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Psychological symptoms and nonfatal unintentional injuries among Chinese adolescents: a prospective study
Journal of Adolescent Health 37 (2005) 460 – 466
Original article
Psychological symptoms and nonfatal unintentional injuries among Chinese adolescents: a prospective study G. Chena,b, G.A. Smitha, S. Dengc, D. Chenb, K. Kellehera, H. Xianga,* a
Center for Injury Research and Policy, Columbus Children’s Research Institute, Children’s Hospital, College of Medicine and Public Health, The Ohio State University, Columbus, Ohio b Department of Health Statistics, School of Public Health, Wuhan University, Wuhan, People’s Republic of China c Department of Preventive Medicine, Youjiang Medical College for Nationalities, Baise City, Guangxi, China Manuscript received July 16, 2004; manuscript accepted September 10, 2004
Abstract
Purpose: To describe patterns of nonfatal unintentional injuries and investigate the association of psychological symptoms with injury risk among adolescents in Guangxi, China. Methods: Adolescents were selected from middle and high school students in Baise City, Guangxi, China. Psychological symptoms at baseline were measured using SCL-90-R and nonfatal unintentional injuries that occurred among participants were recorded using a standardized injury surveillance questionnaire. Annual injury rates per 100 adolescents by adolescents’ demographic and family characteristics were calculated. Student’s t-test and the Chi-square test were used to test differences in mean raw scores of SCL-90-R subscales and injury rates. Relative risks and odds ratios of injury with 95% confidence intervals were calculated in univariate analyses and multivariate logistic models. Results: A total of 1474 middle and high school students finished the study. Of them, 442 reported nonfatal unintentional injuries during the study period, resulting in an annual injury rate of 30.3 per 100 adolescents. Boys had a significantly higher injury rate than girls (32.6% vs. 27.4%). Injury rate decreased as the adolescents’ age increased. Compared with adolescents who were not injured, the injured adolescents had higher average raw scores of all subscales of SCL-90-R, with an exception of the subscale for hostility. All SCL-90-R subscales factors, except those for hostility and phobia, were associated with injury risk. After confounding effects of age, gender, and ethnicity were controlled using logistic regression models, SCL-90-R subscales for somatization (OR ⫽ 2.00, 95% CI 1.52–2.63), obsessive-compulsiveness (OR ⫽ 2.10, 95% CI 1.71–2.58), interpersonal-sensitivity (OR ⫽ 1.66, 95% CI 1.34 –2.06), depression (OR ⫽ 2.00, 95% CI 1.59 –2.51), anxiety (OR ⫽ 2.08, 95% CI 1.62–2.66), and psychoticism (OR ⫽ 1.60, 95% CI 1.26 –2.03) were significantly associated with an elevated injury risk. Conclusion: Psychological symptoms are associated with an elevated risk of nonfatal unintentional injury among middle and high school students. Mental health services, such as psychological counseling, may help reduce the risk of nonfatal unintentional injuries among Chinese adolescents. © 2005 Society for Adolescent Medicine. All rights reserved.
Keywords:
Nonfatal injury; Adolescent; SCL-90-R; Psychological symptoms; China
Unintentional injuries are a leading cause of death among adolescents [1– 4]. Children with psychiatric disorders and antisocial behaviors have been shown to be at an elevated risk of unintentional injuries [5,6]. Bijur et al [7] found that a relationship exists between hyperactivity and
*Corresponding author. E-mail address: [email protected]
unintentional injury risk. Unintentional injury risk is also higher among children with oppositional defiant disorders, compared with normal children [8]. However, a study conducted by Davidson et al [9] found no evidence of a relationship between hyperactivity and unintentional injuries among boys. Demographic, family, socioeconomic, racial, and environmental factors are also associated with unintentional
1054-139X/05/$ – see front matter © 2005 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2004.09.005
G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
injury risk [10 –12]. Bijur et al [7] found that the relationship between psychopathology and unintentional injury risk becomes weaker after controlling for demographic and socioeconomic confounders. These relationships have not been examined among Chinese adolescents. The aim of this prospective study is to investigate the association between psychological symptoms and subsequent nonfatal unintentional injuries, while controlling for potential confounding factors among a sample of adolescents in Baise City, Guangxi, China. Methods and materials Study design This prospective study explores the relationship between baseline psychological symptoms and nonfatal injuries among adolescent students in middle school and high school in Baise City, Guangxi, People’s Republic of China. This region was selected as the study site because a mixture of minority families and Han and Zhang families live in the same region. In this region, the minority population includes Miao ethnicity, Bai ethnicity, Tong ethnicity, and Yao ethnicity, as defined officially in China. Middle and high schools were randomly selected from three districts of Baise City. Once schools were selected, letters of invitation were sent to school principals and nurses via the Baise City Education Bureau. Each school principal reviewed the study design and signed a cooperative agreement to participate in the study. Then, all students and parents attended a special 45-minute session to receive information about the background, aims, and methods of the study. Potential risks and steps to keep data confidential were explained to the students and parents. Written consent was obtained from adolescents and their parents who decided to participate, and adolescents had the choice to withdraw from the study at any time during the study period. This special session was led by the researchers from Wuhan University and local school officials. This study went through regular Institutional Review Board (IRB) reviewing process in China and was approved by the School of Public Health, Wuhan. The Hubei Natural Science and Technology Foundation provided funding to this study. Sample selection Participants were students aged 13 to 18 years enrolled in randomly selected middle schools and high schools in Baise City. A total of nine schools were randomly selected based on the geographical location of schools in the region. Overall, 1747 adolescents were selected from 36 randomly selected classes in 9 middle and high schools. Data collection Demographic information about the students (e.g., age, gender, and ethnicity) and their families (e.g., family in-
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comes, parents’ education and occupation, number of children in the family, and parents’ married vs. divorced status) was collected from parents at the beginning of the new school semester in February 2002 using a survey questionnaire. Students were followed through January 31, 2003. Injury data were collected using an Injury Surveillance Survey Form (ISSF). School nurses collected information about any injury occurring at school. Teachers met parents at a parent–teacher conference once a month. During parent–teacher meetings, teachers collected information from adolescents’ parents about injuries adolescents experienced during the past month outside of school. The ISSF recorded the following information for each injury: date and time of injury, student’s name and gender, cause of the injury, activity the student was participating in when injured, location of the injury, person(s) who caused the injury, body part injured, number of school days missed because of the injury, and medical advice or treatments received after the injury. This article attempted to focus on association between psychological symptoms and injury risk. So the injury characteristics such as cause of the injury, location of the injury, and activity the student was participating in when injured, etc., were not described here. A pilot study was conducted among 45 adolescents at one school in December 2001. Feedback from the pilot study was used to finalize the questionnaire and ISSF. Before the study, all school nurses and teachers of the selected classes received formal training, which was provided by researchers from the School of Public Health, Wuhan University. Definition of injury A reportable injury in this study was defined as any injury meeting at least one of the following criteria: (a) an injury for which the adolescent received first-aid medical treatments at the school nurse’s office; (b) an injury for which the adolescent received emergency medical care from a doctor at a hospital or private medical office; (c) an injury for which the adolescent received first-aid from his/her parent and missed half a day or more of school or regular activities; or (d) an injury that was not treated, but caused the student to miss half a day or more of school or regular activities. All injuries were confirmed by school nurses using the injury definition criteria that they were taught during their training for the study. The focus of this study was unintentional injuries; therefore, medically diagnosed child abuse, suicide, and homicide cases were excluded. Psychological symptoms measured using SCL-90-R At the beginning of the study in February 2002, the revised Chinese version of the Symptom-Checklist (SCL-90-R) [13,14] was used to assess psychological symptoms among participants. SCL-90-R is an instrument for measuring sub-
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G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
Table 1 The number and rate of nonfatal unintentional injuries by selected demographic and family characteristics of chinese adolescents, Guangxi, China Characteristics
Total no. of students
No. of injured students
Injury rate per 100 students
All Subjects Gender Male Female Age (yrs) 13 14 15 16 17–18 Ethnicity Han Zhuang Minorityb Number of children in the family 1 2 Family marital status Divorced family Not divorced family
1474
442
30.0
718 756
236 206
32.6 27.4
375 201 294 436 168
160 71 82 95 34
411 989 74
a b
2a
p Value
4.8
.029
42.7 35.3 27.9 21.8 20.2
53.6
.000
118 290 34
28.7 29.3 45.9
9.5
.009
749 725
242 200
32.3 27.5
4.0
.048
101 1373
30 412
29.7 30.0
0.0
.949
Chi-square statistical test. Includes 34 individuals with Miao ethnicity, 20 individuals with Bai ethnicity, 12 individuals with Tong ethnicity, and 4 individuals with Yao ethnicity.
jects’ psychological symptoms and psychopathologic features on nine subscales using self-reported survey questions: somatization, obsessive-compulsiveness, interpersonal-sensitivity, depression, anxiety, hostility, phobia, paranoid ideation, and psychoticism. Each question is rated on a 5-point Likert distress scale (1 for no distress, 5 for extreme distress) [15]. This instrument has been used extensively in studies to measure a variety of mental disorders, for example, among medical and psychiatric inpatients and outpatients, in clinical drug trials, and in community health surveys [16]. The reliability and validity of the Chinese version of the SCL-90-R has been established in previous studies [15]. Although the SCL-90-R was originally developed for use among adults, it has been used among adolescents. The SCL-90-R has been shown to have good to excellent psychometric properties [17,18]. In our study, each participant spent an average of 20 minutes in the classroom to complete SCL-90-R forms. Statistical analyses were based on raw scores derived by adding the values (1–5) for the responses self-reported by the student in each of the symptom dimensions. Statistical analysis The SPSS statistics software package (version 11.5) [19] was used for all data analyses. Injury rates per 100 adolescents were calculated to describe the incidence of injury by gender, age group, ethnicity, and family characteristics. Student’s t-test for independent group was used to test subscale means of raw scores of SCL-90-R between injured and noninjured adolescents. The difference in the number of injuries by age, gender,
ethnicity, and family characteristics was tested by Chi-square analysis. Results were considered statistically significant if p ⱕ .05. Relative risks (RR) of injury and the associated 95% confidence intervals (CI) for two groups of individuals, one with mean raw scores ⬍ 2.0 and the other with mean raw scores ⱖ 2.0, were calculated to examine the relationship between psychological symptoms and nonfatal unintentional injuries. Multivariate logistic regression models were used to further examine this association while controlling for confounding effects of demographic and socioeconomic factors [20]. Odds ratios (OR) and the associated 95% confidence intervals were estimated in the multivariate logistic regression models.
Results Injury incidence rate A total of 1474 of the 1549 selected adolescents completed the study, yielding a response rate of 95.2%. The distribution of adolescents’ demographic and family characteristics was similar between the selected sample and the entire population of students in the region. A total of 442 adolescents reported having nonfatal unintentional injuries during the 1-year study period, generating an overall injury rate of 30.0 per 100 students in 1 year. Adolescent injury rates by gender, age, ethnicity, and family characteristics are summarized in Table 1. Boys had significantly higher injury rates than girls (32.6% vs. 27.4%, p ⫽ .03). Adolescents of nonminority ethnicities, i.e., Han
G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
463
Table 2 Comparison of mean raw scores (⫾ one standard deviation) of SCL-90-R psychological symptom subscales between injured and noninjured Chinese adolescents, Guangxi, China SCL-90-R Subscale
Noninjured (n ⫽ 1032)
Injured (n ⫽ 442)
ta
p Value
Somatization Obsessive-compulsiveness Interpersonal-sensitivity Depression Anxiety Hostility Phobia Paranoid ideation Psychoticism
1.43 ⫾ 0.48 1.87 ⫾ 0.60 1.77 ⫾ 0.65 1.62 ⫾ 0.62 1.54 ⫾ 0.57 1.70 ⫾ 0.68 1.47 ⫾ 0.53 1.64 ⫾ 0.61 1.60 ⫾ 0.54
1.62 ⫾ 0.56 2.11 ⫾ 0.66 1.96 ⫾ 0.65 1.83 ⫾ 0.66 1.72 ⫾ 0.63 1.73 ⫾ 0.65 1.55 ⫾ 0.54 1.74 ⫾ 0.60 1.78 ⫾ 0.58
7.47 7.62 5.82 6.72 6.32 0.87 3.06 3.09 6.65
.00 .00 .00 .00 .00 .39 .00 .00 .00
a
Student’s t-test.
anxiety, phobia, paranoid ideation, and psychoticism between injured and noninjured adolescents.
and Zhuang, had almost identical injury rates (28.7% and 29.3%, respectively). However, the injury rate (45.9%) of minority adolescents was significantly higher than that of nonminority adolescents (p ⫽ .01). Injury rate decreased from 42.7% at age 13–14 years to 20.2% at age 17–18 years. Adolescents who lived in families with only one child had a significantly higher injury rate than adolescents who lived in families with more than one child (32.3% vs. 27.5%, p ⫽ .05). The injury rate among adolescents from divorced families was not different from the injury rate among those whose parents were married.
Psychological symptoms and injury risk In this study, adolescents were classified into two groups: those with mean raw scores of SCL-90-R subscales ⱖ 2.0 and those with mean raw scores of SCL-90-R subscales ⬍ 2.0. Injury rates between these two groups were compared and results shown in Table 3. Injury rates were higher among individuals with subscale mean raw scores ⱖ 2.0 than among individuals with subscale mean raw scores ⬍ 2.0. All subscale symptoms, with the exception of hostility and phobia, were associated with a significantly elevated relative risk of injury. The symptoms of anxiety (RR ⫽ 1.57, 95% CI, 1.36 –1.80), obsessive-compulsiveness (RR ⫽ 1.57, 95% CI, 1.67–1.78), somatization (RR ⫽ 1.52, 95% CI, 1.30 –1.77), and depression (RR ⫽ 1.50, 95% CI, 1.31– 1.71) were associated with slightly elevated injury risk. After controlling for variables gender, age, and ethnicity in multivariate logistic regression models, the association between psychological symptoms and injury risk was still evident in all dimensions measured by SCL-90-R (Table 4). The psychological symptoms of somatization (OR ⫽ 2.00,
Psychological symptoms measured using SCL-90-R Results from Student’s t-tests comparing mean raw scores of SCL-90-R subscales between injured and noninjured adolescents are shown in Table 2. Injured adolescents had slightly higher mean raw scores than noninjured individuals on all subscales. However, the difference in hostility symptoms between injured and noninjured adolescents was small and did not reach a statistical significance level (p ⬎ .05). However, there was a statistically significant difference in the psychological symptoms of somatization, obsessive-compulsiveness, interpersonal sensitivity, depression,
Table 3 Comparison of injury rates among Chinese adolescents with SCL-90-R factor subscale mean raw scores ⬍ 2.0 vs. mean raw scores ⱖ 2.0, Guangxi, China Mean score ⬍ 2.0
Mean score ⱖ 2.0
95% CIb
Factors
n
Injury ratec
n
Injury rate
RRa
Lower
Upper
Somatization Obsessive-compulsiveness Interpersonal-sensitivity Depression Anxiety Hostility Phobia Paranoid ideation Psychoticism
1234 1017 1042 1062 1151 1080 1236 1108 1110
30.2 26.5 29.1 28.9 29.3 30.9 31.5 31.0 30.2
240 457 432 412 323 394 238 366 364
45.8 41.5 39.8 43.3 45.9 37.1 37.8 37.3 40.5
1.52 1.57 1.37 1.50 1.57 1.20 1.20 1.20 1.34
1.30 1.67 1.20 1.31 1.36 0.97 0.99 1.03 1.16
1.77 1.78 1.56 1.71 1.80 1.39 1.43 1.40 1.55
a
Relative risks. 95% Confidence intervals. c Injury rates per 100 adolescents during one year. b
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G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
Table 4 Odds ratios (OR) of nonfatal unintentional injury among Chinese adolescents by SCL-90-R subscale factors (mean raw score ⬍ 2.0 vs. ⱖ 2.0), logistic regression models adjusting for age, gender, and ethnicity
Factors
Odds ratioa
Somatization Obsessive-compulsiveness Interpersonal-sensitivity Depression Anxiety Hostility Phobia Paranoid ideation Psychoticism
2.00 2.10 1.66 2.00 2.08 1.36 1.31 1.35 1.60
95% CI Lower
Upper
1.52 1.71 1.34 1.59 1.62 0.82 0.96 0.97 1.26
2.63 2.58 2.06 2.51 2.66 1.72 1.74 1.72 2.03
a Adjusted by gender, age, and ethnicity in logistic regression models. Gender, age, and ethnicity were used in logistic regression models as categorical dummy variables. Female and Han ethnicity were treated as reference groups. Two age groups, 13–14 years and 15–18 years, were used, with 15–18 years as the reference group.
95% CI 1.52–2.63), obsessive-compulsiveness (OR ⫽ 2.10, 95% CI 1.71–2.58), anxiety (OR ⫽ 2.08, 95% CI 1.62– 2.66), depression (OR ⫽ 2.00, 95% CI 1.59 –2.51), interpersonal-sensitivity (OR ⫽ 1.66, 95% CI 1.34 –2.06), and psychoticism (OR ⫽ 1.60, 95% CI 1.26 –2.03) remained associated with elevated injury risk at a statistically significant level. Discussion In this large cohort study, we described patterns of nonfatal unintentional injuries and examined the association between psychological symptoms and injury risk among Chinese adolescents in a selected sample of middle and high schools. We observed an overall nonfatal unintentional injury rate of 30.0% during the 1-year study period. Although previous studies reported different injury rates and found an array of injury patterns among adolescents [1,21–23], unintentional injuries have consistently been found to be more common in boys than girls. The injury rates in our study, 32.6% for boys and 27.4% for girls, fell in the mid-range of injury rates found in previous studies [10,21,24]. Numerous studies have also documented that unintentional injury risk varies by demographics, family characteristics, and socioeconomic background [10,12,25]. In our study, injury risk decreased significantly with increasing age, and was higher among males, ethnic minority students, and those with only one child in the family. These findings were generally consistent with results from previous studies. Other investigators [26] have also demonstrated that psychological symptoms among adolescents vary by age, developmental stage, and gender. After controlling for the potential confounding effects of gender, age, and ethnicity using multivariate logistic regression models, the psy-
chological symptoms measured in SCL-90-R subscales for somatization, obsessive-compulsiveness, interpersonal-sensitivity, depression, anxiety, and psychoticism were still associated with significantly elevated risk of injury among adolescents in our study. This suggests that psychological problems may be risk factors for nonfatal unintentional injuries independent of demographics and other socioeconomic factors among adolescents in China. Previous studies documented the persistence of increased injury risk among children and adolescents with attention deficit hyperactivity disorder (ADHD) [5,27–30]. Results from these studies indicated that children with ADHD anticipate less severe consequences following risky behavior and therefore take fewer injury prevention approaches. It was found that children with ADHD exhibited significantly more risky behaviors at home and in public settings. These risk-taking behaviors may explain, at least partially, why children with ADHD/ADD have a greater injury risk than their healthy counterparts. Our study might be the first of its kind to investigate the association between an array of psychological symptoms measured using SCL-90-R and risk of nonfatal unintentional injuries. In our study, the psychological symptoms were based on a self-report measurement, so the symptoms might not be as serious as the medically diagnosed ADHD/ADD. However, some psychological symptoms measured in our study, for example, anxiety, might also reflect risk-taking behaviors and therefore provide explanation for the elevated injury risk among adolescents with abnormal psychological symptoms. A large cross-sectional study among children aged 0 –14 years also found that children who had interpersonal problems had a statistically significant higher injury risk than children who had no such relationship problems [31]. Nevertheless, we believe that reasons for the elevated injury risk among adolescents with abnormal psychological symptoms observed in our study were not clear and also have not been well studied in previous studies. This issue warrants further examination. There are several limitations of this study. The first limitation is related to measurement of psychological symptoms using the SCL-90-R. The SCL-90-R is a self-report instrument that has been used to measure the status of psychological symptoms during the previous 2 weeks [13,14]. In our study, we measured psychological symptoms among study participants only at baseline. Injuries to these participants were then recorded during a 1-year follow-up period. If there was a change in psychological symptoms during the study period, this could threaten the validity of the observed associations of these symptoms with the risk of injury. The inaccuracies inherent in self-reported data on psychological symptoms are another potential limitation of this study. Similarly, another limitation of this study was potential injury-reporting bias. Injuries may be under-reported by parents or adolescents, particularly when they were asked to report injuries that occurred outside school
G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
settings during school breaks. Parents or adolescents may have forgotten an injury that occurred during winter or summer school breaks. Therefore, the nonfatal unintentional injury rates reported in this study may underestimate true values. Finally, our findings describe associations, but not definite causality. For example, separate unmeasured factors may be causing both the psychological symptoms and injuries. However, the association of psychological symptoms and elevated risk of injury persisted even after controlling for important confounding variables known to be associated with injury risk. In spite of these study limitations, results reported here indicate that psychological symptoms, such as anxiety, obsessive-compulsiveness, somatization, depression, interpersonal-sensitivity, paranoid ideation, and psychoticism are associated with an elevated risk of nonfatal unintentional injuries among this Chinese adolescent population. Our study suggests that mental health services, such as psychological counseling, may help reduce the risk of injury among Chinese adolescents.
Acknowledgments This study was funded by the Hubei Natural Science and Technology Foundation. Data analysis and the manuscript preparation were supported by a grant from the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services (Grant no. R49CE000241-01). The views expressed here are those of the authors and do not necessarily reflect the official views of the Hubei Natural Science and Technology Foundation and the U.S. Centers for Disease Control and Prevention. We thank Drs. Yingjia Ma and Qijun Wu at the Department of Preventive Medicine, Youjiang Medical College for Nationalities, Baise City, Guangxi, China for assistance with study design and data collection. We also thank the teachers at middle and high schools that participated in this study for their contributions to data collection. We appreciate advice provided by Dr. Keri Brown of the Department of Psychology, Columbus Children’s Hospital with regard to the application of SCL-90-R among adolescents. This study went through IRB reviewing process in China and was approved by the School of Public Health, Wuhan University, People’s Republic of China.
References [1] Yang CY, Yeh YC, Cheng MF, Lin MC. The incidence of schoolrelated injuries among adolescents in Kaohsiung, Taiwan. Am J Prev Med 1998;15:172–7. [2] Spady DW, Saunders DL, Schopflocher DP, Svenson LW. Patterns of injury in children: A population-based approach. Pediatrics 2004;113: 522–9.
465
[3] Li LP, Wang S, Huang G, Luo JY. A survey on injury incidence in school children in Shantou City, China. Biomed Environ Sci 16 2003;16:180 – 6. [4] Yang GH, Zhou MG, Huang ZJ, Wang LJ. [Study on the trend and disease burden of injury deaths in the Chinese population 1991–2000] Zhonghua Liu Xing Bing Xue Za Zhi 2004;25:193– 8. [5] Rowe R, Maughan B, Goodman R. Childhood psychiatric disorder and unintentional injury: findings from a national cohort study. J Pediatr Psychol 2004;29:119 –30. [6] Bijur PE, Haslum M, Golding J. Cognitive outcomes of multiple mild head injuries in children. J Dev Behav Pediatr 1996;17:143– 8. [7] Bijur PE, Stewart-Brown S, Butler N. Child behavior and accidental injury in 11,966 preschool children. Am J Dis Child 1986; 140:487– 92. [8] Schwebel DC, Speltz ML, Jones K, Bardina P.Unintentional injury in preschool boys with and without early onset of disruptive behavior. J Pediatr Psychol 2002;27:727–37. [9] Davidson LL, Taylor EA, Sandberg ST, Thorley G. Hyperactivity in school-age boys and subsequent risk of injury. Pediatrics 1992;90: 697–702. [10] Grimmer KA, Jones D, Williams J. Prevalence of adolescent injury from recreational exercise: An Australian perspective. J Adolesc Health 2000;27:266 –72. [11] Pickett W, Garner MJ, Boyce WF, King MA. Gradients in risk for youth injury associated with multiple-risk behaviours: A study of 11,329 Canadian adolescents. Soc Sci Med 2002;55:1055– 68. [12] O’Connor TG, Davies L, Dunn J, Golding J. Distribution of accidents, injuries, and illnesses by family type. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. Pediatrics 2000;106:E68. [13] Derogatis L. SCL-90-R: Symptom Checklist-90-R, National Computer System Inc Minneapolis, MN, 1994. [14] Maruish M. Handbook of Psychological Assessment in Primary Care Settings. Lawrence Erlbaum Associates, Mahwah, NJ, 2000. [15] Zhang M, Wang Z. [Mental Health State of Middle and High School Students], Zhongguo Xin li Wei sheng Za zhi 2001;15:226 – 8. [16] Maruish M. The Use of Psychological Testing for Treatment Planning and Outcome Assessment. Lawrence Erlbaum Associates, Hillsdale, NJ 1994. [17] Hart KM, Bryer JB, Martines KA. SCL-90-R symptom patterns for adolescent psychiatric inpatients. J Pers Assess 1991;56:168 – 78. [18] McGough J, Curry JF. Utility of the SCL-90-R with depressed and conduct-disordered adolescent inpatients. J Pers Assess 1992;59:552– 63. [19] SPSS I, SPSS Base Application Guide 11.5, SPSS Inc Chicago, IL, 2003. [20] SPSS I, SPSS Regression Model 11.5, SPSS Inc., Chicago, IL, 2003. [21] Bienefeld M, Pickett W, Carr PA. A descriptive study of childhood injuries in Kingston, Ontario using data from a computerized injury surveillance system. Chronic Dis Can 1996;17:21–7. [22] Overpeck MD, Jones DH, Trumble AC, Scheidt PC, et al. Socioeconomic and racial/ethnic factors affecting non-fatal medically attended injury rates in US children. Inj Prev 1997;3:272– 6. [23] Pickett W, Schmid H, Boyce WF, Simpson K. et. al. Multiple risk behavior and injury: An international analysis of young people. Arch Pediatr Adolesc Med 2002;156: 786 –93. [24] Kramer MD, Lightfoot AC, Knight S, Cazier CR, et al. Classroom injuries in Utah public schools. Acad Emerg 2003;10:978 – 84. [25] Pickett W, Brison RJ, Mackenzie SG, Garner M, et al. Youth injury data in the Canadian Hospitals Injury Reporting and Prevention Program: Do they represent the Canadian experience? Inj Prev 2000; 6:9 –15.
466
G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
[26] Essau CA. Comorbidity of anxiety disorders in adolescents. Depress Anxiety 2003;18:1– 6. [27] DiScala C, Lescohier I, Barthel M, Li G. Injuries to children with attention deficit hyperactivity disorder. Pediatrics 1998;102:1415–21. [28] Mangus RS, Bergman D, Zieger M, Coleman JJ. Burn injuries in children with attention-deficit hyperactivity disorder. Burns 2004;30:148–50. [29] Barkley RA, Guevremont DC, Anastopoulos AD, DuPaul GJ, et al. Driving-related risks and outcomes of attention deficit hyperactivity
disorder in adolescents and young adults: A 3- to 5-year follow-up survey. Pediatrics 1993;92:212– 8. [30] Max JE, Lindgren SD, Knutson C, Pearson CS, et al. Child and adolescent traumatic brain injury: Correlates of disruptive behaviour disorders. Brain Inj 1998;12:41–52. [31] Yin Q, Li H, Zhang K, Li T, et al. [Epidemiologic survey of unintentional injury among 3632 children]. Zhongguo Er Tong Bao Jian Za Zhi 1997;5:216 – 8.
Original article
Psychological symptoms and nonfatal unintentional injuries among Chinese adolescents: a prospective study G. Chena,b, G.A. Smitha, S. Dengc, D. Chenb, K. Kellehera, H. Xianga,* a
Center for Injury Research and Policy, Columbus Children’s Research Institute, Children’s Hospital, College of Medicine and Public Health, The Ohio State University, Columbus, Ohio b Department of Health Statistics, School of Public Health, Wuhan University, Wuhan, People’s Republic of China c Department of Preventive Medicine, Youjiang Medical College for Nationalities, Baise City, Guangxi, China Manuscript received July 16, 2004; manuscript accepted September 10, 2004
Abstract
Purpose: To describe patterns of nonfatal unintentional injuries and investigate the association of psychological symptoms with injury risk among adolescents in Guangxi, China. Methods: Adolescents were selected from middle and high school students in Baise City, Guangxi, China. Psychological symptoms at baseline were measured using SCL-90-R and nonfatal unintentional injuries that occurred among participants were recorded using a standardized injury surveillance questionnaire. Annual injury rates per 100 adolescents by adolescents’ demographic and family characteristics were calculated. Student’s t-test and the Chi-square test were used to test differences in mean raw scores of SCL-90-R subscales and injury rates. Relative risks and odds ratios of injury with 95% confidence intervals were calculated in univariate analyses and multivariate logistic models. Results: A total of 1474 middle and high school students finished the study. Of them, 442 reported nonfatal unintentional injuries during the study period, resulting in an annual injury rate of 30.3 per 100 adolescents. Boys had a significantly higher injury rate than girls (32.6% vs. 27.4%). Injury rate decreased as the adolescents’ age increased. Compared with adolescents who were not injured, the injured adolescents had higher average raw scores of all subscales of SCL-90-R, with an exception of the subscale for hostility. All SCL-90-R subscales factors, except those for hostility and phobia, were associated with injury risk. After confounding effects of age, gender, and ethnicity were controlled using logistic regression models, SCL-90-R subscales for somatization (OR ⫽ 2.00, 95% CI 1.52–2.63), obsessive-compulsiveness (OR ⫽ 2.10, 95% CI 1.71–2.58), interpersonal-sensitivity (OR ⫽ 1.66, 95% CI 1.34 –2.06), depression (OR ⫽ 2.00, 95% CI 1.59 –2.51), anxiety (OR ⫽ 2.08, 95% CI 1.62–2.66), and psychoticism (OR ⫽ 1.60, 95% CI 1.26 –2.03) were significantly associated with an elevated injury risk. Conclusion: Psychological symptoms are associated with an elevated risk of nonfatal unintentional injury among middle and high school students. Mental health services, such as psychological counseling, may help reduce the risk of nonfatal unintentional injuries among Chinese adolescents. © 2005 Society for Adolescent Medicine. All rights reserved.
Keywords:
Nonfatal injury; Adolescent; SCL-90-R; Psychological symptoms; China
Unintentional injuries are a leading cause of death among adolescents [1– 4]. Children with psychiatric disorders and antisocial behaviors have been shown to be at an elevated risk of unintentional injuries [5,6]. Bijur et al [7] found that a relationship exists between hyperactivity and
*Corresponding author. E-mail address: [email protected]
unintentional injury risk. Unintentional injury risk is also higher among children with oppositional defiant disorders, compared with normal children [8]. However, a study conducted by Davidson et al [9] found no evidence of a relationship between hyperactivity and unintentional injuries among boys. Demographic, family, socioeconomic, racial, and environmental factors are also associated with unintentional
1054-139X/05/$ – see front matter © 2005 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2004.09.005
G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
injury risk [10 –12]. Bijur et al [7] found that the relationship between psychopathology and unintentional injury risk becomes weaker after controlling for demographic and socioeconomic confounders. These relationships have not been examined among Chinese adolescents. The aim of this prospective study is to investigate the association between psychological symptoms and subsequent nonfatal unintentional injuries, while controlling for potential confounding factors among a sample of adolescents in Baise City, Guangxi, China. Methods and materials Study design This prospective study explores the relationship between baseline psychological symptoms and nonfatal injuries among adolescent students in middle school and high school in Baise City, Guangxi, People’s Republic of China. This region was selected as the study site because a mixture of minority families and Han and Zhang families live in the same region. In this region, the minority population includes Miao ethnicity, Bai ethnicity, Tong ethnicity, and Yao ethnicity, as defined officially in China. Middle and high schools were randomly selected from three districts of Baise City. Once schools were selected, letters of invitation were sent to school principals and nurses via the Baise City Education Bureau. Each school principal reviewed the study design and signed a cooperative agreement to participate in the study. Then, all students and parents attended a special 45-minute session to receive information about the background, aims, and methods of the study. Potential risks and steps to keep data confidential were explained to the students and parents. Written consent was obtained from adolescents and their parents who decided to participate, and adolescents had the choice to withdraw from the study at any time during the study period. This special session was led by the researchers from Wuhan University and local school officials. This study went through regular Institutional Review Board (IRB) reviewing process in China and was approved by the School of Public Health, Wuhan. The Hubei Natural Science and Technology Foundation provided funding to this study. Sample selection Participants were students aged 13 to 18 years enrolled in randomly selected middle schools and high schools in Baise City. A total of nine schools were randomly selected based on the geographical location of schools in the region. Overall, 1747 adolescents were selected from 36 randomly selected classes in 9 middle and high schools. Data collection Demographic information about the students (e.g., age, gender, and ethnicity) and their families (e.g., family in-
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comes, parents’ education and occupation, number of children in the family, and parents’ married vs. divorced status) was collected from parents at the beginning of the new school semester in February 2002 using a survey questionnaire. Students were followed through January 31, 2003. Injury data were collected using an Injury Surveillance Survey Form (ISSF). School nurses collected information about any injury occurring at school. Teachers met parents at a parent–teacher conference once a month. During parent–teacher meetings, teachers collected information from adolescents’ parents about injuries adolescents experienced during the past month outside of school. The ISSF recorded the following information for each injury: date and time of injury, student’s name and gender, cause of the injury, activity the student was participating in when injured, location of the injury, person(s) who caused the injury, body part injured, number of school days missed because of the injury, and medical advice or treatments received after the injury. This article attempted to focus on association between psychological symptoms and injury risk. So the injury characteristics such as cause of the injury, location of the injury, and activity the student was participating in when injured, etc., were not described here. A pilot study was conducted among 45 adolescents at one school in December 2001. Feedback from the pilot study was used to finalize the questionnaire and ISSF. Before the study, all school nurses and teachers of the selected classes received formal training, which was provided by researchers from the School of Public Health, Wuhan University. Definition of injury A reportable injury in this study was defined as any injury meeting at least one of the following criteria: (a) an injury for which the adolescent received first-aid medical treatments at the school nurse’s office; (b) an injury for which the adolescent received emergency medical care from a doctor at a hospital or private medical office; (c) an injury for which the adolescent received first-aid from his/her parent and missed half a day or more of school or regular activities; or (d) an injury that was not treated, but caused the student to miss half a day or more of school or regular activities. All injuries were confirmed by school nurses using the injury definition criteria that they were taught during their training for the study. The focus of this study was unintentional injuries; therefore, medically diagnosed child abuse, suicide, and homicide cases were excluded. Psychological symptoms measured using SCL-90-R At the beginning of the study in February 2002, the revised Chinese version of the Symptom-Checklist (SCL-90-R) [13,14] was used to assess psychological symptoms among participants. SCL-90-R is an instrument for measuring sub-
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Table 1 The number and rate of nonfatal unintentional injuries by selected demographic and family characteristics of chinese adolescents, Guangxi, China Characteristics
Total no. of students
No. of injured students
Injury rate per 100 students
All Subjects Gender Male Female Age (yrs) 13 14 15 16 17–18 Ethnicity Han Zhuang Minorityb Number of children in the family 1 2 Family marital status Divorced family Not divorced family
1474
442
30.0
718 756
236 206
32.6 27.4
375 201 294 436 168
160 71 82 95 34
411 989 74
a b
2a
p Value
4.8
.029
42.7 35.3 27.9 21.8 20.2
53.6
.000
118 290 34
28.7 29.3 45.9
9.5
.009
749 725
242 200
32.3 27.5
4.0
.048
101 1373
30 412
29.7 30.0
0.0
.949
Chi-square statistical test. Includes 34 individuals with Miao ethnicity, 20 individuals with Bai ethnicity, 12 individuals with Tong ethnicity, and 4 individuals with Yao ethnicity.
jects’ psychological symptoms and psychopathologic features on nine subscales using self-reported survey questions: somatization, obsessive-compulsiveness, interpersonal-sensitivity, depression, anxiety, hostility, phobia, paranoid ideation, and psychoticism. Each question is rated on a 5-point Likert distress scale (1 for no distress, 5 for extreme distress) [15]. This instrument has been used extensively in studies to measure a variety of mental disorders, for example, among medical and psychiatric inpatients and outpatients, in clinical drug trials, and in community health surveys [16]. The reliability and validity of the Chinese version of the SCL-90-R has been established in previous studies [15]. Although the SCL-90-R was originally developed for use among adults, it has been used among adolescents. The SCL-90-R has been shown to have good to excellent psychometric properties [17,18]. In our study, each participant spent an average of 20 minutes in the classroom to complete SCL-90-R forms. Statistical analyses were based on raw scores derived by adding the values (1–5) for the responses self-reported by the student in each of the symptom dimensions. Statistical analysis The SPSS statistics software package (version 11.5) [19] was used for all data analyses. Injury rates per 100 adolescents were calculated to describe the incidence of injury by gender, age group, ethnicity, and family characteristics. Student’s t-test for independent group was used to test subscale means of raw scores of SCL-90-R between injured and noninjured adolescents. The difference in the number of injuries by age, gender,
ethnicity, and family characteristics was tested by Chi-square analysis. Results were considered statistically significant if p ⱕ .05. Relative risks (RR) of injury and the associated 95% confidence intervals (CI) for two groups of individuals, one with mean raw scores ⬍ 2.0 and the other with mean raw scores ⱖ 2.0, were calculated to examine the relationship between psychological symptoms and nonfatal unintentional injuries. Multivariate logistic regression models were used to further examine this association while controlling for confounding effects of demographic and socioeconomic factors [20]. Odds ratios (OR) and the associated 95% confidence intervals were estimated in the multivariate logistic regression models.
Results Injury incidence rate A total of 1474 of the 1549 selected adolescents completed the study, yielding a response rate of 95.2%. The distribution of adolescents’ demographic and family characteristics was similar between the selected sample and the entire population of students in the region. A total of 442 adolescents reported having nonfatal unintentional injuries during the 1-year study period, generating an overall injury rate of 30.0 per 100 students in 1 year. Adolescent injury rates by gender, age, ethnicity, and family characteristics are summarized in Table 1. Boys had significantly higher injury rates than girls (32.6% vs. 27.4%, p ⫽ .03). Adolescents of nonminority ethnicities, i.e., Han
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Table 2 Comparison of mean raw scores (⫾ one standard deviation) of SCL-90-R psychological symptom subscales between injured and noninjured Chinese adolescents, Guangxi, China SCL-90-R Subscale
Noninjured (n ⫽ 1032)
Injured (n ⫽ 442)
ta
p Value
Somatization Obsessive-compulsiveness Interpersonal-sensitivity Depression Anxiety Hostility Phobia Paranoid ideation Psychoticism
1.43 ⫾ 0.48 1.87 ⫾ 0.60 1.77 ⫾ 0.65 1.62 ⫾ 0.62 1.54 ⫾ 0.57 1.70 ⫾ 0.68 1.47 ⫾ 0.53 1.64 ⫾ 0.61 1.60 ⫾ 0.54
1.62 ⫾ 0.56 2.11 ⫾ 0.66 1.96 ⫾ 0.65 1.83 ⫾ 0.66 1.72 ⫾ 0.63 1.73 ⫾ 0.65 1.55 ⫾ 0.54 1.74 ⫾ 0.60 1.78 ⫾ 0.58
7.47 7.62 5.82 6.72 6.32 0.87 3.06 3.09 6.65
.00 .00 .00 .00 .00 .39 .00 .00 .00
a
Student’s t-test.
anxiety, phobia, paranoid ideation, and psychoticism between injured and noninjured adolescents.
and Zhuang, had almost identical injury rates (28.7% and 29.3%, respectively). However, the injury rate (45.9%) of minority adolescents was significantly higher than that of nonminority adolescents (p ⫽ .01). Injury rate decreased from 42.7% at age 13–14 years to 20.2% at age 17–18 years. Adolescents who lived in families with only one child had a significantly higher injury rate than adolescents who lived in families with more than one child (32.3% vs. 27.5%, p ⫽ .05). The injury rate among adolescents from divorced families was not different from the injury rate among those whose parents were married.
Psychological symptoms and injury risk In this study, adolescents were classified into two groups: those with mean raw scores of SCL-90-R subscales ⱖ 2.0 and those with mean raw scores of SCL-90-R subscales ⬍ 2.0. Injury rates between these two groups were compared and results shown in Table 3. Injury rates were higher among individuals with subscale mean raw scores ⱖ 2.0 than among individuals with subscale mean raw scores ⬍ 2.0. All subscale symptoms, with the exception of hostility and phobia, were associated with a significantly elevated relative risk of injury. The symptoms of anxiety (RR ⫽ 1.57, 95% CI, 1.36 –1.80), obsessive-compulsiveness (RR ⫽ 1.57, 95% CI, 1.67–1.78), somatization (RR ⫽ 1.52, 95% CI, 1.30 –1.77), and depression (RR ⫽ 1.50, 95% CI, 1.31– 1.71) were associated with slightly elevated injury risk. After controlling for variables gender, age, and ethnicity in multivariate logistic regression models, the association between psychological symptoms and injury risk was still evident in all dimensions measured by SCL-90-R (Table 4). The psychological symptoms of somatization (OR ⫽ 2.00,
Psychological symptoms measured using SCL-90-R Results from Student’s t-tests comparing mean raw scores of SCL-90-R subscales between injured and noninjured adolescents are shown in Table 2. Injured adolescents had slightly higher mean raw scores than noninjured individuals on all subscales. However, the difference in hostility symptoms between injured and noninjured adolescents was small and did not reach a statistical significance level (p ⬎ .05). However, there was a statistically significant difference in the psychological symptoms of somatization, obsessive-compulsiveness, interpersonal sensitivity, depression,
Table 3 Comparison of injury rates among Chinese adolescents with SCL-90-R factor subscale mean raw scores ⬍ 2.0 vs. mean raw scores ⱖ 2.0, Guangxi, China Mean score ⬍ 2.0
Mean score ⱖ 2.0
95% CIb
Factors
n
Injury ratec
n
Injury rate
RRa
Lower
Upper
Somatization Obsessive-compulsiveness Interpersonal-sensitivity Depression Anxiety Hostility Phobia Paranoid ideation Psychoticism
1234 1017 1042 1062 1151 1080 1236 1108 1110
30.2 26.5 29.1 28.9 29.3 30.9 31.5 31.0 30.2
240 457 432 412 323 394 238 366 364
45.8 41.5 39.8 43.3 45.9 37.1 37.8 37.3 40.5
1.52 1.57 1.37 1.50 1.57 1.20 1.20 1.20 1.34
1.30 1.67 1.20 1.31 1.36 0.97 0.99 1.03 1.16
1.77 1.78 1.56 1.71 1.80 1.39 1.43 1.40 1.55
a
Relative risks. 95% Confidence intervals. c Injury rates per 100 adolescents during one year. b
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Table 4 Odds ratios (OR) of nonfatal unintentional injury among Chinese adolescents by SCL-90-R subscale factors (mean raw score ⬍ 2.0 vs. ⱖ 2.0), logistic regression models adjusting for age, gender, and ethnicity
Factors
Odds ratioa
Somatization Obsessive-compulsiveness Interpersonal-sensitivity Depression Anxiety Hostility Phobia Paranoid ideation Psychoticism
2.00 2.10 1.66 2.00 2.08 1.36 1.31 1.35 1.60
95% CI Lower
Upper
1.52 1.71 1.34 1.59 1.62 0.82 0.96 0.97 1.26
2.63 2.58 2.06 2.51 2.66 1.72 1.74 1.72 2.03
a Adjusted by gender, age, and ethnicity in logistic regression models. Gender, age, and ethnicity were used in logistic regression models as categorical dummy variables. Female and Han ethnicity were treated as reference groups. Two age groups, 13–14 years and 15–18 years, were used, with 15–18 years as the reference group.
95% CI 1.52–2.63), obsessive-compulsiveness (OR ⫽ 2.10, 95% CI 1.71–2.58), anxiety (OR ⫽ 2.08, 95% CI 1.62– 2.66), depression (OR ⫽ 2.00, 95% CI 1.59 –2.51), interpersonal-sensitivity (OR ⫽ 1.66, 95% CI 1.34 –2.06), and psychoticism (OR ⫽ 1.60, 95% CI 1.26 –2.03) remained associated with elevated injury risk at a statistically significant level. Discussion In this large cohort study, we described patterns of nonfatal unintentional injuries and examined the association between psychological symptoms and injury risk among Chinese adolescents in a selected sample of middle and high schools. We observed an overall nonfatal unintentional injury rate of 30.0% during the 1-year study period. Although previous studies reported different injury rates and found an array of injury patterns among adolescents [1,21–23], unintentional injuries have consistently been found to be more common in boys than girls. The injury rates in our study, 32.6% for boys and 27.4% for girls, fell in the mid-range of injury rates found in previous studies [10,21,24]. Numerous studies have also documented that unintentional injury risk varies by demographics, family characteristics, and socioeconomic background [10,12,25]. In our study, injury risk decreased significantly with increasing age, and was higher among males, ethnic minority students, and those with only one child in the family. These findings were generally consistent with results from previous studies. Other investigators [26] have also demonstrated that psychological symptoms among adolescents vary by age, developmental stage, and gender. After controlling for the potential confounding effects of gender, age, and ethnicity using multivariate logistic regression models, the psy-
chological symptoms measured in SCL-90-R subscales for somatization, obsessive-compulsiveness, interpersonal-sensitivity, depression, anxiety, and psychoticism were still associated with significantly elevated risk of injury among adolescents in our study. This suggests that psychological problems may be risk factors for nonfatal unintentional injuries independent of demographics and other socioeconomic factors among adolescents in China. Previous studies documented the persistence of increased injury risk among children and adolescents with attention deficit hyperactivity disorder (ADHD) [5,27–30]. Results from these studies indicated that children with ADHD anticipate less severe consequences following risky behavior and therefore take fewer injury prevention approaches. It was found that children with ADHD exhibited significantly more risky behaviors at home and in public settings. These risk-taking behaviors may explain, at least partially, why children with ADHD/ADD have a greater injury risk than their healthy counterparts. Our study might be the first of its kind to investigate the association between an array of psychological symptoms measured using SCL-90-R and risk of nonfatal unintentional injuries. In our study, the psychological symptoms were based on a self-report measurement, so the symptoms might not be as serious as the medically diagnosed ADHD/ADD. However, some psychological symptoms measured in our study, for example, anxiety, might also reflect risk-taking behaviors and therefore provide explanation for the elevated injury risk among adolescents with abnormal psychological symptoms. A large cross-sectional study among children aged 0 –14 years also found that children who had interpersonal problems had a statistically significant higher injury risk than children who had no such relationship problems [31]. Nevertheless, we believe that reasons for the elevated injury risk among adolescents with abnormal psychological symptoms observed in our study were not clear and also have not been well studied in previous studies. This issue warrants further examination. There are several limitations of this study. The first limitation is related to measurement of psychological symptoms using the SCL-90-R. The SCL-90-R is a self-report instrument that has been used to measure the status of psychological symptoms during the previous 2 weeks [13,14]. In our study, we measured psychological symptoms among study participants only at baseline. Injuries to these participants were then recorded during a 1-year follow-up period. If there was a change in psychological symptoms during the study period, this could threaten the validity of the observed associations of these symptoms with the risk of injury. The inaccuracies inherent in self-reported data on psychological symptoms are another potential limitation of this study. Similarly, another limitation of this study was potential injury-reporting bias. Injuries may be under-reported by parents or adolescents, particularly when they were asked to report injuries that occurred outside school
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settings during school breaks. Parents or adolescents may have forgotten an injury that occurred during winter or summer school breaks. Therefore, the nonfatal unintentional injury rates reported in this study may underestimate true values. Finally, our findings describe associations, but not definite causality. For example, separate unmeasured factors may be causing both the psychological symptoms and injuries. However, the association of psychological symptoms and elevated risk of injury persisted even after controlling for important confounding variables known to be associated with injury risk. In spite of these study limitations, results reported here indicate that psychological symptoms, such as anxiety, obsessive-compulsiveness, somatization, depression, interpersonal-sensitivity, paranoid ideation, and psychoticism are associated with an elevated risk of nonfatal unintentional injuries among this Chinese adolescent population. Our study suggests that mental health services, such as psychological counseling, may help reduce the risk of injury among Chinese adolescents.
Acknowledgments This study was funded by the Hubei Natural Science and Technology Foundation. Data analysis and the manuscript preparation were supported by a grant from the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services (Grant no. R49CE000241-01). The views expressed here are those of the authors and do not necessarily reflect the official views of the Hubei Natural Science and Technology Foundation and the U.S. Centers for Disease Control and Prevention. We thank Drs. Yingjia Ma and Qijun Wu at the Department of Preventive Medicine, Youjiang Medical College for Nationalities, Baise City, Guangxi, China for assistance with study design and data collection. We also thank the teachers at middle and high schools that participated in this study for their contributions to data collection. We appreciate advice provided by Dr. Keri Brown of the Department of Psychology, Columbus Children’s Hospital with regard to the application of SCL-90-R among adolescents. This study went through IRB reviewing process in China and was approved by the School of Public Health, Wuhan University, People’s Republic of China.
References [1] Yang CY, Yeh YC, Cheng MF, Lin MC. The incidence of schoolrelated injuries among adolescents in Kaohsiung, Taiwan. Am J Prev Med 1998;15:172–7. [2] Spady DW, Saunders DL, Schopflocher DP, Svenson LW. Patterns of injury in children: A population-based approach. Pediatrics 2004;113: 522–9.
465
[3] Li LP, Wang S, Huang G, Luo JY. A survey on injury incidence in school children in Shantou City, China. Biomed Environ Sci 16 2003;16:180 – 6. [4] Yang GH, Zhou MG, Huang ZJ, Wang LJ. [Study on the trend and disease burden of injury deaths in the Chinese population 1991–2000] Zhonghua Liu Xing Bing Xue Za Zhi 2004;25:193– 8. [5] Rowe R, Maughan B, Goodman R. Childhood psychiatric disorder and unintentional injury: findings from a national cohort study. J Pediatr Psychol 2004;29:119 –30. [6] Bijur PE, Haslum M, Golding J. Cognitive outcomes of multiple mild head injuries in children. J Dev Behav Pediatr 1996;17:143– 8. [7] Bijur PE, Stewart-Brown S, Butler N. Child behavior and accidental injury in 11,966 preschool children. Am J Dis Child 1986; 140:487– 92. [8] Schwebel DC, Speltz ML, Jones K, Bardina P.Unintentional injury in preschool boys with and without early onset of disruptive behavior. J Pediatr Psychol 2002;27:727–37. [9] Davidson LL, Taylor EA, Sandberg ST, Thorley G. Hyperactivity in school-age boys and subsequent risk of injury. Pediatrics 1992;90: 697–702. [10] Grimmer KA, Jones D, Williams J. Prevalence of adolescent injury from recreational exercise: An Australian perspective. J Adolesc Health 2000;27:266 –72. [11] Pickett W, Garner MJ, Boyce WF, King MA. Gradients in risk for youth injury associated with multiple-risk behaviours: A study of 11,329 Canadian adolescents. Soc Sci Med 2002;55:1055– 68. [12] O’Connor TG, Davies L, Dunn J, Golding J. Distribution of accidents, injuries, and illnesses by family type. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. Pediatrics 2000;106:E68. [13] Derogatis L. SCL-90-R: Symptom Checklist-90-R, National Computer System Inc Minneapolis, MN, 1994. [14] Maruish M. Handbook of Psychological Assessment in Primary Care Settings. Lawrence Erlbaum Associates, Mahwah, NJ, 2000. [15] Zhang M, Wang Z. [Mental Health State of Middle and High School Students], Zhongguo Xin li Wei sheng Za zhi 2001;15:226 – 8. [16] Maruish M. The Use of Psychological Testing for Treatment Planning and Outcome Assessment. Lawrence Erlbaum Associates, Hillsdale, NJ 1994. [17] Hart KM, Bryer JB, Martines KA. SCL-90-R symptom patterns for adolescent psychiatric inpatients. J Pers Assess 1991;56:168 – 78. [18] McGough J, Curry JF. Utility of the SCL-90-R with depressed and conduct-disordered adolescent inpatients. J Pers Assess 1992;59:552– 63. [19] SPSS I, SPSS Base Application Guide 11.5, SPSS Inc Chicago, IL, 2003. [20] SPSS I, SPSS Regression Model 11.5, SPSS Inc., Chicago, IL, 2003. [21] Bienefeld M, Pickett W, Carr PA. A descriptive study of childhood injuries in Kingston, Ontario using data from a computerized injury surveillance system. Chronic Dis Can 1996;17:21–7. [22] Overpeck MD, Jones DH, Trumble AC, Scheidt PC, et al. Socioeconomic and racial/ethnic factors affecting non-fatal medically attended injury rates in US children. Inj Prev 1997;3:272– 6. [23] Pickett W, Schmid H, Boyce WF, Simpson K. et. al. Multiple risk behavior and injury: An international analysis of young people. Arch Pediatr Adolesc Med 2002;156: 786 –93. [24] Kramer MD, Lightfoot AC, Knight S, Cazier CR, et al. Classroom injuries in Utah public schools. Acad Emerg 2003;10:978 – 84. [25] Pickett W, Brison RJ, Mackenzie SG, Garner M, et al. Youth injury data in the Canadian Hospitals Injury Reporting and Prevention Program: Do they represent the Canadian experience? Inj Prev 2000; 6:9 –15.
466
G. Chen et al. / Journal of Adolescent Health 37 (2005) 460 – 466
[26] Essau CA. Comorbidity of anxiety disorders in adolescents. Depress Anxiety 2003;18:1– 6. [27] DiScala C, Lescohier I, Barthel M, Li G. Injuries to children with attention deficit hyperactivity disorder. Pediatrics 1998;102:1415–21. [28] Mangus RS, Bergman D, Zieger M, Coleman JJ. Burn injuries in children with attention-deficit hyperactivity disorder. Burns 2004;30:148–50. [29] Barkley RA, Guevremont DC, Anastopoulos AD, DuPaul GJ, et al. Driving-related risks and outcomes of attention deficit hyperactivity
disorder in adolescents and young adults: A 3- to 5-year follow-up survey. Pediatrics 1993;92:212– 8. [30] Max JE, Lindgren SD, Knutson C, Pearson CS, et al. Child and adolescent traumatic brain injury: Correlates of disruptive behaviour disorders. Brain Inj 1998;12:41–52. [31] Yin Q, Li H, Zhang K, Li T, et al. [Epidemiologic survey of unintentional injury among 3632 children]. Zhongguo Er Tong Bao Jian Za Zhi 1997;5:216 – 8.