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Behavior: Ask the experts


Accident-prone child: Stress, temperament, or ADHD?



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Q Parents of a 4 1/2-year-old boy in my practice are concerned because he takes too many risks. They report that he always seems to be doing something dangerous, which often results in injury. I have repaired lacerations on several occasions. Recently, the child swallowed 11 small toy magnets, which required hospitalization.

I wonder what is going on with this boy and if the accident-prone child really does exist. What makes one child repeatedly injure himself and another child, about the same age, be more careful? I am interested in knowing the range of possibilities because this boy is not the only child I've treated who constantly has accidents and hurts himself.

Muhammad Waseem, MD
Bronx, N.Y.

A This child appears to be at high risk of serious injury. Determining contributing causes may require an evaluation by a child developmental-behavioral pediatrician and/or a social worker. In the meantime, enrolling him in a developmental preschool program may be helpful.

Children's typical activity patterns vary widely with regard to risk-taking vs. cautious behaviors. Both ends of the spectrum raise worries for parents and physicians. At one end is the shy, anxious child who is afraid to take any risks at all; at the other end is the so-called accident-prone child who makes regular trips to the emergency room. The extremes can be viewed as two of the several dimensions of temperament that vary from child to child and that seem to remain stable in individual children across time.

When accidents occur repeatedly, other triggering factors should be considered. They include:

  • The child's cognitive ability to assess risks

  • The family's interpersonal functioning

  • The presence of ADHD

It is an unusual 4-year-old who can be relied on to assess risks correctly. The child who has few accidents may simply be more temperamentally cautious or anxious, or better supervised than the child who has repeated accidents.

Children of families who are stressed, or who function with more conflict and less interpersonal sensitivity than other families, tend to suffer more accidental trauma. When mishaps occur on a regular basis, the pediatrician is in a good position to talk to the parents of the accident-prone child to find out what else may be going on in the family. Does the child's seemingly reckless behavior serve any implicit psychological function for the child and family? Are there gaps in supervision? Could a provocative older sibling be challenging the child to engage in unsafe behaviors?

Finally, consider the possibility of ADHD. Children who have been given this diagnosis have more accidents at all ages than other children. The impulsiveness associated with ADHD may be the cause of this tendency.

When considering ADHD, keep in mind that diagnostic guidelines require that the child show evidence of impairment in at least two settings as reported by each parent and at least one teacher or other adult.1 Because the child with ADHD may be more accident-prone than the average child, it is wise to advise parents that he or she may require extra supervision to prevent injury.

For every child who has more than his share of accidents, it is wise to encourage parents to pay extra attention to child proofing the home. Also remind the parents about the child's need for regular, predictable routines and close supervision, which may help keep him more focused and out of the emergency room.

1. Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics 2000; 105:1158

Ellen Perrin, MD

DR. PERRIN is professor of pediatrics, Tufts University School of Medicine, Boston.


Behavior: Ask the experts. Contemporary Pediatrics December 2003;20:24.

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