Cuestionario de personalidad (EPQR-A) TABLA 6

Trauma is said to be the leading cause of morbidity and mortality in the pediatric age group and the incidence in developing countries is on the increase due to a corresponding increase in child labour.¹

Most road networks particularly in developing countries are constructed without considering children who use the roads as occupants of vehicles or motorcycles, pedestrians and bicyclist in rare occasions. Children may also live in residential houses close to roads, walk along the road or even play on the road with poor knowledge of zebra crossing or ignorance from road users.¹

The roads are considered to be dangerous places for children and younger adults but road traffic injuries should not be the ultimate prices children and their families pay for due to increasing mobility and independence of children as they grow up because there are proven and effective measures that can minimize that.¹

Risk factors for RTI A) Child related:

Children are physically growing and so the impact of RTI is more as compared to adults. Furthermore, children because of their small statue cannot see or be seen over certain heights like packed vehicles or large trucks thereby running over them. Also

xxxiv

because of immature sensory system, their judgment and vision is poor thereby missing critical cues of danger.¹

Secondly, because of poor cognitive development, their ability to make safe decisions particularly with regards to road crossing is poor thereby increasing their risk to RTI.⁹⁸We see more of them been knocked down while attempting to cross the road even along the zebra or pedestrian crossing signs because the users do not respect these particularly in developing countries like Nigeria.

Children in the age group of 5-7 year are always running as they are said to master the acts of speed and distance. This judgment is poorly exhibited as their skills in recognizing dangerous places to cross the road is poor because they rely on visible presence of cars which is made worse by our complex road networks, road obstacles obscuring drivers field of vision otherwise known as blind sections of the roads.^1,98 Road traffic injuries among young children are mostly dart and dash cases in which a child pedestrian is injured due to critical behavioural errors where the childfails to slow down before crossing the road. This type of behavior is due to a child’s concentration defined as the ability of a child to switch attention from one task or responsibility to another.¹

There is evidence that in infants, visual processes needed for a child to cross the road are fully developed but their ability to integrate visual signals into meaningful context or judgment is not fully developed until around the age of 10-12 years.⁹⁹

In adolescents involved in road traffic crash as young drivers, the cognitive processes taking place in the brain particularly the pre-frontal cortex possible for decision making, judgment, reasoning and impulse control are not fully developed until the age of 20-25 years and so putting young drivers at risk of RTI.¹⁰⁰

xxxv

Thirdly, the issue of risk taking behavior put young adolescents at risk of RTI. Older children and adolescents actively seek-out risk as they are carried away by the euphoria or the sense of being in control of their lives thereby not obeying instructions or authorities.¹

The risk seeking in young adolescent drivers between the ages of 16-17 years is said to be a good predictor of their involvement in RTI as well as in child pedestrians which is more common in boys because at the age of eleven they have affinity for speed, always competing with each other and are involved in risk taking behavior.^1,102 Fourthly is peer pressure or influence. As children get older, the influence of parents on them is reduced because at this level they want to be independent. This phase of transition is worsened by social norms as their peers play a significant role to whichever they want to conform to.¹⁰³

Studies have shown that younger drivers tend to experience more peer pressure leading to traffic offences of alcohol than older drivers and this is made worse if their peers or age groups are with them in the car.¹

As compared to adults, adolescents are more likely to drive at high or excessive speed. According to a survey of 20,000 drivers of these age group are more likely to drive at more than 20km/hr above speed limit.¹⁰⁴

Driving under the influence of alcohol impair driving ability more in adolescents even at lower blood concentration levels than in adults as evidence available suggests that adolescents have different physiological response to alcohol compared to adults making them less sensitive to road traffic signals.¹⁰⁵

Research work from New Zealand showed that young drivers less than 20 years of age were five times more likely to have elevated blood alcohol concentration levels compared to fellow drivers older than 30years of age. In the US, 30% of adolescents

xxxvi

admitted to driving with an intoxicated driver and one in ten admitted to drinking and driving.^105,106

Lack of supervision also predisposes children to RTI. Lack of supervision by adults has been sited as a risk factor in children for road traffic injury although it is one among several interrelated risk factors. There are a number of associated characteristics with adults, parents or caregivers with limited ability to supervise children. This is worsened by being a single parent, a working parent or being affected by illness or depression.¹⁰⁷

B) Vehicle related risk factors:

Children have small stature and so poor vehicular design will put them at risk of road traffic injury. The design of a vehicle has an effect on the risk and severity of injuries sustained by a child particularly if the child’s head hit the rigid windshield.¹

Vehicle designers are now coming up with new ways of reducing severity of injuries in pedestrians more especially redesigning bumpers so as to prevent the head from making contact with the front window by allowing the impact to be absorbed by softer bonnets. This allows modificationof vehicles to benefit children interms of RTI.¹⁰⁸ For bicycle related injuries, report from the Netherlands revealed that children carried on bicycles get injured when their feet get trapped in the wheel spokes with 60% of bicycles not having protective features to prevent that Ergonomic changes of bicycles can thus help reduce and improve bicycle safety.¹

C) Environmental factors:

All over the world, motorization and urbanization are proceeding rapidly with associated increase in rapid mobility without considering safe mobility and children safety as they get involved in cycling, walking, running, playing along the road. These activities are important for healthy development of the child from early age of life.

xxxvii

For this reason environment need to be safe without putting the child at risk of injury particularly in the developing countries.¹

These environmental factors include:^109,110

 Lack of facilities to separate the road into lanes for bicycles, cars and having pavements for child pedestrian more especially in LMIC countries.

 Long, straight roads that encourage vehicular speed without bumps or obeying speed limits, commercial activities along roads.

 Residential homes that allow no space along the road compounded by speed crossing of roads by children or walking to and from school.

 Lack of safe and efficient public transport system that allows children to be carried on bikes even on high ways.

 Ignorance of traffic rules and road signs with resultant increase in RTI.

Types of road users:

Children get involved in or suffer injuries depending on the type of activities or roles related to different types of transport. These children may be bicyclists, car occupants, motorcycle riders or motorcycle passenger, pedestrians or even passengers on public transport. In some countries particularly LMIC, children work on the streets selling goods thereby weaving in and out of moving traffic.¹

The patterns of road use among children is said to vary from one country to another affecting the type of injuries they sustain which include:

Bicyclist

In many countries, children are taught to ride bicycles as a form of recreation.¹In many parts of Asia, bicycles are also a common means of transport. Bicyclist constitute 3-15% of children injured in traffic collisions and 2-8% of child traffic related fatalities around the world.^1,111

xxxviii

While there has been a decline in bicycle deaths among children in HIC, bicycle related injuries are increasing in many LMIC more especially South-East Asia and the Western Pacific.^1,112

Although bicycle related injuries are seen in high income countries, most minor bicycle collisions are never reported to the police.

Other risk factors related to bicycling are:

 Riding in mixed patterns of traffic which is more common in LMIC.¹

 Lack of using helmets while riding as the rate of helmet wearing among children riding bicycle even in HIC is low.¹¹³

 Poor visibility of bicyclist Pedestrians:

Majority of children injured or killed on the road are pedestrians globally but more in LMIC.¹ In HIC between 5-10% of children suffering road traffic injuries are pedestrians while in LMIC the proportion ranges between 30-40%.¹¹¹In Africa and Asia, child pedestrian injury is highest as walking along the road is usual.^1,63Child pedestrian injury is low in HIC because of preventive measures but still remains a challenge among those aged 5-14 years.¹

Unintentional child injury surveillance in developing countries among 350 children; found that 39% were pedestrians, 19% were car passengers and 13% were motorcycle or motor riders.²

Motorcyclist:

In many countries particularly developing, children travel as passengers on motor-cycle as a means of transporting them to schools. Young ages sit on the petrol tanks, behind the driver or being backed by parents mostly mothers.¹

xxxix

The rate of helmet use is very low among these small children due to ignorance or lack of small sized helmets resulting in head injury.¹In Vietnam for example, helmet use among adolescents and young adult riders are generally low as compared with older adults.^1,114

Children are legally allowed to drive motorcycle with restricted engine size in many Asian countries from the age of 15 year resulting in mortality or morbidity as seen also in most African countries.⁶³Coincidentally this is the critical age of the child’s development where risk taking is common with resultant deaths as young drivers passangers.¹

Occupants of vehicles:

Childhood injury or mortality as occupants of cars are a serious concern in developed countries as the mortality can be as high as 50%.¹¹²With increase motorization, child occupant deaths is an emerging problem in many LMIC.¹

Young children as occupants of cars are often injured due to ignorance, lack of or improper use of restraints such as seat belts particularly in developing countries. The use of restraints in children varies considerably across countries ranging from nearly 90%in the USAto almost zero in Oman.¹The problem could be a picture of what is seen in countries like Nigeria.

Young people all over the world have the lowest rate of wearing seat belts with survey among youths 14-17 years showing that only one third reported consistent use of seat belt in vehicles and more than a third had been passengers with drivers who had been drinking alcohol.¹ Young drivers between 16-18 years with co-passengers of same age group are also at risk of incurring road traffic crash.¹¹⁵

Young people as drivers:

Young people as drivers are generally a special risk group as there are reports from a number of countries about RTI or deaths especially those learning to drive. Research from Sweden showed that young drivers learning to drive are 33 times more likely to be involved in road traffic collisions than older drivers.¹¹⁶

xl

In developed or HIC, injuries and fatalities are a major problem among young drivers where studies involving young drivers accounts for between 20-30% of all road traffic fatalities while in the western Australia it is 15 times and 5 times in the US for those 16 years of age.^1,103,116

Presentation of RTI cases:

The commonest parts of the body affected in childhood road traffic collisions are the head and limbs. The severity of the injury will vary depending on the child’s age, type of road user and whether protective devices like helmets in bicycle or motorcycle were used.¹

The WHO conducted a school based survey looking at children 13-15 year of age in 26 countries. The outcome of the survey was that for children reporting an injury involving motor vehicle in the previous 12 months, 10% sustained minor head injuries while 37 had fractured limbs.¹

The survey report collaborated results of studies conducted in four low-income countries in children less than 12 years of age where among those involved in RTI, a quarter had incurred a concussion or other type of head injury, followed by cuts, bruises, open wounds, fractures and sprains.¹

Although head and limbs injuries were common, chest and abdominal injuries did occur with serious consequences due to organs involvement and the associated difficulties in the management with a report of multiple traumas in 10-20% of children involved in road traffic collisions.¹¹⁷