
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91
the University of Iowa. The median age was 38 months, and the typical child remained enrolled at the center for approximately two years. Most children were from white, middle-class, two-parent households, although admissions were encouraged from both single- and two-parent families in which both parents were employed or in school.
Consent Procedures and Setting At the time of admission, parents signed forms that permitted their children's records to be used in research. As Elardo et al. (1987) stated, "Congruent with the mission of the university, the goals of the center were to provide service to children and their families, education for university students in a variety of majors, and a facility for research in child development" (p. 62). The day care center was located in a former laboratory school building with well-equipped, spacious rooms, kitchen facilities, nurse's office, and administrative suite. Outdoor play areas overlooked the scenic Iowa River. O f the 5 head teachers, 2 had master's degrees in early childhood education; the others had bachelor's degrees. The assistant teachers were graduate students. High quality group day care was provided for 70 to 75 children each semester. All children attended the center full time, except for the 5-year-old kindergartners, who arrived for lunch and the afternoon program after attending public school in the morning. The ratio of teaching staff to children usually provided more adults than the ratios required by the state of Iowa because of the unpaid student teachers who were not counted as official caretakers. Our group sizes and numbers of paid teachers were: Infant and toddler room, 12 children, 3 adults; 2-year-old room, 10 children, 2 adults; 3-year-old room, 18 children, 3 adults; 4-year-old room, 18 children, 2 adults; 5-year-old room, 15 children, 1 adult. Instrument A one-page " R e p o r t of Accident" was completed by a staff member each time a child had an injury such as a scrape, bump, bruise, or bleeding, or had prolonged crying which staff believed was serious enough to require documentation. Space was provided on each accident sheet for the following information: child's name, date, time, description of the accident, nature of the injury, treatment, and whether the parents were notified and what they were told. Procedure Data for this analysis were obtained from 1,324 accidents that occurred over a 42-month period (Elardo et al., 1987), after which the center closed because of university financial exigencies. Each accident sheet was reviewed anew, and 224 accidents were classified as bites, defined as injury to soft tissue caused by human or animal teeth or an insect sting. This number includes 23 more bites than were reported initially (Elardo et al., 1987). Most
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of these were accidents in which children fell and inadvertently bit themselves; these had been classified earlier as falls rather than bites. Demographic information on each child and the accident reports were coded for computer analysis. Of the 1,324 accident reports, 38 were not dated, so only 1,286 records were used to determine day of the week, month of the year, and age of the child; and 42 did not include time of day, so only 1,282 records were used for this purpose. To calculate the number of bites for each age group, the number of bites was divided by the average number of children per age enrolled each semester. The number of children varied according to age group, so results are presented as averages.
RESULTS Of the 133 children studied over a 42-month period, 66 (49.6O7o) suffered 224 bites. For those children who had been bitten, the mean number was 3.4 bites, the mode was one. One very active child who had the greatest number of bites (16) also had the largest number of non-bite accidents (55).
Timing The 42-month span of this study covered three and one-half calendar years. The average number of bites per month was greatest in September and lowest in the summer months. The frequency of bites did not vary significantly over the five weekdays. Through the course of the morning, the frequency of bites increased to a peak between 10 a.m. and noon, then declined through the afternoon nap time. In contrast with non-bite accidents (Elardo et al., 1987), the frequency of bites was low throughout the afternoon (Figure 1.).
Age Differences The average number of accidents per age rather than the total is reported because the numbers of children of each age were not equal (Table 1). Toddlers of 13 to 24 months were most likely to be bitten ( X ' = 2 4 . 7 8 , 5 df, p < .001); the frequency of bites was significantly lower for older children.
Injury and Treatment All bites were treated by washing, applying ice, and comforting; according to the accident report forms, only four bites actually broke the skin. Parents were rarely notified, since the injuries were not serious.
Sex Differences Of the 66 children bitten, 35 were boys and 31 were girls. The boys received 108 bites and the girls 116. Sex differences were not statistically significant.
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93
20.5 20 a0 °
m
nn o
15 10
¢)
5
(D 13-
0
7-8 9 A.M.
10 11 12
1 2 P.M. Time of Day
Figure 1. Table 1.
Percentage of bites by time of day.
Average Number of Bites for Each Age Group
Age in Months
2-12 13-24 25-36 37--48 49-60 61 +
8 4 - 5 Unknown
Number of Children Per Age Each Semester
Average Number of Bites Per Age Group
4a 8a 10 18 18 15
1.0 11. I 6.4 2.4 .8 .2
Note. Chi square=24.8, 5 df, p < .001.
" These two age groups shared the same classroom. Cause
O f the 224 bites, 171 (76.3070) were delivered b y a n o t h e r child, 44 (19.6070) were self-induced, a n d 3 (1.3070) were caused by an insect. In 6 cases (2.7070), it was not clear whether a n o t h e r p e r s o n or the child was at fault. T h e r e p o r t f o r m s generally read, for e x a m p l e , " B i t t e n on right h a n d b y a n o t h e r c h i l d " a n d rarely i n d i c a t e d the t y p e o f d i s p u t e that p r o b a b l y p r e c e d e d the a t t a c k . F o r t y - t h r e e bites were s e c o n d a r y to falls, a n d one child bit h i m s e l f out o f rage a n d f r u s t r a t i o n .
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Table 2.
Solomons and Elardo Body Part Bitten
Body PaN Head, neck, face Trunk Upper limbs Lower limbs
Percentage of Injuries 27.0 7.3 63.7 2.0
Body Part Injured As shown in Table 2, most bites were to the fingers, hands, and arms (63.7), followed by bites to the head area (27.0). Of those to the head, neck, and face, two-thirds were to the mouth region, an indication of the number of bites that followed falls.
DISCUSSION According to our results and those of Garrard et al. (1988), nearly half of the children in clay care received human bites. Toddlers, defined as 13 to 24 months in our study and 16 to 30 months in theirs, were the age group most likely to be bitten. A weakness in both investigations is that no data were available for the perpetrators. However, since the centers used in both studies were segregated by age, with infants and toddlers in this sample sharing a room, it is highly probable that the biters were in the same age group as the bitten. Some day care centers use multiage groupings, and we do not know whether these data would generalize to those settings. As reported in the medical literature (Mart et al., 1979; Vale & Noguchi, 1983) and in the Garrard et al. (1988) day care paper, the upper limbs were the body areas with the greatest number of bites. The most typical biting incident involved instrumental aggression, defined as aggression aimed toward the achievement of nonaggressive goals (Feshbach, 1970, p. 161) such as "retrieval of an object, territory or privilege" (Hartup, 1974, p. 338). Instrumental aggression is distinguished--not always easily--from hostile aggression, in which the aggressive act is directed toward an object or another person. The frequency of biting was greatest during September, the start of the academic year and the peak month for new admissions to the day care center. Some children need to learn to socialize with their peers and to comply with their teachers' expectations of appropriate behavior. Toddlers lack the reasoning ability and verbal skills that older children have developed for handling conflicts. Furthermore, the young toddler risks bite injury due to awkward motor coordination; 43 bites occurred after children fell or tripped and bit themselves. The earlier speculation that bites may have been due to
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"teething children chomping on anything or a n y o n e " (Solomons et al., 1982) now seems incredibly naive. We see two main avenues for decreasing the frequency of biting in child care centers. First, reduce the need for instrumental aggression by assuring an adequate supply of interesting curriculum materials. At the Early Childhood Education Center, for example, only one wagon was available for the toddlers, and disputes were frequent. The frustrated teacher declared, " W e can't have a wagon a n y m o r e ! " Another teacher, however, suggested providing a second wagon. When this was done, aggressive behavior decreased significantly. Second, anticipate trouble, intervene, and redirect children to other activities. Staff vigilance is crucial to minimize all types of aggressive responses. Nevertheless, even with staff vigilance and enough interesting materials, it is unlikely that biting and other acts of aggression will be eliminated among groups of young children. Further suggestions for reducing these problems are derived from the National Day Care study (Ruopp, Travers, & Goodrich, 1980). The researchers recommended adult-child ratios appropriate for the children's ages, (1:4 for children under 3 years, 1:7 for preschoolers between 3 and 5), with groups limited to twice the number of children recommended per adult, that is, no larger than 8 for children under 2, and a m a x i m u m of 12 for youngsters between 2 and 3 years of age. A further finding was that staff members who had formal training in child development were more likely to be found in higher quality programs. We would recommend in-service continuing education for staff members on a variety of topics, including management of aggression. When biting occurs, we believe more attention should be given to the child bitten than to the biter; do not reinforce biting behavior. Take the biter by the hand and place him or her in a time-out chair, saying firmly, " N o biting is allowed. You hurt So-and-so and made him c r y . " Do not lecture at that time or you may reinforce the biter with your attention. The bite victim should be comforted and the wound examined and cleaned. If the skin is broken, further treatment may be necessary. Soon after the incident, an accident report should be completed. Extinction and punishment are two approaches that we are reluctant to recommend for use by staff members in child care programs. If staff members ignore biting behavior in an attempt to extinguish it, the biter is likely to be doubly reinforced by gaining the disputed toy and seeing the victim in tears. Punishment of biters can take the form of retribution, that is, a bite for a bite, spanking the biter, or the use of aversive substances such as soap, bitter mouthwash, or lemon juice. Since we believe it is inadvisable for children to model aggressive behavior, we advise caretakers to refrain from such disciplinary methods. Moreover, it is against the law to use physical punishment in most child care centers.
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Despite the potential for severe harm from human bites, as documented in the medical literature, the injuries from bites in our study and that of Garrard et al. (1988) were not serious. Nevertheless, biting behavior is a source of concern for child care workers and anguish for the victims.
REFERENCES Adelson, L. (1972). The battering child. Journal of the American Medical Association, 222, 159-161. AIDS carrier convicted of assault. (1987, June 25).Iowa Cio' Press Citizen. Elardo, R., Solomons, H.C., & Snider, B.C. (1987). An analysis of accidents at a day care center. American Journal of Orthopsychiatry, 57, 60-65. Feshbach, S. (1970). Aggression. In P,H. Mussen (Ed.), Carmichael's manual of child psychology, (Vol. 2, pp. 159-259). New York: Wiley. Fiumara, N.J., & Exner, J.H. (1981). Primary syphilis following a human bite. Sexually Transmitted Diseases, 8. 21-22. Fuller, E.M. (1948). Injury-prone children. American Journal of Orthopsychiatry, 18, 708723. Garrard, J., Leland, N., & Smith, D.K. (1988). Epidemiology of human bites to children in a day care center. American Journal of Diseases of Children, 142, 643-650. Groopman, J.E., Salahuddin, S.Z., Sarngadharan, M.D., Markham, P.D., Gonda, M., Sliski, A., & Gallo, R.C. (1984). HTLV-III in saliva of people with AIDS related complex and healthy homosexual men at risk for AIDS. Science, 226, 447-449. Hartup, W.W. (1974). Aggression in childhood: Developmental perspectives. American Psychologist, 29, 336-341. Luiselli, J.K., Helfen, C.S., Colozzi, G., Donellon, S. & Pemberton, B. (1978). Controlling self-inflicted biting of a retarded child by the differential reinforcement of other behavior. Psychological Reports, 42, 435--438. Marr, J.S., Beck, A.M., & Lugo, J.A., Jr. (1979). An epidemiologic study of the human bite. Public Health Reports, 94, 514-521. Matson, J.L., & Ollendick, T.H. (1976). Elimination of low frequency biting. Behavior Therapy, 7, 410-412. McGuire, P.F. (1977). Debbie won't stop biting her playmates: Behavior modification in family medicine. Journal of the Maine Medical Association, 68, 267-268. Peeples, E., Boswick, J.A., Jr., & Scott, F.A, (1980). Wounds of the hand contaminated by human or animal saliva. Journal of Trauma, 20, 383-389. Rawson, R.D., Koot, A., Martin, C., Jackson, J., Novosel, S., Richardson, A., & Bender, T. (1984). Incidence of bite marks in a selected juvenile population: A preliminary report. Journal of Forensic Science, 29, 254-259. Rest, J.G., & Goldstein, E.J.C. (1985). Management of human and animal bite wounds. Emergency Medicine Clinics of North America, 3. 117-126. Ruopp, R., Travers, J., & Goodrich, C. (1980). Report of the National Day Care Study. Cambridge, MA: Abt Associates. Schechter, M.T., Boyko, W.J., Douglas, B., Maynard, M., Willoughby, B., McLeod, A., & Craib, K.J.P. (1986). Can HTLV-II1 be transmitted orally? Lancet, (February 15), 379. Schmitz, K., & ten Bensel, R.W. (1980). The biting child syndrome. Child Abuse and Neglect, 4, 285-288. Solomons, H.C., Lakin, J.A., Snider, B.C., & Paredes-Rojas, R.R. (1982). Is day care safe for children? Accident records reviewed. Children's Health Care, 10, 90-93. Vale, G.L., & Noguchi, T.T. (1983). Anatomical distribution of human bite marks in a series of 67 cases. Journal of Forensic Sciences, 28, 61-69.