In almost all families of every income, ethnicity, and nation, parents want to protect their children while fostering their growth. Yet far more children die from violence—either accidental or deliberate—than from any specific disease.

The contrast between disease and accidental death is most obvious in developed nations, where medical prevention, diagnosis, and treatment make fatal illness rare until late adulthood. In the United States, four times as many 1- to 4-year-olds die of accidents than of cancer, which is the leading cause of disease death during these years (National Center for Health Statistics, 2013). Indeed, in 2010, more young U.S. children were murdered (385) than died of cancer (346). This was not always true, but cancer deaths have decreased over the past half century, while child homicide has increased.

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Worldwide, injuries cause millions of premature deaths among adults as well as children: Not until age 40 does any specific disease overtake accidents as a cause of mortality, and 14 percent of all life-years lost worldwide are caused by injury (World Health Organization, 2010).

In some nations, malnutrition, malaria, and other infectious diseases combined cause more infant and child deaths than injuries do, but those nations also have high rates of child injury. India, for example, has one of the highest rates worldwide of child motor-vehicle deaths; most children who die in such accidents are pedestrians (Naci et al., 2009). Everywhere, young children are at greater risk than slightly older ones. In the United States, 2- to 6-year-olds are more than twice as likely to be seriously hurt than 6- to 10-year-olds.

Why are young children so vulnerable? Some reasons have just been explained. Immaturity of the prefrontal cortex makes young children impulsive; they plunge into danger. Unlike infants, their motor skills allow them to run, leap, scramble, and grab in a flash, before a watching adult can stop them. Their curiosity is boundless; their impulses uninhibited. Then, if they do something that becomes dangerous, such as lighting a fire while playing with matches, fear and stress might make them slow to get help.

Age-related trends are apparent in particulars. Falls are more often fatal for the youngest (under 24 months) and oldest (over 80 years); preschoolers have high rates of poisoning and drowning; motor vehicle deaths peak from ages 15 to 25. Specific statistics reveal reasons for vulnerabilities. For instance, not only are 1- to 4-year-olds more likely to die of drowning than any other age group, they drown in swimming pools six times more often but in boating accidents only one-twelfth as often as older children and adults (MMWR, May 16, 2014). Usually the deadly swimming pool is in their own back yard, with their parents unaware that their preschooler was outside.

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Instead of using the term accident prevention, public health experts prefer injury control (or harm reduction). Consider the implications. Accident implies that an injury is random, unpredictable; if anyone is at fault, it’s a careless parent or an accident-prone child. This is called the “accident paradigm”—as if “injuries will occur despite our best efforts,” allowing the public to feel blameless (Benjamin, 2004, p. 521).

Injury control suggests that the impact of an injury can be limited if appropriate controls are in place, and harm reduction implies that harm can be minimized. Minor mishaps (scratches and bruises) are bound to occur, but serious injury is unlikely if a child falls on a safety surface instead of on concrete, if a car seat protects the body in a crash, if a bicycle helmet cracks instead of a skull, or if swallowed pills come from a tiny bottle. Reducing harm from childhood behavior can be accomplished by a concerted effort of professionals and parents, as I know too well from my own experience described in the following A Case to Study.

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Less than half as many 1- to 5-year-olds in the United States were fatally injured in 2012 as in 1982, thanks to laws that limit poisons, prevent fires, and regulate cars. Control has not yet caught up with newer hazards, however. For instance, many homes in California, Florida, Texas, and Arizona now have swimming pools: In those states drowning is a leading cause of child death. One result: Although overall rates of accidental death increase as income falls, for pool drowning before age 5, rates of more affluent ethnic groups are higher than for poorer groups (MMWR, May 16, 2014).

Prevention begins long before any particular child, parent, or legislator does something foolish. Unfortunately, no one notices injuries and deaths that did not happen. For developmentalists, two types of analysis are useful to predict danger and prevent it.

One is to look at all the systems that led to a serious injury. Causes can be found in the child, the microsystem, the exosystem, and the macrosystem, and thus measures can be taken to protect children in the future.

For example, when a child is hit by a car, it might be because the child was impulsive, the parents were neglectful (microsystem), the community was not child-friendly (no parks, traffic lights, sidewalks, or curbs—all exosystem), and/or because the culture valued fast cars over slow pedestrians (macrosystem). Once all those factors are recognized, preventive measures become clear, from holding the hand of young children when crossing the street all the way to national speed limits.

The second type of analysis involves understanding statistics. For example, the rate of childhood poisoning decreased markedly when pill manufacturers adopted bottles with safety caps that are difficult for children to open; such a statistic goes a long way in countering individual complaints about inconvenience. New statistics show a rise in the number of children being poisoned by taking adult recreational drugs, such as cocaine, alcohol, or marijuana, and that has led to new strategies for prevention (Fine et al., 2012).

Three levels of prevention apply to every health and safety issue.

In general, tertiary prevention is the most visible of the three levels, but primary prevention is the most effective (Cohen et al., 2010). An example comes from data on pedestrian deaths. As compared with 20 years ago, fewer children in the United States today die after being hit by a motor vehicle (see Figure 8.5). How does each level of prevention contribute?

Primary prevention includes sidewalks, pedestrian overpasses, streetlights, and traffic circles. Cars have been redesigned (e.g., better headlights, windows, and brakes), and drivers’ competence has improved (e.g., stronger penalties keep many drunk drivers off the road). Reduction of traffic via improved mass transit provides additional primary prevention.

Secondary prevention reduces danger in high-risk situations. School crossing guards and flashing lights on stopped school buses are secondary prevention, as are salt on icy roads, warning signs before blind curves, speed bumps, and walk/don’t walk signals at busy intersections.

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Finally, tertiary prevention reduces damage after an accident. Examples include laws against hit-and-run drivers, speedy ambulances, efficient emergency room procedures, and effective follow-up care, all of which have been improved from decades ago.

Medical personnel speak of the golden hour, the hour following an accident, when a victim should be treated. Of course, there is nothing magical about 60 minutes in contrast to 61 minutes, but the faster an injury victim reaches a trauma center, the better the chance of survival (Dinh et al., 2013).

I once was the director of a small preschool. I was struck by the diversity of fears and prevention measures, some helpful and some not. Some parents were thrilled that our children painted, but others worried about the ingredients of the paint, for instance. We had an outdoor sandbox; some parents thought that could give the children worms.

I knew that all children need to grab, run, and explore to develop their motor skills as well as their minds, yet they also need to be prevented from falling down stairs, eating pebbles, or running into the street—as many are inclined to do. That meant that teachers needed to balance freedom and prohibition. Yet the specifics of that balance are understood differently by various cultures.

Adults do not agree on the best strategies to prevent injury. Consider what one mother wrote about her flight from Australia to California:

I travelled with my 10-month-old daughter and was absolutely and thoroughly disappointed in the treatment we received from the flight crew captain at the time. I was told or more like instructed that I was to “restrain” my child for the whole flight, which was 13 hours.

I said that other people were able to move around the plane freely, why wasn’t she? I was told that due to turbulence she would have to be restrained for the whole trip. On several occasions the flight crew captain would make a point of going out of his way to almost scold me for not listening to him when I would put her down to crawl around.

[Retrieved April 3, 2011, from Complaints.com]

This same mother praised her treatment on other long flights, specifically on Asian airlines, when her child was allowed to move more freely and the crew was helpful. Which culture is better at protecting children without needlessly restraining them?

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My sympathies were with the mother, and I praised the Asian crews, until I read this response:

Consider the laws in the U.S. regarding child safety in an automobile. Nobody thinks a child should be free to crawl around in a car. No parent thinks their rights have been violated because their child is prevented from free flight inside a car when it impacts. Why not just put the child in the bed of a truck and drive around? … Her child could get stepped on, slammed against a seat leg, wedged under a seat, fallen on, etc.

[Retrieved April 3, 2011, from Complaints.com]

Both sides in this dispute make sense, yet both cannot be right. The data prove that safety seats in cars save lives, but “impact” in planes is unlike that in a car crash. Statistical analysis is needed, or at least studies of injured children on airplanes, considering all the systems involved. Do passengers on planes step on crawling children? If so, is that controllable harm or a serious hazard?