Risk Taking, Reported Injury, and Perception of Future Injury Among ...

Journal of Pediatric Psychology, Vol. 22. No. 4. 1997, pp. 513-531

Risk Taking, Reported Injury, and Perception of Future Injury Among Adolescents1 Elissa Jelalian,2 Anthony Spirito, and Deborah Rasile Rhode Island Hospital and Brown University School of Medicine

Lyn Vinnick Long Island Jewish Medical Center and Albert Einstein College of Medicine

Cynthia Rohrbeck George Washington University

Mark Arrigan Brown University Received March 1. 1996: accepted November 7. 1996

Investigated the relationships among self-reported injury, risk taking, and perception of injury risk in a sample of 1,426 adolescents, 14 to 18 years old. Both risk taking and injury were higher in males than females across age groups. Having a friend injured the same way was the strongest predictor of injury, accounting for 28% of the variance. Risk taking accounted for 4% of the variance. Sociodemographic variables—gender, age, and race—accounted for only 1% of the variance. Findings underscore the potential role ofpediatric psychologists in both understanding and reducing the incidence of adolescent injury. KEY WORDS: adolescents; risk taking; injury.

'Thanks to Freda Weiss for her help on this project. A11 correspondence should be sent to Elissa Jelalian, Rhode Island Hospital, Child and Family Psychiatry, 593 Eddy Street, Providence, Rhode Island 02903. 513

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0146-8693/97/0800-0513$ 12 50/0 © 1997 Plenum Publishing Corporation

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The present study was conducted to evaluate the relationships among risk taking, reported injury, and perceived risk for future injury among a heterogeneous sample of adolescents. A secondary aim was to explore the importance of peer injury in understanding reported injuries by adolescents. Adolescent Injury Unintentional injury has been identified as the leading cause of death during late adolescence and young adulthood (48.9/100,000 among persons 15 to 24 years of age) (National Center for Health Statistics, 1989). Morbidity rates due to injury far exceed fatalities (Runyan & Gerken, 1989) and have been found to account for the highest rates of injury presenting to an emergency department (Fife, Barancik, & Chatterjee, 1984). A consistent finding in studies of adolescent injury is a higher rate of injury for males than females. For example, Rivara, Bergman, LoGerfo, and Weiss (1982) found 90% more injuries related to use of consumer products among adolescent (ages 13-18) males than females. Higher injury prevalence rates for boys began in childhood and peaked during adolescence. A comparable finding was reported in a study of school-related injuries, in which boys had higher rates of injury beginning in elementary school and adolescent boys had the highest rate of injury in the sample (Boyce, Sprunger, Sobolewski, & Schaefer, 1984). Adolescent Risk Taking One factor that may contribute to increased rates of injury during adolescence is risk taking. While risk-taking behavior is considered by many to be a normal part of adolescent development (Jessor, 1983), it may place the adolescent at greater risk of injury. Risk-taking behavior has been defined by Irwin and Millstein (1991) as behavior which "must have a potentially noninjurious outcome as well as one that may result in harm, and the behavior must be volitional" (p. 7). Zuckerman (1994) described risk as partly a function of the objective situation and partly a function of the individual's appraisal of the situation. Because many risk behaviors, such as alcohol and drug abuse, unsafe sex, and failure to use seat belts while driving or riding in a motor vehicle, do result in injury or harm, developmental studies of adolescents are increasingly turning toward the motivations and outcomes of injurious risk-taking behavior. Misinterpretation of risk may be another factor associated with risk-taking behavior. Based on social learning theory (Bandura, 1977), environmental cues may not be salient enough for some adolescents. Therefore, injury among teenagers occurs secondary to a misperception of risk (Tversky & Kahneman, 1981). This misperception may be deliberate to some extent, reflect a lack of awareness

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of risk associated with certain behaviors, and/or be associated with a lack of experience with certain behavior. Perception of risk may vary by age and gender. For example, older adolescents were found to attribute less risk to sexual activity and substance use than were younger adolescents (Irwin & Millstein, 1991). Cohn, MacFarlane, Yanez, and Imai (1995) assessed the extent to which perceptions of decreased risk versus "invulnerability" contributed to adolescent risk-taking behavior. The authors found that adolescents associated less potential harm with a number of healththreatening behaviors (e.g., getting drunk, not using seat belts, using substances) than did parents. However, parents were generally more optimistic regarding the likelihood that their teenagers would encounter a number of injuries or health problems (e.g., getting hooked on cigarettes, developing cancer) in the future than were the adolescents themselves. The authors conclude that adolescent risk taking is more clearly related to underestimating risks associated with activities than to perceived invulnerability.

Adolescent Risk Taking and Injury Although there have been independent efforts to assess the prevalence of adolescent injury and the factors contributing to risk taking in adolescence, few empirical investigations have assessed the relationship between adolescent risktaking behavior and adolescent injury. One study examined the effects of sensation-seeking on sports-related injury. Smith, Ptacek, and Smoll (1992) found that sensation seeking (a variable often related to risk taking) was not related to increased injury in a sample of high school varsity athletes. However, the focus of that study was limited to injuries incurred through organized sports involvement. The relationship between "risky behavior" and injury has also been evaluated in younger children. In a study of preschool children (Speltz, Gonzales, Sulzbacker, & Quan, 1990), preinjury behavior or risky behavior was a significant predictor of injury liability. Similarly, Potts, Martinez, and Dedmon (1995) found a relationship between risk taking and injury in a sample of school-age children between the ages of 6 and 9 years. Several longitudinal studies have examined behavioral characteristics during childhood and adolescence and their relation to injuries during young adulthood. For example, a longitudinal study conducted in Finland (Pulkkinen, 1995) found that disobedience at age 8 and low anxiety at age 8 and age 14 predicted the injury rate in young adult males. Disobedience during childhood doubled the risk of injuries in young adulthood. Indirect evidence for a link between risk taking and unintentional injury comes from research on crime and delinquency. Delinquent adolescents have higher rates of unintentional injuries than nondelinquent youth (see Junger & Weigersma, 1995, for review). The rationale for this rela-

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tionship is that adolescents with poor impulse control are more likely to be injured or engage in criminal behavior because of risk-taking behavior or some other common factor. The impact of peer influences on adolescent injury is another area that has yet to be examined. Findings from related areas suggest it may be important to consider peer influence. A relationship between peer involvement in problem behaviors and the onset of risky sexual behavior in adolescents has been reported in one study (Metzler, Noell, Biglan, Ary, & Smolkowski, 1994). In addition, Horvath and Zuckerman (1993) studied risky behavior and risk appraisal in a large sample of college undergraduates. They found that the best predictor of an individual's risky behavior was the rate of risky behaviors the individual reported in his/her peer group. Present Study The present study was designed to examine the relationships among risktaking behavior, reported injury, and perception of future injury in a sample of adolescent high school students. This study contributes to the existing literature by extending the assessment of risk taking and injury previously conducted with younger children to the age group of adolescence. Peer injury was included as an exploratory variable that might be related uniquely to injury or be related to risk taking and, in turn, injury. Assessment of risk perception was included to evaluate the extent to which previous injury and risk taking impact perception for future risk. Consistent with previous findings, it was hypothesized that males would engage in more risk-taking behaviors and experience higher rates of injury than females. It was further hypothesized that risk taking would relate significantly to reported injury. METHOD Participants A total of 1,688 9th- through 12th-grade students from three local high schools were surveyed. Any subject with an item missing on a dependent measure was eliminated from the sample (n = 205). In addition, as a check on the quality of the data, two procedures were followed. First, whenever there was a logical inconsistency on an item (e.g., if a subject reported medical treatment but no injury), the data from the entire survey were eliminated for that subject. Second, all cases in which a subject reported six or more injuries were pulled and reviewed independently by three of the authors. Those cases that included six or more injuries with low probabilities of occurrence were excluded. A total of 27


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cases out of 108 reviewed were eliminated for inconsistencies. Overall, 232 of the cases (15%) were eliminated from the data set before analyses were conducted, resulting in a final sample of 1,426. These cases did differ slightly on age (16.0 ± 1.2 vs. 16.3 ± 1.1), /(1638) = 3.45, p < .01, but not on gender, x 2 (1 JV = 1634) = 1.10, ns, from the remainder of the sample. One high school was a "magnet" school (i.e., admission is based on ranking from an entrance exam) in an urban area. The median family income for that area was $14,948. There were 248 males (38%) and 410 females (62%) with a mean age of 16.2 years (SD = 1.2). Fifty-two percent of the adolescents were Caucasian, 14% Hispanic, 14% Southeast Asian, 9% African American, and 11% from other ethnic groups. The second school was a regional suburban high school where the median income for the community was $18,000. There were 130 males (57%) and 99 females (43%) with a mean age of 16.0 years (SD = 1.1). Of this group, 69% were Caucasian, 2% were Hispanic, and 29% were from other ethnic groups. There were no Southeast Asians or African Americans. The third school was in a more affluent suburban neighborhood. The median income of this community was $27,900. There were 266 males (49%) and 273 females (51%) with a mean age of 16.4 years (SD = 1.0). Ninety-two percent were Caucasian, 1% African American, 1% Hispanic, 2% Southeast Asian, and 4% from other ethnic groups. Procedure High school students were administered self-report questionnaires on risk taking, perception of future injury, and reported injuries (see below) in their classrooms. Students were approached during health or gym classes by one of the researchers. Passive consent was obtained by students' willingness to complete the assessment packet. All information was kept anonymous to encourage honest responding. This protocol was approval by school district superintendents and school principals, and the investigator's institutional review board. All instructions were read aloud by one of the investigators or a teacher. No identifying information was collected beyond age, gender, race, and grade, and participants were assured of confidentiality. Measures Adolescent Injury Checklist (AIC). The A1C, a self-report measure developed for this study, records which of 16 injuries have occurred in the prior 6 months. The AIC is based on an early version of the Child Health and Illness Profile-Adolescent Edition (Starfield et al., 1995), a detailed interview developed to comprehensively assess positive and negative health behaviors in adoles-

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cence. The form was adapted for the current study to record injuries specific to adolescents (e.g., injured secondary to driving a car) and also included information on whether the injury happened to a friend, involved alcohol, and required medical attention. A copy of this measure is presented in the Appendix. Findings on alcohol-involved injuries have been reported elsewhere (Spirito et al., 1996). A total score was calculated by summing all individual injury items except the "Other" item. Internal consistency in this sample, as measured by an alpha coefficient, was .68 for the 17 items on injury occurrence, .62 for injuries requiring medical care, and .84 for friends injured this way. Risk-Taking Scale. The 4-item risk-taking scale is a subscale from the high school version of the Health Behavior Questionnaire, a self-report measure originally designed to test various aspects of Problem-Behavior Theory (Jessor & Jessor, 1977) among high school students (Jessor, Donovan, & Costa, 1989). Adolescents are asked how often (hardly ever, several times, very often) they engage in risky sports, do something dangerous, do risky things for fun, and take chances with their safety at night. An internal consistency coefficient of .76 was reported by the scale developers. In this study, an alpha coefficient of .77 was obtained. Two items (i.e., wearing seat belts when riding with a friend and riding with a driver who had been drinking) were used to assess risk-taking behavior related to motor vehicles. These items were drawn from the Jessor and Jessor (1977) high school surveys and used most recently in studies of risky automobile driving behavior (e.g., Jessor et al., 1989). Adolescent Risk-Taking Scale (ARTS). This scale (Alexander, Ensminger, Johnson, Kim, & Dolan, 1990) asks adolescents how often they engage in any of six risky behaviors such as stealing, racing on a bike, and so forth, using a 3-point scale labeled never, once/twice, and more than three times. Over 1,400 teenagers participated in scale development. Adequate internal consistency coefficients were reported for a sample of eighth (r = .78) and ninth (r = .80) graders. Factor analyses revealed a unifactorial structure. Validity of the scale was suggested by scores on the scale being related to the initiation of sexual activity and substance use at 1 -year follow-up. In this study, internal consistency was calculated at .66. Risk-Taking Composite Scale. The 6 items from the ARTS, 4 items from the Risk-Taking Scale, and 2 motor vehicle items were combined and subjected to a principal components analysis with a varimax rotation. One factor with an eigenvalue greater than 1 emerged. This factor was composed of 10 (out of 12) items with factor loadings greater than .30, had an eigenvalue of 3.73, and accounted for 31.1% of the variance. One item from the ARTS about racing bikes, skateboards, and boats, and one item from the Risk-Taking Scale about participating in risky sports, did not load on this factor. Statistical analyses were conducted with this new composite risk-taking score (called the Risk-Taking Composite


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Score; RTCS). Scores on this scale ranged from 10 to 32. Internal consistency for the new scale was calculated at .81. Perception of Injury Checklist (PIC). The PIC was designed to assess perceived risk for each of the 16 injuries listed in the AIC. Each subject was asked to rate on a 7-point scale ranging from 1 (not at all) to 7 (most definitely) the chance that he/she would have each specific injury (i.e., getting cut, falling, etc.) "in the next 6 months." The scale was based on similar studies examining risk for AIDS (Aspinwall, Kemeny, Taylor, Schneider, & Dudley, 1991). Scores on the PIC can range from 16 to 112. Internal consistency of the PIC in this sample was calculated at .86 using coefficient alpha. RESULTS Descriptive Statistics To examine the diversity of our sample, the subjects from the three schools were compared on age, gender, and ethnicity. Significant differences were found by gender, x 2 (2, N = 1426) = 31.11,/? < .001; age, F(2, 1423) = 8.58, p< .001; and ethnicity, x 2 (8, N = 1402) = 368.06, p < .001, across schools. A significant difference across schools was also found on reported injuries, F (2, 1424) = 3.72, p < .05. Post hoc analyses with Tukey's procedure revealed that the urban magnet school reported fewer injuries (M = 2.3, SD = 2.0) than the suburban working-class school (M = 2.5, SD — 2.4) or the suburban affluent school (M = 2.6, SD = 1.9). The suburban working-class school (M = 18.2, SD = 5.2) had a higher mean score on the RTCS than both the urban magnet school (M = 16.9, SD = 4.9) and the suburban affluent school (M = 16.1, SD = 4.7), F(2, 1424) = 14.69, p < .001. The urban magnet school reported fewer injuries (M = 0.4, SD = 0.8) than the suburban working-class (M = 0.8, SD = 1.5) and the suburban affluent school (M = 0.7, SD = 1.1), F(2, 1413) = 13.59, p < .001. There were no differences among schools on the PIC, F(2, 1424) = 2.39, ns, or friends injured the same way on the AIC, F(2, 1388) = 0.67, ns. Gender Gender, age, and ethnic differences on the AIC, RTCS, and the PIC are presented in Table I. Significant differences by gender were found on the AIC and the RTCS, but not the PIC. Males had significantly higher reported injury (AIC) and risk-taking (RTCS) scores than females. Additional analyses examined differences on injuries for which medical care was sought and injuries that occurred to a friend. Males (M = 0.6, SD = 1.2) had more injuries which led to

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Table I. Scores on the Adolescent Injury Checklist, Composite Risk-Taking Scale, and Perception of Injury Checklist by Gender, Age, and Racial Group" Composite risktaking scale

Adolescent injury checklist

Gender Male Female

n

M

644 782

2.6 2.4

SD

M

2.2 1.9 ((1424) = 2. 35"

d = .10

SD

Perception of injury checklist M

SD

17.7 5.1 4.6 16.1 /(I424) = 6.02d= .33

37.9 15.1 37.2 13.7 /(1424) = 0.98 d= .02

16.5 16.9 17.1 16.8 15.5 F(4, 1421) == d= .12

39.3 37.4 37.2 38.0 33.4 F{4, 1421) ==