Childhood Psychiatric Disorder and Unintentional Injury:

Findings from a National Cohort Study

Richard Rowe,
1
PHD, Barbara Maughan,
1
PHD, and Robert Goodman,
2
PhD
1
MRC Social, Genetic, and Developmental Psychiatry Center, Institute of Psychiatry,
Kings College London, UK, and
2
Department of Child and Adolescent Psychiatry,
Institute of Psychiatry, Kings College London, UK
Objective We set out to examine the relationship between unintentional injury and
common child psychiatric disorders, including both internalizing and externalizing diagnoses.
Methods The 1999 British Child and Adolescent Mental Health Survey provided a nationally
representative sample of over 10,000 children aged 515 years. Measures included assessment of
diagnoses of psychiatric disorder from the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, unintentional injury, and a range of potentially related psychosocial
factors. Results Children with psychiatric disorders had higher rates of unintentional
injury. After accounting for psychosocial risk factors and comorbid psychopathology,
oppositional deant disorder (ODD) was independently associated with burns and poisoning.
Attention decit hyperactivity disorder (ADHD) was related to fractures, and depression and
anxiety also showed independent links to some injury types. Conclusions ODD and
ADHD, rather than conduct disorder, appear to be the externalizing disorders associated with
unintentional injury. We discuss possible models of the relationships between internalizing
disorders and unintentional injury.
Key words accident; psychopathology; children; adolescents.
Unintentional injury is a major cause of childhood
suffering and mortality. For children aged 514 years in
the United Kingdom, 29% of deaths in boys (41.7 deaths
per million) and 19% of deaths in girls (21.4 deaths per
million) were caused by injuries in 1999 (National Statis-
tics, 2001). Epidemiological studies of the relationship
between child psychopathology and unintentional injury
have been conducted using several large-scale datasets,
with particular attention paid to associations with anti-
social behavior and hyperactivity. There is much less evi-
dence regarding possible links with other common types
of psychopathology, such as anxiety and depression.
There is some agreement that antisocial behavior is
related to unintentional injury (Bijur, Golding, Haslum,
& Kurzon, 1988; Bijur, Stewart-Brown, & Butler, 1986;
Davidson, Taylor, Sandberg, & Thorley, 1992; Langley,
McGee, Silva, & Williams, 1983). Although the Diag-
nostic and Statistical Manual of Mental Disorders, fourth
edition (DSM-IV) (APA, 1994), mentions increased
accident liability as a characteristic of conduct disorder
(CD), a case-control study has shown that unintentional
injury is also increased in children with oppositional
deant disorder (ODD) (Schwebel, Speltz, Jones &
Bardina, 2002). The DSM-IV also mentions physical
injury as an associated feature of attention decit hyper-
activity disorder (ADHD), but the empirical evidence
regarding hyperactivity and related behaviors has been
mixed; a relationship has been reported in some studies
(Bijur et al., 1986; Langley et al., 1983) but not others.
Davidson et al. (1992) found no evidence of a simple
relationship between hyperactivity and later uninten-
tional injury in boys, while Bijur et al. (1988) found that
there was a simple relationship between overactivity and
later unintentional injury, but that this was not indepen-
All correspondence concerning this article should be addressed to Dr Richard Rowe, MRC Social, Genetic,
and Developmental Psychiatry Research Center, Box P046, Institute of Psychiatry, De Crespigny Park,
Denmark Hill, London SE5 8AF, UK. E-mail: r.rowe@iop.kcl.ac.uk.
Journal of Pediatric Psychology 29(2) pp. 119130, 2004
DOI: 10.1093/jpepsy/jsh015
Journal of Pediatric Psychology vol. 29 no. 2 Q Society of Pediatric Psychology 2004; all rights reserved

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dent of the relationship between unintentional injury
and antisocial behavior. In general, the association has
been reported to be stronger in cross-sectional studies
than in prospective designs. Davidson et al. (1992) noted
that this may suggest that cross-sectional ndings have
been inuenced by biases in retrospective injury
reporting. A recent study has suggested that ADHD
may be related to unintentional injury in a design free
from reporting biases. Analysis of population health
records from British Columbia have shown that children
who had been prescribed methylphenidate were at
increased risk of sustaining a variety of injuries (Brehaut,
Miller, Raina, & McGrail, 2003).
Apart from psychopathology, a number of other
demographic, family, and environmental risk factors for
unintentional injury have been demonstrated. For ex-
ample, unintentional injury has consistently been found
to be more common in boys than girls. Other risk factors
identied for unintentional injury include nontraditional
familystructure andparental historyof teenage pregnancy
(OConnor, Davies, Dunn, & Golding, 2000). Because
such risk factors are also well-documented correlates of
psychopathology (e.g., Rutter, Giller, & Hagell, 1998), it
is important to take these confounds into account. Bijur et
al. (1986) addressed this issue, including in their analyses
a range of family and environmental correlates. They
found that the relationships betweenunintentional injury
and psychopathology were reduced after control for
environmental confounds but that they remained sub-
stantial. Viewed fromthe alternative perspective, it is also
possible that demographic and psychosocial associations
with unintentional injury are mediated by psychopathol-
ogy. For example, the preponderance of antisocial
behavior in boys may contribute to the gender difference
in rate of injury.
This study examines the cross-sectional relation-
ships between childhood injury and psychiatric disorder
in a large-scale nationally representative sample of British
children aged 515 years as collected in the 1999 British
Child and Adolescent Mental Health Survey (BCAMHS-
99). Psychiatric disorder was assessed using the Devel-
opment and Well-Being Assessment interview (DAWBA)
(Goodman, Ford, Richards, Gatward, & Meltzer, 2000),
which generates clinically assigned DSM-IV diagnoses.
Arange of psychosocial risk factors was also assessed dur-
ing the interview.
Methods
Population
Full details of the survey design and measures are avail-
able elsewhere (Meltzer, Gatward, Goodman, & Ford,
2000). Briey, the Child Benet Register was used as
a sampling frame to identify children aged 515 years in
England, Scotland, and Wales. The Register should pro-
vide a relatively complete basis for sampling the child
population because the Child Benet program is avail-
able to all families with children in the UK. This frame
was stratied by Regional Health Authority, and within
that by sociodemographic groupings. Information from
up to three informants was collected on 10,438 children.
Ethical approval for the BCAMHS-99 was obtained from
the appropriate multicenter research ethics committee in
the United Kingdom. Informed consent was obtained
from both child and parent. Signed parental consent was
also required before the teacher was invited to provide
information on the index child.
Measures
Demographic data (including ethnicity, family type, and
parental employment status/socioeconomic group) were
collected in the parent interview. Psychiatric disorder
was assessed using the DAWBA (Goodman et al., 2000),
which consists of a parental interview (available for
99.7% of cooperating families), a child interview for
children aged 11 years and over (available for 95.3% of
age-appropriate children), and a teacher questionnaire
(available for 80.3% of children). Data on symptoms and
related psychosocial impairment were probed through
a structured, computer-assisted interview. In addition,
interviewers recorded participants verbatim descrip-
tions of symptomatic behaviors in response to open-
ended questions. Preliminary DSM-IV diagnoses were
made by computer algorithm on the basis of symptom
and impairment data, using evidence from each available
informant. Experienced clinicians then reviewed a com-
puter-generated case summary including both the
symptom and impairment data and the verbatim tran-
scripts and either accepted or amended the computer-
generated diagnoses. A reliability study (see Heyman et
al., 2001) in which two clinicians rated disorder in
500 children showed that the chance-corrected reliability
for the presence of any diagnosis was .86 (95% CI 5
.78 to .95).
The DAWBA assessed all the information required
to make DSM-IV diagnoses of a range of psychiatric
disorders, including duration criteria and measures of
functional impairment. In our analyses, we diagnosed
ODD independently of CD, rather than applying the
DSM-IV rule excluding ODD diagnoses for children with
CD. Information on unintentional injury was also
collected during the parental interview. Parents were
120 Rowe, Maughan, and Goodman

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asked whether their child had ever suffered a head injury
with loss of consciousness, a broken bone other than
head injury (hereafter referred to as fractures), a burn
requiring hospital admission, or a poisoning requiring
hospital admission. Where injuries were reported, the
parent was asked to categorize the timing of the incident
as either less than 1 month ago, at least 1 month ago but
less than 6 months ago, at least 6 months ago but less
than a year ago, or more than a year ago. Severe injuries
of this kind were relatively uncommon, so we analyzed
binary variables indicating whether each type of injury
had taken place at any prior time unless otherwise stated.
A range of child and family/environmental factors,
which are known to correlate with psychiatric disorder
(Meltzer et al., 2000), were also collected during the
assessment procedures. Many of these factors are also
potential correlates of unintentional injury. In order to
account for these factors in our analyses, we formed
a number of binary indicators of risk. The socioeco-
nomic characteristics of the neighborhood were assessed
using the ACORN [A Classication Of Residential
Neighbourhoods] scheme (see Meltzer et al., 2000).
We formed a binary variable to index whether or not
children lived in a striving neighborhood (the most
disadvantaged of the broad categorizations made by
ACORN), which identied 25% of the sample. Ethnic
origin was coded as a binary variable to indicate majority
(white, 91%) or minority status (black, Indian, Pakistani,
or other, 9%), reecting the ethnic mix of the child
population of Great Britain at the time of the study.
Family structure was categorized as traditional (66%),
single parent (22%) or stepparent (11%). Binary variables
were coded to indicate large family (four or more
children; 11%), low income (household income less than
200 [approx $300] per week; 24%), and low social class
(22%). Using the Standard Occupation Classication
(OPCS, 1991), low social class (22%) was coded if the
highest classication of the occupation of both parents
was social class IV (partly skilled) or V (unskilled) or if
neither parent had ever worked. Family functioning was
assessed using the General Functioning Scale of the
McMaster Family Assessment Device (Epstein, Baldwin,
& Bishop, 1983). A binary variable was coded to index
the most unhealthy functioning 19% of families. A binary
variable was also formed to identify parents who used
harsh physical discipline as indexed by the use of an
implement with which to hit their child (2%).
A number of measures of the characteristics of the
interviewed parent (usually the mother) were also
assessed. Current symptoms of anxiety and depression
were assessed using the 12-item version of Goldberg and
Williams (1988) General Health Questionnaire (GHQ)
which has been the subject of a number of validation
studies. For example, it was shown to have good
sensitivity (76.3%) and specicity (83.4%) in identifying
psychiatric diagnoses in a validation study conducted
across 15 clinical settings located around the world
(Goldberg et al., 1997). We formed a binary variable to
identify the most symptomatic 25% of parents on the
GHQ which corresponded to the positive endorsement
of three items. Education level was also assessed and we
coded a binary variable to identify parents who had not
passed any public examinations usually taken on leaving
school at age 16 (26%). The parents age at the index
childs birth was also recorded and we coded a binary
variable to index teenage parenthood (6%).
All children were invited to participate in an
assessment of intellectual ability. Of particular interest
here was global cognitive ability, which was measured
using the British Picture Vocabulary Scale (Dunn, Dunn,
Whetton, & Burley, 1997), and reading ability, which
was measured using the Word Reading Scale of the
British Ability Scale, second edition (BASII) (Elliot,
Smith, & McCulloch, 1996), on an age-standardized
scale. For both measures we formed binary variables to
identify children who performed in the lowest quartile of
the distribution. IQ data were available for 9,884
children (94.7%), and reading data were available for
9,337 (89.4%).
Data Analyses
The survey models of STATA 7 (StataCorp, 2001) were
used for all analyses. These models allowed for the use of
weights to account for the unequal probability of postal
sector selection and to correct for nonresponse bias
associated with region, age, and gender (see Meltzer et
al., 2000). The models also accounted for the clustering
of observations taken from the same postal sector and for
stratication by Regional Health Authority and socio-
economic group.
We analyzed each type of injury separately, and the
rst step in our strategy was to identify signicant
univariate predictors. We employed logistic regression
models for this purpose, which calculate odds ratios
(ORs) as a measure of association. With a binary
predictor, an OR may be interpreted as the difference
between the odds of having suffered the particular injury
by people who have and have not endorsed the predictor
variable. For example, if the OR for ADHD predicting
ever having had a burn is 2.3, this shows that the odds of
Psychopathology and Injury 121

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having ever been burned are 2.3-fold greater for children
with ADHD than for children who do not have ADHD.
Ninety-ve percent CIs are also provided with all ORs,
and these show the range of values which are consistent
with the data. Where the CIs do not include 1, effects are
signicant at the p , .05 level, and we used this
conventional signicance level to guide variable selec-
tion throughout. Within the psychiatric and psychoso-
cial domains, we built joint predictor models from
signicant univariate predictors. Signicant predictors
in these joint models are shown to have effects that are
independent of the other predictors in the model.
Nonsignicant effects in these joint models imply that
the signicant univariate relationships were observed
only because of relationships with other predictors
included in the model. In the case of the psychiatric
models, such interrelation of predictors is usually re-
ferred to as comorbidity. Signicant predictors in these
psychiatric and psychosocial models were then com-
bined into a nal model of each injury type. We
conrmed that the psychiatric correlates of unintentional
injury identied in this way did not differ from models in
which all predictors were entered simultaneously (de-
tails available on request). In view of the wide de-
velopmental range included in the study, we checked
whether the correlates included in the nal models
signicantly differed in subgroups of children aged 11
years and younger and 12 years and older.
Data on all variables of interest in this paper were
available for 8,337 (80%) of the 10,438 children in-
cluded in the study. Although data on psychiatric
diagnoses were available for all observations and missing
data on unintentional injury were rare (1.2 to 1.3%),
information on a number of the risk measures was
unavailable for a slightly larger proportion of cases. In
addition to child IQ and reading levels (noted above),
other variables with limited availability included income
level (6.4%) and teenage parenthood (3.9%). Uninten-
tional injury was reported at similar levels in those with
complete and incomplete observations, but those with
incomplete data did show elevated rates of CD (1.3% vs.
2.1%; OR 5 1.7; 95% CI 5 1.22.4; p 5 .004), anxiety
(3.5% vs. 4.8%; OR 51.4; 95% CI 51.11.7, p 5.003),
and ADHD (2.1% vs. 2.8%; OR 5 1.4; 95% CI 5 1.0
1.8; p 5 .04). Incomplete observations were omitted
from all analyses. This approach should not lead to
substantial bias of the results, although the power to
detect relationships between unintentional injury and
psychopathology may be reduced.
Results
Injury Prevalence and Age/Sex Trends
Twenty percent of girls and 24% of boys had suffered at
least one unintentional injury during their lifetime.
Fractures were most common (15.8%), followed by head
injury (4.3%), burns (2.3%), and poisoning (2.1%). Age
trends in unintentional injury at any time prior to
interview are shown in Figures 1 (boys) and 2 (girls).
As shown in Table I, boys were at greater risk for all
types of injury. Across gender, rate of injury increased
with age, although not signicantly so regarding poison-
ing. The overall age trend was also nonsignicant for
burns, but there was a hint of interaction between age
and sex (p 5.053) in that the age trend was at for boys
(OR [for a 5-year increase in age] 5 0.9; 95% CI 5 0.7
1.2; p 5 .6) but increased signicantly in girls (OR 5
1.5; 95% CI 5 1.02.1; p 5 .04). The increase in frac-
tures across age was signicantly steeper for boys than
Figure 1 The rate of ever having suffered each injury across age in boys.
Figure 2 The rate of ever having suffered each injury across age in girls.
122 Rowe, Maughan, and Goodman

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for girls, and the age trends in poisoning and head injury
were similar across gender.
Burns
Table II shows that burns were more common among
children with all psychiatric diagnoses than in those
without disorder but that these contrasts reached signif-
icance for only ADHD, ODD, and anxiety. Only ODD
remained signicant when these three disorders were
modeled jointly. A number of psychosocial factors pre-
dicted burns in simple models, but the multiple pre-
dictor modeling indicated that only poor reading ability
and stepfamily status were independently signicant.
In the nal model, only ODD and poor reading abil-
ity retained signicant links with increased risk for
burns.
Poisoning
As shown in Table III, poisoning was signicantly more
common in children with all types of psychiatric
disorder. The effects of only ODD and anxiety remained
signicant when all disorders were considered jointly,
however. Of the psychosocial risk factors, poor child
reading, large family size, and high parental GHQ score
had effects that were independent from the other psy-
chosocial measures. In the nal model, ODD, anxiety,
poor reading, and large family size had signicant
independent effects.
Head Injury
Rates of head injury were elevated in all types of psy-
chiatric disorder except depression (Table IV), but only
anxiety remained signicant in the multiple psychiatric
predictor model; ADHD was of borderline signicance
(p 5 .055). Of the psychosocial factors, high parental
GHQ score and poor child reading were independently
signicant risk factors, while rates of head injury were
lower in children from ethnic minorities. We explored
this unexpected nding in more detail and found that
white children had similar rates of head injury (4.4%) as
Pakistani children (6.5%; p 5 .3) but higher rates than
blacks (1.7%; p 5 .08) and Indians (0.8%; p 5 .06).
Anxiety remained signicant in the nal model, as did
the psychosocial predictors. Additionally, we found
some evidence of interaction between age and high
parental GHQ score (p 5 .057). There was a strong
association with head injury in children aged 11 and
younger (OR 5 1.9; 95% CI 5 1.42.5; p , .001) but
not in children aged 12 and over (OR 5 1.3; 95% CI 5
0.91.8; p 5 .2).
Fractures
Of the psychiatric disorders, only ADHD and depression
were signicantly related to fractures, and these relation-
ships were independent of each other. Ethnic minority
status was once again a signicant protective factor;
white children (16.4%) had a similar rate of fractures to
children of Pakistani origin (11.2%; p 5 .2) but signif-
icantly higher rates than blacks (8.8%; p 5 .01) and
Indians (5.7%; p 5.002). None of the other psychosocial
risk factors was signicant. ADHD, depression, and
ethnic minority status remained signicant predictors in
the nal model (see Table V).
The higher frequency of fractures relative to other
injury types meant that fractures during the most recent
12 months (3.0%) could be analyzed. We investigated
whether recall bias was involved in the relationship
identied between ADHD and fracture. We found that
ADHD was related to more recent fractures (OR 5 1.9;
95% CI 5 0.93.7; p 5 .07) in a very similar way to less
recent fractures (OR 5 1.6; 95% CI 5 1.12.5; p 5
.017); the comparison between these coefcients did not
approach signicance (OR 5 1.1; 95% CI 5 0.52.5;
p 5 .8).
Table I. Age and Gender Effects in Unintentional Injury at Any Time Prior to Interview
Gender
a
Age 3 Gender
Injury Type Rate in Boys Rate in Girls OR (95% CI) OR
b
(95% CI) Boys
c
Age
b
Trend Girls
c
Age
b
Trend
Burn 2.8 1.8 1.5 (1.12.0)** 0.6 (0.41.0) 1.1 (.91.4)
Poisoning 2.5 1.8 1.4 (1.01.9)* 1.0 (0.61.6) 1.2 (.91.5)
Head injury 5.3 3.3 1.6 (1.32.0)*** 1.1 (0.81.6) 1.6 (1.41.9)***
Fracture 17.2 14.5 1.2 (1.11.4)** 1.5 (1.21.8)*** 2.7 (2.33.1)*** 1.8 (1.62.1)***
OR 5 odds ratio; coefcients in boldface indicate p , .05.
a
Gender tested in single predictor model.
b
OR given for a 5-year increase in age.
c
Single age coefcient given when Age 3Gender interaction was not signicant.
* p , .05; ** p , .01; *** p , .001.
Psychopathology and Injury 123

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Sex Differences in Unintentional Injury
Many of the factors identied as correlates of uninten-
tional injury such as externalising disorder are more
common in boys than girls. It is therefore possible that
the correlates identied above mediate the relationship
between gender and unintentional injury. However, the
effects of gender in the nal models for each type of
injury (Table VI) were almost unchanged from the
simple effects presented in Table I.
Discussion
The analyses reported here contribute to the growing
body of evidence demonstrating a relationship between
psychopathology and unintentional injury during child-
hood. The BCAMHS-99 has a number of strengths for
this purpose, including a large, nationally representative
sample and assessment of a range of psychosocial factors
known to correlate with psychiatric disorder and
unintentional injury. The use of clinically assigned
DSM-IV diagnostic measures and the assessment of
different types of injury within the same study provide
a unique opportunity to assess the form and specicity of
relationships between psychiatric disorder and uninten-
tional injury. The existing literature provided evidence
that disruptive behaviors were a risk factor for injury,
but there was some controversy over the forms of
disruptive behavior that were particularly salient. Our
study provided clinical assessment of the three most
common types of externalizing disorder: ADHD, ODD,
and CD. The multivariate analysis techniques allowed us
to assess whether the simple relationships identied with
injury were independent of both the high levels of
comorbidity known to exist between these externaliz-
ing disorders (Maughan, Rowe, Messer, Goodman, &
Meltzer, 2004) and shared psychosocial risk factors that
Table II. Predictors of Burns
% Burned If
Predictor Absent
% Burned If
Predictor Present
Joint OR
a
Predictor Simple OR
a
Psychiatric Model Psychosocial Model Final Model
Psychiatric disorder
ADHD 2.2 5.7 2.3 (1.24.6)* 1.5 (0.72.9)
Conduct disorder 2.3 2.9 1.1 (0.33.5)
ODD 2.2 7.1 3.2 (2.05.2)*** 2.7 (1.64.5)*** 2.7 (1.64.5)***
Anxiety 2.2 4.2 1.9 (1.13.5)* 1.6 (0.93.0)
Depression 2.3 5.6 2.5 (0.96.9)
Intellectual functioning
Low child IQ 2.1 3.1 1.5 (1.12.1)** 1.0 (0.71.5)
Poor child reading 1.9 3.4 1.8 (1.32.4)*** 1.5 (1.12.0)* 1.6 (1.22.2)**
Socioeconomic status
Striving neighborhood 2.1 3.1 1.5 (1.12.0)* 1.0 (0.71.5)
Low income 1.9 3.7 2.0 (1.52.7)*** 1.3 (0.91.9)
Low social class 2.0 3.3 1.6 (1.22.0)*** 1.1 (0.81.6)
Family characteristics
Ethnic minority 2.2 3.6 1.7 (1.12.5)* 1.5 (1.02.4)
Single-parent family 2.0 3.5 1.8 (1.32.5)*** 1.4 (0.92.0)
Stepparent family 2.2 3.3 1.5 (1.02.3)* 1.6 (1.02.5)* 1.4 (0.92.1)
Large family 2.2 2.9 1.3 (0.92.0)
Unhealthy family functioning 2.2 3.0 1.4 (1.01.9)
Harsh physical discipline 2.3 2.2 0.9 (0.33.0)
Parent characteristics
Limited educational qualications 1.9 3.5 1.8 (1.32.4)*** 1.3 (0.91.9)
High GHQ score 2.1 2.9 1.4 (1.01.9)* 1.2 (0.91.6)
Teen parenthood 2.2 3.7 1.7 (1.12.8)* 1.2 (0.71.9)
OR 5 odds ratio; ADHD 5 attention decit hyperactivity disorder; ODD5 oppositional deant disorder; GHQ 5 General Health Questionnaire.
Coefcients in boldface indicate p , .05.
a
Adjusted for age and gender.
* p , .05; ** p , .01; *** p , .001.
124 Rowe, Maughan, and Goodman

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the study measured. Unusually for a study of this scale,
we were additionally able to assess the relationships
between anxiety/depression and injury during child-
hood, a topic which has received much less attention in
the existing literature.
Despite the many strengths of this dataset for
studying the relationship between injury and psychopa-
thology, at least two weaknesses should be noted. First,
unintentional injuries were retrospectively reported. It is
possible that parents forgot injuries, particularly if they
had taken place in the less recent past, and that other
retrospective reporting biases (Wazana, 1997) were in-
volved. More serious injuries are more memorable,
however (Harel et al., 1994; Peterson, Ewigman, &
Kivlahan, 1993), so it is likely that the severe nature of
the injuries studied here has minimized any biases
introduced in this way. Second, although we were able to
include a wider range of psychosocial correlates than has
typically been included in studies of unintentional
injury, one feature that may be especially salientthe
quality of parents supervision of the childs activities
was not directly assessed. It is therefore possible that
inadequate parental supervision may contribute to some
of the associations between psychopathology and injury
reported in this study.
Results for the four types of injury studied here
showed an interesting pattern of similarities and differ-
ences. As expected, all four were more common in boys
than girls, but only head injuries and fractures showed
the strong age trends that might be expected in measures
of injury across the lifetime. Poisoning showed no signif-
icant increase across age, while there was some evidence
that the frequency of burns increased with age for girls
but not boys. This suggests that many of the burns and
poisonings reported here took place very early in
childhood, before the study entry age of 5 years. While
Table III. Prediction of Poisoning
% Poisoned If
Predictor Absent
% Poisoned If
Predictor Present
Joint OR
a
Predictor Simple OR
a
Psychiatric Model Psychosocial Model Final Model
Psychiatric disorder
ADHD 2.1 5.1 2.3 (1.14.8)* 1.2 (0.52.6)
Conduct disorder 2.1 6.6 2.9 (1.36.6)** 1.0 (0.42.3)
ODD 1.9 9.0 4.8 (2.88.0)*** 3.9 (2.17.0)*** 3.4 (2.05.8)***
Anxiety 2.0 6.1 3.2 (1.95.4)*** 2.3 (1.34.1)*** 2.2 (1.33.7)**
Depression 2.1 7.2 3.5 (1.39.2)* 1.5 (0.45.4)
Intellectual functioning
Low child IQ 1.9 2.8 1.5 (1.02.0)* 1.0 (0.71.4)
Poor child reading 1.7 3.3 1.9 (1.42.7)*** 1.7 (1.22.4)** 1.6 (1.12.3)*
Socioeconomic status
Striving neighborhood 2.1 2.4 1.1 (0.81.6)
Low income 1.9 2.9 1.6 (1.12.3)* 1.2 (.81.9)
Low social class 2.0 2.6 1.3 (0.91.9)
Family characteristics
Ethnic minority 2.2 1.4 0.6 (0.31.1)
Single parent family 2.0 2.8 1.4 (1.02.0)* 1.2 (.81.8)
Stepparent family 2.0 3.1 1.6 (1.02.4)* 1.5 (1.02.3)
Large family 2.0 3.6 1.9 (1.32.8)** 1.6 (1.12.5)* 1.6 (1.02.4)*
Unhealthy family functioning 2.0 2.7 1.3 (0.91.9)
Harsh physical discipline 2.1 3.1 1.4 (0.53.8)
Parent characteristics
Limited educational qualications 2.0 2.5 1.2 (0.91.7)
High GHQ score 2.0 2.6 1.3 (1.01.8)
Teen parenthood 2.1 3.0 1.5 (0.92.4)
OR 5 odds ratio; ADHD 5 attention decit hyperactivity disorder; ODD 5 oppositional deant disorder; GHQ 5 General Health Questionnaire.
Coefcients in boldface indicate p , .05.
a
Adjusted for age and gender.
* p , .05; ** p , .01; *** p , .001.
Psychopathology and Injury 125

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recall biases cannot be ruled out as contributing to what
might seem a surprising result, it is possible that the
requirement for hospital admission in the denition of
these injuries is salient here. Burns and poisonings of
a similar nature may continue to befall children at older
ages, but hospital admission may more rarely be required
when they happen at later stages of development. Within
the sample there was very little evidence that the
correlates of injury involvement differed for older and
younger children. The only hint we found was that high
parental GHQ score was more strongly associated with
head injury in younger children (11 years and younger)
than older children, although this effect fell below the
conventional level of signicance. The four types of
injury also showed interesting variations in the pattern
of associated psychiatric disorder and psychosocial risk
factors, as discussed below.
Previous studies have consistently reported a strong
relationship between unintentional injury and antisocial
behavior in childhood (Bijur et al., 1986; Langley et al.,
1983; Schwebel et al., 2002). This was conrmed in our
analyses, and we found that ODD was more strongly
related than CD. CD showed simple relationships with
poisoning and head injury, but these were not in-
dependent of the other psychiatric disorders measured.
By contrast, ODD was independently related to both
poisoning and burns. As discussed above, it is likely that
many of the burns and poisonings studied here took
place prior to age 5. The DAWBA addresses symptom-
atology in the present and recent past, but given the
typically early onset of many ODD symptoms (Angold &
Costello, 1996), it is plausible that substantial ODD
behaviors were evident in many of the diagnosed
children at much younger ages. One possible mechanism
Table IV. Prediction of Head Injury
% Injured If
Predictor Absent
% Injured If
Predictor Present
Joint OR
a
Predictor Simple OR
a
Psychiatric Model Psychosocial Model Final Model
Psychiatric disorder
ADHD 4.2 9.4 2.1 (1.23.5)** 1.8 (1.03.3)
Conduct disorder 4.2 11.6 2.2 (1.24.2)* 1.8 (0.83.8)
ODD 4.2 7.6 1.7 (1.02.8)* 1.1 (0.52.1)
Anxiety 4.1 7.9 1.9 (1.22.9)** 1.8 (1.22.8)** 1.7 (1.12.6)*
Depression 4.2 8.4 1.6 (0.73.8)
Intellectual functioning
Low child IQ 4.4 3.9 0.9 (0.71.1)
Poor child reading 4.0 5.1 1.3 (1.01.7)* 1.2 (1.01.6)
Socioeconomic status
Striving neighborhood 4.1 4.8 1.2 (0.91.5)
Low income 4.2 4.7 1.2 (0.91.5)
Low social class 4.3 4.3 1.0 (0.81.3)
Family characteristics
Ethnic minority 4.4 2.4 0.5 (0.30.9)* 0.5 (0.30.8)** 0.5 (0.30.9)*
Single parent family 4.1 4.9 1.2 (0.91.6)
Stepparent family 4.2 4.6 1.1 (0.31.5)
Large family 4.2 4.6 1.2 (0.81.6)
Unhealthy family functioning 4.0 5.7 1.4 (1.11.8)** 1.3 (1.01.7)
Harsh physical discipline 4.3 1.6 0.3 (0.11.4)
Parent characteristics
Limited educational qualications 4.1 4.9 1.2 (0.91.5)
High GHQ score 3.7 6.0 1.6 (1.32.1)*** 1.5 (1.22.0)** 1.6 (1.22.0)***
Teen parenthood 4.3 4.5 1.1 (0.71.6)
OR 5 odds ratio; ADHD 5 attention decit hyperactivity disorder; ODD5 oppositional deant disorder; GHQ 5 General Health Questionnaire.
Coefcients in boldface indicate p , .05.
a
Adjusted for age and gender.
* p , .05; ** p , .01; *** p , .001.
Bold coefcients indicate p , .05.
126 Rowe, Maughan, and Goodman

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for the relationship with unintentional injury may be
through the problematic parent-child relationships that
characterize oppositionality. For example, children with
ODD may not follow the safety instructions of supervis-
ing adults, putting them at greater risk for injury. This
nding is consistent with the growing evidence that
ODD may have important negative consequences that
are independent of its relationships with CD (Greene
et al., 2002; Maughan et al., 2004; Pickles et al., 2001). It
is possible that the relationship between CD and
unintentional injury noted in the DSM-IV might be at
least partly due to the substantial comorbidity of CD and
ODD.
The picture regarding ADHD in the previous
literature was less clear. We found that although ADHD
had simple relationships with all types of injury
measured in this study, this effect was independent of
other psychiatric disorders only for fractures. An
independent relationship with head injury fell just
short of signicance. As noted in the introduction, it
has been suggested that biases in retrospective assess-
ment of injuries may spuriously inate the relationship
between hyperactivity and unintentional injury in
cross-sectional studies (Davidson et al., 1992). Injuries
were reported retrospectively in this study, as discussed
above. However, substantial bias due to differential
rates of forgetting by parents of children with and
without ADHD seems unlikely here. ADHD was related
similarly to fractures reported to have occurred during
the last 12 months and the less recent past. Given the
recovery time required for fractures, many of the
children injured within the last 12 months would still
Table V. Prediction of Fractures
% Injured If
Predictor Absent
% Injured If
Predictor Present
Joint OR
a
Predictor Simple OR
a
Psychiatric Model Final Model
Psychiatric disorder
ADHD 15.7 24.7 1.7 (1.22.4)** 1.7 (1.22.4)** 1.6 (1.22.3)**
Conduct disorder 15.8 18.5 0.8 (0.51.3)
ODD 15.8 18.6 1.1 (0.81.6)
Anxiety 15.8 16.1 0.9 (0.71.3)
Depression 15.7 35.3 1.9 (1.13.3)* 1.9 (1.13.3)* 1.9 (1.13.3)*
Intellectual functioning
Low child IQ 15.3 17.6 1.1 (1.01.3)
Poor child reading 15.7 16.3 1.1 (0.91.2)
Socioeconomic status
Striving neighborhood 15.7 16.3 1.1 (0.91.2)
Low income 15.8 16.1 1.1 (1.01.3)
Low social class 15.7 16.6 1.1 (1.01.3)
Family characteristics
Ethnic minority 16.4 8.8 0.5 (0.40.6)*** 0.5 (0.40.6)***
Single parent family 15.7 16.5 1.1 (0.91.2)
Stepparent family 15.6 18.3 1.2 (1.01.4)
Large family 16.1 13.9 0.9 (0.81.1)
Unhealthy family functioning 15.6 16.8 1.0 (0.91.2)
Harsh physical discipline 15.9 14.1 0.8 (0.51.4)
Parent characteristics
Limited educational qualications 15.3 17.6 1.1 (0.91.2)
High GHQ score 15.3 17.4 1.1 (1.01.3)
Teen parenthood 15.8 16.9 1.1 (0.91.4)
OR 5 odds ratio; ADHD 5 attention decit hyperactivity disorder; ODD5 oppositional deant disorder; GHQ 5 General Health Questionnaire.
Coefcients in boldface indicate p , .05.
a
Adjusted for age and gender.
* p , .05; ** p , .01; *** p , .001.
Bold coefcients indicate p , .05.
Psychopathology and Injury 127

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have been suffering related difculties or would only
recently have returned to full health at the time of the
interview, making it unlikely that recall of these recent
fractures would have been compromised in any
important ways.
Associations between unintentional injury and in-
ternalizing disorder have received little attention in
previous studies. We found that depression was in-
dependently related to fractures, while anxiety was
independently related to poisoning and was the only
independent psychiatric correlate of head injury. In
multiple predictor analyses, we conrmed that these
relationships were not products of the comorbidity
between the internalizing and externalizing disorders
and the relationships between externalizing disorders
and unintentional injury. Given the cross-sectional
nature of the dataset, it is impossible to determine the
order of occurrence of the injury and the onset of
emotional difculties. As with externalizing disorders, it
is possible that anxiety and depression put children at
increased risk for some types of unintentional injury.
One possible mechanism here may be that internalizing
disorders disrupt attentional control during potentially
hazardous activities, making an accident more likely.
First, general anxious and depressive cognitions may be
distracting. Second, anxiety about performing the
activity itself may cause interference. Alternatively,
injury could contribute to risk for psychopathology,
and this pathway may be particularly plausible regarding
internalizing disorders. A range of adverse life events
have been documented as risk factors for anxiety and
depression in children (Goodyer, 1994; Goodyer,
Cooper, Vize, & Ashby, 1993; Silberg et al., 1999),
and it is possible that severe accidents contribute to risk
in a similar way. An alternative mechanism for the
relationship between head injury and anxiety may be
that brain damage suffered as a component of the injury
has led to the disorder (Brown, Chadwick, Shaffer,
Rutter, & Traub, 1981). Our ndings suggest that these
differing possibilities require further examination in
longitudinal studies.
Of the psychosocial risk factors studied, poor
reading skill emerged as an independent correlate of
both burns and poisoning. One possible interpretation of
this association is that reading problems contribute in
a direct way to unintentional injury, by making it
difcult, for example, for children to read safety
instructions. Because most burns and poisonings appear
to have been experienced prior to age 5, however, this
seems an unlikely explanation in the majority of
instances. Instead, two other accounts seem more
plausible. First, reading difculties are known to be
associated with increased rates of inattention and
overactivity (Hinshaw, 1992), which, even if not severe
enough to meet criteria for ADHD, might nonetheless
put poor readers at increased risk for unintentional
injuries. Second, reading problems may act as a marker
for other family difculties, including stressors that
reduce the effectiveness of parents capacity to supervise
young children; the association between large family size
and risk for poisoning may also point in a similar
direction.
One unexpected nding was the lower rate of
fractures and head injury within some ethnic minorities.
Recent ndings from the Health Survey for England
(Nazroo, Becher, Kelly, & McMunn, 2001) have also,
however, documented differences between minority
groups in parental report of recent major accidents,
and more strikingly in relation to minor accidents. As
these authors note, this may suggest underreporting in
some groups; alternatively, other social or family
correlates may be implicated. Once again, additional
research is clearly needed to examine these important
issues more closely.
Finally, we found robust gender differences in
unintentional injury. Consistent with many other
studies, boys were at greater risk for all the injuries
studied here. We had anticipated that some of this effect
might be mediated by gender differences in the
correlates of unintentional injury, and externalizing
disorders, which are more common in boys than in girls
(Rutter et al., 1998), seemed to be the primary
candidates here. Our analyses provided little support
for this hypothesis, however, as the increased rates of
injury in boys compared with girls were little changed
when the important correlates of unintentional injury
were accounted for. This suggests that other factors
might mediate the sex differences; one possibility is that
temperamental characteristics such as activity levels and
impulsivity are important here (Plumert & Schwebel,
1997), indexing a broader spectrum of risk than that
Table VI. Sex Differences in Unintentional Injury after Accounting
for Independently Signicant Predictors of Unintentional Injury
Injury Type
Sex Odds Ratio (95% CI)
from Final Model
Burns 1.4 (1.11.9)*
Poisoning 1.3 (0.91.7)
Head injury 1.7 (1.32.1)***
Fractures 1.2 (1.11.4)**
* p , .05; ** p , .01; *** p , .001.
Coefcients in boldface indicate p , .05.
128 Rowe, Maughan, and Goodman

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identied by diagnostic groups alone. Other overlapping
possibilities include biological differences and differ-
ences in the socialization of boys and girls that make
them more or less vulnerable to unintentional injuries.
For example, gender role stereotypes for boys may
include more injury-prone activities such as contact
sports and rough-and-tumble play. Understanding the
roots of these gender differences in unintentional injury
must remain a challenge for further research.
These analyses provide further evidence that child
behavior is related to unintentional injury. Modication
of behavior therefore offers a potential strategy to reduce
the incidence of unintentional injury during childhood.
Should it prove replicable, the pattern of results found
here suggests that young children with ODD and
children of all ages with ADHD may particularly benet
from such interventions in terms of reducing their injury
liabilities. The strong associations between ODD and
certain types of injury provide additional motivations for
clinicians to focus on treatment of oppositional symp-
tomatology, whether or not the disorder presents with
other comorbid externalizing disorders. If, as discussed
above, the parent/child relationship is of particular
importance in mediating this contingency, then inter-
ventions targeting improvements in parenting (Scott,
Spender, Doolan, Jacobs, & Aspland, 2001) may be of
particular benet for reducing injury risk. Longitudinal
studies will be required to identify whether the in-
ternalizing disorders increase risk for injury rather than
being consequences of it. If anxiety and depression are
found to increase risk, however, then effective treatment
of these disorders may provide an additional benet in
terms of reducing unintentional injury.
As well as targeting psychiatric symptomatology
directly, programs aimed at specically reducing injury
in these high-risk groups may also be useful. One
important issue here is the level at which to target such
interventions (Garbarino, 1988). Children suffering
from disruptive disorders may be unreceptive to such
interventions given the nature of their symptoms.
Therefore programs targeting the primary caregiver,
perhaps aiming to reduce the presence of household
hazards in the childs environment, may be more
appropriate here. Children with internalizing disorders
may be more receptive to safety instructions and could
therefore also be targeted for injury prevention educa-
tion, perhaps as part of a familywide intervention. The
relationships between injury and psychopathology in
childhood mean that health care professionals should be
on the lookout for treatable psychiatric disorder among
children who present with injury in emergency room
and primary care settings.
Received December 2, 2002; revisions received April 2,
2003; accepted April 30, 2003
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