Risks to Students in School

September 1995

OTA-ENV-633

GPO stock #052-003-01447-5
Recommended Citation: U.S. Congress, Office of Technology Assessment, Risks

to Students in School, OTA-ENV-633 (Washington, DC: U.S. Government Printing Office, September 1995).
iii

Foreword

chool-aged children encounter a wide variety of hazards every day.

While the leading causes of mortality for this age group are hazards

that typically occur outside of the school environment, many hazards

resulting in injury or illness exist in schools. These hazards confront

children on their way to school, in the classroom, in the use of potentially hazardous materials in science, art, and industrial arts courses, on playgrounds, in

gymnasiums, on athletic fields, and on their way home.

Because of congressional interest in the health and safety of school children, the House Committee on Energy and Commerce and the House Committee on Education and Labor requested the Office of Technology

Assessment (OTA) to assess the available data on hazards to children in

schools in the United States. A letter of support was received from the Senate

Committee on Labor and Human Resources. As directed, this study focuses

on unintentional and intentional injuries (particularly violence) and illnesses

from infectious diseases and environmental hazards (school materials, indoor

air contaminants, and electromagnetic force).

In addition to estimating the likelihood of injuries and illnesses in schools,

OTA considered the quality, relevance, and predictive value of the available

data about health and safety risks by examining how the data were collected

and interpreted. For many of the hazards in the school environment, the

underpinning scientific research is incomplete and thus of limited use. This

report does not, however, compare or rank risks. Decisionmakers, from Congress to individual school boards, are likely to want much more information

than just numbers of deaths, illnesses, and injuries when setting priorities for

improving school safety. Public fear of particular risks and the feasibility and

cost of reducing the risk are among other very important considerations. As

such, this background paper represents the first step in the process of setting

priorities in risk reduction.

OTA appreciates the support this effort received from hundreds of contributors. Workshop participants, reviewers, contractors, school administrators,

parents, and schoolchildren gave us invaluable support. OTA, however,

remains solely responsible for the contents of this background paper.

ROGER C. HERDMAN

Director

S
iv

Workshop Participants

Allen C. Abend

School Facilities Office

Maryland State Department of 

Education

Barbara Barlow

Harlem Hospital Center

Christine Branche-Dorsey

National Center for Injury 

Prevention & Control

Centers for Disease Control & 

Prevention

Cal Cazier

Child Injury Prevention 

Program

Utah Department of Health

Joycelyn Elders

U.S. Department of Health & 

Human Services

Ron Engle

National Highway Traffic 

Safety Administration

Ruth Etzel (chair)

National Center for 

Environmental Health

Centers for Disease Control & 

Prevention

Sue Gallagher

Education Development 

Center, Inc.

Caren Ginsberg

National Public Health & 

Hospital Institute

Richard Lowry

National Center for Chronic 

Disease Prevention and 

Health Promotion

Centers for Disease Control 

and Prevention

Jim Mercy

National Center for Injury 

Prevention and Control

Centers for Disease Control 

and Prevention

Wesley C. Mitchell

Los Angeles Unified School 

District

Bill Modzeleski

Drug Planning & Outreach 

Staff

Office of Elementary & 

Secondary Education

U.S. Department of Education

Benjamin Schwartz

National Center for Infectious 

Disease

Centers for Disease Control & 

Prevention

David Sleet

National Center for Injury 

Prevention & Control

Centers for Disease Control 

and Prevention

Ronald Stephens

National School Safety Center

Laurie A. Westley

Office of Federal and National 

Education Issues Advocacy

National School Boards 

Association
v

Project Staff

Clyde Behney

Assistant Director

Health, Education, & 

Environment Division

Robert Niblock

Program Director

Environment

CONTRACTORS

Elizabeth Sheley

Editor

Alexandria, VA

Florence Poillon

Editor

Chicago, IL

Cynthia Bearer

Case Western Reserve 

University

Cleveland, OH

Miriam Davis

Washington, DC

Adam Finkel

Resources for the Future

Washington, DC

Baruch Fischoff

Carnegie Mellon University

Pittsburgh, PA

PRINCIPAL STAFF

DALTON PAXMAN

Project Director

Martha Livingston

Analyst

Gerard Fergerson

Fellow

Michael Gough

Senior Associate

David Butler

Analyst

CONTRIBUTING STAFF

Robert Friedman

Senior Associate

Mark Boroush

Senior Analyst

Mark Pedersen

Intern

Tanya Kean

Intern

INTERNAL REVIEWERS

Peter Johnson

Senior Associate

Denise Dougherty

Program Director

Education & Human 

Resources

ADMINISTRATIVE STAFF

Kathleen Beil

Office Administrator

Kimberly Holmlund

Administrative Secretary

Nellie Hammond

Administrative Secretary

Sharon Knarvik

Secretary

Babette Polzer

Contractor
vi

List of Reviewers

Allen C. Abend

School Facilities Office

Baltimore, MD

Barbara Barlow

Harlem Hospital Center

Marisa Bartolomei

Department of Cell & 

Developmental Biology

University of Pennsylvania

David Bates

Department of Health Care and 

Epidemiology

University of British Columbia

Vancouver, BC

Christine Branche-Dorsey

National Center for Injury 

Prevention & Control

Centers for Disease Control & 

Prevention

Atlanta, GA

Patricia Buffler

School of Public Health

University of California

Berkeley, CA

Steve Bumbaugh

Eastern High School

Washington, DC

Cal Cazier

Child Injury Prevention Program

Utah Department of Health

Salt Lake City, UT

Dorothy Cooper

Arizona State Department of 

Health Services

Phoenix, AZ

Donald Crane

W.C. Grace & Co.

Washington, DC

Ann Cronin

National Institute for 

Occupational Safety & 

Health

Atlanta, GA

Miriam Davis

Silver Spring, MD

Felton Earls

Harvard University

Boston, MA

Sandra Eberle

U.S. Environmental Protection 

Agency

Washington, DC

Ron Engle

National Highway Traffic 

Safety Administration

Washington, DC

Ruth Etzel

National Center for 

Environmental Health

Centers for Disease Control 

and Prevention

Atlanta, GA

Albert D. Farrell

Virginia Commonwealth 

University

Richmond, VA

Keith Florig

Resources for the Future

Washington, DC

Sue Gallagher

Education Development 

Center, Inc.

Newton, MA

Caren Ginsberg

National Public Health & 

Hospital Institute

Washington, DC

Louis D. Gonzales

The Center for Safe Schools 

and Communities

Castro Valley, CA

Evelyn Gonzalez

Zora Neale Hurston Academy

New York, NY
vii

Paul Gosselin

California Environmental 

Protection Agency

Sacramento, CA

John Graeff

Boston Children’s Hospital

Boston, MA

John Graham

Center for Risk Analysis

Harvard School of Public 

Health

Boston, MA

Ann Hardy

National Center for Health 

Statistics

Centers for Disease Control & 

Prevention

Hyattsville, MD

Tim Hardy

Kirkland & Ellis

Washington, DC

Cynthia Harp-Beaver

New Haven Public Schools

New Haven, CT

Eric Hensen

Hoyle, Morris, & Kerr

Philadelphia, PA

Wayne Holbrook

Bokeelia, FL

Catherine McVay Hughes

NYPIRG

New York, NY

Richard Jackson

California Department of 

Health Services

Berkeley, CA

Bernard James

Pepperdine University

Malibu, CA

Gary Johnson

General Electric Co.

High Voltage Transmission 

Research Center

Lenox, MA

Patrick Kachur

National Center for Injury 

Prevention

Centers for Disease Control 

and Prevention

Atlanta, GA

Steven R. Kaminsky

Mary McLeod Bethune 

Elementary School

New York, NY

Laura Kann

National Center for Chronic 

Disease Prevention & Health 

Promotion

Chamblee, GA

Myra Karstadt

U.S. Consumer Product Safety 

Commission

Bethesda, MD

William Kaune

EM Factors

Richland, WA

Carole Kimmel

U.S. Environmental Protection 

Agency

Washington, DC

Phil Landrigan

Mt. Sinai School of Medicine

New York, NY

Robert Lewis

U.S. Environmental Protection 

Agency

Atmospheric Research & 

Exposure Assessment 

Laboratory

Research Triangle Park, NC

Richard Lowry

National Center for Injury 

Prevention

Centers for Disease Control 

and Prevention

Atlanta, GA
viii

Jim Mercy

National Center for Injury 

Prevention

Centers for Disease Control 

and Prevention

Atlanta, GA

Susan G. Millstein

University of California

San Francisco, CA

Jim Monroe

Harvard University

Boston, MA

Mark Pepple

California Environmental 

Protection Agency

Sacramento, CA

Jeffrey Phillips

U.S. Environmental Protection 

Agency

Washington, DC

Deborah Prothrow-Stith

Harvard University

Boston, MA

J. Routt Reigart

Medical University of South 

Carolina

Charleston, SC

Michael Reimers

U.S. Geological Survey

Denver, CO

Gary Remafedi

University of Minnesota

Minneapolis, MN

Becky Riley

Northwest Coalition for 

Alternatives to Pesticides

Eugene, OR

Susan Rose

U.S. Department of Energy

Washington, DC

John Rosen

Montefiore Medical Center

Bronx, NY

Cindy Sage

Sage Associates

Montecito, CA

David Savitz

University of North Carolina

Chapel Hill, NC

Anita Schmidt

U.S. Environmental Protection 

Agency

Washington, DC

Benjamin Schwartz

National Center for Infectious 

Disease

Centers for Disease Control 

and Prevention

Atlanta, GA

David Sleet

National Center for Injury 

Prevention

Centers for Disease Control 

and Prevention

Atlanta, GA

Rose Ann Soloway

American Poison Control 

Center

Washington, DC

Carlos Stern

Carlos Stern Associates, Inc

Arlington, VA

Ronald Stephens

National School Safety Center

Westlake Village, CA

Willie Stroble

John Marshall High School

Richmond, VA

David Sundin

National Institute for 

Occupational Safety & 

Health

Cincinnati, OH

Steven Swanson

Sanders International

Washington, DC
ix

Sharon Taylor

Environmental Health 

Coalition

San Diego, CA

Robert Thompson

U.S. Environmental Protection 

Agency

Washington, DC

Debbie Tinsworth

U.S. Consumer Product Safety 

Commission

Directorate for Epidemiology

Washington, DC

Sandra Tirey

Chemical Manufacturers 

Association

Washington, DC

Laurie Westley

National School Boards 

Association

Alexandria, VA

Rae Zimmerman

Robert F. Wagner Graduate 

School of Public Service

New York University
xi

Contents

1 Summary 1

Scope of the Report 2

Key Findings 2

Injury to Students in School 8

School Illness 16

Using the Data 26

References 28

2 Issues in School Health and Safety 31

Health and Safety Data 34

The Significance of Risks and Estimates 41

Road Map to this Report 43

References 43

3 Injury to Students in School 47

Unintentional Injury 49

Playground-Related Injury Data 65

School Athletic Injury Data 71

Transportation Injury Data 82

Unintentional Injury Conclusion 96

Intentional Injury 96

Intentional Injury ConclusionS 107

Injury in School Conclusions 107

References 109

4 Illness in School 115

Nature of Environmental Health Hazards 

and Infectious Disease 115

Nature of Environmental Health Data 117

Materials in The School Environment 117

Indoor Air Quality 138

School Location 156

Infectious Disease 168

Conclusions 179

References 180
xii

5 Using the Data 195

Risk Dimensions 195

Comparing Risks 197

Managing Risks 201

References 202
| 1

Summary 1

chools, like all buildings and institutions,

harbor some risks; inspection of records

of illnesses and injuries in schools reveals

sometimes preventable or reducible hazards. Nevertheless, compared to other places

where children live and play, schools are often

safer environments. This finding must be

qualified by the paucity and occasional poor

quality of data—or even the absence of information about some hazards. For many of the hazards that this study examined, the Office of

Technology Assessment (OTA) could not judge

whether schools were safer or not.

Of course, children daily confront a variety of

risks, in or out of school. In 1992, children ages 5

to 17 suffered 13 million injuries and some 55

million respiratory infections, contributing to

their missing about 214 million school days,

roughly 460 days for every 100 students. Unknown are the possible long-term health consequences, the impact of the lost learning opportunities, or the care-giving problems faced by

families. Averaged over the year, school-aged

children spend about 12 percent of their time in

school; some portion of their injuries and

illnesses arise in connection with the school

environment. Parents, teachers and school

administrators, and leaders in all walks of life

understand that information about the nature of

risks is a basic requirement for thoughtful decisions about the interventions necessary to reduce

illnesses and injuries.

Since government requires school attendance,

it ultimately bears responsibility for children’s

health and safety while they are there. While

local, county, and state governments bear most

responsibility for the operation of schools, the

federal government has taken a role in health and

safety issues, as reflected in the 103d Congress

considering 66 bills that referenced the “school

environment” and 51 that were directed at the

goal of “safe schools.” Congressional concern

led the House Education and Labor and Energy

and Commerce Committees of the 103d Congress to request this background paper, which

examines the scientific data on the risks for

injury and illness in the school environment.1

1 In the 104th Congress, the House Education and Labor Committee was renamed the Education and Opportunity Committee and the

House Energy and Commerce Committee became the Commerce Committee.

S
2 | Risks to Students in School

SCOPE OF THE REPORT

This report focuses on risks2 to students between

5 to 18 years old while they are at school, on the

school grounds, and, to the extent possible, at

school-related activities and traveling to and

from school. The ages correspond to grades kindergarten through the 12th grade. About 46.5

million children were enrolled in over 109,000

elementary and secondary schools for the 1990

school year, and a projected 50 million will

enroll for the fall of 1995.

Hazards are grouped according to whether

they cause injuries or illnesses. For this assessment, injuries are divided into two kinds:

■ those that result from unintentional actions,

such as playground activities or organized

sports, and

■ those resulting from intentional actions, such

as homicide or fighting.

Illnesses are also divided into two groups:

■ those that arise from environmental hazards,

such as asbestos and lead, and

■ those that arise from exposure to infectious

agents, such as influenza virus and respiratory-disease-causing bacteria.

This report takes one critical step—identifying

and commenting on the available data—that may

help in developing priorities for the use of limited resources to protect children from health and

safety hazards in schools. The report does not

attempt to compare and rank risks of a diverse

nature; rather, the data are examined—their quality, how they were produced, the assumptions

made, and their limitations. After consulting with

experts in various fields, OTA staff assembled

morbidity and mortality data, along with estimates and measures of exposures or risks, for

events ranging from school bus crashes and other

accidents to student-on-student violence, and

from infectious disease outbreaks to a number of

2 In this report, risk refers to the probabilistic estimate of the likelihood of an adverse health outcome associated with the hazard in question. Hazards are defined as the agent or action capable of causing the health effect.

“environmental hazards,” including pesticide

poisoning and possible lung cancers from asbestos or radon.

Although this report does not rank risks, one

section is devoted to discussing comparative risk

assessment, a process favored by some to help

individuals and organizations decide where

resources are to be spent to reduce which risks.

Beyond the traditional notions of number and

severity of disease or injury, decisionmakers may

want to consider other subjective attributes of

risk in determining which school-related risks

are most worthy of attention.

KEY FINDINGS

In examining the hazards in schools, OTA found:

❚ Risks of Death in School

The two leading causes of death in

school-aged children are motor vehicles and firearms.

Relatively few deaths from these causes occur in

schools or on school buses.

In children ages 5 to 19, motor vehicle-related

injuries and injuries due to firearms dwarf all

other causes of death for which data are available. In 1992, the approximately 6,720 deaths

due to motor vehicle injuries and 5,260 deaths

related to firearms accounted for about 50 percent of 22,600 deaths in all children ages 5 to 19

(see table 1-1). Motor vehicle-related deaths

include deaths to occupants of cars or other

motor vehicles involved in crashes, as well as

deaths to pedestrians, bicyclists, and others

injured by motor vehicles. Firearm-related deaths

include deaths due to intentional injuries (i.e.,

firearm-related homicides and suicides) and

deaths due to unintentional injuries involving

firearms. In 1992, the number of intentional injuries due to firearms in school-aged children

(about 3,280 firearm-related homicides and

1,430 suicides) far exceeded the number of unintentional injuries due to firearms (470 deaths).

FINDING
Chapter 1 Summary | 3

TABLE 1-1: Leading Causes of Death to School-Aged Children, 1992

Causes

Deaths

5–9 Years

Deaths

10–14 Years 

Deaths

15–19 Years

Deaths

Total

Rate

per 10,000

ALL CAUSES 3,739 4,454 14,411 22,604 42.2

ALL NATURAL CAUSES 1,943 1,916 2,891 6,750 12.6

Malignant neoplasms 557 548 738 1,843 3.4

Diseases of the heart 130 154 333 617 1.2

Congenital anomalies 245 203 224 672 1.3

HIV infection 72 32 48 152 0.3

Pneumonia and influenza 53 51 85 189 0.4

Chronic obstructive pulmonary disease 38 62 90 190 0.4

ALL EXTERNAL CAUSES 1,796 2,538 11,520 15,854 29.6

All Unintentional Injuries 1,628 1,760 6,234 9,622 18.0

Motor vehicle-all 907 997 4,818 6,722 12.6

—Motor vehicle-occupant 378 481 3,269 4,128 7.7

—Motor vehicle-pedestrian 348 214 328 890 1.7

—Motor vehicle-bicycle 93 145 62 300 0.6

—Motor vehicle-other 88 157 1,159 1,404 2.6

Drowning 196 218 398 812 1.5

Fire/burn 211 105 95 411 0.8

Unintentional firearm 48 132 285 465 0.9

Poisoning 15 21 155 191 0.4

Fall 21 30 93 144 0.3

Aspiration 23 16 21 60 0.1

Suffocating 35 61 46 142 0.3

All Intentional Injuries 156 745 5,149 6,040 10.9

Suicide-all 10 304 1,847 2,151 4.0

—Firearm 3 172 1,251 1,426 2.7

—Nonfirearm 7 132 596 735 1.4

Homicide-all 146 441 3,302 3,889 7.3

—Firearm 56 348 2,878 3,282 6.1

—Nonfirearm 90 93 424 607 1.1

All Firearm 111 667 4,484 5,262 9.8

Population (000’s) 18,347 18,105 17,102 53,554

SOURCE: U.S. Department of Health and Human Services, National Center for Health Statistics, Vital Statistics System, 1995.
4 | Risks to Students in School

On the basis of national data from 1992,3

 it

appears that relatively few deaths from motor

vehicle-related injuries in school-aged children

actually occur in school environments, defined

here as school buildings and grounds and bus

transportation to and from school. Except for

school bus-related deaths, estimates of deaths to

schoolchildren going to and from school are

either unreliable or unavailable. Measured on a

passenger per mile basis, the number of occupant

deaths from school bus crashes is one-quarter the

number from passengers of automobile crashes.

Among school bus-related fatalities, children

getting on or off the bus are by far at the greatest

risk. In 1989, the National Academy of Sciences

reported that from 1982 to 1986 an average of

about 50 children died in school bus-related

crashes, and roughly three-fourths of these died

getting on or off a school bus.4

About 1 percent of the deaths from firearms in

school-aged children occur in school environments. An estimated 100,000 to 135,000 guns are

brought to school every day, yet children are

much less likely to die from firearm-related

injuries in school than out of school. During

two recent school years (1992–93 and 1993–

94), researchers identified an average of 53

“school-associated violent deaths”5 per year,

about 40 of which were homicides, and almost

all were related to firearms. Every single killing

in a school—especially the killing of a child—

justifiably receives considerable public attention.

The fact is, however, that school-associated

violent deaths constitute only a tiny portion of

the several thousand violent deaths among

school-aged children each year.

Most of the deaths from motor vehicle and

firearm injuries are concentrated among older

teenagers. No health hazard for any age group

3 OTA’s findings with respect to risks to students in schools are based on national averages. OTA did not make any attempt to compare

regions, districts, or individual schools that may be better or worse than average. 4 The most recently published National Highway Transportation Safety Administration’s school bus crash-related fatality estimates are

available in Traffic Safety Facts, 1992; except for pedestrians, the data are not published by age so the number of school-aged children fatally

injured is not known. 5 The Centers for Disease Control and Prevention includes homicides, suicides, and unintentional firearm fatalities in “school-associated

violent deaths” (12). 

examined in this report compares in magnitude

to the impact of deaths resulting from motor

vehicle injuries and firearm use in 15- to

19-year-olds. Combined motor vehicle and

firearm-injury-related deaths among this group

represent about 40 percent of deaths among

all school-aged children. Among younger

school-aged children (ages 5 to 9 and ages 10 to

14), motor vehicle- and firearm-related deaths

are a smaller proportion of total deaths. In these

children, deaths from natural causes—i.e., acute

and chronic illnesses—exceed deaths from motor

vehicle injuries or firearm-related injuries and

are roughly equal to deaths from all injuries.

There are many other less common

causes of death among school-aged children. For

these, schools sometimes pose a greater risk than

other environments, sometimes about the same risk,

and sometimes less. Quite often, the relative safety of

schools, on a national average basis, is unknown.

Less common causes of death among schoolaged children include infectious and other diseases (e.g., cancer), congenital anomalies, unintentional injuries other than firearms or motor

vehicles (e.g., drowning, fires, poisoning, falls),

and nonfirearm-related suicide and homicide

(see table 1-1). In the school environment, these

hazards do not appear to account for more than

10 to 100 deaths per type of hazard annually.

Childhood exposure to environmental hazards

such as radon and asbestos in schools and other

environments may cause some deaths later in

life, in contrast to deaths from many injuries,

such as homicides, for which death is more

immediate.

Schools probably pose a greater risk to children than out-of-school environments for deaths

from infectious diseases. There is no certainty

FINDING
Chapter 1 Summary | 5

that this is true because a school’s contribution to

disease is rarely determined. But school environments are probably incubators for fatal infections

that can be spread through casual contact in

classrooms. In 1992, about 190 school-aged children died from pneumonia and influenza, two

respiratory infections that can be spread via

casual contact in classrooms. In the same year,

150 school-aged children died from infection

with human immunodeficiency virus (HIV), the

virus that causes AIDS. HIV is spread through

the exchange of bodily fluids (blood or semen)

during sexual activity or intravenous drug use.

Currently, there is insufficient information to

evaluate the importance of school contacts in the

transmission of HIV.

Deaths from cancer that might be related to

in-school exposures to environmental hazards

may not occur for many years after the exposure,

and in-school exposure data, if they exist at all,

are usually inadequate to estimate the risks for

developing and dying from cancer. The concentrations of both radon and asbestos in school

buildings are about the same as concentrations

found in other buildings. Using U.S. Environmental Protection Agency (EPA) estimates of the

cancer-causing potential of asbestos, this study

extrapolates that for a given school year, average

in-school exposures to asbestos may ultimately

result in 2 to 60 lung cancer deaths. Similarly,

extrapolating from EPA estimates of the cancer-causing potential of radon, average per year

in-school exposures to radon may lead to about

60 lung cancer deaths above and beyond those

associated with contributions from other sources

of radon.

There is considerable uncertainty associated

with both of these extrapolations, however, and

the actual numbers of deaths associated with

in-school exposures to asbestos or radon may be

higher than estimated—or zero. There is even

more uncertainty associated with estimates of

cancer deaths due to exposures to electromagnetic fields (EMF), because the biological effects

of electromagnetic fields are not well understood

and too few data exist on in-school exposures

and their possible impact.

Clearly, schools can contribute to exposures to

environmental hazards. While the school environment’s contribution to overall risk can sometimes be calculated, though, it must be

remembered that other environments—notably,

the home—might expose children to these hazards as much or more.

The relative risk to school-aged children of

deaths in schools from most unintentional injuries not due to firearms or motor vehicles is not

known. For example, it is known that about 20

high school students die in school athletics, but it

is difficult to judge whether these activities in

schools are safer or riskier than similar ones out

of school, because comparable out-of-school

data are unavailable for the same activities.

❚ Risks of Injury or Illness in School

Schools contribute to the risks of injury

or illness in school-aged children. Once again,

schools sometimes pose a greater risk than other

environments, sometimes about the same risk, and

sometimes less. But little is known about schools’ contribution to nonfatal illness and injury.

Data on the incidence of injury or illness in

school-aged children—i.e., on the number of

new cases of injury and illness in this population

in a given time period—are available from the

Centers for Disease Control and Prevention. An

important measure of the impact of injuries and

illnesses on students is the number of school

days lost because of an injury or illness. In 1992,

illness accounted for approximately 75 percent

of the nearly 175 million lost school days from

short-term conditions (both injuries and illness).

Illnesses were responsible for more lost school

days than were injuries (even though injuries

resulted in more fatalities than illnesses did).

For most of the hazards related to the incidence of injury and illness in school-aged children, OTA found that the data were inadequate to

allow in-school and out-of-school comparisons.

While for certain hazards the relative risk is not

known because too little information exists, for

others the relative risk cannot be determined

because the nature of the hazard’s effect on chilFINDING
6 | Risks to Students in School

dren’s health precludes the possibility of linkage

to a school location. Athletic injuries, for example, are reasonably well documented in school,

but the out-of-school data are not particularly

useful for comparisons due to inadequate data on

location or their single-sport focus. Other risks

(e.g., fighting) are difficult to determine because

of inadequate reporting on the cause of the

injury.

For a few sources of injury and illness, it

appears that schools pose a risk greater than that

posed by out-of-school environments. Thus, for

example, schools may facilitate the spread of

infectious diseases, especially of highly infectious diseases such as viral respiratory diseases.

Certain disease outbreaks, such as meningococcal infections and food poisonings, can be traced

to the school environment. Furthermore, conditions at certain schools exacerbate exposures to

substances such as lead. The largest source of

exposure to lead comes from younger children

eating paint chips at home, but some schools may

add to this exposure through the presence of lead

in building paint and in water.

For other sources of injury and illness, it

appears that schools pose a risk comparable to

that posed by out-of-school environments. In the

case of elementary school children, for example,

about as many injuries occur on school playgrounds during school hours (9 a.m. to 3:30

p.m.) as occur in other locations. Athletic injuries

are among the most common causes of school

injuries to older students; the few available studies indicate that they occur at similar rates inside

and outside of school.

For many sources of injury and illness,

schools actually pose less of a risk than

out-of-school environments. Thus, for example,

schools pose less of a risk than out-of-school

environments for many environmental hazards.

At most about 7 to 8 percent of reported exposures to poisons among school-aged children

occurred in schools. Furthermore, according to a

1989 study,6

 fewer injuries requiring hospitalizations occurred in school than out of school.

Moreover, in another study,7 about 3 percent of

injuries presented to the national trauma database

were school related. Similarly, school bus

crashes did not result in nearly as many injuries

as crashes of other motor vehicles. Schools were

also less of a risk for violent injuries.

❚ The Risk Assessment Process

For many of the risks OTA reviewed,

national data were usually inadequate for an assessment of risks in schools. The largest data gaps

existed for environmental hazards.

In addition to estimating the likelihood of

injuries and illnesses in schools, OTA considered

the quality, relevance, and predictive value of the

available data by examining how the data were

collected and interpreted. For many of the hazards in the school environment, the underpinning

scientific research is incomplete and thus of limited use.

OTA identified several obstacles to the collection of more complete information on the hazards facing children in schools. One obstacle is a

lack of resources, whether money, expertise, or

both. Another type of obstacle is resistance to

data collection on the part of school administrators, perhaps out of fear of being branded a

“problem school.” Furthermore, epidemiological studies seldom focused on school health and

safety risks, and few surveillance systems at the

Centers for Disease Control and Prevention and

state programs monitored injury or illness in

school. The lack of both standardized federal and

state definitions for reporting hazards, injuries,

and illnesses, and of coordinated reporting

efforts over time also impedes accurate portrayal

of school injuries and illnesses. With respect to

unintentional injury data, for example, there are

inconsistent definitions of reportable injuries and

designations of severity.

6 Injury data compiled by the Massachusetts Statewide Comprehensive Injury Program (8).

7 Data from this study were compiled from September 1979 and August 1982.

FINDING
Chapter 1 Summary | 7

The largest data gaps existed for environmental hazards such as radon, asbestos, and EMF.

OTA generally did not find comprehensive data

on in-school exposures to these types of substances. For most of these agents, the simple

presence of a hazard—not the level to which students are exposed—is reported. With few exceptions, efforts to obtain exposure data have been

sporadic, and reporting has been anecdotal. The

absence of studies documenting exposure in

school presents a fundamental gap in the data

needed to assess risks nationwide. Because of

those gaps, officials and investigators may never

link certain observed health effects to exposure

to the culpable agent in the school environment.

Unlike injuries or illnesses from environmental hazards, cases of specific infectious diseases

must be reported to the Centers for Disease Control and Prevention, but records do not necessarily identify schools as the location of the

culpable exposure. For infectious diseases, data

are usually reported for school-aged children, but

only certain cases of school outbreaks, e.g.,

meningococcal infections or food poisoning,

accurately establish schools as the source of the

illness.

Decisionmakers, from Congress to individual school boards, are likely to want much more

information than just numbers of deaths, illnesses,

and injuries when setting priorities for improving

school safety. Public fear of particular risks and the

feasibility and cost of reducing the risks are among

other very important considerations.

Clearly, 20 deaths from one in-school hazard

are worse than 10 deaths from another, but does

that information tell us which problem to address

first or on which to spend the most money? People naturally tend to order things by their size or

severity, and quantitative estimates of the magnitude of risk—i.e., the likelihood of adverse

health effects arising from the hazardous conditions—are useful in setting priorities. The magnitude of risk can be quantified in any of several

ways (e.g., using measures of the individual

probability of risk, the risk to the population, or

weighting the risk by age, accounting for the

additional years of life lost for the child), each

measure stressing a different aspect of the risk.

But quantitative estimates of the likelihood of

adverse health effects arising from particular

hazards are not all that are needed for local

school boards and other decisionmakers to determine what can and should be done to make

schools safer. Decisionmakers may want to take

into account the social context of the risk.

One aspect of the social context that is particularly important is the degree of public fear associated with a risk. The level of fear of a given

hazard varies widely across individuals and communities. One thing that sometimes determines

the level of fear is the degree to which individuals feel that they are able to control the risk

through personal action. Thus, even though the

risk may not be very great, parents may fear their

child being killed in school by another student

with a weapon because they cannot control the

risk; at the same time, parents may have less fear

of a comparable risk—that their child will die en

route to and from school in a bus crash—because

they feel that they can control this; they can drive

the student themselves or arrange alternative

travel.

Another aspect of social context is the perception that a given hazard—say, playing football—

has benefits that make the associated risks more

worth taking or bearing. In terms of the number

and severity of associated injuries, football is

among the most hazardous of athletic activities

in which high school students participate. Nonetheless, the perceived benefits of athletic accomplishment and social recognition encourage

continued participation in this activity.

Local school boards and other decisionmakers

seeking to determine what can and should be

done to make schools safer need to take into

account the feasibility and cost of reducing different risks. School boards must decide, in some

cases, if the risks of firearms and firearm-related

injuries in their schools justify the substantial

costs of metal detectors. Small risks that are

cheap and easy to eliminate may deserve priority

attention, whereas even very large risks may not

FINDING
8 | Risks to Students in School

emerge as priorities if reducing them would be

technically infeasible or prohibitively expensive.

The remainder of this chapter summarizes the

findings and conclusions from the subsequent

chapters of this report. The next section covers

student injuries, both intentional and unintentional. The illness section examines illnesses

arising from environmental hazards and infectious diseases. Finally, the last section looks at

how the presented data can be used by decisionmakers and those interested in the safety and

health of students in school.

INJURY TO STUDENTS IN SCHOOL

This report examined school injuries in terms of

“intent”—unintentional (accidental) and intentional (assaultive or suicidal). Unintentional and

intentional injuries differ in the type of injury

that results, its severity, the manner in which it is

recorded at schools, and the level of response or

fear it engenders. The types and quality of data

collected for unintentional and intentional

injuries also vary. While some national and state

estimates of school injuries are available, epidemiological studies provide a more detailed picture of injury incidence. In this section, we draw

together available school injury data from both

types of injury.

In 1992, school-aged children in the United

States incurred over 13 million injuries (1).8

Results of epidemiological studies indicate that

from 10 to 25 percent of injuries incurred by the

school-aged population occur at school (29).

However, epidemiological studies use a broader

definition of injury than the national survey.

Regardless of the number of injuries, over 10

million school days are lost each year—22 lost

school days per 100 students (1). Since 12 percent of a child’s year and 15 to 20 percent of a

child’s annual waking hours are spent in school,

the frequency of injury per hour in school or out

is about the same. However, most of these injuries are minor. The more severe injuries tend to

8 This estimate includes only those injuries involving medical attendance and at least half a day of restricted activity.

occur out of school. For certain types of injuries,

such as athletic injuries, the percentage of injuries incurred in schools may be higher than outside the school environment; however, for other

injuries, particularly fatal injuries such as homicide, it is considerably lower: 1 percent of deaths

due to violence for children 5 to 18 occur at

schools.

The leading causes of death to children of

school age (5 to 19 years) are motor vehicle

crashes and injuries, intentional or unintentional,

associated with firearms. In 1992, about 6,720

deaths due to motor vehicle injuries and the

5,260 deaths related to firearms accounted for

approximately 50 percent of 22,600 deaths in the

more than 53 million school-aged children,

dwarfing all other causes of death for which data

are available. Motor vehicle injury deaths

include deaths to occupants, pedestrians, bicyclists, and others injured in automobile crashes.

Firearm-related deaths include firearm-related

homicides and suicides as well as unintentional

firearm injuries.

❚ Unintentional Injury

Given the time students spend at school and the

variety of activities in which they are engaged,

the school environment presents many opportunities for unintentional injury. Risks of unintentional injury to students occur each school day:

in their travel to school; in the controlled, supervised classroom environment; in physical activities in gymnasiums and athletic fields; in the

relatively unsupervised play during recess and

lunch periods; and finally, on their return home

(28). Although many of these injuries are minor

cuts and bruises that heal quickly, significant

numbers are quite serious. The injuries may

result in absence from school, restricted activity,

hospitalization, disability, and even death.
Chapter 1 Summary | 9

Incidence and Distribution of School-Related 

Injuries

Injury rates from school-related injury studies

vary and are likely to underrepresent the number

of actual injuries because of underreporting in

the routine surveillance and reporting of injuries

at schools (9). The variations may be attributed

to one or more of the following: 1) varying case

definitions of injury; 2) reporting methods that

vary (e.g., school-based as opposed to hospital-based reporting); 3) inconsistent reporting

among study schools; 4) variability among student populations; and 5) implementation of

school-based prevention programs.

Population-based estimates of rates of injury

to school-aged children range from about 24 to

28.6 injuries per 100 school-aged children in

1992 (1,8,29,30). As shown in table 1-2, the rates

of injury in school estimated in several epidemiologic studies range from 1.7 to 9.2 per 100 students. Based on 1988 NHIS data, one study

found that 19 percent of all injuries sustained by

children under 17 occurred at school (30). Considering the shorter time spent in school each

year—about 12 percent of a child’s time annually—the data thus suggest that the number of

school injuries may be about the same or higher

than those out of school.

Playgrounds and athletics (including both

physical education and organized sports) account

for the highest injury rates in school. Distribution

of these injuries, however, changes over time

due to students’ development of physical skill,

strength, size, judgment, balance, and experience

with hazards (28). Playgrounds are associated

with most injuries to elementary students and

athletic injuries account for the most injuries to

secondary school students. The rates of playground injuries decrease as children mature,

while the rates of athletic injuries increase

steadily through middle/junior high school to

high school.

The majority of school-related injuries are

minor; they also result in fewer hospitalizations

than injuries sustained outside the school environment, and fatal injuries are relatively rare in

the school environment (28). The percentage of

severe injuries—ranging from 18 to 39 percent

of the total injuries across three epidemiological

studies (two Canadian studies and one United

States study)—varies because, among other

things, severity is defined differently from study

to study. Playground and sports athletic injuries

account not only for the greatest number of injuries but also for the majority of severe injuries

(2,14,32). Falls (either from the same surface or

from elevation), organized sports or athletics,

and unorganized play were the activities most

frequently associated with injuries (9). Compared to outside of school, in-school injuries

were less severe.

Playground-Related Injury Data

The 1990 Consumer Product Safety Commission

(CPSC) Playground Equipment-Related Injuries

and Deaths report (36) provides an analysis of

data on playground injuries and deaths associated with playground equipment.9

 Fatalities

averaged nine per year for children under 15

years of age, with about 170,200 playground

equipment-related injuries in 1988.10 Using

these data, OTA estimated that approximately

13,000 playground equipment-related injuries

occurred on school playgrounds, during school

hours,11 to school-aged children. The 1992

CPSC estimates 241,181 playground equipment

injuries required treatment in hospital emergency

rooms.12 Poor out-of-school data on playgroundequipment injuries prevent comparison with the

in-school data.

9 The CPSC data includes only fatalities and injuries that are product-related and, accordingly, exclude those that occur on playgrounds

but are not equipment related. Moreover, CPSC collects only emergency room data and, thus, only the most serious injuries. 10 From April to December 1988, CPSC completed a special study of a systematically selected sample of playground injury incidents to

follow up in depth. The study identified out-of-scope cases, meaning cases involving injuries that were not associated with outdoor playground equipment. Extrapolating the percentage of out-of-scope cases to the 1988 NEISS, CPSC determined that the estimated 201,400

emergency room-treated playground equipment-related injuries should be reduced to 170,200. 11 School hours are defined as 9:00 a.m. to 3:30 p.m. 12 CPSC has not adjusted these numbers.
1

0|RiskstoStudentsinSchool

TABLE 1-2: School Injury Epidemiological Studies

Lenaway et al. (1992) Boyce et al. (1984a) Sheps & Evans (1987) Feldman et al. (1983) Taketa (1984)

Years analyzed 1988-1989 1980-1983 1981-1983 1981-1982 1981-1982Site Boulder, CO Tucson, AR Vancouver, BC Hamilton, Wentworth, Ont. HawaiiNo. of schools 9 96 108 212 204Grades K–12 K–12 K–12 K–13 K–12Student population

5,518 55,000 53,000 83,692 157,000

Data collection Prospective Prospective Retrospective Prospective RetrospectiveDefinition: reportable injury

Student accident report forms completed by adult administering first aid (i.e., teacher, nurse, or coach). Reportable injuries were those: “requiring medical or dental attention, head injuries necessitating student dismissal to home and those with persistent symptoms beyond a two hour observation period, poisoning, suspected fractures, human bites, puncture wounds, and injuries sustained from fighting or equipment failure”

Must meet one of the following criteria: (1) required a physician’s care and/or major first aid, (2) resulted in an absence from school, or (3) resulted in restricted participation in competitive sports

If a child sustains or requires: “all head injuries, suspected or definite fractures, and ambulance or inhaler, referral to a physician or dentist, sutures or a foreign body in the eye”

Decision as to reportability “made by school principal, consistent with his interpretation of the school board’s policy”

“Any accident which happens at school, or at a school sponsored activity, on or off campus, which (1) interrupts the students’ normal or expected activity for that period to any significant degree, (2) causes any property damages or losses of more than $5 in estimated replacement cost and/or (3) can generate a litigation on behalf of the injured”

Incidence per 100 student years

9.22 4.9 2.82 5.4 1.7

Definition: severe injury

* Amputations, third 

degree burns, concussions, crush wounds, fractures, multiple injuries

Fractures, loss of consciousness, burns, whiplash, open wounds, foreign body in eye

Fractures, loss of consciousness, dislocations, sprains, torn ligaments and cartilage, chipped/broken teeth, internal injury

“Most severe...foreign bodies in the eye and fractures”

Percentage of injuries that were serious or severe

* 18% 35% elementary

39% secondary

28.6%

* no definition of severe or seriousSOURCES: Office of Technology Assessment, 1995, Adapted from R.R. Gratz and K. Finison, “School Injuries: What We Know, What We Need,” Pediatric Health Care 6:256-262, 1992; D.D. Lenaway, et al.,“The Epidemiology of School Related Injuries: New Perspectives,” Am J Prev Med 8(3):193-198, 1992.
Chapter 1 Summary | 11

School Athletic Injury Data

In 1993, approximately 5.6 million students

competed in high school athletics (22), comprising approximately 43 percent of all United States

high school students (37). Student participation

in athletic activities is a principal cause of junior

high and high school injuries and results in a

number of debilitating injuries and deaths each

school year.

The only national school sports injury mortality figures are compiled by the National Center

for Catastrophic Sports Injuries Research. The

Center limits its research to certain high school

and college sports, and does not include physical

education. Over the 10 years of study, 200 deaths

were reported (67 direct and 133 indirect),13 an

average of approximately 20 sports-related

deaths annually (see table 1-3). Of all the direct

deaths in high school sports, only one was a

female (21).

13 The Center categorizes injuries as direct or indirect—direct meaning those injuries that resulted from participation in the skills of the

sport; indirect meaning those injuries that were caused by systemic failure as a result of exertion while participating in a sport activation or by

a complication that was secondary to a nonfatal injury.

Football and soccer resulted in the greatest

number of direct deaths each year among high

school athletes. On average, of the 20 athletic

related deaths each year, about five directly

related deaths occur in football and about five in

soccer. Football is associated with about five

indirectly related deaths per year and basketball

with three to four. While those three sports

account for more than 90 percent of the fatalities,

they are not necessarily the riskiest when judged

by number of deaths per participant in a sport per

year. In those terms, the riskiest high school

sports for males were gymnastics (1.75 deaths

per 10,000 participants), lacrosse (0.57), ice

hockey (0.43), and football (0.35). Basketball

(0.63), lacrosse (0.57), ice hockey (0.43), and

wrestling (0.41) had the highest rate of indirect

deaths per participant.

TABLE 1-3: Reported Catastrophic Injuries from High School Sports, 1982 to 1992

Fatal Nonfatal

Rate/100,000

Participant Years

Sport Direct Indirect Permanent Serious Total Male Female

Cross country 0 5 1 0 6 0.6 0.0

Football 48 52 103 113 316 2.4 —

Soccer 2 8 0 4 14 0.5 0.2

Basketball 0 35 2 2 39 0.6 0.1

Gymnastics 1 0 5 3 9 4.8 2.3

Ice hockey 1 1 4 2 8 3.6 —

Swimming 0 3 4 3 10 0.6 0.6

Wrestling 2 10 16 9 37 1.5 —

Baseball 3 5 7 6 21 0.5 —

Lacrosse 1 1 0 0 2 1.0 —

Track 9 12 6 6 33 0.6 0.0

Tennis 0 1 0 0 1 0.1 0.0

Total 67 128 148 148 491 16.8 3.2

SOURCE: F.O. Mueller, C.S. Blyth, and R.C. Cantue, Tenth Annual Report of the National Center for Catastrophic Sports Injury Research, Fall

1982–Spring 1992. Chapel Hill: University of North Carolina, 1993.
12 | Risks to Students in School

For national school sports, including both

organized sports and physical education, morbidity estimates disclose that sports account for the

greatest number of injuries in school. Of the 1.3

million sports/recreation injuries sustained by

children ages 17 and under annually, schools are

the location for 55 percent (715,000 injuries) and

the cause of 35 percent (455,000 injuries) (30).

Another school sports injury study—based on a

1986 injury surveillance study by the National

Athletics Trainers Association—estimated 1.3

million injuries annually. Epidemiological studies show that sports-related injuries account for

23 to 53 percent of all reported school injuries.

Physical education classes account for a greater

number of injuries than organized school sport

(13). Injuries sustained in physical education

occurred mainly during gym games (e.g., dodge

ball and four square) and basketball, with other

sports far behind. About 60 percent of the basketball injuries occurred during physical education

(45). However, once participation ratios are considered, organized sports (12 injuries/100 students) are riskier than physical education (2.3/

100).

Transportation Injury Data

Children and adolescents travel to and from

school by school bus or car, ride their bicycles,

or walk. The only travel mode for which detailed

injury data exists is by school bus. Though information would be useful regarding injuries from

other modes of transportation to school, particularly parents’ driving students or older students

driving themselves, no studies attempt to quantify these injuries for students.

The few studies that report injuries incurred

on the journey to and from school estimate the

range from 1 to 3 percent of all school injuries.14

In general, the journey home is more dangerous

than the trip to school (37,42). One study attributed this to more children walking home alone or

with other children rather than with an adult (37).

School Bus-Related Crashes

Every school day, school buses transport about

25 million students to and from classes and

school-sponsored activities (23). Although most

crashes involving school buses are minor, catastrophic crashes resulting in student fatalities and

serious injuries occur every year. A comparison

of school bus-related crash and passenger car

crash fatalities and injuries among school-aged

children suggests that school buses are much

safer than the other forms of transportation that

take students to and from school. The National

Academy of Sciences (NAS) estimates that occupant fatalities per mile for school buses are

approximately one-fourth those for passenger

cars (23).15 Of the more than 650,000 fatal traffic

crashes in the past 16 years, less than 0.4 percent

were classified as school bus related (41).

The major studies of fatalities in school

bus-related crashes are listed in table 1-4. The

NAS study reports that on average school

bus-related crashes fatally injured about 50

school-aged children each year from 1982 to

1986. Most of the fatal injuries among

school-aged children occur while they are getting

on or off, rather than while they are riding, the

school bus. It also appears that student pedestrians are at a far greater risk of being killed by the

bus they were on—usually in the school bus

loading zone—than by another vehicle (42).

14 These estimates are based on the Hawaii Department of Education and Utah Department of Health state estimates of school injuries

and the National Safety Council’s national estimates. The NSC reported that about 3.1 percent of all school injuries were incurred going to

and from school, 1.9 percent were motor vehicle related, and 1.2 percent were non-motor vehicle related. Because these injuries were

reported to the NSC by schools, it is likely that a number of transportation injuries occurred but were not reported to the school. 15 According to the National Safety Council’s (25) Accident Facts (1993), the difference between school bus and passenger car fatality

rates was even more pronounced. NSC reported that in 1989–91 the average fatality rate per hundred million passenger miles was 0.02 for

school buses and 1.05 for passenger cars. 
Chapter 1 Summary | 13

NAS developed a school bus-related nonfatal

injury estimate using selected state data. School

bus-related crash data from 14 states were aggregated and analyzed to develop a national estimate of 19,000 total injuries, 9,500 of which

were to school bus passengers. The report concluded that school bus passengers sustained 50

percent of the total injuries, of which 5 percent

were incapacitating.16 The majority of the school

bus-related crashes were minor. About 800 injuries suffered by school-aged pedestrians in

school bus-related crashes were reported; of

those, 35 percent were injured by being struck by

school buses and the remaining 65 percent were

struck by other vehicles. In contrast to fatality

estimates, far fewer pedestrians than school bus

passengers were injured, but pedestrian injuries

were typically more severe.

16 Incapacitating injury is defined as “any injury that prevents the injured person from walking, driving, or normally continuing the activities he was capable of performing before the injury occurred” (23). It includes, but is not limited to, severe lacerations, broken or distorted

limbs, skull or chest injuries, abdominal injuries, being unconscious at or when taken from the accident scene, and being unable to leave the

accident scene without assistance (23).

Pedestrian Injury Data

Fatalities and injuries occur to student pedestrians while walking to and from school. NHTSA

collects school-aged pedestrian mortality and

morbidity data, but the information does not indicate if the travel was school related. However,

databases that record pedestrian injuries by age

and time provide some estimates to indicate the

scope of the problem. At OTA’s request,

NHTSA generated time of day data for schoolaged pedestrians and bicyclists using 1992 FARS

and GES data. Assuming students typically

travel to school between the hours of 6:00 and

9:00 a.m. and travel home between 2:00 and 5:00

p.m., 121 school-aged pedestrians were fatally

injured; an additional 9,600 suffered nonfatal

injuries. Thus, for each death of a school-aged

pedestrian during these hours, there were about

TABLE 1-4: Annual Passenger, Pedestrian, and Bicyclist Fatalities in

School Bus-Related Crashes, by Study

STUDY

Annual Total Number of 

Fatally Injured People in 

School Bus-Related Crashes

School-Aged School Bus (or 

Vehicle Used as School Bus) 

Passengers Fatally Injured

School-Aged 

Pedestrians 

Fatally Injured

School-Aged 

Bicyclists

Fatally Injured 

1992

NHTSA’s Traffic Safety Facts 

(FARS)

124 9 29 2

1983–1992

NHTSA’s Traffic Safety Facts 

(FARS)

157 30

1977–1990

Summary of Selected School Bus 

Crash Statistics (FARS) (average) 

179 11–12 34

1982–1988

NAS Report on Improving School

Bus Safety (FARS) (average)

149 12 37–38 3.2

1991–1992

National Safety Council 110 10 25

SOURCES: U.S. Department of Transportation, National Highway Traffic Safety Administration. Traffic Safety Facts 1992, September 1993; U.S.

Department of Transportation, National Transportation Safety Board, Summary of Selected School Bus Crash Statistics in 1990, 1993; National

Research Council, Transportation Research Board, Committee to Identify Measures That May Improve the Safety of School Bus Transportation,

Improving School Bus Safety (Washington, DC: National Academy Press, 1989); National Safety Council, Accident Facts (Itasca, IL: 1993).
14 | Risks to Students in School

80 injuries. Twice as many fatalities and injuries

occurred in the afternoon as in the morning.

❚ Intentional Injury

Even though the media, parents, students, law

enforcement officials, and many other observers

have taken it as axiomatic that school violence

has increased during the past few years, no comprehensive national surveillance system tracks

injuries from intentional violence in the school

environment. Many researchers and analysts

believe that characterizing physical—and to a

lesser extent, verbal and psychological—assaults

is a required step in understanding school violence. The National School Boards Association

estimates that assaults rank at the top of a list of

more than 16,000 violent incidents reported on a

daily basis in school buildings (26). Seventy-eight percent of the more than 2,000 school

districts reporting to the National School Boards

Association survey about violence noted that

they have had problems with student-on-student

assaults during the past year. This response came

from 91 percent of urban districts, 81 percent of

suburban districts, and 69 percent of rural districts.

School-Associated Violent Deaths

Homicide and suicide are ever-present threats for

children of school age. All killings, especially of

children, occurring in school justifiably receive

considerable public attention. Yet the 53

“school-associated violent deaths”17 in 1992

constitute a small fraction of the relative mortality of the school-age population, with the 3,889

homicides and 2,151 suicides occurring outside

of school in children ages 5–19 years (34). Currently, the National School Safety Center

(NSSC) is the only comprehensive source of

information on these incidents in schools, which

it compiles from analysis of newspaper clippings.

17 NSSC and the CDC define “school-associated violent death” as any homicide, suicide, or weapons-related death in the United States in

which the fatal injury occurred on the school grounds, or at or on the way to an official school-sponsored event. 

Preliminary data from a recent Centers for

Disease Control and Prevention (CDC) analysis

of the NSSC data over a two-year period show

that 105 violent deaths occurred on school campuses from 1992 through 1994. Of these, 87 were

homicides, 18 were suicides, and five were ruled

“unintentional” through the legal process (12).

Suicide, the eighth leading cause of death in

the United States, is the third leading cause of

death for young people 10 to 19 years old (38).

Between 1970 and 1984, suicides in this group

rose 55.2 percent. Though school does not

appear to be a prominent site for the commission

of suicide, parents, students, staff, school health

officials, and researchers interviewed by OTA

stated that depression and general emotional

highs and lows are frequently part of the school

and adolescent experience.

Weapon Carrying

After motor vehicle injury-related deaths, firearm-related incidents are the next leading cause

of death for children ages 5–19 years. In 1992,

firearms accounted for 5,262 deaths—about 10

per 10,000 children of school age. Of these,

3,282 were homicides, 1,426 suicides, and 465

were unintentional firearm-related deaths. Moreover, the firearm-related deaths in 1992 account

for 23 percent of all deaths, the second leading

cause of death for school-aged children (table

1-1). Deaths from firearms occur predominantly

in the young adult age group, ages 15 to 19,

accounting for nearly 31 percent of all deaths in

this population. However, less than 1 percent of

these deaths occur from shootings in school.

Estimates of the number of weapons in school

vary widely (box 1-A). According to the National

School Boards Association and the Center to

Prevent Handgun Violence, anywhere from

100,000 to 135,000 guns are brought into schools

every day (4, 26). In Cleveland, 22 percent of

boys in a sample of 5th, 7th, and 9th graders

reported owning a gun to protect themselves
Chapter 1 Summary | 15

from threats and insults (31). New York City

school security officials told OTA that they had

confiscated 65 guns from students on school

grounds barely four months into the 1993–94

academic school year (35). The State of Florida

has admitted similar problems, with a 61 percent

increase in handguns between the 1986–87 and

1987–88 school years (4).

With recent shootings in many urban, rural,

and suburban communities, concerns about

weapons in schools will probably remain a top

priority for local school boards. A number of

shootings have drawn attention to the problem of

guns in school, but it is important to note that

knives and razors are the weapons most likely to

be found on students in the schools sampled by

the Youth Risk Behavior Surveillance System

(YRBS) (13). Findings from the CDC also identify a fundamental fact related to the demography

of violence in schools: access to weapons and

assaults occurs across a spectrum of social

groups and in many geographic areas. It is not

confined to particular social groups or urban

schools.

BOX 1-A: Weapons Confiscated on School Campuses

Weapons possession is tracked differently in school systems that keep such statistics. This area is rife

with definitional problems, because many school districts report incidents but not necessarily the type of

weapon involved. It is often impossible to discern from local school board incident reports whether a gun,

knife, club, or other weapon precipitated disciplinary action against a student.

Characterization of the seriousness of weapons in schools, however, varies from location to location.

In some areas, such as South Carolina, the Department of Education reported that possession of weapons was the most frequently occurring offense. For other school districts, including New York City, Los

Angeles Unified, and most Connecticut districts, weapons offenses—although not the number one

offense—rank high on school crime lists, preceded by vandalism, assault, harassment, larceny, and burglary, many of which involved weapons possession as a secondary offense.

The difficulty in tracking weapons possession in schools stems primarily from the fact that many

school districts report the most serious offense as the primary incident. Therefore, weapons are ignored

as a secondary offense and consequently are not often reported in school incident data. In South Carolina, for example, from June 1992 through May 1993, weapons possession as the most serious offense

accounted for 21 percent (626 incidents) of all incidents. However, the total number of incidents involving

weapons was 36 percent (1,055) of all school incidents reported in South Carolina during the 1992–93

school year. Other schools districts, such as Los Angeles Unified School District, further classify weapons

incidents to distinguish between assaults and possessions and also to determine at what level (whether

elementary, junior high school, or senior high school) such incidents are occurring. Still, the newness of

mandatory school crime reporting legislation in South Carolina and other areas means that good baselines are in the process of being created to measure trends in these offenses and incidents.

Although the diversity in mechanisms and definitions used to collect statistics on weapons possession

has made it impossible to generalize trends outside a given school district or state, most school districts

reporting to OTA stressed that knives and other sharp objects, such as “box cutters,” are the most commonly employed or confiscated weapons. Perhaps this is due to the accessibility and low cost of knives.

In the 1992–93 school year, South Carolina’s Department of Education reported that approximately 42

percent of weapons incidents involved knives or sharp objects. Handguns and other firearms are usually

the second most popular choice of weapons among students in California, Connecticut, and New York,

where more comprehensive statistics have been kept.

SOURCE: Office of Technology Assessment, 1995.
16 | Risks to Students in School

Physical Fighting

Data on the prevalence and severity of physical

fighting among school-aged youth have emerged

from recent national and local surveys. A 1990

questionnaire from the YRBS18 at the CDC (13)

asked students, “During the past 30 days, how

many times have you been in a physical fight in

which you were injured and had to be treated by

a doctor or nurse?” Approximately 8 percent of

those students reported having been in at least

one fight in which they were injured and required

medical attention during the previous month.

Among students who fought, 53 percent indicated that they had fought one time, while 28

percent of respondents indicated that they had

fought two or three times, and 10 percent stated

that they fought at least four times.

The preponderance of research about physical

fighting has revealed gangs as a leading factor in

interpersonal violence in some schools (3,11).

According to the northern California-based Center for Safe Schools and Communities, “youth

gangs of all races have increased by 200 percent

in the last five years and female gangs now represent 10 percent of all gang groups in the

nation” (5).

SCHOOL ILLNESS

In 1992, school-aged children missed approximately 154 million school days, 285 days for

every 100 students, from illnesses associated

with acute respiratory and digestive conditions

and infectious diseases alone (1). These illnesses

account for about 75 percent of the nearly 175

million lost school days from short-term conditions (both injuries and illness). Although illnesses account for fewer fatalities than injuries in

this age group, three illnesses are among the

leading causes of death: cancers, congenital

anomalies, and heart disease. About 3,130

school-aged children died from these diseases in

1992, but these deaths are not likely to be school

related. The leading causes of death from envi18 The findings covered 11,631 9th through 10th grade students in the 50 states as well as the District of Columbia, Puerto Rico, and the

Virgin Islands.

ronmental hazards and infectious disease include

fatal poisonings, which claimed the lives of 191

children in 1992; the respiratory diseases pneumonia and influenza, which led to 189 deaths;

and infection with the human immunodeficiency

virus (HIV), which contributed to the deaths of

152.

This report splits health hazards leading to illness between environmental hazards and infectious disease hazards. OTA groups these hazards

into four categories, originating from: 1) school

materials, 2) indoor air contaminants, 3) school

location, and 4) infectious diseases. These categories depend most heavily on the source of

exposure, which to a large extent determines the

route of exposure—whether the agent is inhaled,

absorbed through the skin, or ingested—and the

possible health effects (see table 1-5). Such a categorization is useful for removing the focus of

attention away from particular hazards and

toward finding common strategies for preventing

or reducing threats to health from hazards in each

category.

Three types of information are needed to associate an agent found in the school environment

with illness. First, there must be evidence that

exposure to the agent can produce the observed

symptoms. Second, there must be evidence that

the student was exposed to the agent in the

school environment. When these two conditions

are met, there remains the task of showing it was

the in-school exposure and not an exposure elsewhere that caused the disease.

❚ Materials in the School Environment

Some hazardous school materials are intentionally brought to the school environment for use in

the classroom, (e.g., art supplies, chemicals used

in science courses) and for maintenance and

cleaning of the school building and school

grounds (e.g., solvents and pesticides). School

officials and public health professionals have

identified specific school materials that pose
Chapter 1 Summary | 17

health risks to students in school or are perceived

as such by many in the community. The materials covered in this category include lead, pesticides, and other hazards rising from supplies and

materials used in arts, industrial arts, and science

courses. Exposures to high concentrations of

some of these materials can lead to poisoning,

but the effects from long-term exposures are

more varied and less well understood and documented.

Poisoning

Chemicals that are toxic at very low levels are

considered poisons. Exposures to them are often

reported to regional poison control centers, and

those reports are subsequently collected into a

database by the American Association of Poison

Control Centers (AAPCC), the professional organization for regional poison centers. In 1993, the

AAPCC received about 1.75 million reports of

exposure to poison (16), about 55 percent of

which were to children under 5 years of age.

Approximately 260,000 reported exposures

occurred in children ages 5–19, nearly 15 percent

of the total.

About 20,000 exposures occurred in schools,

but some of these were not to school-aged children. The in-school exposures include all exposures, to staff as well as students, and all schools,

including preschools and universities, not just

elementary and secondary schools. The data suggest that relative to households, students in

schools are at less risk from most poison exposures. At most, 7 to 8 percent of exposures to

poison among school-aged children occur in

school. In accordance with that estimate, an analysis of the 1988 National Health Interview Survey determined that about 5 percent of

poisonings occur in school, compared to 80 percent at home (30).

The AAPCC database recorded exposures to

school-aged children to a variety of substances

possibly found in the school environment and

discussed in this report (15,16). Art and craft

materials generated over 4,700 exposures. The

AAPCC system reported more than 7,500 pesticide exposures and 16,000 exposures to selected

TABLE 1-5: Environmental Hazards in School

Nature of Hazard

Type of 

Hazard Source

Route of 

Exposure Possible Effect

Remediation or 

Prevention Strategies

School Materials:

Lead

Pesticides

Cleaners, solvents,

paints

Art supplies

Lab materials

Chemical/

biological

Intentional 

appearance in school 

Result of inadequate 

handling, use, 

storage, labeling

Dermal/oral Exposure at high 

concentrations: 

poisoning, chronic

illness

Proper handling, 

use, storage; 

better education

Indoor Air Quality

Asbestos

Radon

Other air contaminants

Radiation/

chemical/

biological

Unintentional 

appearance in school; 

result of inadequate 

ventilation

Respiratory Chronic lung

disease

Sick building 

syndrome

Redesign; 

maintain heating, 

ventilation, and air 

conditioning

School Location:

Electromagnetic fields

Hazardous waste sites

Noise

Radiation/

chemical/

injury

Siting and location of

school

All Results from lowlevel exposure: 

chronic illness/

loss of hearing

Move school/

prudent avoidance

Infectious Disease Biological Communicable 

pathogens

Respiratory/

oral

Infectious disease Hygiene

SOURCE: Office of Technology Assessment, 1995.
18 | Risks to Students in School

indoor air contaminants in 1992. Presumably, the

school environment should have better supervision of the children and better instruction on the

proper use and handling of these materials than

nonschool environments. However, sporadic

in-school inspections revealed that many instructors and others responsible for handling hazardous material were inadequately trained or that the

schools failed to develop proper care and storage

facilities for these materials. The underlying data

and existing studies suggest the presence of toxic

materials in schools, yet few efforts are made at

determining actual exposures to schoolchildren.

In contrast to the AAPCC data, which

reported only possible poison exposures and not

the resulting health effects, the National Center

for Health Statistics (NCHS) examines hospital

discharge records and conducts household surveys to assess impacts of poisoning and injury.

For poisoning from drugs and other chemical

substances, NCHS estimated that in 1992, poisonings hospitalized about 47,000 school-aged

children, of which 191 died. Data are not kept on

whether these poisonings occurred in school or at

home.

Lead

Lead is recognized by many public health

authorities as the foremost environmental health

hazard to children (41). Even low levels of lead

exposure during preschool years can produce

adverse effects on intelligence and behavior.

Once absorbed into the child’s body, lead can

exert adverse effects that vary according to dose

and age at exposure. While school-aged children

may not be as susceptible as preschoolers to

low-level exposures, higher exposures at any age

can result in lead poisoning, with the major concerns being adverse effects to the nervous system.

Lead exposure from all sources, whether in

the home or the school environment, is cumulative. While it is difficult to rank sources in terms

of their contribution to the overall problem of

childhood lead poisoning, lead-based paint is

considered of premier importance, followed by

leaded gasoline fallout into dust and soil, and

then by lead in drinking water (23).

OTA was not able to identify any studies

that examined the contribution of lead in preschools or schools either to total lead exposure

or to adverse health effects in children. The

only studies uncovered are those monitoring

drinking water or paint lead levels in some facilities in selected areas of the United States. These

studies do not systematically and comprehensively assess the presence of lead in preschools

and schools nationwide, in contrast to the data

available for United States housing. Nor do they

examine lead levels in all media combined—

paint, drinking water, and soil. They focus primarily on drinking water, despite the fact that

this source is not the greatest contributor to the

problem of childhood lead poisoning. Finally,

the preschool environment, where children are at

greater risk because of their age, has been studied

far less than the school environment.

The existing data do not demonstrate that the

level at which students are currently exposed to

lead in classroom or school facilities constitutes

a significant risk in itself. However, given the

limited extent of environmental monitoring of

preschools and schools where lead is likely to

be present, the risks from all sources of lead

exposure warrant further evaluation.

Pesticides

Despite their uses and benefits in schools, pesticides can also pose a public health problem. The

health effects known or suspected to arise from

pesticide exposure are rather well established.

Generally, exposures to high concentrations of

pesticides can result in acute toxicity, but far

more controversial than poisoning is determining

the health effects from chronic exposure to low

doses of pesticides. Existing exposure and toxicity data are insufficient to assess these risks in

schools.

The California Pesticide Illness Surveillance

Program (CAPISP) identifies school exposures

in its reporting system, although it does not

report the amount of exposure. From 1982 to

1991, student exposures represented 0.6 percent
Chapter 1 Summary | 19

of total pesticide exposures (15,700) and 1.2 percent of total nonagricultural exposures (8,594)

reported to CAPISP. During that 10-year period,

the program recorded an average of about 10 students exposed a year, although the numbers

ranged from zero to 40.

OTA could not find evidence that in-school

exposures presented a greater health threat than

exposures outside the school environment for

school-aged children. Most exposures that did

occur in schools were to school staff, who were

often untrained in pesticide handling and application. Those cases in which students became ill

from pesticide exposures resulted almost entirely

from poisonings following inadvertent use, an

accidental spill, or intentional or unintentional

ingestion. Clearly, inadequate data exist on

which to base an assessment of risk from pesticide poisoning.

However, the available data for certain pesticides suggest the potential for adverse health

effects and that children may be more susceptible

to toxicity with certain pesticides than are adults.

Moreover, schools may contribute to the cumulative impact of all the exposures that the student

may receive in his or her daily life. Consequently, the steps taken by state and local agencies to promote either pest control strategies that

reduce pesticide use or the use of pesticide alternatives in schools seem appropriate (box 1-B).

Other School Materials

In addition to lead and pesticides, other potentially toxic materials can be present in the school

environment, in particular, agents used for

school maintenance and as teaching aids in the

classroom. The Center for Safety in the Arts

(CSA), the largest nonprofit clearinghouse on art

safety information (19), has identified toxic

materials used in arts and industrial art classes,

such as lead in ceramic glazes and solvents in

paints. They have also presented information on

possible exposures to potentially toxic material

found in science and other courses in elementary

and secondary schools.

Despite many potentially hazardous chemical

and biological materials, few data demonstrate

that these are making students ill. The sparse data

offer random case reports of mishandled materials, but OTA found few case studies of exposures

and fewer cases of illness. In fact, CSA claims

that most of the reports of illness they receive

come from teachers, who are made ill from long

exposures in school, as well as from frequent

at-home exposures (18).

Ample evidence exists that some of these

materials are health hazards: the presence of metals—lead and mercury—and organic solvents—

trichloroethylene—all present health risks, especially to school-aged children. These materials

cannot be taken lightly or ignored. However,

OTA could not find a substantial database demonstrating school exposures, let alone data on illness arising from them. Too little information is

available to estimate the likelihood that children

become ill following school exposures.

❚ Indoor Air Quality

Indoor air quality considers the thermal environment—temperature, humidity, and air movement—and air contaminants. This report

examines the presence of physical, chemical, and

biological contaminants in schools. Harmful

indoor air hazards include asbestos, which is

present in some building materials; radon, a naturally occurring radioactive gas; combustion

products; various volatile compounds; and noninfectious biological materials.

Indoor Air Quality in School

Beyond the data on asbestos and radon in schools

discussed below, there are no national surveys of

indoor air quality (IAQ) in schools. Some state

indoor air quality programs exist, however. To

provide some information about IAQ problems

in schools across the nation, OTA reviewed

requests made to the National Institute for Occupational Safety and Health by school teachers

and staff for Health Hazard Evaluations (HHEs).

OTA analyzed the requests for investigations in

26 schools, to provide a picture of the current

nature of school IAQ problems. The health complaints suffered in these schools—neurological
20 | Risks to Students in School

effects, headaches, fatigue, dizziness, and throat

and eye irritations—reflect the subjective and

rather nonspecific nature of the health effects

resulting from IAQ problems, including “sick

building syndrome” (SBS). SBS is used to

describe situations in which adverse, often general and nonspecific, health effects are associated

with a building, but the exact cause is unknown.

Specific Indoor Air Contaminants

Although many possible air contaminants may

exist in the school environment, OTA considers

asbestos, radon, environmental tobacco smoke,

volatile organic compounds, combustion byproducts, and biologic organisms as agents worthy of

special attention in IAQ issues. These are not the

only agents in indoor air associated with health

effects, but they are among the best studied and

of most concern. Although some information

exists about the presence of these agents in

schools, there is little direct evidence linking

in-school exposures to the diseases discussed.

Instead, information is primarily from studies in

highly exposed occupational populations—insulation workers for asbestos risks, miners for

radon risks, etc.—studies of other nonstudent

populations, and animal studies.

Asbestos

About 31,000 primary and secondary schools in

the United States have asbestos-containing building materials in some form: insulation and fire

protection in heating plants and distribution

systems, sprayed-on material for structural fire

BOX 1-B: Integrated Pest Management in School

Rather than using conventional pesticides to kill pests after they have become a problem, integrated

pest management (IPM) approaches the pest problem from a different angle, emphasizing prevention

and reduction of the source of the pest problems rather than trying to get rid of all of the pests at once.

Comprehensive information regarding the lifecycles of the pests and their interactions with the environment, such as food and habitat, are used instead of relying solely on chemical-based pesticides to eradicate the problem. Through preventative measures, such as education of janitorial staff and improved

janitorial practices, landscaping, occupant education, and staff training, IPM creates inhospitable environments for the pests by removing basic needs like food, moisture, and shelter. This use of natural controls can minimize the use of pesticides, therefore reducing possible hazards to people, property, and the

environment. The IPM programs do not completely eliminate the use of pesticides, but these measures

can help to reduce the amounts used and the exposure to them.

Most school districts do not require that IPM programs be adopted. However, many school districts

across the country, including Eugene, Oregon; Conroe, Texas; Dade County, Florida; Montgomery

County, Maryland; Cleveland Heights, Ohio; and elsewhere, have voluntarily integrated IPM programs

into their pest control management.

Evaluating the costs is almost always a concern when initiating a new program such as an IPM program. IPM programs reduce pesticide use, thereby reducing possible health problems (potential liability)

and costs (materials). Long-term reductions in the purchase of pesticides can offset the initial one-time

expenses, including structural and grounds modification. Labor costs, however, usually are higher for

IPM programs than they are for conventional pest control programs.

Setting up an effective IPM program will take time, money, and the support of all of the participants,

including faculty, students, and staff. IPM programs are proving to be a viable alternative to conventional

pesticide programs in the California cities of Los Angeles and San Diego.

SOURCES: Dade County Public Schools, Department of Safety, Environment and Hazards Management, Integrated Pest Management Procedures, September 12, 1994. Northwest Coalition for Alternatives to Pesticides, “A Better Way: Integrated Pest Management (IPM),” Getting Pesticides Out of Schools, 8–13. U.S. Environmental Protection Agency, Pest Control in the School

Environment: Adopting Integrated Pest Management, EPA 735-F-93-012, August 1993.
Chapter 1 Summary | 21

protection, asbestos-containing tiles, and asbestos-containing plasters, where the asbestos contributes to sound dampening as well as fire

resistance (10).

For all of its useful properties, asbestos has a

definite downside. Exposures to asbestos are

associated with increased occurrence of mesotheliomas (cancers of the lining of the chest or

abdomen), but the type of asbestos most commonly used in buildings—chrysotile—is generally considered to present less of a cancer risk

than other types. Also most lung cancer cases

among asbestos workers occur in smokers; the

risks for nonsmokers are much less. Finally, cancer risk decreases with reduced exposures (10).

Following their measurements of asbestos

levels in schools, Mossman et al. (20) and Corn

et al. (6) calculated the risk of lung cancer and

mesotheliomas from measured concentrations

of asbestos in schools in the absence of any

abatement. The calculated lifetime risks from

exposures to asbestos levels of 0.00017 to

0.00024 f/m3 over a period of five to six years

range from 0.3 to 6.5 cancers per million people.

This is equivalent to about two to 60 lung cancers per year, out of the entire school population

of 46.4 million students.

There is a long lag (usually 20, 30, or more

years) between the first recorded occupational

exposures to asbestos and increases in asbestos-related cancers. It must be assumed that any

cancers that might result from in-school exposures would occur after a similar lag. As sources

of asbestos decline nationwide, any in-school

exposure might be a child’s only contact with the

material.

Radon

Radon is a naturally occurring radioactive element that can move from soil and rocks into air

and water, and through air and water into homes

and other buildings. Radon is concentrated inside

buildings because structures retard its dilution

into the enormous volume of outside air; thus,

“environmental exposures to radon” refers to

exposures inside buildings.

The Environmental Protection Agency and the

Department of Health and Human Services (44)

as well as several independent scientists (17,27)

have calculated that environmental exposures to

radon are associated with about 13,000 to 15,000

lung cancer deaths annually in the United States.

That risk, based on studies of underground miners who were exposed to radon in the course of

their work, is the largest cancer risk that the

Environmental Protection Agency associates

with any environmental exposure (38). If there

are any deaths due to exposure as children, these

deaths will be decades in the future and mostly

among smokers, who are at a much greater risk

of getting lung cancer following radon exposure.

EPA has established 4 pCi/L as an “action level”

(38), and it recommends that actions be taken to

reduce any inside radon concentration above that

level.

In its National School Radon Survey: Report

to Congress, EPA made short-term radon

“screening measurements” in 927 public schools

over seven-day periods during February and

March 1991, and long-term radon measurements

in 100 schools over the period December 1990 to

May 1991. The short-term screening measurements indicate that 2.7 percent (± 0.5 percent,

not shown on table) of the tested school rooms

had radon at concentrations > 4 pCi/L. The percentage of rooms at concentrations > 4 pCi/L as

determined by the long-term measurements was

1.5 percent (± 1.2 percent).

On average, schools have slightly lower radon

concentrations than homes: about 0.8 pCi/L in

schools versus 1.25 pCi/L for the average home.

Thus, on average, a student faces about equal or

slightly lower risk from radon spending the same

amount of time in school than at home. By

assuming that students will be exposed to the

average in-school radon levels for the 12 years of

school, it is possible to estimate the numbers of

future lung cancer deaths per year due to exposure while in school. This ignores the differences

in the distribution of radon among schools in various parts of the country. A one-year exposure to

the average in-school level of radon results in 64

cancer deaths, with about half of the total risk
22 | Risks to Students in School

borne by high school students that smoke.19 The

risks estimated for in-school exposures are about

10 percent of the risks for school-aged children

from residential radon, due to both the slightly

lower radon concentration and the considerably

lower amount of time spent in school. These

deaths are in addition to the 15,000 lung cancer

deaths EPA estimates for residential exposures

each year in the United States and the 3,000

deaths associated with outdoor exposures.

Only in what appear to be exceptional circumstances do in-school exposures make significant

contributions to lifelong radon exposures, which,

at certain levels, are unavoidable. In contrast to

asbestos, exposure to radon will likely occur

throughout a child’s lifetime.

Other Air Contaminants

The presence of other air contaminants poses

possible hazards in schools. OTA examined the

available illness, exposure, and health effects

data for environmental tobacco smoke, volatile

(and semivolatile) organic compounds, combustion products, and biological contaminants. In

each category, ample health effects data suggest

that exposure to particular agents can lead to

adverse health effects, especially in school-aged

children. Nevertheless, little evidence exists to

demonstrate that school children are being

exposed to dangerous levels of agents. The available data come from case studies of a single

school or a few schools with specific problems.

Hence, inadequate data are available to conduct a

quantitative assessment of the health risks in

schools from these indoor air contaminants.

❚ School Location

Parents, teachers, and administrators often

express concern about, and even fear of, hazards

arising from the location of a school. Environmental hazards associated with location can

19 A Centers for Disease Control and Prevention survey indicates that 70 percent of high school students had tried smoking, even one or

two puffs, and 28 percent were considered “current cigarette users,” having smoked one or more cigarettes on one or more of the 30 days preceding the survey (40). For these calculations, OTA assumes that 28 percent of the high school population (grades 9–12) smoke; younger students are assumed to be nonsmokers.

come from the community, such as polluted air

or water, or from placement of the school on or

near hazardous waste sites or close to power

transmission lines. This report discusses some of

the risks associated with those hazards; however,

insufficient data exist to assess their risk quantitatively or even qualitatively.

Electromagnetic field (EMF) exposure is

among the most uncertain of the environmental

risks described in this report. Although concerns

have been raised that prolonged, elevated exposures may place individuals at increased risk,

there is still no consensus among scientists as to

whether power frequency EMF exposure presents a health risk. Those who believe a cancer

risk exists are in general agreement that EMF

does not cause cancer but instead acts as a promoter— that is, a cancer may be more likely to

occur when an individual is exposed. The magnetic field component of power frequency

EMF—which is generally unperturbed by buildings and walls, and penetrates the human body—

is the typical focus of such concerns.

Electromagnetic fields are ubiquitous in the

home and school. Each of these environments is

replete with opportunities for exposure. Power

frequency EMF exposure may come from

sources inside buildings, such as electrical

devices and wiring, or outside sources, such as

transmission or distribution lines. A child’s

exposure, whether in the home or the school, varies greatly: it depends on the number of sources,

their intensity and configuration, their proximity

to the child, and the amount of time he or she

spends in their presence. The impact of exposures at school and the school’s contribution to a

child’s overall exposure are almost impossible to

predict, even if the sources within both the

school and the home are well characterized.

Much depends on the child’s dose, and no one

knows exactly what measure of dose is most
Chapter 1 Summary | 23

informative or how variations in dose might

affect the response to the exposure.

Knowledge of power frequency EMF exposure at school comes from a limited number of

studies. We do know whether levels at some

schools equal or exceed those associated with

increased incidence of certain forms of cancer in

some residential studies. However, these residential studies of cancer address prolonged exposures (more than 12 hours per day), and their

results may or may not be applicable to school

exposures of equal magnitude. We also know

that transmission lines are just one of many

sources of exposure and not necessarily the most

important source. So much of the school research

has been driven by public concerns about transmission lines that other sources of exposure, particularly sources inside the school, have been

neglected. Finally, we know that EMF levels

vary from one school to another, vary among

locations within a school, and vary over time at

any one location. Additional research is needed

to better characterize school EMF exposures and

exposure sources so that more informed decisions can be made as our knowledge of health

effects improves.

❚ Infectious Disease

Infectious diseases are spread mostly by student

to student contact in the course of a normal

school day, and inadequate ventilation or overcrowding in schools may contribute to the spread

of diseases for which the airborne route is a factor. Infectious conditions represent a substantial

cause of morbidity and mortality in school-aged

children. On top of that, researchers and public

health officials are raising additional concerns

about infectious diseases as new infectious

problems continue to occur, such as human

immunodeficiency virus (HIV) infection and

streptococcal toxic shock syndrome, and new

infectious disease challenges, such as the

emergence of drug-resistant bacteria and mycobacteria.

Substantial data are available from a variety of

sources on many of the infectious conditions that

occur in school-aged children. Sources of data

include national surveys, disease-specific surveillance, focused epidemiologic and laboratory

research, and national or hospital-based databases. Nevertheless, the source of an infectious

disease is typically not known; thus, there are no

data on infectious disease from the school environment. This section presents the available data

on infectious disease in school-aged children

regardless of origin, from the results of a national

household survey and cases of notifiable diseases.

The NCHS National Health Interview Survey

(NHIS) is a continuing nationwide survey of

households. The NHIS data of the incidence and

severity of infectious disease in school-aged children are shown in table 1-6. The table shows that

over 82 million acute conditions occurred in

1992 for children 5–17 years old, but does not

represent all of their diseases. The acute conditions presented here include infective and parasitic diseases, such as common childhood

diseases (e.g., measles), respiratory conditions,

such as influenza, and acute ear infections. These

infectious diseases were responsible for 81

percent of the lost school days from all acute

conditions, which include injuries and digestive

system complaints.

The NHIS results can give an indication of the

health impact of a particular condition. Respiratory diseases account for the greatest number of

acute conditions, influenza being the most prevalent. Accordingly, more school days are lost

from respiratory conditions; common childhood

diseases account for the largest numbers of lost

school days per condition.

Data on the reported occurrence of notifiable

diseases are collected and compiled by the Centers for Disease Control and Prevention from

reports to the National Notifiable Diseases Surveillance System, which has morbidity information for 49 currently notifiable conditions, for

which notification to public health authorities by

the attending physician is mandatory. Many

common diseases do not require reporting.

According to the reported cases of infectious

disease in the United States for school-aged chil-
24 | Risks to Students in School

dren, ages 5–19, gonorrhea was the most

reported disease in 1992, with over 151,000

cases. This was about four times greater than the

second most numerous category, chickenpox,

with over 37,000 cases. Hepatitis A had 7,565

cases, and two diseases arising from contaminated food and water are the next most numerous

cases: salmonellosis with 5,943 cases and

shigellosis with 5,193. Finally, authorities

reported 4,060 cases of syphilis and 2,970 cases

of aseptic meningitis.

The school environment may put students at a

greater risk than other environments for catching

many infectious diseases. However, this remains

a speculative determination since the school’s

contribution to disease is rarely determined. Nevertheless, the school environment would appear

to be an incubator for many diseases. Respiratory

infections, in particular, can spread from student

to student during interactions in crowded classrooms. Two of these, pneumonia and influenza,

led to the deaths of about 190 school-aged children in 1992.

In that same year, infection with the human

immunodeficiency virus (HIV) contributed to the

deaths of about 150; while its transmission may

occur in schools, the data are inadequate to estimate the importance of school contacts, although

about half of fatalities are in the pre-adolescent

population (5 to 9), which suggests these deaths

are not attributable to school contact.

In box 1-C, OTA presents those disease categories that warrant more attention than others

based on their implications for schoolchildren

and public health. Based on those categories,

OTA examined the available information on illnesses of school-aged children from these specific diseases: meningococcal infections, viral

respiratory infections, Group A streptococcal

infections, Hepatitis B and human immunodeficiency virus infections, and food poisoning.

Infectious diseases are among the best understood and documented causes of disease in

TABLE 1-6: Number of Acute Conditions and School-Loss Days in 

Youths 5–17 Years of Age from the National Health Interview Survey, 1992

Acute conditions School loss days

Type of Acute Condition

Number

(in thousands)

Rate

(per 100 youths)

Number

(in thousands)

Rate

(per 100 youths)

School loss days/

condition

All acute conditions 112,340 239.9 164,797 351.9 1.47

Infective and parasitic 

diseases

21,155 45.2 40,751 87.0 1.92

Common childhood 

diseases

2,399 5.1 12,225 26.1 5.12

Intestinal virus, unspecified 5,122 10.9 6,312 13.5 1.23

Viral infections, unspecified 5,826 12.4 7,910 16.9 1.36

Other 7,808 16.7 14,303 30.5 1.83

Respiratory conditions 55,783 119.1 85,509 182.6 1.53

Common cold 16,562 35.4 21,978 46.9 1.32

Other acute upper 

respiratory infections

8,303 17.7 13,321 28.4 1.60

Influenza 27,653 59.1 43,532 93.0 1.57

Acute bronchitis 1,922 4.1 3,517 *7.5 1.83

Pneumonia 584 *1.2 2,001 *4.3 3.58

Other respiratory conditions 758 *1.6 1,160 *2.5 1.56

Acute ear infections 5,424 11.6 7,149 15.3 1.32

SOURCE: Benson, V. and Marano, M.A. Current estimates from the National Interview Survey, National Center for Health Statistics, Vital Health

Stat, 10 (189), 1994.
Chapter 1 Summary | 25

BOX 1-C: Diseases of Concern to School-Aged Children

Based on interviews with infectious disease experts, the Office of Technology Assessment (OTA) considers the following disease categories as warranting more attention than others based on their implications for schoolchildren and public health.

1. Diseases with high incidence: Diseases such as respiratory viral infections, especially influenza,

are noteworthy because they occur so commonly. Other diseases of high incidence in schools include

common childhood diseases and conditions such as head lice, conjunctivitis, strep throat, otitis media

(ear infection), and mononucleosis. These conditions inflict costs not only on the child in terms of lost

school days but also indirect costs due to parents’ lost time from work.

2. Diseases of high severity: Diseases such as pneumonia, AIDS, and meningococcal infections

(meningitis and bloodstream infections) that are not common but have a high case fatality rate (CFR) in

school-aged children are a significant public health problem. CFRs refer to the deaths attributable to a

specific condition in relationship to the reported cases of the condition. Bacterial meningitis used to have

a fatality rate of more than 50 percent, but more treatment has reduced the rate to 10 percent.

3. Diseases with a major impact on the public health systems: Diseases that occur in outbreaks in

schools may deplete public health resources in an affected community. Such impacts may include investigation and intervention in foodborne disease outbreaks or mass immunization campaigns for meningococcal disease clusters.

4. Diseases that spread from school children to families and the community: Schools may act as

an “incubator” for certain diseases that then spread to families and the community. Influenza and group A

streptococcal infections are rarely severe in children but may cause substantial morbidity and mortality in

infected family members, especially the elderly. The spread of antibiotic-resistant bacterial infections

initially within childcare settings and subsequently into the community is another example of such a

problem.

5. Diseases that are becoming increasingly common (“emerging infections”): Many microbiological agents can adapt and even mutate in response to their environment. Often these adaptations can

result in organisms that can proliferate where they could not before, or previously harmless organisms

that can become disease-producing agents. These changes can create new infectious diseases (HIV

infection and group A streptococcal toxic-shock syndrome), new problems associated with well-recognized infections (drug resistance in bacteria and tuberculosis), and changes in the epidemiology of infectious disease (clusters of cases of rheumatic fever). Infectious disease in the school environment is an

important focus for studying these emerging diseases because it provides an opportunity for surveillance, research, and the development of preventive interventions.

6. Diseases that offer substantial opportunity for prevention in schools: This category includes

diseases such as meningococcal infections and influenza, for which effective vaccines already exist, and

efforts are focused on determining the most cost-effective approach for immunization; respiratory syncytial virus and parainfluenza virus, for which new vaccines are being developed that may offer the opportunity for prevention; foodborne illness, where application of proper food handling practices can eliminate

outbreaks; and diseases such as hepatitis B and HIV infection, where schools provide a focus for education on risk factors for illness and on prevention through behavior modification.

SOURCE: Office of Technology Assessment, 1995.
26 | Risks to Students in School

school-aged children. The transmission of disease through social interaction and the often

crowded conditions at school suggest that

schools are a primary incubator for the growth

and spread of infectious organisms; however,

OTA could find little national data linking illness

specifically to the school environment. Although

case studies document the outbreaks of disease

and disease clusters emanating from schools,

more information is needed on the role of

schools as a source for the spread of infectious

and foodborne disease.

USING THE DATA

Chapters 3 and 4 of this report are compilations

of information about health and safety risks in

schools. However, decisions on whether to deal

with these risks require more than listing the

health and safety data. Decisionmakers likely

will want an understanding not only of the hazard but the perceptions of the hazard, why it

exists, and what it would take to remove it. When

deciding which risks to address first, many people naturally tend to order things by their size or

severity, yet simple point estimates of risk often

do not convey the spectrum of other important

factors. This section briefly reviews several subjective risk attributes that decisionmakers may

want to consider in efforts to compare and rank

diverse in-school risks. In addition, OTA briefly

reviews different types of comparative risk

assessment (CRA), that is, a process for using

risk estimates, such as those presented in this

report, to help set priorities for risk reduction.

❚ Risk Dimensions

Risk attributes, or “dimensions” of risk, can be

grouped into three categories: magnitude of the

risk; social aspects of the hazard; and feasibility,

cost, and other implications of reducing the risk.

Risk magnitude refers to the quantitative estimates of the likelihood of adverse health effects

arising from the hazardous conditions. This category reflects the more conventional notions of

the number of deaths or cases of injury and illness and their severity. There are several common measures for quantifying risk magnitude.

This report used number of incidents and incidence rates as measures of injury or illness in the

school population, and lost school days as a measure of severity. There are also measures of the

individual probability of risk or the risk to the

population. One measure of particular relevance

to this report is in the number of years of life lost,

rather than the numbers of lives lost. The death

of a child is then weighted much more heavily

than that for an elderly adult.

Some reasons for wanting to reduce risks

extend beyond the benefits to health and safety,

but rather relate to the social context of a risk.

Some risks are more worth taking—or bearing—

than others. This difference is largely governed

by the perceived benefits that accompany the

risk. Football, for example, is among the most

hazardous athletic activities—in terms of the

number of injuries—in which high school students participate, yet the perceived benefits of

athletic accomplishment and social recognition

encourage continued participation in it.

Fear can be one of the most significant dimensions of risk, especially in schools, and one that

varies widely across individuals and communities. Contributing to the fear of a hazard is the

extent to which individuals can or cannot control

the risk through personal action. Parents may

fear their child’s in-school exposure to asbestos

or to a student carrying a weapon because they

cannot control it, but they are probably less

afraid of the exposures to most infectious pathogens—even though the bacteria and viruses are

responsible for more lost school days—because

they have more control from antibiotics, vaccines, and rest. The irreversibility of an illness or

injury also adds to the fear associated with a hazard; the more irreversible the effect, such as spinal cord injury or HIV infection, the greater the

fear.

Another factor is the desire to focus attention

on reducing risks where in so doing injustices

can also be redressed and blame for the hazard

can be affixed. Inadvertent release from a nearby

hazardous waste site, or an industry that exposes

schoolchildren to toxic material, generates more
Chapter 1 Summary | 27

public interest than the risks from radon—even

though the risks of the latter are probably

greater—because radon is a natural gas and no

one is to blame for children’s exposure to it.

An especially important consideration now

confronting schools is the cost and feasibility of

reducing the risk of a hazard. Small risks that are

cheap and easy to eliminate may deserve priority

attention, whereas even very large risks may not

emerge as priorities from a thorough risk comparison if reducing them would be technically

infeasible or prohibitively expensive. Metal

detectors, for instance, may provide protection

from firearms in schools, but they are expensive

and school boards must decide if the risks in their

schools justify the costs. The risk of the intervention itself, the dimension of “offsetting or substitution risks,” arises whenever reducing one risk

would create new risks in so doing. For example,

closing the schools to remove asbestos exposes

the children to risks of being out of school.

❚ Comparing and Managing Risks

This course of making decisions about which

risk reduction measures to undertake leads to

suggestions for the use of comparative risk

assessment (CRA). CRA remains a controversial

and mostly untested process. Nevertheless,

efforts at federal, state, and local levels to undertake CRA to establish risk priorities and strategies for reducing them suggest the possible

utility for some of CRA’s methods and social

processes. This section presents some of these

processes and the nature of the information

needed for them.

Much of the discussion of the process for

comparing risks revolves around the distinctions

between the so-called “hard” and “soft” versions

of risk-based priority setting (7). The “hard” version—also referred to as “expert-judgment”—

involves the use of a small group of experts to

develop estimates of the magnitude of various

risks and a ranking of risk reduction opportunities. The “soft” version uses a societal representative group—composed of citizens as well as

experts—that works together to generate a more

“impressionistic” ranking of risk based on many

factors in addition to quantitative estimates of

deaths, illness, and injuries.

The open process that is part of the soft version of CRA helps to inform risk assessors about

public values and the relative importance the

community places on subjective risk attributes

such as fear. By involving the public, a soft CRA

can go beyond probability estimates of risk and

incorporate ethical and political concerns, which

are usually neglected in risk assessments (33).

Comparison and ranking inevitably involve

incorporating these value judgments as well as

the scientific estimates and measurements. The

process helps to educate the public on the scientific and technical issues associated with risk

assessment, and helps to educate everyone

involved—parents, school boards, risk assessors,

and others—about the nature of suspected risks.

After ranking risks, the next step involves

comparisons of risk-control strategies, where

feasible. Setting priorities for risk reduction is

more than simply ranking risks. Setting priorities

means to guide where resources should flow.

The biggest problems may bear little resemblance to the highest priorities for risk reduction.

Decisionmakers are likely to want to incorporate

social, political, and technical factors as well as

economic costs.

The purpose of comparing the wide range

of risks in schools is to help allocate or reallocate resources among the many possible riskreduction options, including the option of no

action on one or more perceived risks. The public

may be delighted to have funds spent more

efficiently, but probably not at a cost of visibly

greater risks to students. To such a combustible,

emotional debate, the need for clear, objective

analyses and straightforward, understandable

information becomes increasingly clear. This

report, then, consists of a first step in this process.
28 | Risks to Students in School

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1. Benson V., and Marano, M.A., Current Estimates from the National Health Interview

Survey, 1992, National Center for Health

Statistics, Vital Health Stat 10 (189), 1994.

2. Boyce, W.T., et al., “Playground Equipment

Injuries in a Large, Urban School District,”

American Journal of Public Health 74:984–

986, 1984.

3. Cantrell, R.P., and Cantrell, M.L., “Countering Gang Violence in American Schools,”

Principal 73(2):6–9, 1993.

4. Center to Prevent Handgun Violence,

Caught in the Crossfire: A Report on Gun

Violence in Our Nation's Schools (Washington, DC: 1990).

5. Center for Safe Schools, Streetwise: A Parent-Community Information Packet Relating to Gangs (Castro Valley, CA: 1992).

6. Corn, M., et al., “Airborne Concentrations of

Asbestos in 71 School Buildings,” Regulatory Toxicology Pharmacology 13:99–114,

1991.

7. Finkel, A., and Golding, D., Worst Things

First? The Debate over Risk-Based National

Environmental Priorities (Washington, DC:

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8. Gallagher, S.S., and Finison, K., “The Incidence of Injuries Among 87,000 Massachusetts Children and Adolescents: Results of

the 1980-81 Statewide Childhood Injury

Prevention Program Surveillance System,”

American Journal of Public Health

74:1340–1347, 1984.

9. Gratz, R.R., and Finison, K., “School Injuries: What We Know, What We Need,”

Pediatric Health Care 6:256–262, 1992.

10. Health Effects Institute—Asbestos Research, Asbestos in Public and Commercial

Buildings: A Literature Review and Synthesis of Current Knowledge (Cambridge, MA:

1991).

11. Hutson, H.R., Anglin, D., and Pratts, M.,

“Adolescents and Children Injured or Killed

in Drive-By Shootings in Los Angeles,” The

New England Journal of Medicine 330:324–

327, 1994.

12. Kachur, S.P., Centers for Disease Control

and Prevention, Atlanta, GA, personal communication, Apr. 10, 1995.

13. Kolbe, L.J., “An Epidemiological Surveillance System to Monitor the Prevalence of

Youth Behaviors that Most Affect Health,”

Health Education 21:44–47, 1990.

14. Lenaway, D.D., et al., “The Epidemiology of

School Related Injuries: New Perspectives,”

American Journal of Preventive Medicine

8(3):193–198, 1992.

15. Litovitz, T.L., et al., “1992 Annual Report of

the American Association of Poison Control

Centers Toxic Exposure Surveillance System,” American Journal of Emergency Medicine 11(5):494–555, 1993.

16. Litovitz, T.L., Clark, L.R., and Soloway,

R.A., “1993 Annual Report of the American

Association of Poison Control Centers Toxic

Exposure Surveillance System,” American

Journal of Emergency Medicine 12(5):546–

584, 1994.

17. Lubin, J.H., et al., Radon and Lung Cancer

Risk: A Joint Analysis of 11 Underground

Miners Studies (Bethesda, MD: National

Institutes of Health, 1994).

18. McCann, M., “Art Hazards,” Goldfrank's

Toxicologic Emergencies, L.R. Goldfrank

(ed.) (Norwalk, CT: Appleton and Lange

Publishers, in press).

19. McCann, M., School Safety Procedures for

Art and Industrial Art Programs (New York,

NY: Center for Safety in the Arts, 1994).

20. Mossmann, B.T., et al., “Asbestos: Scientific

Developments and Implications for Public

Policy,” Science 247:294–301, 1990.

21. Mueller, F.O., Blyth, C.S., and Cantue, R.C.,

Tenth Annual Report of the National Center

for Catastrophic Sports Injury Research,

Fall 1982-Spring 1992 (Chapel Hill, NC:

University of North Carolina, 1993).

22. National Federation of State High School

Associations, Summary 1993–1994 Athletics

Participation Survey (Kansas City, MO:

1994).

23. National Research Council, Transportation

Research Board, Committee to Identify
Chapter 1 Summary | 29

Measures That May Improve the Safety of

School Bus Transportation, Improving

School Bus Safety (Washington, DC:

National Academy Press, 1989).

24. National Research Council, Commission on

Behavioral and Social Sciences and Education, National Academy of Sciences, Losing

Generations: Adolescents in High Risk Settings (Washington, DC: National Academy

Press, 1993).

25. National Safety Council, Accident Facts

(Itasca, IL: 1993).

26. National School Board Association, Violence in the Schools: How America's Schoolboards Are Safeguarding Your Children

(Alexandria, VA: 1993).

27. Nazaroff, W.W., and Teichman, K., “Indoor

Radon,” Environmental Science and Technology 34:774–782, 1990.

28. Passmore, D.L., Gallagher, S., and Guyer,

B., “Injuries at School: Epidemiology and

Prevention,” unpublished paper presented at

The Annual Convocation of the New

England Education Research Organization,

Portsmouth, New Hampshire, April 1989.

29. Rivara, F.P., Calonge, N., and Thompson,

R.S., “Population-Based Study of Unintentional Injury Incidence and Impact During

Childhood,” American Journal of Public

Health 79(8):990–994, 1989.

30. Scheidt, P.C., et al., “The Epidemiology of

Nonfatal Injuries among U.S. Children and

Youth,” American Journal of Public Health

85(7):932–938, 1995.

31. Sheley, J.F., Mcgee, Z.T., and Wright, J.D.,

“Gun-Related Violence In and Around

Inner-City Schools,” American Journal of

Diseases of Children 146:677–682, 1994.

32. Sheps, S.B., and Evans, G.D., “Epidemiology of School Injuries: A Two Year Experience in a Municipal Health Department,”

Pediatrics 79:69–75, 1987.

33. Shrader-Frechette, K., Risk and Rationality

(Berkeley, CA: University of California

Press, 1991).

34. Stephens, R., Director, National School

Safety Center, West Lake, CA, fax to Mark

Pedersen, Office of Technology Assessment,

U.S. Congress, Washington, DC, July 11,

1995.

35. Tama, P.J., Division of School Safety, New

York City Board of Education, personal

communication, April 6, 1994.

36. Tinsworth, D.K., and Kramer, J.T., Playground Equipment-Related Injuries and

Deaths (Washington DC: U.S. Consumer

Products Safety Commission, April 1990).

37. Towner, E.M.L., et al., “Measuring Exposure to Injury Risk in Schoolchildren Aged

11–14,” British Medical Journal 308:449-

452, 1994.

38. U.S. Congress, Office of Technology Assessment, Researching Health Risks, OTABBS-570 (Washington, DC: U.S. Government Printing Office, November 1993). 

39. U.S. Department of Education, National

Center for Education Statistics, Office of

Education Research and Improvement,

Digest of Education Services 1993, NCES

93–292 (Washington, DC: 1993).

40. U.S. Department of Health and Human Services, National Center for Health Statistics,

Vital Statistics System, 1995.

41. U.S. Department of Health and Human Services, Public Health Service, Centers For

Disease Control, Preventing Lead Poisoning

in Young Children (Washington, DC: 1991).

42. U.S. Department of Transportation, National

Transportation Safety Board, Summary of

Selected School Bus Crash Statistics in 1990

(Washington, DC: 1993).

43. U.S. Department of Transportation, National

Highway Traffic Safety Administration,

Traffic Safety Facts 1992 (Washington, DC:

September 1993).

44. U.S. Environmental Protection Agency and

U.S. Department of Health and Human Services, A Citizen’s Guide to Radon (2d ed.),

EPA/ANR-464 (Washington, DC: 1992).

45. Zaricznyj, B., et al., “Sports Related Injuries

in School-Aged Children,” American Orthopaedic Society for Sports Medicine 8(5):

318–324, 1980.
| 31

2

Issues in

School Health

and Safety

chools, like all buildings and institutions,

harbor some risks. Some of the illnesses

and injuries in schools stem from preventable or reducible hazards. Nevertheless, compared to other places where children

live and play, schools are often safer environments. This finding must be qualified by the paucity and occasional poor quality of data—or even

the absence of information about some hazards.

Children daily confront a variety of risks, in or

out of school. In 1992, children ages 5 to 17 suffered 13 million injuries and some 55 million

respiratory infections, which contributed to their

missing about 214 million school days, roughly

460 days for every 100 students. Unknown are

the possible long-term health consequences, the

impact of the lost learning opportunities, or the

care-giving problems faced by families.

Averaged over the year, school-aged children

spend about 12 percent of their time in school,

and some portion of these injuries and illnesses

arise in connection with the school environment.

Since government requires school attendance, it

ultimately bears responsibility for children’s

health and safety while they are there. While

local, county, and state governments bear most

responsibility for the operation of schools, the

federal government has taken a role in health and

safety issues, as reflected in the 103d Congress

considering 66 bills that referenced the “school

environment” and 51 that were directed at the

goal of “safe schools.” Congressional concern

led the House Education and Labor and Energy

and Commerce Committees of the 103d Congress to request this report, which examines the

scientific data on the risks for injury and illness

in the school environment.1

Important interactions between the student’s

home life—such as the presence of only a single

parent, poor family dynamics, limited supervision, or poor nutrition—and school-connected

behavior and health and safety problems are

beyond the scope of this report, as are mental

health problems of children and adolescents.

“Behavioral” risks, such as drugs and pregnancies, are high on the public’s list of concerns, but

they are not included in this report. Two OTA

reports, Healthy Children: Investing in the

Future (25) and Adolescent Health (26), provide

broader information about the health of children

1 In the 104th Congress, the House Education and Labor Committee was renamed the Education and Opportunity Committee and the

House Energy and Commerce Committee became the Commerce Committee.

S
32 Risks to Students in School

and adolescents through 18 years of age; this

report is narrowly centered on health and safety

risks to students while in school.

This chapter introduces the issues of school

health and safety. It initially describes the student

population and the school environment. The rest

of the chapter is devoted to introducing concepts

concerning health and safety data: the nature of

the studies generating them, how the data are

collected and interpreted, and the inherent difficulties in obtaining reliable and credible information. It ends by discussing the significance of

risk estimates in deciding which risks need to be

reduced, strategies for reducing them, and to

what levels they should be reduced.

❚ Student Population

The student population covered in this report

spans the ages 5 to 18, which correspond to

grades kindergarten through the 12th grade (see

figure 2-l). According to census figures (31),

over 46 million children were enrolled in the

109,000 elementary (kindergarten-8th grades)

and secondary (9th–12th grades) schools for the

1990 school year, and a projected 50 million will

enroll for the fall of 1995 (see table 2-1A and

1B). Except for the section on lead, the report

does not cover nursery schools and students

below the age of 5, nor does it cover the provision of health care in schools.

High school diploma 17

16 Senior

4-Year High Schools

I

High Schools

15

13

12

11

10

9

8

7

6

(8-4)

Junior

High Schools

Middle

Combined

Junior-Senior

High Schools

Elementary (or Primary) Schools

1

5 Kindergartens

Nursery Schools

Age Grade

SOURCE: U.S. Department of Education, National Center for Education Statistics
Chapter 2 Issues in School Health and Safety | 33

Almost all information concerning schoolbased risks comes from studies and reports

related to public schools. While the data could be

applied to the 5 million children in the 24,690

private schools, this report could not find data

suggesting one way or the other the appropriateness of that application.

One admitted data shortfall is limited knowledge about the particular susceptibilities of

school-aged children, as age is known to be a

major determinant of individual risks for particular illnesses and injuries (1,21). In general, compared to adults, children absorb more of any

substance in the environment because of the

larger ratios of their skin surface and, lung surface area to body weight and their higher metabolic rates. Because of the ongoing growth

processes in children, many injuries, for example

to the head, can have long-term health implications. These differences have implications for the

interpretation of data on school children since

most health studies are conducted on adults, and

children may not be adequately addressed in the

design or analysis of the data.

❚ School Environment

Schools’ primary mission is education; their end

product can be considered an educated individual. Given the importance of education for an

individual’s ultimate happiness and satisfaction

and the documented benefits to society of an

education (34), disruption of the learning process

must be considered an adverse effect. Clearly a

sick or injured student, even if he or she attends

school, is not as prepared to learn as a well student. A student fearful about assault or other violence on the way to and from school or on the

playground is not prepared to learn.

Although the impact of sickness or injury on

learning is difficult to estimate, one measure of

this impact—used in this report—is the number

of school days lost from an injury or illness. Injuries and illnesses resulting in absences from

school may impede the learning process: a comTABLE 2-1A: Enrollment in Educational 

Institutions by Level and Control of 

Institution:

Fall 1990 to Fall 1995 (in thousands)

Level of Instruction and 

Type of Control Fall 1990

Projected

Fall 1995

Elementary and 

secondary educationa 46,448 50,709

Public 41,217 45,049

Private 5,232 5,660

Grades K-8b 33,973 36,668

Public 29,878 32,275

Private 4,095 4,393

Grades 9-12 12,475 14,041

Public 11,338 12,774

Private 1,137 1,267

a Includes enrollments in local public school systems and in most private schools (religiously affiliated and nonsectarian). Excludes subcollegiate departments of institutions of higher education, residential

schools for exceptional children, and federal schools. Excludes preprimary pupils in schools that do not offer first grade or above.

b Includes kindergarten and some nursery school pupils.

SOURCES: U.S. Department of Education, National Center for Education Statistics, Common Core of Data and “Fall Enrollment in Institutions of Higher Education” surveys; Integrated Postsecondary

Education Data System (IPEDS), “Fall Enrollment” surveys; and Projections of Education Statistics to 2004. 

TABLE 2-1B: Public School Districts and 

Public and Private Elementary and 

Secondary Schools: 

1990-91

School Year 1990-1991

Public school district 15,358

Public Schools

Total all schools

Total all regular schools

84,538

81,746

Elementary Schools

Total

One-teacher

61,340

617

Secondary Schools 22,731

Private Schools

Total

Elementary

Secondary

24,690

22,223

8,989

SOURCES: U.S. Department of Education, National Center for Education Statistics, Statistics of State School Systems; Statistics of Public

Elementary and Secondary School Systems; Statistics of Nonpublic

Elementary and Secondary Schools; Private Schools in American

Education; and Common Core of Data surveys.
34 | Risks to Students in School

mittee of pediatricians reviewed the medical and

educational literature and concluded that “children that are frequently or persistently absent

from school tend to perform poorly in school and

are likely to drop out before graduation” (34).

Further, they cited a number of social implications, including maladaptive behavior and future

unemployment and welfare costs, as ramifications of excessive school absence.

School absences stem from many sources, and

injuries and illnesses from the school environment make some unknown contribution to them.

Even though the contribution of the school environment to a student’s health and education has

been discussed for decades (6,12,23), our understanding of it remains limited. Complicating our

understanding is the lack of knowledge of the

environmental, structural, and social hazards

found in schools (22), which is partly manifested

in not knowing which injuries and illnesses originate in schools and which arise elsewhere.

Despite the lack of knowledge of the hazards

in them, schools contribute to student safety by

protecting them from most hazards and instructing them on how to live safely in an often dangerous world. School prevents exposures to

many of the worst risks. A student sitting at a

desk, changing classes in an orderly fashion, and

playing in supervised sports is likely to be safer

than a child in unsupervised play in a neighborhood playground or park. As discussed in Chapter 1, relatively few deaths (less than 1 percent)

occur in schools or school buses from the two

leading causes of death in school-aged children,

motor vehicles and firearms.

Schools also teach the proper use of potentially hazardous equipment, safe conduct on

playgrounds and in athletic activities (like swimming), and respect for others and for dangerous

situations. These skills carry over to the nonschool environment since many of the same

activities occur off the school grounds. In addition, a growing number of organizations offer

school-based programs that teach children the

importance of health, safety, and the environment. One of the most notable examples is the

Enviro-Cops program in the Dade County school

system (see box 2-1). Because of this instruction

and because of constant supervision by responsible adults, schools are often a safer place for children than most nonschool environments. Despite

the concern for school safety, especially school

violence, the overwhelming majority of polled

school board members responded that they

believed schools are still safe places for students

and staff (33).

HEALTH AND SAFETY DATA

Collecting and analyzing data about illnesses and

injuries are the cornerstones of efforts to identify

and control health and safety risks. Although

data and estimations come from different sources

and are collected by different processes, certain

generalities describe the data for the four kinds

of risks that are considered here: unintentional

injury, intentional injury, environmental illness,

and infectious disease. The sources of data are

considered in detail in the appropriate section;

the following briefly discusses the nature of the

data collection and interpretation.

❚ Nature of Data Collection

Data collection constitutes the first, and in many

ways, the most important step in having credible,

usable, and understandable information for making decisions. The kinds of data described in this

report are usually derived from surveys or

reporting systems that specify what sorts of data

to collect. More specific data and, generally,

more information important to the interpretation

of the data are collected through focused studies.

Despite the obvious desirability of more complete information on the hazards facing children

in schools, obstacles to data collection activities

exist. Obstacles can be simple, such as the lack

of resources—money, expertise, or both—or

more complicated, like the fear of being branded

a “problem school.”

Surveillance: Surveys and Reporting Systems

Surveillance is an active process for collecting,

analyzing, and disseminating information on the

occurrence of illness or injury (4). The meth-
Chapter 2 Issues in School Health and Safety | 35

odology for surveillance activities is basically

descriptive. Its functions, however, extend

beyond data gathering, as the information forms

the basis for action by authorities to control or

prevent public health hazards.

Surveillance systems were first developed for

illnesses from infectious diseases and more

recently are becoming established for other

causes of disease and injury. Although disease

surveillance began in the mid-1800s in England

and Wales, in this country the collection of

national morbidity data began in 1878, when

Congress authorized the Public Health Service to

collect reports of the occurrence of quarantined

diseases such as cholera, smallpox, plague, and

yellow fever (4). In 1893, Congress passed an act

stating that weekly health information should be

collected from all state and municipal authorities.

This developed over time into a weekly bulletin:

the Morbidity and Mortality Weekly Report

(MMWR), issued by the Centers for Disease

Control and Prevention (CDC), which was given

responsibility for receiving morbidity reports

from states and cities in 1960. National disease

surveillance programs are maintained by most

countries, and the World Health Organization

(WHO) maintains a global surveillance system

on quarantined and other selected diseases (2).

In establishing its global surveillance system,

the WHO (35) identified 10 distinct sources of

surveillance information. Sources of surveillance

data relevant to this report include mortality and

morbidity data, individual case reports for rare

diseases or unusual cases, and the reports of epidemics for clusters of cases. Surveys, such as

household or population surveys, can provide

information on the prevalence and occurrence of

a disease. Demographic information, such as age,

and environmental information, such as the presence of lead, are also important sources of data.

Surveillance systems are run from central

locations with the objective of monitoring a

region—local or national—for any changes in

the incidence or nature of particular injuries or

illnesses. Surveillance data are often reported by

health providers to health authorities, such as the

state health department. Reporting can be routine

or active for specific cases, but both cases require

a standardized process whereby comparisons can

be made between and across geography or time.

BOX 2-1: Enviro-Cops and Enviro-Mentors

Enviro-Cops/Enviro-Mentors is just one of many successful programs concentrating on making the

world safe for children. The Enviro-Cops and Enviro-Mentors program involves students in projects that

teach them to save energy, recycle, and eat well, as well as personal, home, auto, and bicycle safety.

The Enviro-Cops program starts with second grade students of the Dade County public school system. It

teaches them to be eco-smart while developing their self-esteem and personal safety. More than 225,000

elementary school students have become involved with Enviro-Cops. Many of the Enviro-Cops continue

their involvement in the program and return to become Enviro-Mentors, which is the second half of the

program and consists of high school and college students who volunteer to be role models for the

younger students.

Enviro-Cops take on many issues that affect all of the children of the world. The program incorporates

safety issues, including personal safety (for example, eating good food, avoiding guns (“see a gun, dial

911”), and saying no to drugs and alcohol), traffic safety (such as wearing bicycle helmets and seat belts

and using child seats for younger children), and environmental safety (like confronting issues such as the

use of pesticides, the depletion of the world’s resources, and destruction of the world). Enviro-Cops

actively help reduce waste, recycle, precycle, and reuse. They learn that their actions do make a difference and that they can make the world safe for themselves, their families, their friends, and everyone

else. 

SOURCE: ARISE Foundation, Enviro-Cops Guidebook and Lesson Plans, 1993. ARISE Foundation, A 10-Year Retrospective,

1993.
36 | Risks to Students in School

Data collection forms are distributed to the

reporting units, and the completed forms are usually collected with similar forms, sometimes

analyzed, and sometimes simply stored away.

Some well-established systems, such as the

CDC’s MMWR, are designed to disseminate the

collected information. Other reporting systems

may not disseminate the information as widely

because the system may be designed for purely

local purposes, or because of other reasons, such

as fear of bad publicity. For example, school

nurses file reports for observed injuries and illnesses, but these reports are often not released to

the public. In any case, regardless of the difficulties of establishing and maintaining a survey or

reporting system, these activities must be compatible with other sets of data. Surveys and studies must follow accepted or clearly described

protocols if the results are to be informative and

useful.

Studies

In contrast to the standardization and routine of

surveys or reporting systems, studies can be

designed to investigate a particular outbreak or

situation, and thus require careful attention to

design, execution, and analysis. Studies can be

especially informative because they allow

researchers to account for the complexity of the

school environment and activities by incorporating relevant information from the community,

such as lead being released from a nearby

smelter. That flexibility also increases the complexity of the study. Epidemiological studies provide most of the relevant data in this report.

However, toxicological and human exposure

studies also provide important information for

determining students’ risks.

Epidemiological studies

Epidemiology is the study of the distribution of

disease in human populations and the factors that

influence the distribution of disease. Epidemiological techniques are used to identify causes of

disease and determine associations between disease and risks. There are three basic designs for

such studies: descriptive, experimental, and

observational. This section provides a simple

sketch of the field and defines some terms for the

reader with no background in epidemiology. For

more in-depth discussions, there are many available references, including Hennekens and Buring

(13), Lilienfeld (18), Evans (8), and Brachman

(4).

Descriptive epidemiology studies examine the

patterns of distribution of disease and the extent

of disease in populations in relation to characteristics such as age, gender, race, etc. Sources for

descriptive studies include census data, vital statistics data, and clinical records from hospitals

and private practices. By examining the differences in disease rates over time, descriptive

epidemiology provides clues about disease causation. Descriptive studies can also focus on

comparisons of geographical regions.

Experimental epidemiology studies involve a

deliberate exposure or withholding of a factor

and observing any effect that might appear. In

these studies the investigator controls exposure

to a risk and assigns subjects, usually at random,

to either receive the treatment/risk or a placebo.

The effects on the two groups are compared and

analyzed. Experimental studies are hard to conduct, however, because of the need for a cooperative and eligible group of individuals who will

allow intervention in their lives. Also, ethical

reasons (either withholding a beneficial treatment from some subjects or introducing subjects

to potentially harmful treatments) may make the

study difficult to conduct.

Observational epidemiology studies analyze

data from observations of individuals or relatively small groups of people in order to determine whether or not a statistical association

exists between a factor and disease. Observational studies have two design options: cohort

studies or case-control studies. In either design,

the risk factor under investigation should define

the groups, which otherwise should be comparable.

Cohort studies look forward (prospective),

choosing subjects who are free from the disease

under study, but who differ in respect to the risk

factor under study. The health status of the indi-
Chapter 2 Issues in School Health and Safety | 37

viduals in the study group is observed over time

to determine whether there is an increased risk of

a disease associated with that exposure.

Case-control studies, on the other hand, compare individuals with the disease under study

(cases) with individuals who do not have the disease under study (controls). Risk factors that are

thought to be relevant to the study are compared

between the groups. The extent of exposure to

the risk in the case group is contrasted with the

extent of exposure in the control group. Because

of the presence or absence of the risk factor in

the past, case-control studies are retrospective

studies.

Toxicological Studies

Most often, the information needed to predict

adverse health outcomes from exposure to potentially hazardous chemicals comes from testing

substances in animals or through in vitro tests,

that is, in cells or tissues isolated from animals

and humans. Such toxicological studies allow

scientists to test chemicals and control conditions

that cannot be controlled in most epidemiological studies, such as the amount and conditions of

exposure and the genetic variability of the subjects. Toxicological studies are the only means

available to evaluate the risks of new chemicals.

Biologically, animals, even the rats and mice

typically used in toxicity testing, resemble

humans in many ways. A substantial body of evidence indicates that results from animal studies

can be used to infer hazards to human health

(14,15,16). There are exceptions to this generalization, but each must be proved to be able to set

aside the assumption that animal tests are predictive.

Toxicological disciplines can be distinguished

by the “endpoint” studied, the resulting disease

or the organ affected by exposure to a toxic substance. Increasingly, researchers are studying

subtle endpoints other than cancer, such as

immunotoxicity (27), neurotoxicity (29), reproductive and developmental toxicity, liver and

kidney toxicity, and lung toxicity (28). More

attention is also being devoted to studying the

effects of long-term (chronic) exposures, rather

than the effects of large, short-term (acute) exposures.2

Toxicological studies, however, have limitations. Cost considerations limit most animal

studies to a few hundred test animals, and in

most instances, researchers use high levels of

exposure to increase the likelihood of observing

a statistically significant effect in a relatively

small group of animals. It can also be very difficult to verify any quantitative extrapolation of

the results of animal studies to human effects.

The reader is directed to the many detailed references in toxicology, in particular Klaassen et al.

(17).

Human Exposure Studies

Human exposure studies measure the presence of

an agent in air, soil, or food. The most accurate

information about exposure is based on monitoring the amounts of a substance to which people

are exposed (20). Personal monitoring measures

the actual concentrations of a hazardous substance to which people are exposed by using

devices that individuals wear or by sampling the

food, air, and water they eat, breathe, and drink.

Biological monitoring measures the toxicant or

its metabolite in biological samples such as

blood or urine. Ambient monitoring measures

hazardous substances in air, water, or soil at

fixed locations. That method is often used to provide information about the exposure of large

populations, such as people exposed to air pollution in a region. Often, monitoring data are not

available. As a result, assessors often estimate

exposures to emissions from a distant source like

a factory by using exposure models (20). Exposure models simulate the dispersion of substances in the environment.

2 For excellent reviews and research papers on the various types of toxicological studies on noncancer effects being conducted, see Environmental Health Perspectives, 1993, vol. 100; in particular see Luster and Rosenthal (19); Schwetz and Harris (24); and Fowler (10).
38 | Risks to Students in School

❚ Difficulties with Data Interpretation

Data, however collected, are usually analyzed for

their implications and significance at the local

level. These analyses use the results of an investigation—“raw data”—and place it in context of

the reliability and the strengths, weaknesses, and

limitations of the methods used. Analysts and

decisionmakers are best able to do their work

when they understand the process of measuring

adverse events and the numerical estimates of

risk; the nature of the data; and the problems

inherent in their interpretation. This is particularly true when the data are being used to support

legislation or public health action because of the

likely scrutiny and the resulting commitments of

resources. Besides estimating the likelihood of

injuries and illnesses, analysts and decisionmakers must consider the quality, relevance, and predictive value of the available data.

Data are always limited, and generalizations

and extrapolations are often necessary to interpret and apply the available data. Most often,

gaps in data, knowledge, or both force the use of

assumptions and generalizations in drawing conclusions. Even with sufficient data, however,

interpretation can be fraught with difficulties.

This section describes some of these difficulties

in data interpretation.

Completeness and Generalizability of Data

For some hazards, the only information comes

from limited studies of specific populations. It is

common practice to generalize results from studies of one or a few schools to schools statewide

or even nationally. Two types of generalizations

are commonly made: geographic generalizations use data from one area, such as urban

schools, and generalize to another setting, such

as suburban schools. Conversely, national databases can be used to infer risks to certain schools

or student subpopulations. Similarly, temporal

generalizations apply results from earlier studies

to current circumstances.

All data-reporting systems confront problems

of underreporting, self-reporting, and selection

bias. School injury data, for example, rely almost

entirely on school-based reporting, for which the

common methodological concern is underreporting (11). One study designed to measure the

extent of underreporting found that for every

injury reported, about 4.3 injuries go unreported;

however, most of the injuries that are not

reported are minor (9). Reporting practices may

also vary from school to school. These discrepancies can result in an injury problem being

overlooked at a school or the employment of

inappropriate remediation measures.

Most of what is known about the risk of

intentional injury in schools is derived from voluntary, school-based surveys of particular behaviors, such as physical fighting and willingness to

carry a weapon, or particular injuries or illnesses.

Frequently, however, response rates are poor,

and students do not report honestly. Administrators and school officials from major districts do

not always respond to national surveys.

Health questionnaires are often given to

patients or family members who must rely on

their memory of the illness to describe symptoms. Such self-reporting involves subjective and

selective recall about exposures and health

effects (18). The National Health Interview Survey relies on parental recall of their children’s

illnesses. To overcome the problems of faulty

recall, they return to the family every other week

(3). This requires the careful analyst to look for

additional evidence or supporting examples

before drawing conclusions.

Even accounting for underreporting and selfreporting, analysts of injury and illness data must

determine the extent to which the study can be

representative of the larger population or only a

narrow segment of it. Even well-designed studies

can fall victim to what is termed “selection” bias,

where an association is thought to exist but is in

reality an artifact of the population being studied.

In the case of schools, the finding of illness in

certain schools may reflect underlying difficulties of a particular school or small group of

schools—not schools at large. For example, a

survey of schools with indoor air quality problems is not representative of air quality in

schools generally but represents “problem
Chapter 2 Issues in School Health and Safety | 39

schools,” which suffer from actual or perceived

elevated indoor air contaminants or other indoor

air quality problems.

Uncertainty and Variability

Estimates of the health risks are both uncertain

and variable. Uncertainty means that we do not

yet know the true risk; uncertainty can be

reduced through additional data or research. For

example, uncertainty exists in estimates of injuries on school playgrounds because of underreporting. Variability, in contrast, means that the

risk differs considerably from school to school or

person to person; variability cannot be reduced,

only better understood. Variability appears in

estimates of the likelihood that any single

smoker will develop lung cancer: some do, and

some do not, based on a variety of individual factors that include age and genetics but may

include other factors that are not now recognized.

Extrapolation

Extrapolation is most often seen as a problem in

environmental health studies. The use of animal

data requires extrapolating from animal results to

human projections, and from very high exposures to low exposures. When human data are

available, they are usually from studies of high

levels of exposure, mostly in occupational settings. Analysts then have to extrapolate from the

effects of high-level exposures to mostly healthy,

working-age men in order to predict effects in

young people of varying health characteristics in

the school environment. The most prominent

occupational-to-school risk extrapolations found

in this study are those for lung cancers arising

from asbestos or radon exposures. The data come

from high-level occupational exposures of populations of men that included many smokers.

Extrapolations are not limited to the environmental health arena. For example, there are no

school transportation injury data; thus, injury

data reported for school-aged school bus occupants, pedestrians, and bicyclists are assumed to

represent students on their way to and from

school.

❚ MOTIVATIONS FOR DATA COLLECTION 

AND ANALYSIS

A fundamental problem for everyone concerned

about risks in schools is whether the available

information is good enough to help make the

decision to accept a risk or expend resources trying to reduce it. It is impossible to collect all the

data that might be useful. Instead, analysis of the

available data and careful thought about what

kinds of data might alter an already-made or

pending decision can guide the decision on what

additional data to collect.

The surveys and studies that generate health

and safety data are usually quite expensive and

time-consuming and require considerable expertise to conduct. Decisions to expend those

resources can be made for one or more specific

reasons, and knowledge of the reasons can help

in understanding how the surveys and studies

were designed and by whom and the principle

objectives of the research. These reasons can

include legal requirements (e.g., federal, state, or

local reporting laws), litigation, investigations of

“rashes” or “outbreaks” of injuries or illnesses,

or fear of adverse health effects. These motivations sometimes impugn the credibility of

researchers, reducing the usefulness of their

results.

Mandates

The most potent motivations for collecting health

and safety data are laws that mandate reporting

of various kinds. Illnesses and the potential for

exposures to environmental toxics are subject to

more mandated reporting requirements in

schools than are injuries. On the federal level, the

Federal Bureau of Investigation (FBI) requires

reporting of homicides and suicides, but not in

such a way that permits identification of those

that occur in schools. Three agencies collect

intentional school injury data for national surveys, but there are no mandated nationally

reporting systems.

Some federal laws require either the reporting

of illnesses and the potential for exposures or the

identification of hazards. The Asbestos School
40 | Risks to Students in School

Hazard Abatement Act of 1985 and its 1990

reauthorization (ASHAA) require schools to

inspect for asbestos. Both the Superfund Amendments and Reauthorization Act of 1986 and the

Indoor Radon Abatement Act of 1988 directed

the U.S. Environmental Protection Agency (EPA)

to conduct surveys of radon concentrations in

schools (as well as other buildings), and the

school survey results were reported to Congress

in 1993 (32). School are encouraged but not

required, under the 1988 Lead Contamination

Control Act, to test their drinking water and meet

a recommended lead level.

Some states also have reporting requirements.

Three—Hawaii, South Carolina, and Utah—

have voluntary school injury reporting. Some

states require reporting of school crimes, including those involving intentional injuries; the

South Carolina legislature was the first to pass

such legislation. Other state laws and initiatives

trigger investigations or surveillance of environmental illness. California and Washington

require the reporting of pesticide illness, including school exposures. South Carolina requires

lead testing in day care facilities and foster

homes as a condition of licensure. The New York

City board of education monitors the physical

appearance of all school buildings on an ongoing

basis and presents its findings about such hazards

as lead paint chips on an annual basis.

Fear and Litigation

Fear and concern can also motivate data collection, resulting in an ebb and flow over time.

Urban violence has resulted in increased interest

in weapons carrying, not only in big cities but in

smaller communities as well. If concern about

that wanes, fewer studies of weapons carrying

can be expected. The installation of resilient pads

covering the ground of some New York City

playgrounds dramatically decreased injuries

from falls, reducing the motivation for continued

surveillance of such injuries. To a major extent,

public perceptions of risk provide the motivation

for data collection and studies, and that motivation is transmitted through legislation, legal

actions, and public pressure.

Data collections and investigations are also

performed in anticipation of possible litigation

and as a response to pending litigation. Litigation

against schools is increasing, particularly negligence cases (11). As a defensive measure, some

schools attempt to keep records of injuries occurring on school grounds. However, unless there is

an actual suit, these records are rarely tallied and

analyzed, and thus are of no value in estimating

injury risks. Lawsuits against schools for environmental exposures have led to the gathering of

exposure data. A lawsuit filed against the state of

Texas required various investigators to assess the

presence and concentration of asbestos in the

state schools (7). A lawsuit by a teachers’ union

forced California to investigate EMF exposures

(5). Because large sums of money are often

involved in litigation, researchers can obtain

research funds to conduct studies they otherwise

could not afford. However, they must maintain

strict independence and follow scientific protocols to avoid perceptions of biased research,

which damage the credibility of the results.

Credibility of Researchers, 

Bias, and Fraud

Researchers and investigators who collect health

and safety data and conduct studies about risks

can come to their tasks with or without vested

interests. People who depend on those data and

who disagree with them can accuse the researchers of bias or fraud, even if there is little evidence

for the charges. The media can report those

charges, giving them credibility, without any

independent investigation.

Consider the situation when stakeholders in

arguments about risk generate some of the data

necessary for decisionmaking. They are tarred

with bias no matter how honestly they do their

work. On one side of the ideological spectrum,

investigators may believe a particular agent or

environment, such as a school setting, is responsible for adverse health effects and gather data to

show an association between exposure and

effect, with the objective of forcing government

action or winning a lawsuit. On the other side,

studies conducted or supported by manufacturers
Chapter 2 Issues in School Health and Safety | 41

of a substance under suspicion or those responsible for releasing it into the environment, or by a

school district that wants to avoid paying for risk

removal, may be viewed skeptically, especially if

they fail to show an association between exposure and illness.

Bias or prejudice can be knowing or unknowing, overt or covert, and it can be readily apparent or hidden from all but the most astute

observer. Moreover, neither bias nor prejudice

may play a role in data collection or study, but

either one can be cited as a criticism by participants in a controversy who do not agree with the

study results. The conventions of both science,

which include publication of results and making

data available to other researchers, and democracy, which include discussion, public accountability, and involvement of concerned parties,

will not necessarily erase unwarranted charges or

validate accurate ones. Nevertheless, they are the

most effective tools for ensuring that data are as

accurate as possible, that the methods used to

collect the data are appropriate, and that the presentation of results is as free from bias as possible.

THE SIGNIFICANCE OF RISKS AND 

ESTIMATES

This study is intended to inform decisionmakers

about the available information and its sources,

and to provide some evaluation of the quality of

that information. Deciding what to do, if anything, about any of these risks involves consideration of many more factors than are covered

here—including fairness, public fears, cost, and

feasibility of controlling the risk.

The results of available risk estimates can be

compared against certain thresholds or standards

as indicators of their significance. In discussions

with experts and administrators who contributed

data and information to this report, four general

kinds of comparisons emerged: baselines, endpoints, school vs. nonschool risks, and risk

thresholds.

❚ Baselines

Baseline values are the normal background rates

of the injuries or illnesses against which the risk

from a particular hazard can be compared.

Whether in comparing different risks or evaluating various policy options, baseline values are

used as the expected numbers of illnesses and

injuries. Officials use baselines to identify hazards by recording increased incidence or monitoring certain trends to see whether the measured

rates are above or below the levels expected in a

population. There are few established baselines,

but the ones that exist are widely applied.

Increases in influenza are identified by comparing current reported cases to historical averages;

the District of Columbia’s 11 percent decrease in

homicides in 1994 is based on a comparison of

the numbers of killings in 1992 and 1993.

A number of states have established or are

attempting to establish a database to track trends

in school injuries. More subtle baselines have

been established as well. The CDC’s Youth Risk

Behavior System is creating baselines for behaviors that can forecast risks of intentional injuries

in school.

❚ Endpoints

This report uses the incidence of death, injury, or

illness as a measure of risk. However, incidence

only refers to the number and frequency and not

the severity of risk, which—to a large extent—

determines the risk’s health impact. The impact

of risks can be evaluated by considering their

endpoints, as measured by the nature of the

injury or illness. Endpoints can range from acute

effects such as poisonings and broken bones to

chronic effects including cancer and debilitating

injuries that result in paralysis. Some endpoints—traumatic death, death from cancer,

long-term mental or physical impairment—are

far worse than others—a scrape or bruise, a 24-

hour fever. Beyond such obvious differences, it

is difficult to put endpoints on a comparative

scale. The endpoints, or impacts, of illnesses and

injuries can be distinctly different from each
42 | Risks to Students in School

other, and the differences complicate comparisons of risks.

Even with related endpoints, comparisons

remain complicated. Most significantly, methods

for determining risks of the major risk factors

differ: infectious diseases and injuries are

counted and measured; illnesses from environmental hazards are estimated for some and

counted for others. One endpoint used in this

report common to both injury or illness is measuring the number of school days lost.

❚ School and Nonschool Risks

Children and adolescents spend some time in

school and a much greater proportion of their

time elsewhere. One way to put school risks in

perspective is to compare them to nonschool

risks. This report, wherever possible, compared

injuries and illnesses in school, where students

spend about 12 percent of their total time, to

injuries and illnesses in the nonschool environment, making allowances for the different times

spent in the two environments.

In this report, safety is described in terms of

relative risk between in-school and out-ofschool. Such comparisons to other environments

where children spend time may show that

schools and school grounds offer a “safer” environment from certain risks, i.e., relative to outof-school environments, in-school exposures to a

potentially harmful situation for injury or illness

may not be as great; conversely, in other situations, the risk is greater and hazards may be more

prevalent in schools. Safety is a relative term

since it is not a guarantee of a risk-free environment—violence even erupts in “safe cities” and

on “safe streets” and in peaceful rural areas.

Infections are spread in clean homes and schools

and in hospitals despite expert, directed precautions. Nevertheless, comparisons serve to illuminate differences inherent in the various

environments in which children learn, play, and

reside.

❚ Risk Thresholds for Intervention

Wherever possible, OTA presents baselines or

nonschool comparisons and, in a few cases, regulatory exposure limits, all of which can serve as

benchmarks to help determine whether interventions are warranted. This information comes

from a variety of sources, including federal or

state governments and other credible authorities.

School-specific benchmarks are most useful, but

few are available. More general comparisons,

from nonschool situations, are best used with

care, but they provide important information for

decisionmaking. Federal, state, and local regulations for many environmental hazards specify

certain thresholds that trigger actions to reduce

or prevent exposure.

Few regulatory thresholds exist for infectious

disease or injury hazards. The tolerable level for

injuries varies by type of injury and from

community to community. Certainly, some levels are unacceptable. They are, equally, undefined. Some injuries are of high incidence and

low severity, others are of low incidence and

high severity, and reactions to them often differ.

For example, proper playground surfacing may

not be installed until a large number of children

suffer abrasions or broken fingers, but one homicide can trigger installation of metal detectors.

A large number of cases of common childhood diseases may not elicit medical attention,

but outbreaks of illness from foodborne pathogens or with high severity, such as meningitis,

can trigger further investigation and interventions to prevent disease spread. There are, however, no specified thresholds that require action.

Also, reported environmental illnesses—such as

complaints about indoor air quality problems—

can trigger investigations. In this case, no threshold has to be crossed; a complaint is sufficient.

Asbestos is an example where the presence of

a substance, without knowledge of its concentrations, is sufficient to trigger some forms of intervention. EPA, as mandated by Congress, requires

visual inspections of schools for the presence of

asbestos-containing materials. Airborne asbestos

fibers are the hazard in schools, but EPA never
Chapter 2 Issues in School Health and Safety | 43

established a level of airborne asbestos that was

considered sufficiently high to require action or

sufficiently low to ignore.

In other cases, numerical thresholds exist.

EPA can require remediation actions when lead

concentrations in drinking water exceed 20 parts

per billion. EPA does not enforce a standard for

radon in homes, schools, or other buildings.3

ROAD MAP TO THIS REPORT

The remainder of this report presents the data on

hazards in the school environment that can

adversely affect students’ health and a chapter on

how these data may be used. OTA separates the

hazards based on their health effects, whether

injuries or illnesses. Chapter 3 covers injuries to

students in schools and the nature, incidence, and

causes of injuries. Injury is broken down by

intentional and unintentional injuries. Unintentional injuries are injuries from playgrounds,

school athletics, and transportation to and from

school. Intentional injuries include homicides,

suicides, physical fighting, and assaults.

Chapter 4 examines student illnesses. The

major school-related causes of illness identified

in the report are environmental hazards and

infectious diseases. Environmental hazards

include toxic materials in the school environment, indoor air quality problems, and hazards

arising from the location of the school. Infectious

diseases arise from a number of pathogenic

organisms and either occur with a high incidence

on an endemic or seasonal basis, or they occur

less frequently and primarily as outbreaks.

The final chapter discusses how the data

presented in the report can be used by decisionmakers—from Congress to individual school

boards—in setting priorities for improving

school safety. A section of the chapter examines

other attributes of risks, beyond the numbers of

deaths, injuries, or illnesses, that can play an

important role in decisionmaking. A final section

3 EPA has proposed a standard for radon in water (30), but recommends that homeowners undertake mitigation efforts when the radon

concentration is equal to or exceeds 4 pCi/L; its report of the survey of radon in schools (23) emphasized that concentration as a level of concern.

explores comparative risk assessment, a process

that can be used for comparing and ranking the

diverse risks in the school environment.

REFERENCES

1. Bearer, C., How Are School-Aged Children

and Adolescents Different from Adults,

prepared for the Office of Technology

Assessment, U.S. Congress, #M3-0596-0

(Washington, DC: U.S. Government Printing Office, 1994).

2. Benenson, A., Control of Communicable

Diseases in Man, 5th ed. (Washington, DC:

American Public Health Association, 1990).

3. Benson V., and Marano, M.A., Current Estimates from the National Health Interview

Survey, 1992, National Center for Health

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4. Brachman, P., “Epidemiology of Infectious

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J. Bennett (eds.) (New York, NY: Churchill

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5. Brodeur, P., The Great Power-Line CoverUp (Boston, MA: Little Brown and Co.,

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6. Callan, L., and Rowe, D., “The Role of the

School Sanitarian,” Journal of School

Health 52:360–362, 1972.

7. Corn, M., et al., “Airborne Concentrations of

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114, 1991.

8. Evans, A., “Epidemiologic Concepts and

Methods,” Viral Infection in Humans: Epidemiology and Control, 3rd ed., A. Evans

(ed.) (New York, NY: Plenum Medical

Book Co., 1991).

9. Feldman, W., et al., “Prospective Study of

School Injuries: Incidence, Types, Related

Factors and Initial Management,” Canadian
44 | Risks to Students in School

Medical Association Journal 129:1279–

1283, 1983.

10. Fowler, B., “Mechanisms of Kidney Cell

Injury from Metals,” Environmental Health

Perspectives 100:57–63, 1993.

11. Gallagher, S., Children’s Safety Network,

Newton, MA, personal communication, February, 1994.

12. Hanlon, J., and McHose, E., Design for

Health: The Teacher, the School, and

the Community (Philadelphia, PA: Lea &

Febiger, 1963).

13. Hennekens, C., and Buring, J., Epidemiology

in Medicine (Boston, MA: Little Brown and

Co., 1987).

14. Huff, J., et al., “Scientific Concepts, Value,

and Significance of Scientific Studies,”

Annual Review of Pharmacology and Toxicology 31:621–652, 1991.

15. Huff, J., and Rall, D., “Relevance to Humans

of Carcinogenesis Results from Laboratory

Animal Toxicology Studies,” MacyRosenau: Last Public Health and Preventive

Medicine, J. Lastand and R. Wallace (eds.)

(Hartford, CT: Appleton Century Crofts,

1992).

16. Huff, J., “Chemicals and Cancer in Humans:

First Evidence in Experimental Animals,”

Environmental Health Perspectives 100:

201–210, 1993.

17. Klaassen, C., Amdur, M., and Doull, J.

(eds.)., Casarette and Doull’s Toxicology:

The Basic Science of Poisons, 3rd ed. (New

York, NY: Macmillan Publishing Co.,

1986).

18. Lilienfeld, A., and Lilienfeld, D., Foundations of Epidemiology, 2nd ed. (New York,

NY: Oxford University Press, 1980).

19. Luster, M., and Rosenthal, G., “Chemical

Agents and the Immune Response,” Environmental Health Perspectives 100:219–

226, 1993.

20. National Research Council, Commission on

Geosciences, Environment, and Resources,

Human Exposure Assessment for Airborne

Pollutants: Advances and Opportunities

(Washington, DC: National Academy Press,

1991).

21. National Research Council, Board on

Agriculture and Board on Environmental

Studies and Toxicology, Commission on

Life Sciences, Pesticides in the Diet of

Infants and Children (Washington, DC:

National Academy Press, 1993).

22. Ornstein, A., “Prescriptions for Sick

Schools,” Principle (November):25–27, 1993.

23. Rowe, D., “Healthful School Living: Environmental Health in the School,” Journal of

School Health 57:426–431, 1987.

24. Schwetz, B., and Harris, M., “Developmental Toxicology: Status of the Field and

Contribution of the National Toxicology

Program,” Environmental Health Perspectives 100:269–282, 1993. 

25. U.S. Congress, Office of Technology

Assessment, Healthy Children: Investing in

the Future (Washington, DC: U.S. Government Printing Office, 1988).

26. U.S. Congress, Office of Technology

Assessment, Adolescent Health—Volume

II: Background and the Effectiveness of

Selected Prevention and Treatment Services,

OTA-H-466 (Washington, DC: U.S. Government Printing Office, November 1991).

27. U.S. Congress, Office of Technology

Assessment, Identifying and Controlling

Immunotoxic Substances, OTA-BP-BA-75

(Washington, DC: U.S. Government Printing Office, 1991a).

28. U.S. Congress, Office of Technology

Assessment, Identifying and Controlling

Pulmonary Toxicants, OTA-BP-BA-91

(Washington, DC: U.S. Government Printing Office, 1991b).

29. U.S. Congress, Office of Technology

Assessment, Neurotoxicity: Identifying and

Controlling Poisons of the Nervous System,

OTA-BA-436 (Washington, DC: U.S. Government Printing Office, 1991c).

30. U.S. Congress, Office of Technology

Assessment, Researching Health Risks,

OTA-BBS-570 (Washington, DC: U.S.
Chapter 2 Issues in School Health and Safety | 45

Government Printing Office, November

1993).

31. U.S. Department of Education, National

Center for Education Statistics, Office of

Educational Research and Improvement,

Digest of Education Statistics (Washington,

DC: U.S. Government Printing Office,

1993).

32. U.S. Environmental Protection Agency,

Office of Radiation and Indoor Air, National

School Radon Survey: Report to Congress

(Washington, DC: U.S. Government Printing Office, 1993).

33. Weisenberger, W., “Are Schools Safer Than

We Think?” The Education Digest

(May):13–16, 1995.

34. Weitzman, M., et al., “School Absence: A

Problem for the Pediatrician,” Pediatrics

69:739–746, 1982.

35. World Health Organization, “The Surveillance of Communicable Diseases,” WHO

Chronicles 22:439, 1968.
| 47

3

Injury to

Students in

School

njury is the leading cause of death and disability of children in the United States

(54,101). School-aged children ages 17

and younger sustain about 16,614,000

injuries annually (67)1

 which often take a heavy

physical, emotional, and financial toll on the

children and their families. Children lose over 10

million school days each year due to injuries

alone, an average of 22 lost school days per 100

students (8). However, students reduce their

exposure to the most serious risks of injury for

school-aged children simply by attending school

because the leading causes of death and injury to

children, such as motor vehicle-related injury,

homicide, suicide, falls, and drowning (see figure

3-1), are more frequent outside of school. Nevertheless, a significant number of deaths and disabling injuries occur in the school environment.

This chapter defines risks to students in

schools by number and severity of injuries. An

injury occurs from an “acute exposure to energy,

1 This estimate is based on data from the Child Health Supplement to the 1988 National Health Interview Survey (NHIS). Injury is

defined by the NHIS as “a condition of the type that is classified according to the nature-of-injury code numbers (800-999) in the ninth revision of the International Classification of Diseases. In addition to fractures, lacerations, contusions, burns, and so forth, which are commonly

thought of as injuries, this group of codes includes poisonings and impairments caused by accidents or nonaccidental violence” (8). “A person may sustain more than one injury in a single accident (for instance, a broken leg and laceration of the scalp), so the number of injury conditions may exceed the number of persons injured. Statistics of acute injury conditions include only injuries that involved medical attendance

or at least a half day of restricted activity” (8).

such as heat, electricity or kinetic energy of a

crash, fall, or bullet. Injury may also be caused

by the sudden absence of essentials, such as heat

or oxygen, as in the case of drowning” (54).

Risks of unintentional injury to students vary

each school day: in their travel to school; in the

controlled, supervised classroom environment; in

physical activities in gymnasiums and athletic

fields; the relatively unsupervised play during

recess and lunch periods; and finally, on their

return home (63). Demographic factors such as

age, sex, race, economics, and geography influence the incidence and severity of injuries (4).

The degree of risk to each student is a result of

the interaction of many other factors, including

the student’s developmental stage, staff awareness and supervision, environment, equipment or

products used at school (21), and school location.

This chapter presents information on school

injuries based on “intent”—unintentional (accidental) and intentional (assaultive or suicidal).

I
48 Risks to Students in School

Falls

Poisoning

Motor vehicle bicycle

Fire/burns

Unintentials firearms

Drowning

Motor vehicle pedestrian

Other motor vehicle

Suicide

Homicide

Motor vehicle occupant

Death rates per 100,000

NOTE: Rates based on fewer than 20 deaths are not reliable,

SOURCE: National Center for Health Statistics, data from the National Vital Statistics System,

For a number of reasons, other reports have chosen to use the term “accidental injury” when

reporting unintentional injuries. The term “unintentional injury,” however, is more commonly

used by experts in the injury prevention field

because it connotes the ability to predict and pre2 Intentional injury vent most of these injuries.

means the “threatened or actual use of physical

force against oneself or an individual or group

that either results, or is likely to result, in injury

or death” (88). In this report, intentional injuries

include interpersonal violence and suicidal

behavior. Unintentional and intentional injuries

differ in the type of injury that results, its severity, and the level of response or dread it engenders. Because of these differences, the types and

quality of data collected for unintentional and

intentional injuries also vary.

OTA surveyed the available injury data and

examined three interrelated questions:

1.

2.

3.

What school injury data currently exist?

What is the quality of the existing data?

Given that most estimates are uncertain and

variable, what additional data are needed to

help decision makers?

To answer these questions, this chapter

reviews and comments on the available data concerning injuries occurring in the school environment. As discussed in chapter 2, the types of data

2 As explained by the Centers for Disease Control and Prevention (CDC), “[injuries are mistakenly referred to as ‘accidents’ because

they occur suddenly and are seen as unpredictable and uncontrollable. In particular, parents often believe that ‘accidents’ will not happen to

their child because the child is well supervised. Injury prevention in children is much more than a question of supervision; injuries, like disease, occur in highly predictable patterns and are controllable.”
Chapter 3 Injury to Students in School | 49

included are: 1) surveillance;3

 2) survey; 3) epidemiological; and 4) anecdotal. This chapter

identifies the data sources of school injury data

and assesses their strengths and weaknesses.

Data on unintentional and intentional injuries

in schools are widely dispersed. While some

national and state estimates of both unintentional

and intentional school injuries are available, the

databases either do not clearly distinguish

between intentional and unintentional injuries or

collect information on one or the other. A study

based on the Child Health Supplement to the

1988 National Health Interview Survey (NHIS),

which provides national estimates of nonfatal

childhood injuries, is the one study to analyze

national data by school as a location of injury

(67). While not limited to the school environment, national databases of playground, athletics,

and school bus-related crash injuries provide

data used to calculate or estimate the number of

school-related unintentional injuries associated

with these activities. There are also national estimates of the number of homicides and suicides in

the school environment as well as national and

local self-report surveys on physical fighting and

weapon carrying that provide additional data on

nonfatal intentional injuries.

State and epidemiological studies rely on

school reports for estimates of school injuries.

Epidemiological studies provide a more detailed

picture of injury incidence. Because of diverse

reporting, underreporting, and inadequate reporting, school injury trends are difficult to characterize. Often within single school districts certain

schools report injuries more conscientiously than

others. The absence of standardized definitions

of reportable injuries among the states and

school districts limits comparisons of data. Injury

data regularly lack elemental aspects of injuries

such as the location, characteristics, causative

contributors, socioeconomic, and demographic

3 Surveillance data has been defined as the “ongoing and systematic collection, analysis, and interpretation of health data in the process of

describing and monitoring a health event. This information is used for planning, implementing, and evaluating public health interventions

and programs” (42).

factors, such as gender and race, particularly for

nonfatal events (54). The absence of this information prevents the determination of the circumstances of injury.

Assessment of the available school injury data

identifies the need for additional or better quality

data to aid decisionmaking. Quality data can turn

public attention and possible resources from

well-publicized but infrequent occurrences

toward more common injuries that represent a

greater public health problem. Data collection

and analysis can uncover school injury problems

or reveal more about a problem already suspected. Implicit in this process is that it can eventually lead to the overall reduction of school

injuries.

UNINTENTIONAL INJURY

Unintentional injuries are recognized as a leading cause of childhood mortality and morbidity

in the United States. One of the health objectives

set forth in Healthy People 2000: National

Health Promotion and Disease Prevention

Objectives4 is to “provide academic instruction

on injury prevention and control, preferably as

part of quality school health education, in at least

50 percent of the school systems (grades K

through 12)” (87). Compared to unintentional

injuries in general, little public attention is given

to those occurring in the school environment

except in the aftermath of a particularly tragic

incident, such as a fatal school bus crash or football injury. Injury deaths, however, are not

always representative of injury incidence at

school.

Given the time students spend at school and

the variety of activities they engage in, the school

environment presents many opportunities for

injury. For school-aged children, epidemiological studies estimate that 10 to 25 percent of their

4 Healthy People 2000 is a U.S. Public Health Service plan that developed health objectives designed to reduce preventable death, disease, and disability by the year 2000. Unintentional injury is a priority area targeted for specific reductions in mortality and morbidity.
50 | Risks to Students in School

injuries occur in the school environment (66).5

Although many of these injuries are minor cuts

and bruises that heal quickly, significant numbers are quite serious, resulting in absence from

school, restricted activity, hospitalization, disability, and death.

Incidence of injury of students is a function of

the type of activities in which they participate

and their developmental stage (21). For example,

elementary school students are most likely to be

injured on the playground, while secondary

school students are most likely to be injured

playing sports. Their developmental stage also

affects their ability to recover from injury. The

healing processes of school-aged children are

remarkably different from adults because they

are still growing (6).

Activities at school differ from those of children and adolescents outside the school. Accordingly, it is essential to recognize patterns of

frequency and severity specifically related to

school injuries. Students’ activities during the

day are, for the most part, supervised and

restricted to relatively non-risky behavior. The

leading causes of childhood unintentional fatal

injuries, including motor vehicle crashes, drowning, and fires (see figure 3-1), are more likely to

occur outside of school. Thus, the nature of injuries and the focus of prevention efforts directed

at school injuries can differ from childhood injuries at other locations. Knowledge of the circumstances involved in such unintentional injuries is

important for the development of prevention and

control efforts that adequately address the potential risks to students in the school environment.

Due to their frequency and severity, playground and athletic injuries generate considerably more data than other school-related injuries.

Accordingly, a separate discussion of playground

and athletic injuries follows the general discussion of school-related injuries below. Injuries

sustained on the journey to and from school are

also discussed separately because they involve

different data sources.

5 The NHIS reports that school-aged children sustained 13 million injuries in 1992.

❚ Sources and Limitations of SchoolRelated Injury Data

Sources of data on the incidence and prevalence

of unintentional injuries in the school environment are:

1) National sources:

■ National Center for Health Statistics, U.S.

Department of Health and Human Services;

■ Centers for Disease Control and Prevention

(CDC), U.S. Department of Health and

Human Services;

■ National Highway Traffic Safety Administration (NHTSA), U.S. Department of Transportation;

■ Consumer Products Safety Commission’s

(CPSC) National Electronic Injury Surveillance System (NEISS);

■ National Safety Council (NSC); and

■ National Pediatric Trauma Registry (NPTR).

2) State studies and surveys.

3) Epidemiological studies.

National Sources of Data on Unintentional 

Injuries in Schools

While OTA found no continuous national surveillance system that supplies comprehensive

information about school-related unintentional

injuries, national databases collect general information relating to childhood injury (54). There

are five major national types of unintentional

school-related injury data: death certificates, hospital discharge abstracts, hospital emergency

room reports, national health survey data, and

traffic accident data. These sources have their

various advantages and disadvantages, as

explained in box 3-1. National data can provide a

perspective of injuries and allow for comparisons

to local injury data. For the most part, however,

the existing national data sources focus on particular problems that include school injuries, but

rarely distinguish them from non-school injuries.

Even when differentiated, school injuries may

include many types of schools, such as colleges

and vocational schools.
Chapter 3 Injury to Students in School | 51

BOX 3-1: National Sources of Data on Unintentional Injuries in School

Mortality data

The National Center for Health Statistics (NCHS) of the U.S. Department of Health and Human Services (DHHS) is the primary source of fatality data; it collects mortality statistics from all 50 states. Fatality

data are collected from death certificates, which include information on the cause of death. However, the

national report is usually published about three years after the death occurred. The coding of fatal injuries

is based on the apparent intent of the persons involved—unintentional, homicide, or suicide (NRC, 1985).

Additional coding as to circumstances and location is limited; there is no categorization of the school

locale on hospital injury coding forms or death certificates. Also there is no standard system among the

states for filling out death certificates, which are often completed without an autopsy or before one can

establish the cause of death. Moreover, fatality data may overstate the unintentional fatalities if some

intentional injuries, such as suicides, are incorrectly reported. Or conversely, the unintentional fatality

data may be understated if some intentional deaths, as a result of child abuse, for example, are reported

as unintentional. While these statistics are useful in monitoring national fatality trends, without the reporting of school as a location there is not enough detail to determine fatality trends occurring at schools.

The National Highway Traffic Safety Administration (NHTSA) of the U.S. Department of Transportation compiles and analyzes mortality data on school bus-related accidents and on pedestrian and bicyclist mortality for the school-aged population. NHTSA’s Fatal Accident Reporting System (FARS)

database, established in 1975, compiles information relating to fatal motor vehicle crashes from state

agencies. FARS sources include police accident reports, death certificates, and coroner or medical

examiner reports. Data include geographic details, roadway and other conditions, information about the

driver of the vehicle, and on fatally and nonfatally injured persons involved (including passengers, pedestrians, and others). These data do not distinguish whether travel was school-related.

Morbidity data

DHHS’s National Health Interview Survey (NHIS) collects data on nonfatal injuries based on household interviews of the civilian noninstitutionalized population. In 1992, 49,401 households containing

128,412 persons were sampled; 96 percent of these households were interviewed.a While the NHIS

includes “school” as a location for injury, the data are not analyzed regularly or published by school

location. Scheidt et al. studied the Child Health Supplement to the 1988 National Health Interview

survey to derive national estimates of nonfatal school injuries. The study included a breakdown of the

location of injury, including school; the data are not routinely analyzed by school as a location of

injury. School as a “place of accident” is defined in the NHIS to include “all accidents occurring in

school buildings or on the premises. This classification includes elementary schools, high schools,

colleges, and trade and business schools.” Thus, the injuries incurred by adults as well as by students K through 12 are included. By limiting the study to persons aged 17 and younger, Scheidt et

al. resolved this problem—previous school data were not analyzed by age.

The U.S. Consumer Product Safety Commission (CPSC) maintains the National Injury Information

Clearinghouse, another source of data on nonfatal injury. Its database includes: death certificate data,

the National Electronic Injury Surveillance System (NEISS), accident investigations, consumer complaints, and other injury reports. The NEISS database, the primary CPSC data source for this OTA report,

collects injury data from a sample of 91 hospital emergency rooms located throughout the United States.

The small sample number precludes determination of regional trends. CPSC data are by definition confined to consumer product-related injuries, thereby limiting the database’s usefulness for purposes of this

report. For example, the NEISS database does not record all playground and sports-related injuries; it is

limited to injuries relating to playground equipment and sports equipment. Thus, reports from NEISS

reflect national estimates of persons with injuries associated with products under CPSC’s jurisdiction

treated in emergency rooms. CPSC does not have jurisdiction over firearms and motor vehicles.

(continued)
52 | Risks to Students in School

State Sources of Data on Unintentional 

Injuries in Schools

No state currently requires mandatory reporting

of school-related injuries to the state departments

of education or health. OTA identified four states

(Arizona, Hawaii, South Carolina, and Utah) that

maintain school injury databases, but all four

depend on voluntary reporting. These databases

are described in box 3-2.

Although few states require reporting at the

state level, most schools and school districts keep

injury records. For example, Miami, Florida’s

NEISS collects injury data by location categories, including school, but does not analyze data using

school as a category. Again, school includes all types—for example, elementary, secondary, vocational,

college, and graduate school. Restricting the analysis of injuries to ages 5 to 18 would theoretically

restrict the data to elementary and secondary students. CPSC produces such data but does not analyze

it. NEISS is capable of discovering national injury trends in a timely fashion, allowing for preventive action.

CPSC also publishes safety alerts concerning consumer products, which include equipment used in

schools.

Transportation-related nonfatal injury data are from NHTSA’s General Estimate System (GES), which

is a nationally representative probability sample selected from police reports of motor vehicle crashes.

NHTSA produces data related to school bus accidents, as well as pedestrian and bicyclist morbidity

data. GES data are from a nationally representative probability sample selected from police reports of

motor vehicle crashes.

OTA identified two additional national sources of school-related injury data: 1) the National Safety

Council (NSC) and 2) the National Pediatric Trauma Registry (NPTR). NSC collected data on “student

accidents” from 7,500 responding school jurisdictions. Accidents were defined as causing the loss of

one-half day or more of school time or activity during non-school time and/or any property damage as a

result of a school jurisdictional accident. NSC reports the number of injuries in terms of student days

rather than student years, which makes it difficult to compare injury rates with other studies, almost all

of which are reported in years. Moreover, NSC figures are outdated—the last edition of its Accident

Facts to include school injuries was published in 1987 and the reported data was collected in academic years 1984–85 and 1985–86.

NPTR data include information from 61 hospitals located in 28 states, Puerto Rico, and Ontario, Canada. From December 1987 to February 1993, 871 cases of school-related injuries of students aged 5 to

19 were recorded in the Registry. In an epidemiological study, Gallagher et al. analyzed 907 school injury

cases to assess the causes and consequences of serious injuries occurring among students (Gallagher,

1994). The data evaluated included 19-year-olds, but it was unclear whether “school” was limited to high

schools or included college campuses. Since trauma center data are not population-based and catalogue only a few of the most serious cases, conclusions cannot be generalized to the less seriously

injured or non-injured school population (NRC, 1985). Moreover, trauma centers receive referrals from

other hospitals and many trauma centers specialize in particular types of injuries. Nevertheless, these

valuable data illustrate the types and distribution of severe injuries suffered by children and adolescents

at school.

aThe 1992 questionnaire enabled identification of out-of-school youth (aged 12-21 years) by inquiring whether they

were either now going to school or on vacation from school. The results will be used in the Youth Risk Behavior Survey.

SOURCES: Office of Technology Assessment, 1995. National Research Council, Commission on Life Sciences, Committee on

Trauma Research & Institute of Medicine, Injury in America: A Continuing Public Health Problem (Washington, DC: National Academy Press, 1985); Gallagher, S., Bowdler, M., and Di Scala, C., unpublished data on the cause of severe injuries at school:

Results of an Analysis of 907 Severe School Injuries Reported to the National Pediatric Trauma Registry, Newton, MA, 1994.

BOX 3-1: National Sources of Data on Unintentional Injuries in School (Cont’d.)
Chapter 3 Injury to Students in School | 53

BOX 3-2: State Sources of Data on Unintentional Injuries in School

OTA indentified only four states with voluntary state-wide reporting requirements (Arizona, Hawaii,

South Carolina, and Utah). In the absence of national reporting, voluntary or otherwise, there is no uniformity in reporting school injuries among states that do compile injury data. Each state uses diferent reporting methods and criteria. Arizona and Utah have computerized forms, which greatly facilitate data

collection. Other states have completed studies but currently do not have an ongoing surveillance program (Kansas and Washington) or are just beginning to implement ongoing school injury surveillance

systems (Michigan, Minnesota, and Washington). Although Arizona and Michigan have drawn on Utah’s

experience, for the most part there is little coordination among state departments surveying school injuries; in some cases, states were not aware of other efforts. Some states, such as Massachusetts, have

injury surveillance programs from which school injury data can be culled.

Arizona Department of Health Services

In 1991, Arizona instituted the Arizona Injury Surveillance Program. The first reporting year was limited

to playground and athletics injuries. The study evaluated 212 elementary schools including 122,056 students in grades K–8, representing 29 percent of the school population. Student health personnel were

required to complete a report form when an injured student 1) was sent home, 2) was sent to a physician,

3) was transported or admitted to a hospital, or 4) required restricted activity. The second year’s data will

be published in early 1995 and the third year data are being analyzed. In 1993, with input from school

districts and the main school insurance companies, Arizona officials developed a scannable report form.

The front of the form is for recording injury information and the back now includes information for insurance purposes. The program will soon include all school injuries and all grades, starting at preschool and

daycare and going through high school. The program will soon include more schools and entire districts.

An Early Childhood/School Injury Task Force meets quarterly to determine the direction of the program.

Hawaii Department of Health

In 1984, Taketa attempted a statewide analysis of school injury data collected by the Hawaii Departments of Education and Health. The study evaluated 204 of Hawaii’s 224 public schools by collecting

Student Accident Report Forms completed by school nurses during the 1981-82 academic year. However, the information varied considerably, impeding efforts to identify particular risks. The Hawaii Department of Education’s most recent data are for 1989-90. The data are compromised by the uncertainty of

the percentage of the school population included in the report. The data are presented only in terms of

location, activity, and nature of injury; not by gender, age, or grade.

Kansas Department of Health

Until 1981, the Kansas Department of Health and Environment biannually published a Student Accident Report. The 1981 report, the 32nd edition, summarized the nonfatal student accidents occurring in

Kansas during the 1979–80 and 1980–81 school years. Injuries reported to the department involved

those severe enough to cause a student absence of half a day or more from school or to require a doctor’s attention. Study authors noted that reporting was incomplete. Significantly, the study was able to

track trends over a 25-year period, particularly increases in rates and percentages over the years.

Minnesota Department of Education

In 1989, the Minnesota Department of Education first administered the Minnesota Student Survey with

the aim of furthering the understanding of student behaviors and attitudes. The survey was given to students in the 6th, 9th and 12th grades. The only relevant injury questions ask whether an injury occurred at

“school not sports” and at “school sports.” While the overall injury numbers are useful for comparing the

two categories of injuries, the survey provides no insight into the factors causing student injury.

(continued)
54 | Risks to Students in School

South Carolina Department of Health

The South Carolina Department of Health administers the Annual School Health Nursing Survey to

compile data about the health status of children in schools. Surveys were distributed to head nurses in 91

school districts; however, not all schools have a nurse. In the two years the report has been completed,

school district response rates were 44 and 45 percent. In the 1992–93 school year, this represented

about half of the school districts, 69 percent of the 300 school nurses and 60 percent of the students

(342,587 students). Data are analyzed to assist those responsible for school health and policy decisions

at the state and local level. School nurses in South Carolina have used this survey to identify injury problems and to coordinate and develop injury intervention programs. In fact, in 1992–93 there was a

reported decrease in the total number of injuries, despite a fourfold increase in reporting. The 1992-93

report attributes the reduction to data collection efforts that have been translated into local school prevention and intervention efforts.

Utah Department of Health

In 1984, Utah established a voluntary reporting system in which school districts use the Department of

Health’s student accident report form to report injury information. Since that year, the Department of

Health has collected statewide information on injuries sustained by students in schools.a Its computerized database is the most comprehensive statewide school injury data source in the United States.

Reportable injuries are defined as those severe enough to cause school absence of at least a half

day or to warrant medical attention and treatment. To increase the accuracy of description, the form

has been revised a number of times in response to problems identified by schools using the form.

Participation of the 40 state school districts has progressed to 100 percent since the database’s

inception. As a result of increased participation and reporting refinements, data collected since the

1988-89 academic year are the most reliable. Nonetheless, as with all school-based injury data, incidents are probably underreported. For example, in 1988–89, the incidence in grades K–6 was 1.7

injuries per 100 students, which increased to 2.1 per 100 students by 1991–92. The Utah Department of Health does not attribute this increase to an overall increase in incidence but to an increase

in reporting by school districts. Further analysis of this data by individual grade, if possible, would

more accurately define incidence grade peaks and indicate when a student is most at risk from a

particular hazard.b Similarly, analysis by grade and sex would yield significant insight into the occurrence of school injuries. The Utah data are not contained in a formal report; rather, they were

amassed by the Department of Health and presented by category for the two grade divisions, K–6

and 7–12, for each academic year from 1988–89 to 1991–92.

The Utah State Department of Health and Utah State University used the data to identify playgrounds

as the leading cause of school injuries at schools and to develop the 1988 publication “Playground Perspectives: A Curriculum Guide for Promoting Playground Safety.”

Two additional school injury studies were sponsored by states. These are epidemiological studies;

they were limited to specific locations rather than statewide.

(continued)

BOX 3-2: State Sources of Data on Unintentional Injuries in School (Cont’d.)
Chapter 3 Injury to Students in School | 55

Dade County Public Schools maintains unintentional injury information annually (23). While

some schools maintain records as part of their

state’s voluntary school injury reporting systems,

many maintain injury records for liability purposes (28). The state departments of education or

health rarely collect, tally, or analyze injury

reports, and often the data on the local level are

not computerized, making it difficult to retrieve

information. In addition, such reporting is conducted through school districts and, therefore,

evaluates only public schools. Injury data colMassachusetts Statewide Comprehensive Injury Prevention Program

The Massachusetts Department of Public Health established the population-based Massachusetts

Statewide Comprehensive Injury Prevention Program (SCIPP), a hospital-based injury surveillance system (Passmore et al., 1989). The advantage of hospital-based over school-based data is that the diagnosis and circumstances relating to the incident are more accurate and reliable. As with all hospital-based

data, however, only the most severe cases are seen and selection biases are inevitable. The SCIPP system compiled data on injuries among 86,876 children and adolescents (0–19 years) living in 14 communities from September 1979 to August 1982. Twenty-three participating hospitals accounted for an

estimated 93 percent of all pediatric discharges. Since the information is hospital-based, visits to doctor’s

offices, clinics, health maintenance organizations, or dentist’s offices were not included. Passmore and

Gallagher analyzed the SCIPP database to determine the incidence of school injuries in a Massachusetts

community. This study is particularly important because the authors compare school and out-of-school

injury incidence data.

Washington Department of Health

The Washington State Department of Health completed a two school-year study in 1986-87 and 1987–

88, The School Injury Surveillance Project: Results and Recommendations, of a single school district as a

pilot test program. The aim was to test the efficacy of school injury surveillance, with the ultimate goal of

identifying potential prevention and investigation priorities. The district studied the Clover Park school district, which had a school-aged population of 12,781 in 1986–87. Injury reports were completed by school

nurses and given to district risk managers to pass to the Department of Health. School nurses were to

report injuries: 1) that were severe enough for the child to be sent home, including unsuccessful attempts

to send the child home; 2) that required a physician’s care and/or major first-aid treatment; or 3) that

occurred during athletic activities and restricted competitive sports, competition, or practice for two or

more days, including all joint injuries, fractures, head and neck injuries, and internal injuries.

aUtah’s computerized school injury database was used for the article by Sosin et al. (1993) on surface-specific falls on

Utah school playgrounds.

bEnrollment data for grades 7–12 were not readily available; therefore, rates could not be determined. The percentages

of injuries in grades K–6 can be compared to the those in grades 7–12 to contrast the injury experience of the two groups.

SOURCES: Arizona Department of Health Service, Community and Family Health Services, Office of Women’s and Children’s

Health, A Study of the Nature, Incidence, and Consequences of Elementary School Playground-related Injuries (Arizona, 1993);

C. Cazier, Project Director for Family Health Services, Utah Department of Health, Salt Lake City, UT, personal communication,

1994; S.S. Gallagher and K. Finison, “The Incidence of Injuries Among 87,000 Massachusetts Children and Adolescents: Results

of the 1980–81 Statewide Childhood Injury Prevention Program Surveillance System,” Am J. Public Health 74:1340–1347, 1984;

Kansas Department of Health and Environment, Athletic Injuries in Kansas Secondary Schools 1990–91, unpublished report

(Topeka, KS: 1992); South Carolina Department of Health & Environmental Control, Division of Children’s Health, Annual School

Nurse Survey 1993, 1994; Utah Department of Health, Division of Family Health Services, Student Injury Report Database 1988–

1992; S. Taketa, “Student Accidents in Hawaii’s Public Schools,” Journal of School Health 54:208–209, 1984; Washington State

Department of Health, Office of Community Environmental Health Programs, The School Injury Surveillance Project: Results and

Recommendations (Olympia, WA: 1990).

BOX 3-2: State Sources of Data on Unintentional Injuries in School (Cont’d.)
56 | Risks to Students in School

lected by private schools are not readily accessible or collected in any systematic manner; thus,

comparisons of injury rates in private versus

public schools cannot be made.

Epidemiological Studies on Unintentional 

Injuries in Schools

Epidemiological studies and state surveillance

data complement each other. Although state surveillance data are better for identification of particular injury problems, epidemiological studies

allow for more detailed analysis of a suspected

problem. The five most prominent epidemiological studies found by OTA are presented in table

3-1. Despite the advantages, the available epidemiological studies have numerous drawbacks

and methodological problems.

As with most epidemiological data, the available studies are narrowly focused on a small

number of school districts, which prevents the

determination of regional trends. It is apparent,

however, that student populations and injury

risks vary widely from school district to school

district. Moreover, the focus on injuries occurring at schools does not inform about schools as

a source of injury relative to other locations. The

lack of standardization of what constitutes a

reportable injury and what qualifies as a serious

or severe injury across epidemiological studies

hinders their comparability. Moreover, four out

of the five studies are over 10 years old. The

studies used varying reporting categories. For

instance, some reported cause of injury by location, others by activity. Most studies define a

reportable injury as one that causes the student to

restrict school activity for at least half a day, but

this criterion may select against late-afternoon

injuries. Nevertheless, to the extent that the

results of these studies are consistent, they indicate general characteristics of school injury incidence.

These studies draw from school-based, parentbased, and/or hospital-based reports. Of these,

school-based reports collected from school districts are the primary source of data used by state

surveillance systems and epidemiological studies. Parent-based reports complement schoolbased reports to assist in determining the accuracy of school-based reporting. Hospital-based

reporting provides more comprehensive case

information, but only for the most serious injuries.

Most state and epidemiological school-related

data differ from national data in that they rely

almost entirely on school-based reporting.

School-based reporting generally involves completion of an injury report by a teacher, coach,

administrator, or other staff member. In most

cases, however, the forms are kept at school or a

copy is sent to the school district office. Only

four states actually collect and tabulate the number of injuries. The primary advantage of schoolbased data is that it theoretically captures all

injuries that occur at school, regardless of the

treatment. Moreover, school-based data is local.

Decisionmakers at the local level can use the

data to verify the actuality of an injury problem

before committing scarce resources to a local

injury control program.

Methodological concerns common to epidemiological and surveillance data are inherent in

school-based reports. Such concerns include

underreporting of both minor and serious injuries

(13,103), and inconsistent definitions of injury

and the school environment. Reporting practices

may also vary significantly from school to

school. The lack of standardized reporting for

school-related injuries compromises the reliability of data. Although underreporting and inconsistent reporting among schools undermine the

completeness of the data, school-based data are

the most comprehensive and accurate data available.
Ch

apter3InjurytoStudentsinSchool|57

TABLE 3-1: School Injury Epidemiological Studies

Lenaway et al. (1992) Boyce et al. (1984a) Sheps & Evans (1987) Feldman et al. (1983) Taketa (1984)

Years analyzed

1988–1989 1980–1983 1981–1983 1981–1982 1981–1982

Site Boulder, CO Tucson, AZ Vancouver, BC Hamilton, Wentworth, Ont. HawaiiNo. of schools 9 96 108 212 204Grades K–12 K–12 K–12 K–12 K–12Student population

5,518 55,000 53,000 83,692 157,000

Data collection

Prospective Prospective Retrospective Prospective Retrospective

Definition: reportable injury

Student accident report forms completed by adult administering first aid (i.e., teacher, nurse or coach). Reportable injuries were those: “requiring medical or dental attention, head injuries necessitating student dismissal to home and those with persistent symptoms beyond a two hour observation period, poisoning, suspected fractures, human bites, puncture wounds, and injuries sustained from fighting or equipment failure”

Injury must meet one of the following criteria: (1) required a physician’s care and/or major first aid; (2) resulted in an absence from school; or (3) resulted in restricted participation in competitive sports

If a child sustains or requires: “all head injuries, suspected or definite fractures, and ambulance or inhaler, referral to a physician or dentist, sutures or a foreign body in the eye”

Decision as to reportability “made by school principal, consistent with his interpretation of the school board’s policy”

“Any accident which happens at school, or at a school sponsored activity, on or off campus, which (1) interrupts the students’ normal or expected activity for that period to any significant degree, (2) causes any property damages or losses of more than $5 in estimated replacement cost and/or (3) can generate a litigation on behalf of the injured”

Incidence per 100 student years

9.2 4.9 2.8 5.4 1.7

(continued)
58 | Risks to Students in School Definition: severe injury * Amputations, third-degree burns, concussions, crush wounds, fractures, multiple injuries Fractures, loss of consciousness, burns, whiplash, open wounds, foreign body in eye Fractures, loss of consciousness, dislocations, sprains, torn ligaments and cartilage, chipped/broken teeth, internal injury “Most severe...foreign bodies in the eye and fractures” Percentage of injuries that were serious or severe

—

18% 35% elementary

39% secondary

28.6%

—

* no definition of severe or seriousSOURCE: Office of Technology Assessment, 1995, adapted from R.R. Gratz and K. Finison, “School Injuries: What We Know, What We Need,” Pediatric Health Care 6:256–262, 1992; Lenaway,

D.D., et al., “The Epidemiology of School Related Injuries: New Perspectives,” Am J Prev Med 8(3):193–198, 1992.

TABLE 3-1: School Injury Epidemiological Studies (Cont’d.)
Chapter 3 Injury to Students in School | 59

A study designed to determine the extent of

underreporting (103) of injuries in school-based

reporting found about a fourfold difference: 24.0

injuries occurring per 100 students compared to

5.4 injuries reported, indicating that for every

injury reported about 3.4 go undetected. Most of

the unreported injuries appeared to be minor,

while serious injuries were more likely to be routinely reported. Serious injuries were underreported by a factor of two, while minor injuries

were underreported by a factor of five (27).

The study also contrasted parent and school

reports of injury; parents reported three times as

many school-related injuries (15.3 injuries per

100 student years) as schools did.6

 In terms of

serious injuries, parents reported close to 30 percent of the total injuries as serious (19.5 percent

elementary and 45.5 percent secondary school),

in contrast to 13 percent categorized as such by

schools (37). While the accuracy of the parental

reports is unknown, the study concluded that

estimates of the number and severity of injuries

by educational authorities should not be relied on

as the sole source for accurate injury information.

Hospital-based reporting, an alternative to

school-based reporting, is generally more accurate and reliable than school-based reporting

because health professionals diagnose the injury.

Moreover, hospital records contain more detailed

information about the circumstances of the injury

and the final disposition of the case (13). In the

context of school injuries, however, hospitalbased data only represents the most severe injuries and does not include those untreated or

treated by a school nurse, at home, or at a doctor’s office. Also, hospital admissions may not

be reflective of the distribution of injury, because

selection biases such as bed supply and social

6 As part of a random sample, parents of about 200 children attending schools were surveyed over 10 months and asked if the student had

sustained any school-related injuries during the previous month and, if so, the numbers, types, and treatment of injuries. Parent survey questionnaires were mailed at the beginning of the each month. If after three weeks the questionnaire was not returned, the parents were contacted

by phone when possible. About 53 percent of these surveys were returned by mail and 32 percent were completed over the phone.

class affect admission for all but the most severe

injuries.

Hospital-based data are also problematic in

that E-coding, the current system for classifying

and coding cause of death and nonfatal injury,

does not permit adequate description of activities

surrounding the incident. E-coding, which codes

for the external cause of injury, is part of the

injury classification established by the World

Health Organization and used with the International Classification of Disease (ICD) (86). Hospitals and vital statistics recordkeeping

sometimes use the ICD, in its ninth revision, to

explain how and where an injury occurred. Currently, there is not a national requirement for

hospitals to record E-codes on injury records,

with one exception (14).7 In 1994, however, thirteen states had mandated E-coding of hospital

records. As more states use E-coding, the data

will improve; currently, however, the quality of

the morbidity data is uneven. OTA concludes

that mandatory use of E-codes for injuries and

inclusion of school as a location classification

would provide invaluable information for the

study of nonfatal school injuries.

❚ Incidence and Distribution of SchoolRelated Injuries

Incidence

Scheidt et al. estimate that 16,614,0008 injuries

are sustained by children ages 17 and under in

the United States annually; thus, medically

attended injuries occur in at least 25 percent of

children each year. Of those, it is estimated that

approximately 3 million injuries occurred at

school. Authors of the epidemiological studies

estimate that 10 to 25 percent of injuries to the

school-aged population occur at school (66). Epi7 E-code recording is required in those cases “where drugs or medicinal and biological substances caused an adverse effect in therapeutic

use” (14). 8 This estimate includes only those injuries involving medical attendance or at least half a day of restricted activity.
60 | Risks to Students in School

demiological studies are likely to include more

injuries than national estimates, the excess attributable primarily to minor injuries.

Injury rates from school-related injury studies

vary and are likely to underrepresent the number

of actual injuries because of underreporting in

the routine surveillance and reporting of injuries

at schools (35). The variations may also be attributed to one or more of the following: 1) inconsistent case definitions of injury; 2) reporting

methods (e.g., school-based as opposed to hospital-based reporting); 3) inconsistent reporting

among study schools; 4) natural variability

among student populations; and 5) implementation of school-based injury prevention programs.9

 The reporting methods also affect the

number of injuries reported. For instance, prospective studies reported higher rates of injuries

than retrospective studies (35).

In-School and Out-of-School Incidence

The NHIS reported 28.6 injuries per 100 schoolaged children in 1992 (8). Similarly, based on

1988 NHIS data, the Scheidt study revealed an

injury rate of 27.0 per 100 children. Population

based studies are in close agreement—the Massachusetts Statewide Comprehensive Injury Prevention Program (SCIPP) data show about 24

injuries per 100 children or adolescents ages 6 to

19 (30), and a Puget Sound, Washington HMO

population study show about 25 injuries per 100

children, ages 19 and under10 (66). As shown in

table 3-1, the rates of injury in schools found by

epidemiological studies range from 1.7 to 9.2 per

100 students.11 Considering the shorter time

spent in school, about 12 percent of a child’s year

and about 15 to 20 percent of their waking hours

9 Some injury investigators have suggested that injury rates among children may be inflated by a small number of children that suffer a

large number of injuries (12). Studies found little evidence to support the accident-prone child notion (12, 27). Although the number of students with recurrent injuries are slightly higher than the rate expected by chance, the overall incidence rates were not greatly influenced. 10 The study identified injuries of the 8,603 children, ages 0-19, enrolled with an HMO and treated in an HMO clinic, ER, or hospital. It

was performed over a one-year period in 1985-86 (66). 11 Studies of school-related injury outside North America report much lower rates. For example, Pagano et al. (1987) evaluated the student population in Milan, Italy, and found an average annual rate of 1.44 injuries per 100 students (62). Similarly, a study of primary and secondary students in West Lothian, Scotland, disclosed an injury rate of 2.6 per 100 students—3.7/100 for primary students and 1.9/100 for

secondary students (11).

annually, the data suggest that the number of

school injuries may be about the same or slightly

higher than out-of-school injuries. However, the

majority of school-related injuries are minor and

result in fewer hospitalizations than injuries sustained outside the school environment, and fatal

injuries are relatively rare in the school environment (63).

Age-Related and Gender-Related Incidence

Incidence and characteristics of injuries correlate

strongly with age and gender. Elementary students incur more injuries than secondary students, but the difference is primarily due to

minor injuries. However, Feldman et al. identified a “small but statistically significant” difference between the rate of serious injury among

elementary (1.6 injuries/100 students) and secondary (1.3/100) students and concluded that

younger students sustained more severe injuries

than older ones. Scheidt et al. found that adolescents aged 14 to 17 were at greater risk of injury

at school than other students. Epidemiological

studies, however, disclose that students aged 10

to 14, or in grades 6 to 8, appear to be at

increased risk of injury (10,27,43,69,73). Feldman et al. explained the incidence crest as the

effect of increased activities coupled with the

onset of puberty. Growth of students in the 6th to

8th grades is characterized by rapid increase in

body size, muscle mass, and strength, and consequently termed the “clumsy age” (27).12 The 10

to 14 age group may also be at greater risk of

serious or severe injury. The NPTR study found

that 44 percent of hospitalized students were

ages 10 to 14.

12 However, one population-based study demonstrated injury peaks at ages 14-15, normally associated with 9th grade (63).
Chapter 3 Injury to Students in School | 61

While playground and athletics (including

both physical education and organized sports)

account for the overall highest injury rates in

school, distribution of these injuries changes

over time due to students’ development of physical skill, strength, size, judgment, balance, and

experience with hazards (63). The rates of playground injuries decrease as elementary school

children mature, while the rates of athletic injuries increase steadily through middle/junior high

school to high school.

Across studies and grade levels, injuries

occurred nearly twice as often to males than

females and the difference was even more pronounced in adolescents (63,67). Minor injuries,

rather than severe ones, constituted the difference between the genders (27). In a study

designed to determine incidence of underreporting in schools, Woodward et al. found that girls’

minor injuries were underreported more routinely (103). Most studies found little difference

in gender rates for serious or severe injuries. One

exception was the NPTR study of hospitalizations resulting from school injuries—it found a

male to female ratio of 2:1. Regardless, the gender gap for overall injuries increases with age.

The disproportionate increase in injuries to boys

may be accounted for by the greater participation

of boys in sports and also the type of sports

played by boys.

Predictive Factors

Review of the effects of demographic and social

factors, type of school, condition of school buildings, and the availability of health care at schools

on injury incidence in schools is meager. With

few exceptions, school injury studies have not

compiled this type of data, even though such factors may strongly influence students’ risk of

injury. One non-school-related study in New

York City showed that children living in lowincome neighborhoods were twice as likely to

suffer injuries as children in neighborhoods with

few low-income households (24). It follows that

students from low-income households are more

likely to attend schools in low-income neighborhoods and to confront a broader range of risks in

the school and non-school environment than students from more advantaged backgrounds (52).

Conditions resulting from inadequate resources

due to budgetary constraints, such as poor maintenance of school buildings (78), grounds, and

equipment, or higher student-to-faculty ratios

resulting in less supervision, are likely to have a

significant impact on the potential for injury

(52).

Boyce et al. surveyed school principals and

nurses with regard to ecological variables that

can affect the incidence of injuries at schools.13

The results indicated that four particular variables were “significantly and independently predictive” of higher injury rate at a particular

school: 1) increased length of school day; 2)

presence of alternative educational programs; 3)

less experienced school nurses; and 4) higher

student-to-staff ratio. Significantly, two ecological factors were equally predictive with regard to

severity of injury: greater length of school day

and higher percentage of minority group students

(10). More studies of the association between

these factors and school injury rates are essential

for understanding the ecological factors that

impact the incidence of injury. The connections

allow prevention efforts to appropriately target

injury problems.

Severity

While overall incidence of school injury is tremendously important in determining the existence of an injury problem, equally important is

13 The ecologic variables included: demographic characteristics (student enrollment, percentage of minority students, and student-staff

ratio), social characteristics (transience rate, absence rate, drug or alcohol problems, family stability in student population, and behavior

problems), programmatic characteristics, category of school (elementary, junior high school, high school), alternative educational programs,

level of PTA (Parent-Teacher Association) activity, and school hours, physical characteristics (age of school building and playground condition), and health program characteristics (variety of nursing experience, years of nursing experience, nursing education, nurse hours, presence of nurse’s aide, presence of safety program) (10).
62 | Risks to Students in School

injury severity. Severe injuries that can result in

long-term disability justify attention due to their

economic and emotional costs and health implications. Severity, however, is subjective and various terms are used to connote the gravity of an

injury, including severe, serious, significant, and

major. The percentage of severe injuries—ranging from 18 to 39 percent across studies—varies

because, among other things, severity is defined

differently from study to study (see table 3-1).

The diversity of definitions inhibits meaningful

cross-comparisons. Since most studies do not

have medical diagnoses, other indicators are used

as indices of severity, including the type of

injury, nature of injury, school days lost, and

school days in the hospital. Also the number of

serious injuries compared to minor injuries is

somewhat distorted because student injury report

forms are usually completed by the attending

adult, whether a teacher, school nurse, coach, or

administrator, rather than by medical personnel.

The extent of the distortion is unknown.

While most studies define severity by the type

of injury (i.e., a fracture), each study uses a different set of criteria to determine if the type of

injury is severe (69). According to Sheps and

Evans, using the nature or body area of an injury

to serve as a proxy for severity is generally

unsound because, while they are associated, no

specific correlation exists (26). For example,

while a head injury is classified as severe, the

actual injury may only be a surface abrasion on

the head. However, nature of the injury appeared

to have a stronger association with severity than

body area. Moreover, the inclusion of particular

types of injuries can substantially affect total

numbers. In one study, for example, severe

sports injuries increased from 25 to 56 percent if

sprains, strains, and dislocations were classified

as severe (69). Nonetheless, the variation of rates

for severe injuries was small (0.9 to 1.7 severe /

100) compared to that of overall injury rates (1.7

to 9.2/100) (69).

Regardless of the definition used, playground and sports athletic injuries account

not only for the greatest number of injuries,

but also for the majority of severe injuries at

school (10,43,69). Boyce et al. found that playground and sports equipment related injuries

were 1.6 times more likely to be severe when

compared to all other causes of injury. National

Safety Council (NSC) data, however, indicate

that motor vehicle-related injuries occurring on

the trip to or from school resulted in the most

severe injuries, indicated by the highest average

number of school days lost (2.6 days) per injury,

followed by interscholastic sports (1.6 days).

Passmore and Gallagher reported that the

Massachusetts SCIPP data indicate that school

injuries result in slightly lower proportions of

hospital admissions and fewer bed-night stays

than injuries occurring outside the school environment (63). Some of the more serious injuries

incurred in schools are profiled in the NPTR

study (29). Of the 907 emergency room cases

identified during the NPTR study period December 1987 to February 1993 as being schoolrelated, there were five deaths and nine debilitating injuries that required extensive rehabilitation.

The injury rate may be influenced by students

with pre-existing conditions, as they contributed

disproportionately to the number of injuries.

Many of the most serious injuries also resulted

from falls: three of the five deaths and four of the

nine rehabilitation cases. The most severe injuries for all students were associated with the head

and spinal cord. All five deaths resulted from

injuries to the head.

Cause

Falls (either from the same surface or from elevation), organized sports or athletics, and unorganized play were the activities most frequently

associated with injuries (35,67). Sports activities

accounted for a relatively high rate of severe

injuries across studies. Comparison of the causes

among studies, however, is not feasible because

each study categorizes cause differently (69). To

compound the problem, many studies approach

the characterization of each cause differently.

For example, Boyce et al. defined cause as “self,

other student intentional, other student accidental, playground or sports equipment, mechanical

equipment, and athletics,” whereas Sheps and
Chapter 3 Injury to Students in School | 63

Evans included “fall, mechanical or object

related, struck by or against another person,

sports injury including drowning, and foreign

body in eye.” The Utah student report form gives

cause as a contributing factor, which includes

“common falls, fighting, collision, compression,

contact with equipment, hit with thrown object,

overexertion, and tripped/slipped.” These significant methodological variances must be resolved

before comparative data can be developed (69).

Locale

Not surprisingly, the most common locales for

school injuries were playgrounds, gymnasiums,

and athletic fields (10,27,56,73,99). Lenaway et

al. found that injuries on the playground, for

which data were collected only in elementary

grades, occurred close to three times more frequently than those in the gymnasium. Sheps and

Evans found that 29 percent of injuries were sustained on the playground. Comparatively, the

Boyce study estimate of 65 percent playground

injuries is high; however, it includes both playground and gymnasium.

Better supervision of elementary school children, especially on the playground, was a common study recommendation to reduce the risk for

falls and other injuries (22,77). Sheps and Evans

found an overall relative risk of 6.3 between

uncontrolled and controlled areas of the school

environment, suggesting that playground and

sports activities in school require more attention

and targeted prevention.

Injuries in school buildings, which include

auditoriums, classrooms, corridors, stairways,

and lab and shop facilities, represent a significant

portion of all injuries. The NSC reported that

they accounted for 24 percent of the injuries. The

Utah Department of Health data indicated that

students in grades 7-12 sustained 9.7 percent of

their injuries in lab activities and 5.4 percent in

classroom activities. There is a marked lack of

detailed information on exactly which classroom

activities caused the injuries. For example, it is

not known whether these injuries are occurring

in specific types of classes, such as industrial

arts, science, or home economics. Moreover,

there has been no evaluation of whether certain

locations are more frequently reported than others (e.g., sports injuries versus classroom injuries).

Type and Body Area

As found by Boyce et al., the majority of injury

types were those normally associated with playgrounds and athletics: swelling, bumps, cuts,

bruises, and sprains or strains (see table 3-2).

Elementary students sustained more minor injuries (e.g., contusions, abrasions, and swelling),

which accounted for the difference in rates

between elementary and high school students

(27,69) and the decreasing rate of injury in secondary school (27). Types of injuries and body

areas affected by injuries were distinct between

elementary and secondary students. Elementary

TABLE 3-2: Types of Injuries Among 

Students

Type of injury

No. (and percent) 

of injuries to

students

Swelling or bump 1,439 (27.1)

Cut 917 (17.3)

Bruise 740 (14.0)

Sprain 588 (11.1)

Scrape/scratch 382 (7.2)

Fracture 298 (5.6)

Chipped or broken teeth 180 (3.4)

Torn cartilage/ligament 83 (1.6)

Dislocation 65 (1.2)

Nosebleed 60 (0.1)

Loss of consciousness 22 (0.4)

Internal injury 13 (0.2)

Other 515 (9.7)

*The numbers and percentages were calculated from the 5,302

reported injuries among the Canadian schoolchildren attending the

schools included in the Feldman study. The type of injury was not

specified in 32 instances.

SOURCE: W. Feldman et al., “Prospective Study of School Injuries:

Incidence, Types, Related Factors and Initial Management,” Canadian Medical Journal 129:1279–83, 1983.
64 | Risks to Students in School

school students injured the head and face most

frequently, while secondary school students were

more likely to injure the upper extremities (69).

Secondary students suffered twice as many

sprains, strains, and dislocations as elementary

students; however, the rates of fracture, concussion, whiplash, and foreign body in the eye were

comparable (69). As expected, the predominant

injuries correlate with types sustained on playgrounds and athletic fields. With few exceptions,

studies failed to analyze injuries sustained in

classrooms. One study showed that classroom

injuries most frequently consisted of cuts and

abrasions, punctures, foreign bodies, and poison

or burns (43).

Fractures were the most frequent of the more

severe injuries. Feldman et al. reported that fractures accounted for 5.6 percent of overall injuries

and occurred primarily in the hand (34.2 percent), wrist (18.8 percent), and arm (12.4 percent). Boyce et al. found that 13 percent of all

injuries were fractures. In Utah, fractures represented the highest percentage of injuries for

grades K-6 (26.4 percent) and the second highest

for grades 7-12 (20.9 percent) (99).

Time, Day, and Month

Studies that have attempted to associate the time,

day, or month of injury with injury incidence

indicate that no one day had significantly more

injuries than any other (27,43,73). However,

injuries did peak at certain times during the day.

Both the Feldman and Lenaway studies reported

increased numbers of injuries during recess and

lunch hour; similarly, the Utah data revealed an

overwhelming majority (62.5 percent) of injuries

among students in grades K-6 occurring during

recess or lunch. This is not surprising given the

Sheps and Evans finding that there were six

times as many injuries in uncontrolled areas as

compared to controlled areas of the school environment.

Distribution trends of injuries by month were

also evident. Rates increased with the return to

school and the advent of warm weather that

allows more time outdoors. The highest frequency of cases was in September, followed by

October. The fall injury rates may be attributable

to the excitement of returning to school and to

football, the leading cause of sports injuries,

which is played during the fall months. Rates

rose again in January, as students return to school

after the holiday vacation. Of course, to the

extent that the pattern varies according to climate, injury rates may rise and fall at different

times of the year in different regions of the country (43).

Product and Equipment Involvement

The U.S. Consumer Products Safety Commission (CPSC) maintains the National Electronic

Injury Surveillance System (NEISS), which collects injury data from a national sample of hospital emergency departments (see box 3-1). NEISS

data is based on injuries that patients say are

product-related only; therefore, the injuries are

not necessarily caused by the product but only

related to the product. Non-product-related injuries are not included. Although collected using

school as a location, the data are not analyzed by

that criterion. At the request of OTA, the CPSC

produced raw data of injuries incurred at school

by persons aged 5 to 18. CPSC did not analyze

the data; the discussion below presents OTA’s

limited examination of the data by age, gender,

body part injured, and severity. If the CPSC regularly analyzed these data, national estimates of

school injuries, albeit only product-related injuries, could be provided. The NEISS data also

includes medical diagnoses that provide more

accurate information on the types of injuries

occurring in schools than reports filed primarily

by school staff.

Estimates from the 1993 NEISS data disclose

that persons aged 5 to 18 incurred 670,584 injuries requiring treatment in a hospital emergency

department. The younger children sustained the

fewest injuries, but as the children got older they

gradually incurred more injuries, peaking at age

14 or 15 and then gradually decreasing. Thirteen

to 17-year-olds combined sustained about 56

percent of the injuries—14- and 15-year-olds

alone accounted for nearly a quarter of all injuries.
Chapter 3 Injury to Students in School | 65

Finger and ankle injuries were the most prevalent, 113,357 and 90,977 injuries, respectively.

For 5- to 9-year-olds, head injuries were the most

frequent, followed closely by finger and wrist

injuries. Among 10- to 14-year-olds, finger injuries were the most prevalent; ankle and wrist

injuries followed at about half the number of finger injuries each. Face, head, and knee injuries

were each less than a third of finger injuries. For

15- to 18-year-olds, ankle injuries were the most

frequent. Finger and knee injuries were also

prominent injuries for this age group.

Ranking severity levels from 1 to 8 (8 meaning fatal), the most frequent severity level for 5-

to 9-year-olds was level 3, accounting for almost

a third of total injuries (31.7 percent). Severity

levels 2 and 4 accounted for another 41 percent.

There were zero injuries occurring in this study

for severity levels 7 and 8, and only 0.9 percent

of 5- to 9- year-olds had injuries of severity 6.

For 10- to 14-year-olds, the most frequent severity level was level 1, accounting for 32.5 percent

of the total injuries. Levels 2 and 3 accounted for

more than half of the total number of injuries.

The most frequent severity level for 15- to 18-

year-olds was likewise level 1, accounting for

32.9 percent of the total injuries. Levels 2 and 3

accounted for a little less than half of the injuries

incurred. While there were no injuries in 7 and 8

for students below age 15, for ages 15 to 18, 0.01

percent and 0.02 percent of the injuries were

severity level 7 and 8, respectively.

The CPSC also produces safety alerts concerning consumer products; these include products used in schools. Two 1988 CPSC Safety

Alerts involving mobile folding tables and audiovisual carts illustrate equipment hazards in

schools. Mobile tables in school cafeterias are

commonly 6 feet high when folded and weigh up

to 350 pounds. When moved in the folded position, they can tip over and seriously injure a student. CPSC received reports of four deaths and

14 injuries to students who were moving such

tables in the period 1980-1988, but the injuries

generally occurred during after-school or nonschool-sponsored events. Tip-over injuries also

occurred with audiovisual carts in classrooms: in

1988, CPSC reported four deaths and nine serious injuries of students aged 7 to 11. All incidents involved slant-top carts, but CPSC noted

concern over flat-top carts as well. Like folding

tables, the carts characteristically overturned and

injured the child pulling rather than the child

pushing them.

The Massachusetts SCIPP data considered

product involvement and concluded that 35.7

percent of school-related injuries involved products, 58.1 percent of which were structures (e.g.,

stairs, floors, walls, and fences) and sports or recreation equipment. Table 3-3 lists the types of

injury-causing products that present risks to students in schools. Approximately 50 percent of

the product-related injuries at school were sustained by 7- to 13-year-olds. Moreover, playground equipment is associated with about onehalf of the injuries to 6- to 10-year-olds that

involve sports or recreation equipment.

PLAYGROUND-RELATED INJURY DATA

Play is an integral part of each student’s school

day; it is a natural part of physical and cognitive

development. School playgrounds provide elementary and junior high school students with the

opportunity to develop motor, cognitive, perceptual, and social skills. The risk-taking part of that

activity is inherent in the learning process. In the

course of playing, however, children sustain

injuries. Indeed, playground injuries are the leading cause of injuries to elementary and junior

high students, ages 5 to 14, in the school environment. Relative to other school injury issues,

playground safety has attracted much public

attention and been the subject of considerable

study. Researchers have collected and analyzed

data on the nature, distribution, and prevention of

injuries sustained on public playgrounds, providing insight into the ability to control such incidents at schools.

❚ Sources and Limitations of Playground 

Injury Data

Because of the lack of national estimates of

school injuries, there are no data available for
66 | Risks to Students in School

comparing playground injuries to other school

injuries on a national level. It is clear, however,

from the state surveys and epidemiological studies focusing on school injuries, that playground

injuries are the primary cause of injuries in the

school environment for younger students. Definitional issues provided the greatest obstacle for

assessing the extent of such injuries. Depending

on the study, a playground injury could include

minor injuries as well as injuries necessitating a

visit to a doctor or to an emergency room. Moreover, some studies of playground injuries have

included all injuries sustained on playgrounds,

whereas other data, such as the CPSC’s NEISS

data, may only record injuries involving playground equipment.

OTA reviewed the following data sources: 1)

CPSC NEISS data; 2) state survey and study

data; 3) epidemiological studies; and 4) the 1994

U.S. Public Interest Research Group (PIRG) and

Consumer Federation of America (CFA) Playing

It Safe survey. Each source, as discussed in box

3-3, has substantial limitations for purposes of

this report. In addition, the sources have varying

sample populations and distinct methods that do

not allow cross-comparisons of conclusions.

❚ Incidence and Distribution of 

Playground Injuries

Mortality Data (Equipment-Related)

The 1990 CPSC Playground Equipment-Related

Injuries and Deaths report (the CPSC Report)

provides an analysis of data on playground injuries and deaths associated with playground

equipment. In the 16-year study period, 276

deaths of children were identified as playground

equipment-related, for an average of 17 deaths

each year. Fatalities among school-aged children averaged nine per year: approximately 50

percent to children under age 6, about 75 percent

to children under age 9, and 90 percent to children under age 12. The CPSC Report did not distinguish whether these occurred on public, home,

or homemade equipment. OTA could not identify national estimates of the number of total

playground non-equipment-related fatalities.

TABLE 3-3: Types of Productsa Involved with Injuries in School

Products

Percent of

school injuries

involving productsb

Structures and construction materials (e.g., stairs, floors, walls, fences) 29.2

Sports and recreation equipment 28.9

Furnishings, fixtures, and accessories 15.0

Powered and unpowered tools and workshop equipment (e.g., saws, drills, welding 

equipment, batteries, hoists) 7.1

Personal use items (e.g., clothing, pencils, pens) 6.1

Housewares (e.g., small kitchen appliances, drinking glasses, tableware, cutlery, cookware) 5.2

Food, alcohol, and medicine 1.9

Packaging and containers (e.g., cans, containers, glass bottles) 1.8

Heating, cooling, and ventilating equipment (e.g., radiators, fans, heating devices) 1.5

Communications, entertainment, and hobby equipment 0.5

Appliances 0.3

Miscellaneous 2.6

aThese are the products involved with injuries at school to 1,704 children 5 to 19 years old in 14 Massachusetts communities, September 1979–

August 1982. Products classified according to codes shown in United States Consumer Product Safety Commission (1987) and aggregated to

general reporting levels commonly employed by the Commission (see, e.g., United States Consumer Product Safety Commission). Products are

associated with an injury, but are not necessarily the cause of the injury.

bProducts are involved with 35.7 percent of all school injuries.

SOURCE: From Harvard Injury Prevention Research Center analysis of injuries from SCIPP Injury Surveillance System data.
Chapter 3 Injury to Students in School | 67

BOX 3-3: Sources of Data on Playground Injuries in School (Cont’d.)

National data

The only national data for playground injuries are derived from CPSC’s National Electronic Injury Surveillance System (NEISS) database, which keeps statistics on playground equipment-related deaths and

injuries that are recorded in hospital emergency rooms. NEISS records only fatalities that are productrelated injuries and, accordingly, excludes those that occur on playgrounds but are not equipmentrelated. Moreover, NEISS collects only emergency room data, providing only information on the more

serious playground equipment-related injuries. NEISS reports on playground equipment that is public,

used at home, or homemade.

In April 1990, CPSC published a report entitled Playground Equipment-Related Injuries and Deaths.

For the report, CPSC examined 1973–89 NEISS fatality data, CPSC files containing death certificate information, consumer complaints, newspaper clippings, and other sources to obtain fatality data. Nonfatal

injury data were obtained from a special study of NEISS data that analyzed information from April to

December 1988 (which was extrapolated to a full year). For both mortality and morbidity estimates, the

data were limited to children under age 15.

From analyses of playground injury data, CPSC published playground equipment safety guidelines in

1991. The guidelines are intended for those who purchase, install, maintain, and use playground equipment; however, they are not mandatory (see box 3-4). In addition, more technical standards that are voluntarily applicable to manufacturers have been devised by the American Society for Tests and Materials

(ASTM).

State data

OTA identified six states that have some data on school playground injuries. These are the best

sources of data for school playground injuries because injuries are reported in relation to other schoolrelated injuries and include minor as well as serious injuries. Moreover, the data are not limited to injuries

associated with playground equipment but include all injuries sustained on school playgrounds. Hawaii,

South Carolina, Utah, and Washington include playground injuries in their surveys and studies of the

entire range of school injuries, as reviewed in the previous section (see box 3–2). The data has been

used by these states to develop safety programs. The Utah school injury data was used to design a curriculum guide for promoting playground safely in schools. Furthermore, the Utah data were also used for

a 1993 study by the Centers for Disease Control and Prevention (CDC) of injury rates from falls for grades

K–6 students on Utah playgrounds. The analysis was restricted to injury report forms detailing a fall

involving equipment on the playground or athletic field. Arizona and Virginia have completed studies that

focus specifically on school playground injuries.

The Arizona Department of Health Services completed a comprehensive school playground injury

study from 1991 to 1992. However, the study included athletics and sports, so estimates are not

restricted purely to playground-related injuries. It evaluated 212 elementary schools including 122,056

students in grades K–8, representing 29 percent of that population. Student health personnel were

required to complete a report form when an injured student either 1) was sent home, 2) was sent to a physician, 3) was transported or admitted to a hospital, or 4) required restricted activity. The study was

intended to reduce the number of injuries by providing the opportunity to target appropriate interventions.

In 1991, the Virginia Department of Education conducted a study on the safety of school playgrounds in that state. However, significant methodological problems with both the survey and the

responses limit the reliability of those data. As part of the study, the Department of Education surveyed 75

school districts, of which 65 responded. The districts, representing 348,976 students enrolled in schools

that had playgrounds, reported the numbers and types of injuries sustained on school playgrounds; there

was no information relating to the grade, age, or sex of the students. One of the major problems of the

study was the inconsistent reporting. For example, school districts reported 5,708 total injuries but 12,734

injuries when classified by type, resulting in a more than twofold disparity in the number of injuries.

(continued)
68 | Risks to Students in School

Strangulation resulting from entanglement and

entrapment was the primary cause of fatalities; it

was responsible for about 47 percent of the

deaths. However, these deaths typically involved

children under the age of 5, not school-aged children. Falls were the second highest cause of

death (31 percent). The authors noted, however,

that the number of falls is probably underreported, since in 1983 the CPSC ceased collecting

death certificate information involving accidental falls except for one or two states (75). For

fall-related deaths, the associated equipment

included swings (52 percent), slides (24 percent),

and climbers (17 percent). Equipment tipover or

failures were associated with 13.5 percent of the

deaths.

Morbidity Data

For each death on playgrounds there were

approximately 14,000 emergency room visits for

treatment of playground equipment-related injuries. In 1992, public playground equipment injuries were responsible for approximately 241,180

visits to emergency rooms.14 The American

Academy of Orthopedic Surgeons estimated the

total cost of playground equipment-related injuries to children under age 15 at $1 billion in

1992.15 There are no national estimates encompassing the complete extent of school playground injuries since the CPSC estimate is

limited to equipment-related injuries and does

not include injuries treated at schools, homes,

and doctors’ offices; however, it provides estimates of injuries by location, age, and time.

For each death on playgrounds there were

approximately 10,000 emergency room visits for

treatment of playground equipment-related injuries. CPSC projected about 200,000 playground

equipment-related injuries in 1988; however,

when adjusted by the proportions of verified

cases for the CPSC Report, the number was

reduced to about 170,000 (75).16 Public equipment was involved in 70 percent of these injuries; home equipment and homemade equipment

accounted for 24 and 4 percent, respectively.

Most of the public equipment injury incidents

occurred in school playgrounds and public parks,

14 “Public playground equipment” refers to “equipment intended for the use in the play areas of parks, schools, childcare facilities, institutions, multiple family dwellings, restaurants, resorts and recreational developments and other areas of public use” (83). 15 Costs include, but are not limited to, medical and travel expenses for initial and follow-up treatment, forgone earnings of the injured

child’s visitors, and disability costs. 16 From April to December 1988, CPSC completed an in-depth special study of selected playground injury incidents. The study identified

cases involving injuries that were not associated with outdoor playground equipment. Extrapolating the percentage of these cases to the 1988

NEISS, CPSC determined that the estimated 201,400 emergency room-treated playground equipment-related injuries should be reduced to

170,200. The special study was limited to 1988 data.

Epidemiological studies

State school injury data and epidemiological studies of the percentages of school playground injuries

in relation to other school injuries are remarkably consistent. The epidemiological studies discussed earlier provide valuable insight into the incidence of playground injuries, because many of the epidemiological studies, as discussed in box 3-1, cover the complete school injury experience, allowing playground

injuries to be studied relative to other school injuries. The epidemiological study conducted in Tucson,

Arizona, by Boyce et al. (1984) evaluated playground injury data separately from other school injuries.

There are also a number of studies that concentrate on playground injuries alone, in particular Sosin’s

study of the surface-specific injury rates on Utah school playgrounds and Bond and Peck’s study of injuries on Boston playgrounds.

SOURCES: Office of Technology Assessment, 1995. Bond, M.T., and Peck, M.G., “The Risk of Childhood Injury on Boston’s Playground Equipment and Surfaces,” American Journal of Public Health 83:731–733, 1993. Sosin, D.M., et al., “Surface-Specific Fall

Injury Rates on Utah School Playgrounds,” American Journal of Public Health 83:773–735, 1993.

BOX 3-3: Sources of Data on Playground Injuries in School (Cont’d.)
Chapter 3 Injury to Students in School 69

each accounting for approximately 42 percent of

the 1988 estimated injuries incurred on public

playgrounds. Using this data, OTA calculated

that approximately 30 percent of publicly owned

playground equipment injuries occurred on

school playgrounds. Furthermore, 13,000 playground equipment-related injuries to school-aged

children occurred on school playgrounds during

school hours, which is about 8 percent of playground equipment-related injuries.

The CPSC’s most current estimate of 241,181

playground equipment injuries requiring treatment in hospital emergency rooms in 1992 has

not been adjusted in the manner of the 1988 data.

The estimate includes 168,827 public playground

equipment, 57,883 home playground equipment,

and 14,471 homemade playground equipment

injuries (84).

Playground injuries were the most prevalent

of all injuries sustained by students in school,

accounting for 30 to 45 percent of all schoolrelated injuries reported in the available state

data (see figure 3-2). This is also true of the epidemiological studies; the percentages of playground injuries ranged from 29 to 43 percent of

total school injuries. The percentages are even

higher when limited to children in grades K-6.

For example, Utah reported that playground injuries accounted for about 65 percent of all school

injuries for those grades. Besides being the most

prevalent, playground injuries represented some

of the most severe injuries ( 11 ,27). Boyce et al.

found that a quarter of the playground injuries

were severe, meaning that they resulted in concussions, crush wounds, fractures, and multiple

injuries.

Unlike school injuries in general, there was no

significant difference between the frequency of

injuries suffered by boys and girls (1 1,71 ,75).

For all children, the body area most frequently

affected by playground equipment-related injuries-was the head and face (47 percent), followed

by the arm and hand (34 percent). Children under

the age of 6 were significantly more likely to sustain an injury that involved the head or face (60

percent) than the arm or hand (20 percent). Inju4 0 ;

3 0 -

2 0 -

l o -

0

Hawaii South Carolina Washington Utah

SOURCE Office of Technology Assessment, 1995, based on Hawaii

Department of Education, “Summary-School Accident Report, 1989-

1990” (Honolulu, HI: 1991), Washington State Department of Health,

Office of Community Environmental Health Programs, The School

Injury Surveillance Project” Results and Recornrnendations (Olympia,

WA 1990); South Carolina Department of Health & Environmental

Control, Division of Children’s Health, Annual School Nurse Survey

7993 (Columbia, SC 1994), and Utah Department of Health, Division

of Family Health Services, Student Injury Report Database, 1988-

1992

ries were more equally distributed across body

areas for children ages 6 and over (75).

The types of injuries most frequently sustained on playgrounds were abrasions, contusions, sprains, dislocations, lacerations, and

fractures (3,75). The percentages reported by

CPSC were as follows: 29 percent lacerations, 28

percent fractures, 22 percent contusion/abrasions, and 13 percent strain/sprains. Lacerations,

contusions, and abrasions—relatively minor

injuries—were associated with 81 percent of the

head injuries; however, 7 percent of the head

injuries were potentially more serious, involving

fractures, concussions, and internal injuries.

Fractures were the most frequent arm and hand

injuries, accounting for 65 percent. Strains and

sprains accounted for another 22 percent of the

arm and hand injuries (75).

The Arizona Department of Health playground study found that 72 percent of the students with reportable injuries were taken to a
70 Risks to Students in School

doctor or the emergency room: 38 percent were

taken to the doctor by parents, about 19 percent

were taken to the emergency room by parents,

and about 15 percent were taken to the doctor or

emergency room by school personnel. Of these

students, 1 percent were hospitalized with a

mean stay of 1.9 days (the longest was 7 days),

Moreover, 15 percent of the students taken to a

doctor or emergency room required restricted

activity for an average of 13.6 days (the longest

being 120 days). The study estimated that in Arizona the 10,500 school playground injuries

resulted in 6,500 days of absenteeism, 4,300 doctor visits, and 2,000 emergency room visits.

Many of the studies focused on the association

between playground equipment and injuries.

Boyce et al. found that about 23 percent of the

total injuries across all grades in public schools

were associated with playground equipment; the

rate of playground equipment-related injury at

the schools was about 0.9 playground equipment

injury per 100 student years (1 1). 17 Lenaway et

al. found that playground-related equipment injuries alone accounted for 38 percent of all school

injuries, the rate of injury being about 2.4 per

100 students (43). The equipment most often

involved in injury-causing events were climbers,

swings, and slides (see figure 3-3). Among 5- to

14-year-olds, climbers and swings accounted for

71 percent of injuries (75). Other equipment

commonly involved in playground injuries

included slides (15,5 percent) and teeter-totters

and seesaws (3.4 percent) (75). Across studies,

remarkably similar percentages were reported

(3,9,43).

As shown in figure 3-4, falls associated with

playground equipment present the greatest risk to

students. Falls from climbing equipment

accounted for nearly 25 percent of the injuries on

public playgrounds (75) and a disproportionate

number of severe injuries (11). The body areas

See-saw

1% Climbers

37%

Other

3%

SOURCE: National Electronic Injury Surveillance System (NEISS)

Special Study, Apr,-Dee, 1988, U.S. Consumer Product Safety Commission/EPHA.

most affected by falls to the surface were arm

and hand (47 percent) and head or face (36 percent). The overwhelming majority of serious arm

and hand injuries resulted in fractures (70 percent).

18 Falls to the surface involved mainly

climbers, swings, and slides. In fact, falls to the

surface from climbers accounted for 23 percent

of all the playground equipment-related injuries;

surface falls from swings and slides accounted

for approximately 16 and 13 percent, respectively.

Although climbers, slides, and swings

accounted for about 87 percent of the overall

playground injuries, CPSC found that the proportion of injuries attributed to each type of playground equipment was nearly equivalent to the

proportion of each type of equipment used, suggesting that no one type was particularly more

risky than any other (75). While no analysis was

17 The study also found that higher incident rates correlated with two ecologic variables, small student enrollment and ‘he Presence ‘ f

alternative education programs (e.g., magnet schools). Alternative schools had a mean injury rate of 1.37 per 100 student years compared to

0.71 in other elementary schools (10).

18 Serious head injuries due to falls from heights of more than 4.5 feet were reported. There did not appear to be a strong correlation

between diagnosis and the distance of the fall; however, some fractures, to the wrist and collarbone, occurred at falls from heights of two feet

or less (75).
Chapter 3 Injury to Students in School 71

Impact (moving equipment)

13%

SOURCE. National Electronic Injury Surveillance System (NEISS)

Special Study, Apr.-Dec. 1988. US. Consumer Product Safety Commission/EPHA

completed relating the state of the equipment to

the injury rate, three-quarters of the equipment

involved in injuries was reported in good condition and only one-tenth of the equipment was

reported to be abused, scarred, rusted, or broken.

The study, however, did not consider whether

there was good protective surfacing, or whether

the playground equipment was adequately

spaced or at a safe height.

The available studies on the adequacy of surfacing on public playgrounds have, without

exception, found that most playground surfacing

is unsafe. A study of Boston playgrounds conducted by the Childhood Injury Prevention Program of the Boston Department of Health and

Hospitals found that all the surfaces observed

were unsafe (9). Sixty-four percent of the surfacing was appropriate (matting, sand, or wood

chips) but poorly maintained—making it unsafe.

The remaining 36 percent was unsafe due to

unsuitable playground surfacing material

(asphalt, grass, bare ground). Similarly, a survey

of 57 elementary schools around Philadelphia

revealed that 99 percent of climbers and slides,

equipment associated with many injuries, were

placed on inappropriate surfacing of asphalt or

packed dirt (65). A 1994 study performed by the

PIRG and CFA, Playing It Safe, presented the

findings from observation of 443 playgrounds in

22 states (102). Consistent with the above findings, 92 percent of the playgrounds lacked “adequate protective surfacing,” meaning loose fill

material (e.g., hardwood chips) properly maintained at depths of 9 to 12 inches under or around

19 Thirteen percent had hard sur- all equipment.

faces under and around all equipment, a substantial decrease from the 31 percent found in 1992.

For playground injuries, the problem is not so

much lack of data, but rather the lack of the necessary implementation of the safety recommendations and rigorous maintenance of playground

equipment. Based on CPSC and other epidemiological studies, voluntary guidelines for safe

playgrounds have been devised, and intervention

and prevention strategies have been developed

(see box 3-4). Short of developing mandatory

playground standards, those responsible for the

construction and maintenance of playgrounds

should be included in efforts to make playgrounds safe and to minimize injuries. Box 3-5

illustrates the impact a successful playground

safety program can have on preventing injuries.

Physical playground site safety should also be

combined with staff supervision of the students.

Programs designed to increase supervision have

resulted in reductions of injuries (77).

SCHOOL ATHLETIC INJURY DATA

By participating in physical education and interscholastic sports, students benefit from the

advantages of regular exercise (33), the opportunity to develop motor and judgment skills, and

participation in competitive team sports. Engaging in sports activities entails some risk of being

19 Of the 443 playgrounds observed for the PIRG and CFA Playing It Safe report, 62 percent had loose fill surfacing but only 3 percent

. .

maintained the loose fill at an adequate depth of at least 9 inches. In addition, 19 percent had loose-filled surfacing under some equipment,

but hard surfaces under other equipment. Only 5 percent of the playgrounds had synthetic surfacing, such as premolded rubber tiles, under

and around all equipment.
72 | Risks to Students in School

BOX 3-4: Playground Guidelines and Standards

Public playgrounds cannot exist without injuries. Due to the nature of the playground equipment,

potential hazards exist, even when safety standards are met and maintained. The U.S. Consumer Product

Safety Commission (CPSC) and the American Society for Testing and Materials (ASTM) have published

safety standards for playground equipment to minimize the risk of injuries.

The guidelines recommended by the CPSC are based on a March 1990 report by the COMSIS Corporation. The CPSC handbook, which evaluates the safety of each individual piece of playground equipment along with the entire layout of the playground, is intended for school officials, parents, equipment

purchasers, recreation personnel, and anyone else concerned with general playground safety.

ASTM guidelines provide a more technical approach than CPSC standards. Guidelines recommended

by the ASTM, published in December 1993, are directed toward equipment manufacturers, designers,

and playground planners rather than toward the general public. ASTM standards focus on technical

details, including testing information, and are stricter and more extensive than the CPSC standards.

However, these guidelines and standards, which include design, layout, installation, construction, and

maintenance, are not mandatory. Schools, child centers, parks, and other public facilities must voluntarily

upgrade and maintain the equipment and surrounding areas to help prevent injuries and deaths resulting

from incidents related to playground equipment.

Many of the injuries and deaths related to playground equipment can be prevented by providing safer

playground equipment. By limiting the height of equipment and providing adequate fall zones and protective

surfaces, many injuries and deaths caused by falls would not occur or would be less severe. These injuries

could also be prevented by providing adequate protective surfacing. Of 443 playgrounds investigated by the

Public Interest Research Group (PIRG) and CFA using CPSC standards, 92 percent did not maintain adequate protective surfacing under and around equipment. Since 1992, fewer playgrounds surveyed had hard

surfaces (from 31 percent in 1992 to 13 percent in 1994), such as asphalt and concrete, below the equipment.

According to the guidelines, protective materials should be soft so as to reduce the severity of injuries

due to falls. Hard surfaces, such as asphalt, concrete, grass, and packed dirt, do not provide enough

protection. Loose-fill materials like sand and hard wood chips, along with unitary synthetic surfaces such

as molded rubber tiles, are acceptable when maintained properly. Maintenance of the materials requires

keeping proper depths (compressed or uncompressed). Depending on the type of equipment and distance a child might fall, different materials gave different critical heights. For example, compressed double shredded bark mulch at a depth of 9 inches had a critical height of 7 feet, while uncompressed

double shredded bark mulch’s tested critical height was 10 feet. A difference in critical heights is also

seen when comparing wood mulch (10 feet) to fine sand (5 feet) at uncompressed depths of 9 inches.

Adequate fall zones may be often missing. Often protective surfaces did not extend far enough

around the equipment, or other structures are built too close. Again, depending on the type of equipment,

varying fall zones are recommended. For instance, for a single-axis swing set, CPSC recommends a distance of 6 feet from the perimeter of the supports and a distance that is twice the greatest possible

height, both in front of and behind the swings, as a safe fall zone that should have protective surfaces.

Another problem is that in building the structures recommended, height limitations are not always

adhered to. Instead, some structures, such as climbers and slides, are built so that if a child falls from

them, there is a greater potential for injury than if it was a smaller structure that was equally challenging

yet less dangerous. Height limitations depend on the type of equipment, and also on the age of the children using it. For instance, older students have more muscle control and better natural instincts (e.g., to

risk an arm to protect the head) than younger children. Therefore, the structures intended for older student use could be built at greater height without a proportionate increase in danger.

SOURCES: U.S. Consumer Product Safety Commission, Handbook for Public Playground Safety, 1991; U.S. Public Interest

Research Group and Consumer Federation of America, Playing it Safe: A Second Nationwide Safety Survey of Public Playgrounds, May 1994.
Chapter 3 Injury to Students in School | 73

BOX 3-5: An Effective Injury Prevention Program

After seeing many children come into the trauma unit with injuries incurred on the playgrounds or indirectly caused by the lack of playgrounds, Barbara Barlow, MD, director of pediatric surgery at the Harlem

Hospital Center in New York City, decided to start an injury prevention program. Founded in 1988 and

based at the Harlem Hospital Center, the Injury Prevention Program (IPP) has three main targets: playground injury prevention, motor vehicle/pedestrian/bicycle injury prevention, and window guards to prevent falls. Other projects have also grown out of the IPP, such as art and dance programs to keep

children off the streets and away from drugs and gunfire.

Working with public schools, state and community agencies, and volunteers from the community, the

IPP has contributed to the reduction of the number of children patients at the Harlem Hospital Center.

From 1988 to 1993, a reported 38 percent decrease in major trauma and 42 percent decrease in major

injury admissions involving children of Central Harlem has occurred (IPP, 1994). Project Oasis and Safety

City are two exemplary programs of the IPP that have aided in the dramatic decrease in childhood injuries. These programs implement key parts of the IPP mission: upgrading playgrounds at school, introducing safety features, and teaching the children how to safely encounter traffic situations, such as crossing

the street.

Project Oasis focuses on improving the safety of school playgrounds and creating gardens for the

schoolchildren. Before the involvement of IPP, school playgrounds often consisted of concrete slabs and

rusty monkey bars. While school officials recognized the need to upgrade the playgrounds, monetary and

labor resources were not readily available. With the efforts of IPP, the resources were found in grants and

contributions of both money and labor. Safety improvements included rubber matting below swings,

slides, and jungle gyms; rounded corners on the wooden structures; and railings on elevated structures.

These features, among others, have considerably reduced the occurrence of preventable playground

injuries, and consequently have reduced the risks of the children at the schools that have reconstructed

playgrounds. Since 1988, IPP has completed the reconstruction of four playgrounds and has plans for

four more playgrounds at Harlem schools (IPP, 1994).

In addition to rebuilding playgrounds, the IPP has joined forces with the New York City Department of

Transportation and the New York public schools to establish Safety City, a program that educates students about traffic safety. With few suitable playgrounds available, children often turn to the streets as a

place to play; as a result, motor vehicle crashes have been a leading cause of death and injury to New

York City children. Safety City teaches third-grade students in the community street safety skills in a fullsize yet protected street section built on the school grounds. The children are able to learn street safety in

the fenced-in area, which includes real trucks and cars, street signs and signals, and other street paraphernalia. The realistic approach to learning has dramatically reduced the number of preventable deaths

and injuries due to traffic accidents involving children. Since the onset of the program, hospital admissions for accidents involving motor vehicles and pedestrians have dropped by 5 percent (IPP, 1994). The

IPP has prevented numerous injuries and deaths by successfully teaching the children of Harlem the

importance of street safety.

SOURCES: T. Hiss and E. Koren, “Child’s Play: New York’s Best Places to Play,” The New Yorker 69(14):80, May 24, 1993; Injury

Prevention Program, “Injury Prevention Using Community Coalitions,” unpublished article sent by IPP, New York, NY, 1994; R.

Mora, “The Creative Playground/Outdoor Learning Center,” Children’s Environments Quarterly 8(1):59–62, 1991; New York City

Department of Transportation, “Safety City,” New York, NY, June 1992; “An Ounce of Prevention: ED’s Outreach Efforts to Reduce

Childhood Injuries,” ED Management, April 1994, pp. 59–61; “Project Oasis: New Playground and Garden Thrive in Harlem,”

Columbia Community Affairs, January 1994, p. 15; A.A. Sgarro, “A Surgeon and Her Community,” Vassar Quarterly, spring 1993,

pp. 10–13; “The Unique Safety Street in Harlem,” Childhood Injury Prevention Quarterly, fall 1992, p. 5.
74 | Risks to Students in School

injured as all such activities involve some degree

of danger. In 1993, approximately 5.6 million

students competed in high school athletics

(51)—about 43 percent of high school students

(85). Student participation in athletic activities is

a principal cause of junior high and high school

injuries and results in a significant number of

debilitating injuries and deaths each school year.

Compared to the number of studies on sports

injuries in general, few have been directed specifically at school athletic injuries. Most studies

survey all sports injuries, including recreational,

community, or school athletic activities. This

lack of school specific data makes it difficult to

draw conclusions regarding athletic-related injuries occurring only in the school environment.

The majority of information focuses on junior

high and high school student sports injuries primarily because these students are typically the

segment of the school-aged population participating in athletics, and thus sustaining the majority of athletic injuries.

❚ Sources and Limitations of Athletic 

Injury Data

The major sources of school athletic injury data,

as shown in box 3-6, are the National Center for

Catastrophic Sports Injury Research, CPSC’s

NEISS database, the National Athletic Trainers

Association, and epidemiological studies. In

addition, the American Academy of Pediatrics

publication Sports Medicine: Health Care for

Young Athletes reviews sports injury studies,

although they are not limited to schools. Sources

providing athletic injury data suffer from the

same problems as organizations reporting injury

data in general. Limitations of studies typically

include: underreporting, inconsistent definitions

of athletic injury, inaccurate reporting of injuries,

unavailability of athletic exposure times, discrepant criteria for classifying severe or serious

injury, and inability to control for certain variables (33).

School sports injuries, or risks, are expressed

in a number of ways in different studies, including: 1) total number of injuries, 2) percentage of

overall injuries that occur in school, 3) number of

injuries per student population, 4) number of

injuries per student population participating in a

particular sport, 5) number of injuries per athletic

season, and 6) number of injuries per duration of

athletic exposure (days or hours). Risk is portrayed most accurately by the number of injuries

per duration of athletic exposure because it

adjusts for differences in the lengths of seasons

(64). As typically used, athletic exposure means

“one athlete participating in one practice or contest where he or she is exposed to the possibility

of an athletic injury” (64). The other measures

used and the different indices of severity (for

example, missed academic days and missed practices or competition days) inhibit cross-comparison of studies.

Epidemiological studies are directed at determining the distribution or rate of health injuries

that result from athletic participation. Most often,

the studies focus on a particular problem associated with a single sport. Few studies have examined the range of athletic injuries in the school

environment; physical education injury studies

are particularly lacking. The major school sports

injury studies include those of Garrick and

Requa (31), Zaricznyj et al. (104), and Rice (64)

(see table 3-4). Both the Garrick and Requa and

the Zaricznyj et al. studies are over a decade old,

and each was a study in one city. In 1978, Garrick and Requa published their study of student

athletes in four high schools in Seattle, Washington, over a two-year period, 1973-75 (31). In

1980, Zaricznyj et al. studied reports of injuries

to all school-aged children and adolescents in

Springfield, Illinois, from 1974 (104). The

Zaricznyj study evaluated all types of injuries

sustained during participation in physical education, school team sports, community team sports,

and nonorganized sports.

Rice studied sports injuries in 20 high schools

in the Seattle and Puget Sound areas of Washington state since 1979. He established a sports

injury surveillance system and instructed

coaches in record keeping and completing a

Daily Injury Report (DIR) to record the participation status and types of injuries at practices
Chapter 3 Injury to Students in School | 75

BOX 3-6: National and State Sources of Data on Sports Injuries in Schools

The National Center for Catastrophic Sports Injury (the Center) at the University of North Carolina

records catastrophic injuries occurring in all high school and college sports for both men and women.

Since 1982, researchers have recorded catastrophic injuries in high school sports nationally. The Center

is funded by grants from the National Collegiate Athletic Association, the American Football Coaches

Association, and the National Federation of State High School Associations. The Center was founded, in

part, to counter the lack of sports injury data, particularly for women. Data are collected from coaches,

athletic directors, executive officers of state and national athletic organizations, a national newspaper

clipping service, and a team of researchers. When the Center is notified of a possible catastrophic injury,

the injured player’s coach or athletic director is contacted by telephone, personal letter, and questionnaire. The most current edition of the data reviews information collected from the fall of 1982 to the spring

of 1992.

The Center defines catastrophic injury as any severe injury incurred during participation in a sport.

Catastrophic includes three degrees of injury: fatal, nonfatal, and serious. Nonfatal injuries are those

resulting in permanent severe functional disability, while serious injuries result in severe injury without permanent functional disability (i.e., a fractured cervical vertebra with no paralysis). The Center also categorizes injuries as direct or indirect—direct meaning those injuries that resulted directly from participation in

the skills of the sport; indirect meaning those injuries that were caused by systemic failure as a result of

exertion while participating in a sport activity or by a complication that was secondary to a nonfatal injury.

The CPSC’s NEISS database (see box 3-3) contains national estimates of the number of nonfatal injuries incurred by school-aged sports participants; currently the data are not analyzed using school as a

location for injury. However, these data can be broken down by age and location to give some sense of

sports injuries at school. NEISS data, however, include only those injuries involving consumer products

and come from a sample of patients in hospital emergency rooms. Many athletic injuries are never seen

in hospital emergency rooms but are tended to by sports trainers or doctors. Moreover, hospital emergency room data inherently contain a selection bias since, except for the most serious injuries, the cost of

emergency care affects the decision to seek medical care. CPSC also identifies sports-related deaths

from NEISS data and other data sources (death certificates, newspaper clippings, consumer complaints,

and medical examiner reports).

The National Athletics Trainer’s Association (NATA) completed a single-year sports injury surveillance study. The 1986 study was based on medical records of 32,647 of the estimated two million high

school athletes participating in football, basketball, and wrestling. NATA extrapolated from the injuries

incurred in those three sports to include all other sports. The authors recognized that the study included

only those schools that had certified athletic trainers or the equivalent on staff, which only includes 16 to

18 percent of all schools. The fact that these schools have that level care probably indicates that they are

more likely to be sensitive to preventing athletic injuries.

In addition, the Kansas Department of Health and Environment completed a survey of athletic injuries in secondary schools during the 1990–91 academic year. The survey covered a random sample of

283 schools, with 162 responding. Injuries were reported for grades 7 to 12, but rates were calculated

only for grades 9 to 12.

SOURCE: Office of Technology Assessment, 1995.
76 | Risks to Students in School

TABLE 3-4: School Athletic Injury Studies

Garrick and Requa

(1978)

Zaricznyj et al.

(1980)

Rice

(1992)

Location Seattle, WA Springfield, IL Seattle, WA (Puget Sound area)

Population 

studied

3,049 high school student sport 

participants

25,512 school-aged children 6,057 high school athletes

Method of 

assessment

An athletic trainer was assigned 

to each of the four high schools 

studied to collect case and 

control data on injuries to 

athletes.

For one year, reports were 

received from principals and 

coaches of all 53 public and 

private schools, supervisors of 

community sports programs, two 

hospital emergency rooms, 

schools’ accident insurance 

company and local physicians.

Coach or student trainer, adult 

athletic trainer, or manager 

reported injuries on a “Daily 

Injury Report,” which was 

completed daily and submitted 

monthly.

Reportable 

injury

A medical problem resulting 

from athletic participation 

necessitating removal from a 

practice or competitive event 

and/or resulting in missing 

practice or competitive event.

Any traumatic act against the 

body sufficiently serious to have 

required first aid, filing of school 

accident reports, or medical 

treatment.

A medical problem resulting 

from athletic participation 

necessitating removal (or limiting 

participation) from a practice or 

competitive event and/or 

missing a subsequent practice 

or competitive event. An injury 

implies a time loss—either 

missing a practice or game or 

participating on a limited basis.

Incidence of 

injury

39 injuries per 100 student 

participants

About half of all sports injuries 

sustained by school-aged 

children in the community 

occurred in physical education 

class (15 percent) and 

organized school sports (38 

percent).

32.7 injuries/100 athletes/

season and 7.8 injuries/1,000 

athletic exposures. Mean injury 

time loss (practices and games) 

was 4.6 days.

Severe/

serious

Severe injury: indexes of the 

severity of injuries sustained 

include time lost (from practice 

and /or events), the necessity for 

special diagnostic tests (e.g., xray films) or the need for 

physician consultation, 

hospitalization, or operative 

procedures.

Serious injuries: injuries causing 

disruption of one or more 

supporting structures of the 

body or damage to important 

organs (e.g., brain, liver, kidneys 

etc.).

Permanent injuries are those in 

which body structure was not 

restorable to its original 

anatomy or function, such as a 

broken tooth.

Severity categorized by the 

amount of time lost from full 

unrestricted participation. 

Injuries that kept an athlete from 

participation are minor, those 

with time loss between one and 

three weeks are significant and 

those with time loss over three 

weeks are termed major.

Incidence of 

severe/

serious

About 75% of the injured 

students returned to practice 

with fewer than five days of 

practice or competition missed. 

42% were examined by a 

physician (note: 53% of wrestling 

injuries were examined by a 

physician).

20% of the injuries were serious. 

About half of the serious injuries 

were related to schools sports, 

physical education (27%), and 

organized team sports (25%). 

Nonorganized sports accounted 

for about 48% of the serious 

injuries.

1.8 significant injuries/1,000 

athletic exposures.

0.5 major injuries/1,000 athletic 

exposures.

(continued)
Chapter 3 Injury to Students in School | 77

and contests. The participation status indicated

whether each athlete was present at full participation, present but participating on a limited

basis only, unable to participate due to injury, or

not at practice (absent or sick).

❚ Incidence and Distribution of Athletic 

Injuries

Mortality Data

The only national school sports injury mortality

figures are compiled by the National Center for

Catastrophic Sports Injuries Research (the Center). The Center limits its research to certain high

school and college sports and does not include

physical education. Over the 10 years of study

from the fall of 1982 to the spring of 1992, 200

high school deaths were reported (67 direct and

133 indirect), an average of approximately 20

sports-related deaths annually (49) (see table 3-

5). Direct deaths are those resulting directly from

an injury sustained from participation in the

skills of the sport. Indirect deaths are those

resulting from a systemic failure due to exertion

while participating in a sport activity or by a

complication that was secondary to a nonfatal

injury, such as overexertion resulting in cardiac

failure or heat exhaustion.

Sports with 

highest injury 

rates

Highest rates were in: football 

(81/100) and wrestling (75/100). 

Overall sport injury rates were 

lower in the second year of 

study, primarily due to 

elimination of trampoline as a 

competitive event.

Highest injury to participant 

ratios in school team sports were 

football (28%), wrestling (16%), 

and gymnastics (13%).

ALL INJURIES

football: 70.6 injuries/athlete 

season; 15.1 injuries/1,000 

athletic exposures.

girls’ cross-country: 58.8 injuries/

athlete season; 14.7 injuries/

1,000 athletic exposures.

Overall: football (19%), 

basketball (15%), gym games 

(11%), baseball (10%), and 

roller-skating (6%).

PE class: of 594 injuries, 

basketball (142), gym activity 

(164), gymnastics (44), volley 

ball (45), and football (40).

School sports teams: of 229 

injuries, football (126), 

basketball (29), wrestling (27), 

and track and field (23).

boys’ cross-country: 55.3 

injuries/athletic season; 13.1 

injuries/1,000 athletic exposures.

girls’ soccer: 41.4 injuries/athlete 

season; 10.2 injuries/1,000 

athletic exposures.

wrestling: 41.9 injuries/athlete 

season; 9.5 injuries/1,000 

athletic exposures.

SIGNIFICANT INJURY RATES

football: 3.8 injuries/1,000 

athletic exposures.

boys’ cross-country: 3.5 injuries/

1,000 athletic exposures.

wrestling: 3.2 injuries/1,000 

athletic exposures.

girls’ cross-country: 2.9 injuries/

1,000 athletic exposures.

girls soccer: 2.2 injuries/1,000 

athletic exposures.

MAJOR INJURY RATES

wrestling: 1.2 injuries/1,000 

athletic exposures.

football: 1.1 injuries/1,000 

athletic exposures.

girls’ cross-country: 1.0 injuries/

1,000 athletic exposures.

SOURCE: Office of Technology Assessment, 1995.

TABLE 3-4: School Athletic Injury Studies (Cont’d.)
78 | Risks to Students in School

Football resulted in the greatest number of

direct deaths each year among high school athletes, with an average of about five deaths

(48,49). Football is associated with about five

indirect deaths per year and basketball with three

to four. While those three sports account for

more than 90 percent of the fatalities, they are

not the riskiest when judged by number of deaths

per participant in a sport per year. In those terms,

the riskiest high school sports for males were:

gymnastics (1.75 deaths per 10,000 participants),

lacrosse (0.57), ice hockey (0.43), and football

(0.35). Basketball (0.63), lacrosse (0.57), ice

hockey (0.43), and wrestling (0.41) had the highest rate of indirect deaths per participant. The

single female fatality occurred in track.

Morbidity Data

The Scheidt study, based on 1988 NHIS data,

disclosed that about 1.3 million sports/recreation

injuries occur annually. Of these injuries, schools

are the location for 55 percent (715,000 injuries)

and the cause of 35 percent (455,000 injuries)

(67). Based on a 1986 injury surveillance study,

the National Athletics Trainers Association also

reported that about 1.3 million injuries occur in

high school sports annually (50). About 75 percent of the injuries were categorized as minor,

meaning the athlete was sidelined for a week or

less.

Sports injuries are reported in differently

defined categories in various studies, making

cross-comparisons difficult. A review of the state

and epidemiological studies illustrates this problem. While the Hawaii Department of Education,

Minnesota Department of Education, and Utah

Department of Health all reported school sport

injury estimates, the reporting categories varied

tremendously (36,47,99). The Hawaii Department of Education reported that athletics and

physical education represented 9 and 15 percent,

respectively, of total school injuries in 1989-90.

Injuries were not analyzed according to any

demographic considerations. Minnesota’s student survey divided school injuries into sport and

non-sport categories for the 6th, 9th, and 12th

grades and reporting in relation to all injuries

both in and out of the school environment.

School sports resulted in the following percentages of all injuries to children and adolescents:

6th grade—male 20 percent, female 17 percent;

9th grade—male 30 percent, female 27 percent;

TABLE 3-5: Reported Catastrophic Injuries from High School Sports, 1982 to 1992

Fatal Nonfatal

Rate/100,000

participant years

Sport Direct Indirect Permanent Serious Total Male Female

Cross-country 0 5 1 0 6 0.6 0.0

Football 48 52 103 113 316 2.4 —

Soccer 2 8 0 4 14 0.5 0.2

Basketball 0 35 2 2 39 0.6 0.1

Gymnastics 1 0 5 3 9 4.8 2.3

Ice hockey 1 1 4 2 8 3.6 —

Swimming 0 3 4 3 10 0.6 0.6

Wrestling 2 10 16 9 37 1.5 —

Baseball 3 5 7 6 21 0.5 —

Lacrosse 1 1 0 0 2 1.0 —

Track 9 12 6 6 33 0.6 0.0

Tennis 0 1 0 0 1 0.1 0.0

Total 67 133 148 148 491 16.8 3.2

SOURCE: F.O. Mueller, C.S. Blyth, and R.C. Cantue, Tenth Annual Report of the National Center for Catastrophic Sports Injury Research, Fall

1982–Spring 1992, (Chapel Hill, NC: University of North Carolina, 1993).
Chapter 3 Injury to Students in School | 79

and 12th grade—male 28 percent, female 18 percent. The Utah Department of Health data contain information on 14 different athletic

activities, including physical education and organized school sports. Overall, from 1988 to 1992,

sport activities accounted for 21.3 percent of the

total school injuries for grades K-6 and 44.1 percent for grades 7-12. The different reporting

methodologies among states obviously deter

efforts to analyze studies beyond total numbers

and percentages.

Epidemiological studies estimate that athleticrelated injuries, including interscholastic school

sports and physical education classes, account

for 23 to 53 percent of all reported school injuries. Some epidemiological studies include

school injury percentages and comparisons of

school sports injuries to other school injuries.

Boyce et al. found that athletics were associated

with 26 percent of male and 16 percent of female

school injuries; athletics were the leading cause

of injury for males. Lenaway et al. reported that

far more school injuries, 53 percent, were associated with both formally and informally organized

school sports.

The few available studies that provide comparisons of in-school and out-of-school sports

injuries indicate that they occur at similar rates.

Zaricznyj et al. found that about half of all the

sports injuries sustained by school-aged youth in

Springfield, Illinois, occurred in school.

Lenaway et al. found very high percentages of

sports-related injuries that increase as students

progressed from elementary (40 percent of

school injuries) through junior high (54 percent

of school injuries) to high school (69 percent of

school injuries); however, the rate of injury was

highest in junior high. In contrast, the Kansas

Department of Health and Education sports

study, which was limited to secondary schools,

found that 12th grade sports participants had the

highest rate of injury (37.8 per 1,000 participants).

The studies indicate that boys generally sustained approximately twice as many injuries as

girls (67 and 33 percent, respectively) (104), the

difference being more prominent in high school

(43). Garrick and Requa concluded that the difference, at least for organized school sports, was

due primarily to participation in different sports.

When catastrophic sports injury rates of boys and

girls are compared, however, girls’ sports actually have higher rates of injury than the same

boys’ sports (49,64). However, since the passage

of Title IX, 20 U.S.C. sections, 1681-1688, as

amended by the Civil Rights Act of 1987, Pub.

L. No. 100-259, and after many of the sports

studies reported here were completed, there has

been an increase in female athletic participation

and female teams. Moreover, the National Federation of State High School Associations Athletics Participation Survey indicates a steady

increase of girls participating in sports over the

last 20 years. In 1971, there were 294,015 participants and by 1993-1994 it had increased almost

10-fold to 2,124,755 participants. Accordingly,

there may be a corresponding increase in girls

sport injuries.

The number, severity, and type of injury

depend on the athletic activity. According to the

Centers for Disease Control and Prevention’s

(CDC) 1993 Youth Risk Behavior Survey

(YRBS), only 34.3 percent of high school students had attended physical education class daily

during the 30 days preceding the survey (91).

Physical education classes have been reported in

epidemiological studies to account for a greater

number of injuries than organized school sports,

in which 43 percent of high school students participate.20 Zaricznyj et al. found that physical

education accounted for 38 percent and organized school sports accounted for 15 percent of

all community sports injuries. Nonorganized and

unsupervised sports (40 percent) and community

team sports (7 percent) accounted for the remaining 47 percent of injuries.21 However, when par20 In 1993-94, 3,478,530 male high school students and 2,124,755 female high school students participated in competitive sports (51). 21 Zaricznyj et al. studied all community sports injuries, including both school sports (physical education class and organized school

sports) and non-school sports (nonorganized and unsupervised sports and community sport teams (e.g., Little League)).
80 Risks to Students in School

ticipation ratios are considered, organized sports

(12 injuries/100 student years) were riskier than

physical education (2.3/100). Injuries sustained

in physical education occurred mainly during

gym games (e.g., dodge ball and four square) and

basketball, with other sports far behind. In fact,

60 percent of the basketball injuries occurred

during physical education (104). In a 1990-91

study of physical education injuries in Kansas

secondary schools, basketball was associated

with the most injuries as well, followed by volleyball and weight training (see figure 3-5) (41).

The highest number of injuries occurred in

some of the most popular sports. Table 3-6

shows the most popular sports for high school

boys and girls. The Rice study of high school

athletics showed that high-risk sports, in terms of

both incidence and severity, are generally those

expected to be so: girls’ cross country (17.3 injuries per 1,000 athletic exposures), football (12.7),

wrestling (1 1.8), girls’ soccer (11.6), boys’ cross

country (10.5), girls’ gymnastics (10.0), and

boys’ soccer (36.4) (64). Lenaway et al. found

Gymnastics/tumbling

60/0

36%

Flag/touch football 9 %

11%

SOURCE: Kansas State Department of Education, Kansas Secondary

Schools Study, 1990-91.

that the sports resulting in the most injuries by

grade level were: 1) in elementary school: football, soccer, and tetherball; 2) in junior high:

football, basketball, and soccer; and 3) in high

school: football, volleyball, and baseball. Garrick

and Requa calculated participation rates for high

school sports to find that for boys, football (81

injuries/100 participants) and wrestling (75 injuries) accounted for the highest injury rates,

mainly due to the greater force of impact as boys

get older. The next most frequent injuries per 100

participants were for boys’ track and field (33

injuries), basketball (31 injuries), soccer (30

injuries), and cross country (29 injuries). The

sports particularly risky for girls were softball

(44 injuries/100 participants) followed by gymnastics (40 injuries), track and field (35 injuries),

cross-country (35 injuries), basketball (25 injuries), and volleyball (10 injuries).

Across studies, football was the sport associated with the greatest number of school sports

injuries. In organized school sports, football

accounted for four times more injuries than any

other sport. Football was the leading cause of all

serious injuries, fractures, injuries to the knee,

and hospitalization (104), and not surprisingly,

more school days were lost due to football injuries than to any other sport (41). However, it is

important to note that football has the greatest

number of participants.

As of 1993, only two state athletic associations, Michigan and West Virginia, recognized

cheerleading as a sport, but many students are

being injured while participating in this activity.

CPSC estimates that in 1993 there were 15,560

emergency room visits as a result of cheerleading

injuries. In the wake of highly visible stories

about catastrophic injuries that occurred during

cheerleading, a number of high schools across

the country have limited the types of stunts that

cheerleaders may attempt (49). North Dakota and

Minnesota regulations governing high schools,

for instance, banned the use of the pyramid after

the death of a cheerleader.

Fall sports had a higher rate of injury than

spring sports. One study author, Rice, postulated

that this was a result of school athletes not main-
Chapter 3 Injury to Students in School | 81

taining their conditioning over the summer

months. When the intensive conditioning

regimes began in preparation for the fall season,

these athletes were susceptible to overuse injuries and strains (64). However, football is a fall

sport and probably contributes to this higher fall

number.

Comparison of studies rating the severity of

sports injuries is difficult because of varying definitions of severe or serious (69). For example,

Sheps and Evans recognized that some studies

included sprains, strains, and dislocations while

others did not. In analyzing their own data they

noted that when sprains, strains, and dislocations

are classified as severe injuries, approximately

56 percent of sports injuries are severe; when

they are excluded, about 25 percent are severe

(69). However, most school athletic injuries are

not serious.

Zaricznyj et al. found in the study of sports

injuries in Springfield, Illinois, that about 80 percent of sports injuries were not serious or severe;

these injuries included sprains, contusions, lacerations, and superficial injuries (104). Of the

remaining 20 percent of the injuries that were

serious or severe injuries, about half occurred in

school. Physical education produced 27 percent

of serious injuries (one-third of which involved

basketball), 25 percent occurred during organized school sports (more than half of which

involved football), and 48 percent were

accounted for by nonorganized sports. Of the

serious or severe injuries (312 injuries), the most

frequent included fractures (252 injuries), followed by torn ligaments (20 injuries), concussions (16 injuries), and dislocations (13 injuries).

There were 65 hospitalizations, and 1.2 percent

of all sports injuries were permanent (18). More

than half of the serious injuries were sustained by

high school students (51 percent). Junior high

and elementary school students accounted for 30

and 19 percent of serious injuries, respectively.

Garrick and Requa, defining severity of injuries in terms of days missed from practice and

competition, found in a study of 3,049 participants in 19 sports sustaining 1,197 injuries that

nearly three-fourths (73.4 percent) of the injured

student participants returned to the sport without

missing more than five practice or competition

days (31). Of the more serious injuries requiring

x-ray examination (360 injuries), 18 percent (65)

were fractures. Twenty-five athletes were hospitalized, 21 of whom required surgical procedures. Football players accounted for 16 of the

25 hospitalizations and 12 of the 21 surgical procedures, suggesting that football accounted for

the majority of severe injuries. Again, football

has the highest number of student participants.

Of the catastrophic injuries (fatal, permanent,

and serious injuries), the National Center for Catastrophic Sports Injury Research found that in

terms of raw numbers over 10 years (1982-92),

football (316), basketball (39), wrestling (37),

and track (33) appear to entail the most risk (49).

TABLE 3-6: Ten Most Popular Sports for High School Boys and Girls

Boy participants Girl participants

Football 928,134 Basketball 412,576

Basketball 530,068 Track & field (outdoors) 345,700

Baseball 438,846 Volleyball 327,616

Track & field (outdoors) 419,758 Softball (fast pitch) 257,118

Soccer 255,538 Soccer 166,173

Wrestling 233,433 Tennis 136,239

Cross-country 162,188 Cross-country 124,700

Tennis 135,702 Swimming & diving 102,652

Golf 131,207 Field hockey 53,747

Swimming & diving 81,328 Softball (slow pitch) 41,118

SOURCE: National Federation of State High School Associations, 1993-94 Athletics Participation Survey.
82 | Risks to Students in School

When these numbers are associated with participation, however, it appears that gymnastics (4.8

injuries per 100,000 participation years), ice

hockey (3.6), and football (2.4) result in the most

serious injuries per participating high school

male athlete. Gymnastics and swimming are

most commonly associated with serious injuries

in participating high school female athletes.

The athletic injury studies discussed herein

provide a description of the magnitude of injuries

sustained by children and adolescents who participate in athletic activities. As the injury literature

reflects, however, each sport presents different

risks, which necessitates sport-specific summaries

of the available data and a characterization of the

types of injuries typically incurred in each sport (1)

(see box 3-7). Most of the studies relating to specific sports injuries depend on medical or clinical

reports, and incidence information is incomplete.

TRANSPORTATION INJURY DATA

Every school day, children encounter a variety of

risks on their way to and from school, whether

they are transported by school bus or car, ride

their bicycles, or walk. Data regarding injuries

resulting from crashes involving school buses,

pedestrians, and bicyclists are described in this

section. While there are a number of other modes

of transportation to school, particularly parents

driving students or older students driving themselves, no data are available to attempt to quantify these injuries.

Estimates from the few studies of injuries

incurred on the journey to and from school range

from 1 to 3 percent of all school injuries.22 In

general, the journey home is more dangerous

22 These estimates are based on the Hawaii Department of Education and Utah Department of Health state estimates and the NSC

national estimates of school injuries. The NSC reported that about 3.1 percent of all school injuries were incurred going to and from school,

1.9 percent were motor vehicle related, and 1.2 percent were non-motor vehicle related. Because these injuries were reported to the NSC by

schools, it is likely that a number of transportation injuries occurred but were not reported to the school.

than the trip to school (76,95). One study attributed this to more children walking home alone or

with other children rather than with an adult (76).

Most of the risks of unintentional injury to

students en route to school cannot be controlled

by schools except by prevention education. Students, for example, can be taught to behave more

safely and cross streets correctly, or to wear helmets when riding their bicycles and seat belts

when riding in cars. School buses, however, are

subject to state regulation, and school bus safety

is evaluated by the U.S. Department of Transportation. Consequently, data specifically relating to

school bus safety, including mortality and morbidity statistics, are available.

❚ Sources and Limitations of School 

Transportation-Related Injury Data

The National Highway Safety Transportation

Administration’s (NHTSA) Fatal Accidents

Reporting System (FARS) and General Estimates System (GES) are the primary databases

for fatalities and injuries associated with school

bus-related crashes, pedestrians, and bicyclists.

Both systems are subject to limitations, discussed

in box 3-8. The publications listed below have

analyzed FARS and GES data to calculate incidence, prevalence, and trend data. The data were

analyzed in the following publications:

1. NHTSA’s Traffic Safety Facts 1992;

2. NHTSA’s Traffic Safety Facts 1992, School

Buses;

3. NHTSA’s Summary of School Bus Crash Statistics in 1990; and

4. National Academy of Sciences’ (NAS)

Improving School Bus Safety (NRC, 1989).23

23 A provision in the federal Surface Transportation and Uniform Relocation Assistance Act of 1987 (Public Law 100-17, 204(a) (April 2,

1987)) required the Department of Transportation to contract with the National Academy of Sciences to perform a “comprehensive study and

investigation of the principal causes of fatalities and injuries to school children riding in school buses and the use of seat belts in school buses

and other measures that may improve the safety of school bus transportation” (55). 
Chapter 3 Injury to Students in School | 83

BOX 3-7: Common Sports Injuries in School-Aged Children

Baseball

1. At the high school level, reported injury rates ranged from 14 to 18 percent of participants.

2. Elbow and shoulder overuse injuries were the most frequent.

3. Contact and collision injuries were infrequent.

4. Most Little League (ages 5 to 14) injuries occurred when players were hit by a pitched ball (22 percent), hit by a batted ball (19 percent), while catching (14 percent), hit by a thrown ball (10 percent),

or when sliding (10 percent).

5. For Little League participants, the body areas most affected were the head (38 percent) and upper

extremities (37 percent), while the common types of injuries were contusions (40 percent), fractures

(19 percent), and sprains (18 percent).

6. Deaths have resulted from cardiac damage secondary to non-penetrating chest trauma; 23 deaths

were recorded in 5- to 14-year-olds between 1973 and 1981.

Basketball

1. In school-organized teams, the injury rate was 10.2 percent.

2. Among high school players, boys’ rates of injury ranged from 6 to 31 percent and girls’ from 8 to 25

percent. 

3. Girls had a significantly higher rate of injury than boys (76 to 16 percent) and a higher proportion of

significant injuries (18 to 8 percent).

4. The ankle, knee, and leg were most often injured. Girls appear to be at greater risk of knee injury and

developing significant knee injuries, while boys had a greater chance of injuring their shoulders; there

was a high prevalence of ankle sprains for both boys and girls.

Football

1. Injury experience is related to level of competition, which may in turn be related to the intensity of force

generated at the time of contact.

2. Injury rates for young players (ages 8 to 14) ranged from 15 to 20 percent.

3. Injury rates for high school players ranged from 25 to 64 percent.

4. At the youth level, significant injuries occurred to 10 percent of the participants. The hand or wrist and

knee were the most common injury sites, the upper body accounting for almost 50 percent of the injuries. Fractures, sprains, and contusions were the most common types of injury, and surgery was rarely

required. Variables that appeared to be related to risk of injury included larger size in the oldest division, pileups after the play was completed, reinjury of an incompletely resolved prior injury, and

impact with helmet.

5. At the high school level, significant injury occurred in 12 to 17 percent of participants. Lower-extremity

injuries were most likely; knee and ankle were the most common injury sites. Knee injuries alone

accounted for 15 to 20 percent of all injuries annually, approximately 92,000. Sprains and strains were

the most common types of injury, and surgery was required for 4 percent of players. Knee injuries

accounted for 69 percent of the injuries requiring surgery.

6. A high school football team can expect to average about 32 injuries per season, of which eight will be

significant.

7. While more injuries occurred at practice, if corrected to numbers of injuries per exposure, games were

associated with eight times the frequency of injury.

8. Tackling and blocking have been associated with the majority of catastrophic football injuries.

(continued)
84 | Risks to Students in School

Gymnastics

1. Injury rates for club gymnastic programs were between 12 to 22 percent.

2. The lower extremities were most often injured, but head, spine, and upper extremities were also common sites.

3. Floor exercises and tumbling accounted for the greatest number of injuries, followed by the balance

beam, uneven parallel bars, and vault.

4. Half the injuries were macro-traumatic and half were due to overuse syndromes.

5. Spondylolysis occurred four times more often than in the general population.

Soccer

1. Youth soccer was associated with a low rate of injury, 2 to 5 percent.

2. Adolescent players had a higher rate of injury, 6 to 9 percent.

3. Most injuries arose from direct contact or collision with a player, the ball, or the ground.

4. Because of the running and kicking demands of soccer, overuse syndromes were also prevalent.

5. The ankle, knee, and forefoot were most often injured.

6. Significant knee sprains were not uncommon.

7. Repeated heading of the soccer ball may cause brain damage.

Track

1. Risk of injury resulted almost entirely from repetitive micro-trauma and acute strains.

2. Youth track and field athletes’ (ages 10 to 15) injury rate was 50 percent; two-thirds of the injuries were

related to overuse.

3. High school track athletes reported injury rates of 33 percent for males and 35 percent for females.

4. The lower leg was most frequently injured, followed by the knee, ankle, and thigh.

5. Of high school track athletes, sprinting (46 percent), distance running, activities before and after practice, and pole vaulting were most often associated with injuries.

Wrestling

1. High school wrestler injury rates from 23 to 75 percent were reported; the rate of significant injury was

15 percent.

2. Injuries arise from direct blows from an opponent, from friction on hitting the mat, falls particularly during a takedown, and from twisting and leverage forces during controlling maneuvers.

3. High school wrestlers were most likely to sustain knee sprains, back strains, and shoulder injuries; the

site of injury was distributed among the upper extremities (29 percent), the lower extremities (33 percent), and the spine and trunk (34 percent).

4. More injuries occurred in competition (43 percent) than in practice (37 percent) or scrimmages (20

percent).

5. “Cauliflower ears” were decreasing in frequency due to use of head gear and improved mat surfaces,

and severe neck strains and fractures appeared to be controlled by the strict rule against slams.

aSignificant injuries are those requiring more than seven days of restriction from participation (Goldberg et al.).

SOURCE: American Academy of Pediatrics, Committee on Sports Medicine and Fitness, Sports Medicine: Health Care for Youth

Athletes, 2nd ed., P.G. Dyment (ed.) (Elk Grove Village, IL, 1993); Goldberg, B., et al., Injuries in Youth Football. Pediatrics,

1988;12:122–132; Mueller, F.O., and Cantu, R.C., Annual Survey of Catastrophic Football Injuries 1977–1992 (Chapel Hill, NC:

1993).

BOX 3-7: Common Sports Injuries in School-Aged Children (Cont’d.)
Chapter 3 Injury to Students in School | 85

The NAS study Improving School Bus Safety

reviewed and analyzed school bus-related crash

data on fatalities and injuries from 1982 to 1988

(55).

School Bus-Related Crashes Injury Data

School buses transport about 25 million students

to and from classes and school-sponsored activities (55). Although most crashes involving

BOX 3-8: Sources and Limitations of School Transportation-Related Injury Data

Estimating the extent of school-related travel in transportation and deaths is difficult because fatalities

and injuries are not reported by purpose of travel. Estimates can be made, however, from the sources of

data that are discussed below, remembering that each source has substantial limitations. None of them

differentiates whether the injuries were incurred during school-related travel.

The National Highway Traffic Safety Administration’s (NHTSA) Fatal Accidents Reporting System

(FARS) maintains fatality census data on crashes involving a traveling motor vehicle and resulting in the

death of a vehicle occupant or non-motorist within 30 days. FARS is a collection of state-reported data.

Since 1975, 50 states, the District of Columbia, and Puerto Rico have submitted qualifying data from

police crash reports, state vehicle registration files, state drivers’ license files, state highway departments, vital statistics, death certificates, coroner/medical examiner reports, hospital medical reports, and

emergency medical service reports, and those data are the primary source for mortality data related to

crashes involving school buses, pedestrians, and bicycles. Data, however, vary significantly from state to

state. For instance, because the definition of school bus differs among the jurisdictions registering vehicles, there is no accurate number of school buses that transport students and no truly accurate number

of school-related crashes.

FARS data are reported for ages 0–20+ at age intervals of 0–4, 5–9, 10–14, 15–19, and 20+. In the discussion below, school-aged children and adolescents in terms of FARS data include ages 5–19. FARS

includes data on school bus-related crashes, pedestrians, and bicyclists; however, the information is limited for the purposes of this report as the reason for travel at the time of the crash is not indicated. Thus, it

is indeterminable whether the death of a school-aged child was also school related.

In 1988, NHTSA established the General Estimates System (GES), the injury counterpart to FARS.

Unlike FARS, however, GES estimates are based on a national probability sample of about 45,000 police

crash reports collected each year rather than census data. To qualify for the GES sample, a police accident report must be completed for the crash; the crash must involve at least one traveling motor vehicle

and property damage, injury, or death must result. Like FARS, GES includes information on school busrelated crashes, pedestrians, and bicyclists. The actual difference between estimates and true values

varies depending on the sample selected. GES pedestrian and bicycle injury data are particularly problematic. The relatively low numbers reported for pedestrian and bicycle injuries result in high standard

errors. For example, NHTSA calculated that 1992 GES estimated a generalized standard of error of 400

for 1,000, 1,000 for 5,000, and 1,500 for 10,000.

FARS and GES define school buses by body type as opposed to purpose. Thus, even after a bus is

sold by a school to another organization (e.g., a church), it is still classified as a “school bus.” NHTSA

estimated, however, that approximately 81 percent of bus occupant fatalities from 1977 to 1990 involved

school buses providing school-related group transport.

SOURCE: Office of Technology Assessment, based on U.S. Department of Transportation, National Highway Traffic Safety

Administration. Traffic Safety Facts 1992, September 1993; U.S. Department of Transportation, National Highway Traffic Safety

Administration, Traffic Safety Facts 1992: School Buses, U.S. Department of Transportation, National Highway Traffic Safety

Administration, School Bus Safety Report, May 1993; U.S. Department of Transportation, National Transportation Safety Board,

Summary of Selected School Bus Crash Statistics in 1990, 1993
86 | Risks to Students in School

school buses are minor, catastrophic crashes

resulting in student fatalities and serious injuries

do occur every year (98). A comparison of

school bus-related crash and passenger car crash

fatalities and injuries among school-aged children suggests that school buses are much safer

than other forms of transportation used to take

students to and from school. NHTSA reports

roughly 650,000 fatal traffic crashes in the past

16 years, of which less than 0.4 percent were

classified as school bus-related (95). Of these

crashes, 90 percent were school bus-type vehicles and 10 percent were other vehicles providing school-related group transportation (95). In

fact, NAS estimates that occupant fatalities per

mile for school buses are approximately onefourth those for passenger cars (55).24 Moreover,

given the typical school bus size and weight of

more than 10,000 pounds, injuries are more

likely to occur to the occupants of a passenger

car involved in a crash with a school bus than to

the occupants of the school bus (93). Nonetheless, the incidence of school bus-related crash

injuries indicates that improvements in school

bus safety are essential (55).

While standards passed in 1977 (see box 3-9)

have improved the crashworthiness of school

buses, national information regarding school

bus-related crashes remains sparse. Despite

efforts to improve the reporting of school bus

crashes, according to the 1989 NAS study on

school bus safety, the availability and quality of

data have not improved much. The NAS study,

the most extensive study of school bus injuries

and attendant safety measures, characterized

national statistics as inadequate and claimed that

its efforts to collect valid national data were seriously hampered by lack of a standard definition

24 According to the NSC’s Accident Facts (1993), the difference between school bus and passenger car fatality rates was even more pronounced (57). NSC reported that in 1989-91 the average fatality rate per hundred million passenger miles was 0.02 for school buses and 1.05

for passenger cars.

among states of school bus crashes or school

bus-related crashes. As a result, NAS recommended that “NHTSA work with the states, and

other interested organizations to upgrade and

standardize school bus crashes data collected by

the states” (55). Nevertheless, NAS concluded

that the imperfect national and state reports can

be used in attempts to understand the magnitude

of the problem and where, when, and to whom

such crashes occur.

Mortality data

The major studies of fatalities in school busrelated crashes are listed in table 3-7A. The NAS

study reports that about 50 school-aged children

are fatally injured in school bus-related crashes

each year, including school-aged pedestrians and

passengers. About 75 percent of the deaths, 37 to

38 children, were pedestrians in loading zones

around school buses: of those, approximately 24

were struck by school buses, two were killed by

vehicles operated as school buses, and 11 to 12

were killed by other vehicles in the bus loading

zone.25 Approximately 12 school-aged children

were killed each year while riding to and from

school or school-sponsored activities on school

buses or on vehicles used as school buses.

Between 1982 and 1986, 60 school bus passengers were killed in 26 separate accidents; of

those, 48 were passengers under 20 years old

(55). Students aged 10 to 14 were reported to

account for 32 percent of all school bus passenger fatalities, followed by students aged 15 to 19

(27 percent) and 5 to 9 (17 percent); the remaining 24 percent were over 20 and most likely drivers of school buses. Fatality rates by age,

however, were not presented. It may be that students aged 10 to 14 are more likely to be riding

the school bus because more parents drive

25 The most recently published FARS estimates of school bus-related crash fatalities and injuries are available in NHTSA’s Traffic Safety

Facts 1992; except for pedestrians, the data are not published by age so the number of school-aged children injured is not known (94). This

data indicated that in 1992 an estimated 124 people were killed in school bus-related crashes, of which 83 were occupants of other vehicles,

29 were pedestrians, 9 were school bus passengers, 2 were bicyclists, and 1 was a school bus driver. Of the 29 pedestrians struck by a school

bus, 21 were of school age, 50 percent of whom were 5-6 years old.
Chapter 3 Injury to Students in School | 87

younger children to school or more adolescents

drive themselves to school. Moreover, children

who walk to neighborhood elementary schools

may be bussed to larger and more centralized

middle schools

The studies also reveal that for the general

population (not limited to school-aged children),

occupants of other vehicles and nonoccupants,

primarily pedestrians, are at greater risk of experiencing a fatality than school bus passengers: 56

percent of the total fatalities involved occupants

of other vehicles; 33 percent involved nonoccupants, including pedestrians and bicyclists.

School bus passengers represented the remaining

11 percent of the overall fatalities (95).

All studies based on NHTSA’s FARS data

concluded that school-aged children are at

greatest risk of fatal injury while they are getting on or off, as compared to while they are

riding, the school bus. It also appears that student pedestrians are at a far greater risk of being

struck by their own bus than by another vehicle

(98). An average of roughly two-thirds of all

pedestrians killed were struck by a school bus

(95,98), and 6 percent were struck by vehicles

operating as a school bus. In these crashes, “inattention” and “failure to yield” were the contributing factors most often cited by police. Thirty

percent of pedestrian fatalities were killed by

other vehicles in school bus-related crashes (95).

For drivers of other vehicles, the common contributing factors reported by police were “failing

to obey signs, safety zones, or warning signs on

vehicles,” “passing where prohibited,” and “driving too fast.”

NHTSA further examined the 1983-92 data by

time of day. Significantly, more school-aged

pedestrians were killed in school bus-related

crashes in the afternoon (73 percent) than in the

morning (27 percent); 42 percent were killed

between 3:00 and 4:00 p.m. alone.

BOX 3-9: School Bus Safety

In 1977, NHTSA issued regulations that mandated stricter safety for school buses, including requiring

seat belts for post-1977 buses of 10,000 pounds or less but not for those of more than 10,000 pounds.

The rationale was that buses weighing more than 10,000 pounds are heavy, strong, and well-padded,

and their seats are “compartmentalized” to protect passengers in the event of a crash. The NAS report

concluded that the 1977 standards greatly improved the crashworthiness of school buses and that the

estimated 10 percent of pre-1977 school buses still operating should be replaced by buses manufactured after 1977 as soon as possible.

Additional safety measures and their efficacy, particularly for seat belts, are continually under debate.

In recent years, a number of school districts and two states have mandated that all buses ordered after a

certain date be fitted with seat belts. New York requires all school buses manufactured after June 30,

1987, and operated within the state to be equipped with seat belts; New Jersey similarly directs that all

school buses purchased after September 1, 1992, have seat belts. These laws differ in that New York

does not require actual use of the belts whereas New Jersey does. In commenting on the cost and effort

of equipping buses with safety belts, NAS concluded that because children are at greater risk of being

killed in loading zones (i.e., boarding or leaving a bus) than onboard the bus, a larger share of the total

effort should be targeted at improving the safety of school bus loading zones.

The federal government also developed Highway Safety Program Manual #17, Pupil Transportation,

which provides standards governing school bus driver licensing and training, loading and unloading of

students, bus maintenance and inspection, operation, and crash records. The guidelines, which were

revised in 1991, are voluntary and, as such, not enforceable; incentive programs or policies are offered to

encourage states to adopt the guidelines. Technical assistance is also provided to state transportation

officials in reviewing their school bus safety programs.

SOURCE: Office of Technology Assessment, based on U.S. Department of Transportation, National Highway Traffic Safety

Administration, School Bus Safety Report, May 1993.
88 | Risks to Students in School

Risk of school bus-related crash pedestrian

death appears to be linked to age; younger children are more likely than older children to be

fatally injured in school bus-related crashes.

NAS determined that 54 percent of the schoolaged pedestrians killed in school bus-related

crashes were 5- to 6-year-olds and similarly,

NHTSA reports that half of all school-aged

pedestrians killed by school buses from 1983 to

1992 were between 5 and 6 years of age (55,95).

Seven- and 8-year-olds also accounted for a significant proportion of fatalities (23 percent).

Fatalities caused by non-school bus vehicles

were more equally distributed among all ages;

the NAS report concluded that age-specific

safety devices for school buses, particularly for

young pedestrians, may reduce the occurrence of

fatalities.

The NSC also provides annual school busrelated fatality and injury data (57). NSC surveys

state departments of education and state traffic

authorities each year for information from which

it generates national estimates of school busrelated crash injuries. These estimates were generated despite the fact that in 1992, 13 states did

not submit data. The NAS study noted that

because of the absent information and varying

definitions under which state data are collected,

the NSC data underestimated the actual numbers

(55).

Morbidity data

In a 1977 report to Congress, William Coleman,

then Secretary of Transportation, stated that:

Wholly reliable information on school bus

crashes is not readily available on a national

basis. This is particularly true for nonfatal

injury crashes, and even more so for crashes in

which no injury is present. The information

deficiency exists with respect to descriptive statistics as well as to accident-injury causation

data; and it stems from both inadequate investigation at the accident site and the lack of formal

TABLE 3-7A: Annual Passenger, Pedestrian and Bicyclist Fatalities

in School Bus-Related Crashes, by Study

Study

Annual total number of 

fatally injured people in 

school bus-related 

crashes

School-aged school bus (or 

vehicle used as school bus) 

passengers fatally injured

School-aged 

pedestrians 

fatally injured

School-aged 

bicyclists 

fatally injured

1992

NHTSA’s Traffic Safety Facts 

(FARS)

124 9 29 2

1983–1992

NHTSA’s Traffic Safety Facts 

(FARS)

157 — 30 —

1977–1990

Summary of Selected School 

Bus Crash Statistics (FARS) 

(average)

179 11–12 34 —

1982–1988

NAS Report on Improving 

School Bus Safety (FARS) 

(average)

149 12 37–38 3.2

1991–1992

National Safety Council

110 10 25 —

SOURCE: U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA); Traffic Safety Facts 1992, September

1993; U.S. Department of Transportation, National Transportation Safety Board, Summary of Selected School Bus Crash Statistics in 1990, 1993;

National Research Council, Transportation Research Board, Committee to Identify Measures that May Improve the Safety of School Bus Transportation, Improving School Bus Safety (Washington, DC: National Academy Press, 1989); National Safety Council, Accident Facts (Itasca, IL:

1993).
Chapter 3 Injury to Students in School | 89

and systematic data collection and synthesis

process to produce aggregated information.

More than 10 years later, the NAS report recognized a similar lack of national data from

which to develop a certain number or even an

adequate estimate of injuries suffered by children

in school bus-related crashes (55). There is tremendous underreporting and inconsistent reporting of school bus-related crash injuries. For

example, some states include all school bus passengers when reporting injury statistics, while

others report only those involving students (55).

The major studies of school bus-related crash

injury data are presented in table 3-7B.

To compensate for the lack of reliable data on

nonfatal injuries, NAS developed a school busrelated injury estimate using selected state data.

School bus-related crash data from 14 states

were aggregated and analyzed to develop a

national estimate of 19,000 injuries, 9,500 of

which were to school bus passengers (see figure

3-6). By using the same data, average characteristics of school bus-related crashes were identified. The report concluded that of the total

injuries, 50 percent were sustained by school bus

passengers, of which 5 percent were incapacitating.26 The majority of the school bus-related

crashes were minor. A review of a few state

crashes and of the National Crashes Sampling

System revealed that about half of the injuries

suffered in school buses affected the head, face,

and neck (55).

About 800 additional injuries suffered by

pedestrians in school bus-related crashes were

reported. In contrast to fatality estimates, far

fewer pedestrians than school bus passengers

were injured, but pedestrian injuries were typically more severe. An estimated 20 percent of the

pedestrian injuries were incapacitating, com26 Incapacitating injury is defined as “any injury that prevents the injured person from walking, driving, or normally continuing the activities he was capable of performing before the injury occurred” (NRC, 1989). It includes, but is not limited to, severe lacerations, broken or

distorted limbs, skull or chest injuries, abdominal injuries, being unconscious at or when taken from the accident scene, and being unable to

leave the accident scene without assistance (55).

pared to 5 percent for passengers. The NAS

report stated that research aimed at reducing student transportation injuries should focus on

school bus loading zones and additional protections available for students in these zones.27 Figure 3-6 shows the mortality and morbidity data.

Estimates of injuries on school buses from

1990 GES data were higher than the NAS estimates. The 1990 GES data indicated about

17,500 injuries to school bus passengers; 1,000

(5.9 percent) of these were severe. An additional

4,500 injuries were sustained by occupants of

other vehicles; 500 (11.1 percent) of these were

severe. Thus, NHTSA’s GES data estimates a

total of 22,000 injuries as compared to the NAS

estimate of 19,000 injuries.

The body locations and types of injuries to

students in school bus-related crashes are not

reported on a national level. Tables 3-8 and 3-9

provide police reported injury data collected by

the New York Department of Motor Vehicles for

bus passengers and for pedestrians on the way to

and from a stopped school bus (55); they illustrate the type and severity of injuries sustained in

these crashes. The figures include all school bus

passengers—students and adults. The head, face,

and eyes were the predominant sites of injury:

about 58 percent of the incapacitating, 65 percent

of the non-incapacitating, and 34 percent of the

possible injuries were to the head or face. The

most frequent types of incapacitating injury were

concussion (27.0 percent), fracture/dislocation

(24.7 percent), and severe bleeding (14.7 percent). Among those who sustained non-incapacitating injuries, more than half complained of

contusion/bruise and 30 percent minor bleeding.

Of injuries to pedestrians going to and from

stopped school buses in New York (table 3-9),

the lower extremities accounted for approxi27 Injury data from the Utah Department of Health support the conclusion that students are at greater risk in the loading area than in the

school bus. From 1988 to 1992, 102 students were reportedly injured on school buses and 177 in school bus loading zones. Among grades K6, school bus and bus loading areas injuries accounted for 0.38 and 0.57 percent of total grades K-6 school injuries. The incidence of injury

of school bus and bus loading area injuries of students in grades 7-12 was 0.2 and 0.6 percent, respectively.
90 | Risks to Students in School

TABLE 3-7B: Annual Passenger and Pedestrian Injuries in School Bus-Related Crashes, By Study

Study

Annual or average 

annual total 

school bus-related 

crash injuries

School bus passenger 

injuries

Occupant of other vehicle injuries Pedestrian injuries

NHTSA’s Traffic Safety Facts 

(GES)

1992

23,000 11,000 9,000 1,000

National Safety Council

1991–1992

14,000 8,300 students — 200

Summary of School Bus Crash 

Statistics (GES) 1990

17,500

(5.9 percent)a — 4,50

(11.1 percent)a —

NAS Report on Improving 

School Bus Safety (average) 

1982–1988

19,000 9,500

(5 percent)a — 800

(20 percent)a

aPercentage of severe or incapacitating injury

SOURCE: U.S. Department of Transportation, National Highway Traffic Safety Administration, Traffic Safety Facts 1992, September 1993; U.S.

Department of Transportation, National Transportation Safety Board, Summary of Selected School Bus Crash Statistics in 1990, 1993; National

Research Council, Transportation Research Board, Committee to Identify Measures that May Improve the Safety of School Bus Transportation,

Improving School Bus Safety (Washington, DC. National Academy Press, 1989); National Safety Council, Accident Facts (Itasca, IL: 1993).
School bus

drivers injured 1,900

1,900 (10%)

r

I

I

Pedestrians

injured

950 (5%)

All others

injured

6,650 (35%)

I I

Struck by

school bus 0.30 B

283 (35°/0)

85

0.50 c

1 4 1

Struck by 0.30 B

other vehicles

525 (65%) 158

0.50 c

262

Nonstudents

142 (15%) 142

I I

 6,650 

I I

“Level A: Incapacitating injury. Any injury that prevents the injured person from walking, driving, or normally continuing the activities he was capable of performing before the injury

occurred, Inclusions. Severe lacerations, broken or distorted limbs, skull or chest injuries, abdominal injuries, unconscious at or when taken from the accident scene; unable to leave

accident scene without assistance; and others. Exclusion: Momentary unconsciousness, and others.

Level B: Non-incapacitating evident injury Any injury, other than a fatal injury or an incapacitating injury, that is evident to observers at the scene of the accident where the injury

occurred. Inclusions Lump on head, abrasions, bruises, minor Iacerations; and others Exclusion: Limping (the injury cannot be seen); and others

Level C: Possible injury. Any injury reported or claimed that IS not a fatal injury, incapacitating injury or non-incapacitating evident injury. Inclusions Momentary unconsciousness Claim

of injuries not evident Limping, complaint of pare, nausea, hysteria, and others.

SOURCE. National Research Council, Transportation Research Board, Improving School Bus Safety (Washington, DC: National Academy Press, 1989),
92 | Risks to Students in School

mately one-third of all injuries. A significant

number of head injuries occurred for both the

incapacitating and non-incapacitating injuries,

about 30 and 27 percent respectively.

TABLE 3-8: Police-Reported Injuries Sustained by Passengers

in School Bus Accidents in New York (1980–1986)

Injury severity (%)

Aa

(N=170)

Bb

(N=971)

Cc

(N=2,619)

Location of most severe physical complaint

Head 33.4 31.7 27.9

Face 10.0 32.7 6.1

Eye 14.1 1.4 0.0

Neck 5.9 1.1 12.6

Chest 2.4 2.0 3.2

Back 1.8 1.1 9.3

Shoulder/upper arm 4.1 3.1 5.9

Elbow/lower arm/hand 7.1 8.7 4.8

Abdomen/pelvis 4.7 0.5 2.7

Hip/upper leg 5.9 2.9 2.7

Knee/lower leg/foot 6.5 12.8 10.0

Entire body 1.8 0.4 5.9

Unspecified 2.3 1.6 8.9

100.0 100.0 100.0

Most severe physical complaint

Amputation 0.6 0.0 0.0

Concussion 27.0 0.0 0.0

Internal 9.4 0.0 0.0

Minor bleeding 6.5 30.9 0.0

Severe bleeding 14.7 0.0 0.0

Minor burn 0.6 0.6 0.0

Moderate burn 0.0 0.0 0.0

Severe burn 0.0 0.0 0.0

Fracture/dislocation 24.7 0.0 0.0

Contusion/bruise 0.6 53.0 0.0

Abrasion 0.6 15.5 0.0

Complaint of pain 12.9 0.0 77.7

None visible 2.4 0.0 16.9

Unspecified 0.0 0.0 5.4

100.0 100.0 100.0

(continued)
Chapter 3 Injury to Students in School | 93

Victims’ physical and emotional status

Unconscious 4.7 0.0 0.0

Semiconscious 11.8 0.0 0.0

Incoherent 2.9 0.0 0.0

Shock 3.5 1.1 1.3

Conscious 77.1 98.9 98.7

100.0 100.0 100.0

aLevel A injury means an incapacitating injury that “prevents the injured person from walking, driving, or normally continuing the activities he was

capable of performing before the injury occurred. Inclusions: severe lacerations, broken or distorted limbs, skull or chest injuries, abdominal injuries, unconscious at or when taken from the accident scene; unable to leave accident scene without assistance; and others. Exclusion: Momentary unconsciousness; and others.”

bLevel B injury means a non-incapacitating evident injury that includes “any injury, other than a fatal injury or an incapacitating injury, that is evident to observers at the scene of the accident where the injury occurred. Inclusions: Lump on head, abrasions, bruises, minor lacerations; and

others. Exclusion: Limping (the injury cannot be seen); and others.”

cLevel C injury means a possible injury that includes “any injury reported or claimed that is not a fatal injury, incapacitating injury, or non-incapacitating evident injury. Inclusions: Momentary unconsciousness. Claim of injuries not evident. Limping, complaint of pain, nausea, hysteria; and others.”

SOURCE: National Research Council, Transportation Research Board, Improving School Bus Safety (Washington, DC: National Academy

Press, 1989).

TABLE 3-9: Police-Reported Injuries Sustained by Pedestrians

Going to and from Stopped School Buses in New York (1980–1986)

Injury severity (%)

Aa

(N=56)

Bb

(N=130)

Cc

(N=192)

Location of most severe physical complaint

Head 30.4 26.9 11.5

Face 0.0 9.2 1.6

Eye 1.8 0.0 0.0

Neck 1.8 0.0 1.0

Chest 0.0 1.5 1.0

Back 0.0 2.3 5.7

Shoulder/upper arm 7.1 4.6 5.2

Elbow/lower arm/hand 5.4 10.0 6.8

Abdomen/pelvis 1.8 0.0 4.2

Hip/upper leg 5.4 13.1 18.2

Knee/lower leg/foot 35.6 30.8 37.0

Entire body 8.9 0.8 5.2

Unspecified 1.8 0.8 2.6

100.0 100.0 100.0

Most severe physical complaint

Amputation 5.4 0.0 0.0

Concussion 12.5 0.0 0.0

Internal 3.6 0.0 0.0

Minor bleeding 3.6 19.2 0.0

Severe bleeding 10.7 0.0 0.0

(continued)

TABLE 3-8: Police-Reported Injuries Sustained by Passengers

in School Bus Accidents in New York (1980–1986) (Cont’d.)
94 | Risks to Students in School

Pedestrian Injury Data

Fatalities and injuries occur to student pedestrians while walking to and from school. NHTSA

collects school-aged pedestrian mortality and

morbidity data, but the information does not indicate if travel was school related. However, databases that record pedestrian injuries by age and

time provide some estimates to indicate the

scope of the problem. At OTA’s request,

NHTSA generated time of day data for schoolaged pedestrians using 1992 FARS and GES data

(96,97). Assuming students typically travel to

school between the hours of 6:00 a.m. and 9:00

a.m. and travel home between 2:00 p.m. and 5:00

p.m., some estimates can be made and age and

time trends identified. Table 3-10 presents the

number of school-aged pedestrians fatally and

nonfatally injured during these times students are

typically going to and from school. While the

data provide an instructive illustration of pedestrian injuries for age groups and time of day, for

OTA purposes, the data probably represent overestimates since they include school-aged pedestrians who were not necessarily on the way to or

from school.

One hundred and twenty-one school-aged

pedestrians were fatally injured during the two

school travel time periods; an additional 9,600

suffered nonfatal injuries. Thus, for each death of

a school-aged pedestrian during these hours,

there were about 79 injuries. Fifty percent of the

fatalities were to the 5- to 9-year-olds alone;

however, the 10- to 14-year-olds suffered 54 perMinor burn 0.0 0.0 0.0

Moderate burn 0.0 0.0 0.0

Severe burn 0.0 0.0 0.0

Fracture/dislocation 60.6 0.0 0.0

Contusion/bruise 0.0 53.1 0.0

Abrasion 0.0 27.7 0.0

Complaint of pain 3.6 0.0 82.8

None visible 0.0 0.0 14.6

Unspecified 0.0 0.0 2.6

100.0 100.0 100.0

Victims’ physical and emotional status

Unconscious 5.4 0.0 0.0

Semiconscious 7.1 0.0 0.0

Incoherent 1.8 0.0 0.0

Shock 10.7 5.4 4.2

Conscious 75.0 94.6 95.8

100.0 100.0 100.0

aLevel A injury means an incapacitating injury that “prevents the injured person from walking, driving, or normally continuing the activities he was

capable of performing before the injury occurred. Inclusions: severe lacerations, broken or distorted limbs, skull or chest injuries, abdominal injuries, unconscious at or when taken from the accident scene; unable to leave accident scene without assistance; and others. Exclusion: Momentary unconsciousness; and others.”

bLevel B injury means a nonincapacitating evident injury that includes “any injury, other than a fatal injury or an incapacitating injury, that is evident to observers at the scene of the accident where the injury occurred. Inclusions: Lump on head, abrasions, bruises, minor lacerations; and

others. Exclusion: Limping (the injury cannot be seen); and others.”

cLevel C injury means a possible injury that includes “any injury reported or claimed that is not a fatal injury, incapacitating injury, or nonincapacitating evident injury. Inclusions: Momentary unconsciousness. Claim of injuries not evident. Limping, complaint of pain, nausea, hysteria; and

others.”

SOURCE: National Research Council, Transportation Research Board, Improving School Bus Safety (Washington, DC: National Academy Press,

1989).

TABLE 3-9: Police-Reported Injuries Sustained by Pedestrians

Going to and from Stopped School Buses in New York (1980–1986) (Cont’d.)
Chapter 3 Injury to Students in School | 95

cent of the nonfatal injuries. Of particular note,

60 percent of the injuries suffered by 10- to 14-

year-old pedestrians occurred between 2:00 p.m.

and 5:00 p.m. Twice as many fatalities and injuries occurred in the afternoon than in the morning.

Bicyclist Injury Data

In 1992, 40 percent of the bicyclists killed in

traffic crashes were between the ages of 5 and

15. The fatality rate for this age group was 7.2

per million population—more than 2.5 times the

rate for all bicyclists (94). There are about 1 million school-aged children injured on bicycles and

skates annually (67). Schools are the reported

location for 2.7 percent and the cause of 1.4 percent of these injuries (67). The majority of these

injuries occur on the street (42 percent) or at

home (32 percent). However, there are no estimates of the number of children and adolescents

that ride their bicycles to school. Some children

or adolescents injured on the street or at home

may have been en route to school. The 1992

FARS and GES data, described above relating to

pedestrians, were also used to generate data for

bicyclists from 6:00 to 9:00 a.m. and 2:00 to 5:00

p.m. (96,97) (see table 3-11).

Thirty-nine school-aged bicyclists died and

7,000 were injured during these times. More 10-

to 14-year-olds were killed or injured than the

other age groups; however, they are also the age

group more likely to be riding bicycles. Bicyclerelated deaths and injuries of school-aged children likewise occurred more often in the afternoon. GES injury data estimates by age for the

morning hours were too low to publish due to the

large sampling error (95 percent). Nevertheless,

GES data estimate a total of 1,200 injuries in the

morning, which—when compared to the 5,800

injuries in the afternoon—indicates that schoolaged children and adolescents are four to five

times more likely to be injured in the afternoon.

Increased fatalities and injuries in the afternoon

may be attributable to the number of children

riding bicycles for recreation as well as for transportation (5). Thus, these data, as they relate to

the school environment, are undoubtedly overinclusive.

Head injuries sustained when bicycle riding

are the foremost cause of fatal injuries. At least

70 to 80 percent of fatally injured bicyclists of all

ages had significant head injuries (5). In a study

of children less than 16 years old admitted to

Maryland hospitals in 1982 for bicycle crashrelated injuries, 97 percent were of school age (5

to 15 years). Forty-five percent of the children

had head injuries (fractured skull, concussion, or

other brain injury). It has been well documented

that these injuries could be prevented or ameliorated if the children wore helmets. One case control study estimates that helmets reduce the risk

of head injury by 85 percent in emergency room

cases (78).

TABLE 3-10A: 5- to 18-Year-Old 

Pedestrians Killed on Monday Through 

Friday, September 1991–May 1992

Age

6 a.m. to

9 a.m.

2 p.m. to

5 p.m.

All other 

times Total

5-9 19 42 90 151

10-14 17 27 68 112

15-18 6 10 87 103

Total 42 79 245 366

SOURCE: U.S. Department of Transportation, National Highway Traffic Safety Administration, Fatal Accident Reporting System 1992 Data

for Pedestrians and Pedalcyclists Ages 5–18 (Washington, DC:

1994).

TABLE 3-10B: 5- to 18-Year-Old 

Pedestrians Injured Monday Through 

Friday, September 1991–May 1992

Age

6 a.m. to

9 a.m.

2 p.m. to

5 p.m.

All other 

times Total

5–9 900 1,800 3,700 6,400

10–14 1,400 3,800 2,900 8,100

15–18 1,000 700 1,400 3,100

Total 3,300 6,300 8,000 17,600

All estimates subject to large sampling error due to small sample

size. 95 percent confidence interval.

SOURCE: U.S. Department of Transportation, National Highway Traffic Safety Administration, General Estimates System 1992 Data for

Pedestrians and Pedalcyclists Ages 5–18 (Washington, DC: 1994).
96 | Risks to Students in School

UNINTENTIONAL INJURY CONCLUSION

Unintentional injury is a significant health problem that follows children and adolescents into

the school environment. Nonetheless, there is no

systematic, organized process for collection of

national data on school injuries. Data are collected by many different organizations, public

and private, but national data are not available

systematically from any identified source. More

detailed analysis of existing databases such as

NHIS and NEISS by location (school) and age

(school-aged persons) could yield some national

estimates. OTA identified at least four states that

collect school injury data (Arizona, Hawaii,

South Carolina, and Utah). Arizona, South Carolina, and Utah have used this data to identify particular injury problems in their respective states

and to create specific school injury prevention

programs. Epidemiological studies provide a

more detailed study of injuries occurring at

school; however, caution must be used in generalizing results from local epidemiological studies

to national and state school populations. Despite

studying different student populations in various

geographic locations, most epidemiological studies reached similar conclusions regarding school

injuries. Thus, while conclusions about the relative safety of schools are sound, there is a deficiency of reliable school-related unintentional

injury data.

In terms of unintentional injury, play at playgrounds and sports are the most risky school

activities. While national data provide some estimates on the incidence of these injuries, state and

epidemiological studies provide some data on the

circumstances of the injuries. Although other

injuries that occur in the school building also

represent a significant number, little is known

about them. Classrooms, laboratories, shop facilities, stairs, and hallways all present some risks

of injury to students. While some studies have

collected some data on these locations, not much

is known about the circumstances of the injuries.

INTENTIONAL INJURY

In recent years, school violence has been a priority for both the executive and the legislative

branches (25,79,80,81,82). Support for research

at the National School Safety Center (NSSC)

(see box 3-10), and the launching in October

1993 of a Division of Violence Prevention at the

CDC (see box 3-11) are two initiatives that

reflect this interest. In late 1993, Clinton Administration officials also formed a multidisciplinary

Interdepartmental Working Group on Violence

Prevention with a Subgroup on Schools.

Burgeoning congressional concern and general public inquiry about risks related to intentional injuries have precipitated calls for more

accurate measurements of violence and more

TABLE 3-11A: 5- to 18-Year-Old Bicyclists 

(Pedalcyclists) Killed on Monday Through 

Friday, September 1991–May 1992

Age

6 a.m. to

9 a.m.

2 p.m. to

5 p.m.

All other 

times Total

5–9 1 9 29 39

10–14 4 15 35 54

15–18 2 8 15 25

Total 7 32 79 118

SOURCE: U.S. Department of Transportation, National Highway Traffic Safety Administration, Fatal Accident Reporting System 1992 Data

for Pedestrians and Pedalcyclists Ages 5–18 (Washington, DC:

1994).

TABLE 3-11B: 5- to 18-Year-Old Bicyclists 

(Pedalcyclists) Injured Monday Through 

Friday, September 1991–May 1992

Age

6 a.m. to

9 a.m.

2 p.m. to

5 p.m.

All other 

times Total

5 to 9 * 1,400 1,900 —

10 to 14 * 3,300 3,900 —

15 to 18 * 1,100 1,000 —

Total 1,200 5,800 6,700 13,800

*Estimates by age for this time period are too small to publish. All estimates subject to large sampling errors due to small sample sizes. For

example, the 95 percent confidence interval for an estimate of 1,400

pedalcyclists is 1,400 ± 900.

SOURCE: U.S. Department of Transportation, National Highway Traffic Safety Administration, General Estimates System 1992 Data for

Pedestrians and Pedalcyclists Ages 5–18 (Washington, DC: 1994).
Chapter 3 Injury to Students in School | 97

extensive evaluation of new public health and

school security technological interventions in

many of the nation’s school districts (see box 3-

12). By early 1994, the National School Boards

Association (NSBA) and the Children’s Defense

Fund issued reports outlining some risks of

school violence in their respective profiles of

public and privately supported reduction and prevention strategies (20,58).

Even though the media, parents, students, law

enforcement officials, and many other observers

have taken it as axiomatic that school violence

has increased during the past few years, no comprehensive national surveillance system tracks

injuries from intentional violence in the school

environment. Nevertheless, authorities are being

urged to take action. The 103d Congress submitted 61 bills on school violence. States have spent

considerable sums of monies allocated for

schools on efforts to decrease violence in school;

for example, the New York City Board of Education spent $1,009,000 in the 1992-1993 school

year on metal detectors, such as walk-through xray equipment, hand-held detectors, and mats

(74). Given the costs associated with these policy

decisions, it is necessary to evaluate the data that

provide the basis for these decisions for accuracy, certainty, and limitations associated with

them. 

This section considers the following questions

related to the information available on intentional injury: What are the data on intentional

injuries in school in the United States? How are

the data obtained and reported?

National representative samples and surveys

of school districts as well as diverse local school

records provided the main source of primary data

on the risk of interpersonal violence and suicidal

behavior in the school environment (61). For the

most part, however, these instruments are relatively new. For instance, 1993 is the first year for

which data singling out violence-related behaviors and risks on school campuses have been

integrated into the Youth Risk Behavior Survey

(YRBS). The YRBS is an instrument of the

Youth Risk Behavior Surveillance System

(YRBSS) developed by the CDC and conducted

every two years at the national, state, and local

levels. It continues to rank among the most cited

sources of information on weapon carrying and

physical fighting among the school-aged population.

BOX 3-10: National School Safety Center

Founded by presidential mandate in 1984, the National School Safety Center (NSSC) is the product of

a partnership between the U.S. Department of Justice and the U.S. Department of Education. Located

near its affiliate—Pepperdine University—in Westlake Village, California, the NSSC’s mission has been

twofold: to provide education about the problem of school safety and to serve as a clearinghouse for data

on trends in violence and innovative programs dealing with school crime prevention. Ronald D. Stephens,

the Center’s Executive Director, and his staff work very closely with the Centers for Disease Control and

Prevention and local school districts. “We’re generally working with a different school system somewhere

each week around the country with some type of school crime and violence behaviorally related issues,”

Stephens acknowledges.

In addition to its more active participation in the construction of local programs to tackle school violence and safety concerns, the NSSC issues a set of publications on a regular basis to inform the public,

educators, government officials, and law enforcement officials about national and local developments.

Two examples of recent publications are School Safety Update and Gangs in School. The Center’s publications have carried articles ranging from “Weapons: A Deadly Role in the Drama of School Violence” to

“Dealing with Diversity.”

SOURCE: Office of Technology Assessment, 1995.
98 | Risks to Students in School

BOX 3-11: Division of Violence Prevention, National Center for Injury Control and Prevention

Although the Division of Violence Prevention at the Centers for Disease Control and Prevention (CDC)

was officially founded in the fall of 1993, the investigation of factors leading to violence-related morbidity

and mortality has been a part of CDC’s research agenda for more than a decade. The Violence Epidemiology Branch was initially founded at CDC in 1983. With the more widespread acceptance of a public

health focus on violence, which stresses the role of prevention as well as the influence of various social,

economic, and behavioral factors, a multidisciplinary team of social and behavioral scientists, epidemiologists, and educators has worked to bring visibility to homicide, domestic and spousal abuse, suicide,

and other forms of interpersonal violence through the Division of Violence Prevention. Implicitly, this has

also entailed greater attention to the improvement of national and local surveillance systems to track the

epidemiology of violence-related injury patterns in American society.

In the aftermath of the 1979 Surgeon General’s Report “Healthy People” and a Surgeon General’s

“Workshop on Violence and Public Health” in 1985, both of which helped to lay the groundwork for later

goals to reduce rates of intentional injury, interpersonal violence among youth has remained a top priority.

It became clear to researchers at the CDC that rising rates of homicide and suicide among youth

reflected the need to address pressing social problems through more specific public health interventions

at younger ages. For this reason, schools are currently targeted as a site for public health education, and

the CDC’s Division of Violence Prevention runs such programs throughout the country. The Division for

Violence Prevention also collaborates with other centers at the CDC and federal agencies in the design of

the Youth Risk Behavior Surveillance System, which measures the incidence of weapon carrying and

other violence-related behaviors among youth. Most recently, members of the Division of Violence Prevention collaborated with the National School Safety Center as well as the U.S. Departments of Education

and Justice in a retrospective analysis of violence-related deaths on school campuses during the past

two years.

SOURCE: Mark L. Rosenburg and Mary Ann Fenley, Editors, Violence in America: A Public Health Approach. (New York and

Oxford, England: Oxford University Press, 1991); “New Directions in Violence Prediction: The Public Health Approach.” Violence

and Victims 3 (1988): 285–288.

BOX 3-12: Technology and Violence Prevention

Students in urban, suburban, and rural schools across the nation find themselves confronted with a

barrage of new technological devices employed to deter the bringing of weapons, such as guns, knives,

and razors, into the school environment. Walkie-talkies, video cameras, metal scanners, large airport-size

metal detectors, and x-ray machines, as well as the equipment that transports security personnel among

and within school campuses, represent a few of the strategies currently implemented in some districts.

For instance, one suburban community in Washington state recently purchased bullet-proof vests for its

security personnel after several shooting incidents on or near school campuses.

Technologies to deal with the incidence of school violence have recently been adopted in many

school districts across the nation. The National School Safety Center reports that the proportion of large

school systems employing metal detectors somewhere in their districts increased from 25 percent to 70

percent in two years.
Chapter 3 Injury to Students in School | 99

❚ Sources and Limitations of Intentional 

Injury Data

OTA has identified three kinds of data bearing

on intentional injury in the school environment:

incident reports compiled at the school level,

crime statistics, and health/vital statistics. The

national sources described in box 3-13 were chosen because they were devised as parts of ongoing surveillance efforts.

Definitional inconsistencies, underreporting,

and poor baselines characterize each data source.

OTA found a number of school crime logs and

security reports that failed to identify a police

number and official offense in the school district’s records, illuminating the problem of definitional inconsistencies. Even when school

districts encourage the use of standardized forms

to collect information on risks and injuries, parts

of the form detailing crucial demographic characteristics, such as age, grade, and race/ethnicity,

are often left out of the final product or report.

Underreporting results from the failure of many

school officials and districts to report criminal

acts to police authorities. Finally, researchers

have only recently started collecting much of the

available data and too little is known from previous years to discern increases or decreases in

violence. Together, these handicaps contribute to

the poor quality of data that obscures the public’s

perception and identification of trends in risks of

intentional injury in the school environment.

❚ Incidence and Distribution of Intentional 

Injuries

School-Associated Violent Deaths

Homicide and suicide are ever-present threats for

children of school age. Every single killing,

especially of children, occurring in school justifiably receives considerable public attention. Currently, the NSSC is the only comprehensive

source of information on these incidents, which it

compiles from analysis of newspaper clippings

(box 3-10). Since July 1992, the NSSC has collected data on “school-associated violent

deaths,” defined as any homicide, suicide, or

weapons-related death in the United States in

which the fatal injury occurred either on the

school grounds, or on the way to an official

school-sponsored event. The NSSC identified 45

school associated violent deaths for the 1993-94

school year and 53 for 1992-1993 (72).

Since the NSSC culls its estimates from news

clippings received from various clipping services

and other periodicals, it may underreport the

exact numbers of cases. Given the limitations of

using newspaper clippings as a data source, the

CDC’s Division of Violence Prevention initiated

in 1992 an ongoing collaborative study with the

NSSC and the Departments of Justice and Education to collect death certificate data and other

school and Justice Department data. Their objective is to verify the number and circumstances

around violent deaths at school, on school property, or during school-sponsored events.

Students at one urban school arrive for a daily metal scanning. During the entire process, which takes

about a minute and a half per student, pupils place their bookbags on a scanning machine before stepping on a floor metal detector unit. The student then proceeds through a metal detector. If the light turns

red on the metal detector unit, he or she is then asked to step aside and is rescanned to detect the

source of the problem. Each detector can cost school districts up to $20,000 for a state-of-the-art airporttype unit. Although policy analysts and researchers still do not agree about the effectiveness of metal

scanning as a deterrent to weapon carrying, the fact remains that the deployment of technologies to stem

violence has changed the character of the school day for many of America’s students. 

SOURCE: Office of Technology Assessment, 1995.

BOX 3-12: Technology and Violence Prevention
100 | Risks to Students in School

BOX 3-13: National Sources of School-Related Intentional Injury

School Data

Incident reports obtained from local school officials constitute the bulk of school-based data. Forms

are usually completed indicating that a particular student was involved in an incident where an injury or

crime took place, but forms often are not filed. While some school officials keep detailed records for their

own purposes, OTA found that many local school authorities failed to report criminal incidents to a district

or state-level office. This reluctance or inaction stemmed from fears among principals and teachers of the

stigmatization of a particular school or group of students. These problems were illustrated by a crisis at

the New York City Board of Education in July 1994, when the Chancellor of Schools rejected a school

security report after discovering that 400 schools had failed to report a single incident (Dillon, 1993). A

subsequent investigation identified more than 1,300 unreported incidents. Although South Carolina has

passed a legislative directive mandating the reporting of school crime to the state’s Department of Education, most local school districts have only recently begun to encourage the use of a standardized form

to report an incident.

Crime Statistics

The Department of Justice sporadically collects data on school crime in traditional crime surveillance

statistics on the federal level. The Bureau of Justice Statistics’ annual victimization survey Criminal Victimization in the United States provides some pertinent interview information related to school participants 12

years of age and older for: percentage of incidents inside school building or on school property; whether

self-protective measures were taken; whether strangers or nonstrangers were involved; whether a

weapon was used; race/ethnicity and gender of victim; and the number of offenders. The 1991 victimization survey results stated that 12 percent of violent crimes occurred in school buildings.

The Department of Justice’s School Crime: A National Crime Victimization Report (1989), an extension of the National Crime Victimization Survey, provides data from a representative sample of 21.6 million students aged 12 to 19 years. According to the survey, 2 percent of respondents indicated that they

had been victims of violent crimes at school, such as aggravated assault, robbery, and rape.

Health/Vital Statistical Data

The National Center for Health Statistics estimates the number of intentional injury fatalities that occur

to the school-aged population; however, it does not have a systematic mechanism to link injuries in youth

aged 5 to 18 in the school environment. The lack of coordination with state-level efforts has handicapped

this process. OTA has identified two federal surveillance mechanisms at the CDC that provide some epidemiological information on intentional injury in the school environment on an ongoing basis:

Youth Risk Behavior Surveillance System. The YRBSS is the most comprehensive national initiative

to monitor the prevalence of behaviors that result in intentional injuries (such as physical fighting and

weapon carrying) among youth. It has of four components: national school-based surveys; state and

local school-based surveys; a national household-based survey; and a national college survey. First

administered in the spring of 1990, the school-based components of the YRBSS will be implemented

biennially during odd-numbered years to national, state, and locally representative samples of 9th to 12th

graders.

Two of the YRBSS’s principal limitations are that it does not cover students below the 9th grade and

relies on student self-reports to characterize trends in physical fighting and weapon carrying. Not all state

and local education agencies conduct the YRBSS, and response rates in some states and cities that do

participate in the YRBSS have at times been poor.

(continued)
Chapter 3 Injury to Students in School | 101

Preliminary results from their search of 8,000

newspapers show that 105 violent deaths

occurred on school campuses over the two

school years (1992-93 and 1993-94): 87 homicides, 18 suicides, and five ruled “unintentional”

through the legal process (39). This averages to

about 44 homicides and 9 suicides per year or 53

“school-associated violent deaths.” Their finding

is the most reliable estimate available because

they followed up on every report submitted from

the NSSC.

Students in school do not appear to be at a

great risk for homicide or suicide. The 53

“school-associated violent deaths” constitute a

small fraction of the relative mortality of the

school-age population, with the 3,889 homicides

and 2,151 suicides occurring in children aged 5

to 19.

Suicide, the eighth leading cause of death in

the United States, is the third leading cause of

death for young people 10 to 19 years old (88).

Between 1970 and 1984, suicides in this group

rose 55 percent. Though school does not appear

to be a prominent site for the commission of suicide, the parents, students, staff, school health

officials, and researchers interviewed by OTA

stated that depression and general emotional

highs and lows are frequently part of the school

and adolescent experience at all levels.

Prior to the CDC collaborative study, the most

comprehensive national representative sample

of risks for suicide in schools has come from the

YRBSS and a few surveys of high school behavior (61). Data from several sources indicate that

suicide and attempted suicide are problems for

some school-age youth, even though schools

have not been a common location for commission of these acts (60,88). The 1993 YRBSS

noted that 24.1 percent of students surveyed

admitted having “thought seriously” about suicide during the 12 months preceding the survey

(91).

Furthermore, about 9 percent of students

admitted that they attempted suicide during the

12 months that preceded the survey and about 3

percent of students indicated that they needed

medical treatment for an injury, poisoning, or

overdose as a result of their attempt. Gender differences were noted, as 5 percent of males in the

sample had attempted suicide compared to 13

National Adolescent Student Health Survey (NASH). Administered and developed by the American

School Health Association in partnership with the Association for the Advancement of Health Education

and the Society for Public Health Education, Inc., the NASH provides data on student perceptions of

physical fighting, strategies to resolve conflicts, victimization (one of the few studies that covers sexual

assault in detail), weapons possession, and participation in violence prevention programs. During the

1987–88 school year, the survey was administered to 3,789 students attending 176 schools in 20 states.

School Health Policies and Programs Study (SHPPS). The SHPPS is a part of the CDC’s recent

effort to provide a better nationwide profile of public and private school policies in the area of violence.

Based on national surveys (voluntary) of 780 schools in 480 school districts that support a comprehensive health program, the SHPPS collects data from state, school district, and school personnel who make

or enforce policies related to violence in schools. Data will be used to measure 18 national health objectives and National Education Goal 6 for violence-free schools. The study omits elementary schools,

except where they have 7th graders.

Data from the first set of surveys was collected during the first half of 1994. Results will be available

late in 1995. When the results are reported individual schools will not be singled out. Instead, the data will

be available in aggregate form. Officials at the CDC hope that this new survey instrument will help create

better measurements of efforts to reduce and prevent violence in schools with more national data on the

influence of particular policies on incidence levels.

BOX 3-13: National Sources of School-Related Intentional Injury (Cont’d.)
102 | Risks to Students in School

percent of females; however, males are more

likely to die in a suicide attempt than females.

Weapon Carrying

After motor-vehicle-related injuries, injury due

to firearms is the second leading cause of death

in children ages 5 to 19; together they dwarf all

other causes of death for which data are available. In 1992, there were 5,260 firearms-related

deaths of children ages 5 to 19, which include

deaths due to intentional injuries (i.e., firearmrelated homicides and suicides) and deaths due to

unintentional injuries involving firearms. In

1992, the number of intentional injuries due to

firearms in school-aged children (about 3,280

firearm-related homicides, and 1,430 suicides)

far exceeded the number of unintentional injuries

due to firearms (470 deaths).

However, children are much less likely to die

from firearm-related injuries in school than out

of school. During two recent school years (1992-

93 and 1993-94), researchers identified an average of 53 “school-associated violent deaths”—

homicides, suicides, and unintentional weapon

fatalities—per year, almost all of which were

related to firearms.

Estimates of the number of weapons in school

vary widely (see box 3-14). According to the

NSBA and the Center to Prevent Handgun Violence, anywhere from 100,000 to 135,000 guns

are brought into schools every day (18,58,59). In

Cleveland, 22 percent of boys in a sample of 5th,

7th, and 9th graders admitted owning a gun to

protect themselves from threats and insults (68).

New York City school security officials confiscated 65 guns from students on school grounds

barely four months into the 1993-94 academic

school year (74). The State of Florida has admitted similar problems, with a 61 percent increase

in handguns between the 1986-87 and 1987-88

school years (18). With recent shootings in many

urban, rural, and suburban communities, concerns about weapons in schools will probably

remain a top priority for local school boards.

In some communities, even young schoolaged children have access to weapons. According to the NSBA, 63 percent of gun-related incidents on school grounds occurred among high

school students and 24 percent among junior

high school students, while elementary school

and preschool students constitute 12 percent and

1 percent, respectively, of total incidents (58).

These disparities are consistent with other local

studies among students on their general access to

weapons, as well as with the demographics of

where weapons are found by school authorities.

One-third of Seattle’s 11th graders acknowledge

that they have “easy” access to guns (15). Of the

1,249 weapons found in Virginia public schools

during the 1991-92 school year, 853 were recovered from middle school students (18).

BOX 3-14: Weapons Confiscated on School Campuses

Weapons possession is tracked very differently among the U.S. school systems that keep such statistics. This area is rife with definitional problems because many school districts report incidents but not

necessarily the type of weapon involved. It is often impossible to discern from local school board incident

reports whether a gun, knife, club, or other weapon precipitated disciplinary action against a student.

Characterization of the seriousness of weapons in schools, however, varies from location to location.

In some areas, such as South Carolina, the Department of Education reported that possession of weapons was the most frequently occurring offense. For other school districts, including New York City, Los

Angeles Unified, and most Connecticut districts, weapons offenses—although not the number one

offense—ranked high on school crime lists, preceded by vandalism, assault, harassment, larceny, and

burglary, many of which involved weapons possession as a secondary offense.
Chapter 3 Injury to Students in School | 103

Students carry weapons to school for a variety

of reasons (68,92,100). Iowa education officials

report that 23 percent of their high school students who carry a weapon to school do so for

protection (32). In the 1993 MetLife national

sample, 22 percent of boys and 4 percent of girls

said that they had brought weapons to school

(45). When asked to state a reason for weapon

carrying, 66 percent answered that it was to “be

accepted” and 49 percent emphasized “selfdefense to and from school.” Such statistics and

statements provide an important social context

for rates of weapon carrying across the country.

The motivation for and access to guns outlined in MetLife’s results and the recent sample

of Seattle’s 11th graders are consistent with levels of weapon carrying reported in the most

extensive national and regional/local investigations at the CDC. According to the YRBSS, 22

percent of high school students admitted to carrying a weapon (i.e., a gun, knife, or club) to

school in the preceding 30 days, and almost onethird of these students (8 percent) admitted to

carrying a gun (91). However, due to repeat

offenders, there are around 92 weapon-carrying

incidents monthly per 100 students (91). Important gender and racial breakdowns accompanied

these results. The YRBSS showed that male students were much more likely to carry a weapon

to school than females. Black students were

much more likely to carry a weapon to school

than Hispanic or white students—29 percent of

black students carried a weapon to school in the

preceding 30 days compared to 24 percent for

Hispanics and 21 percent for white students.

A number of shootings have drawn attention

to the problem of guns in school, but it is important to note that knives and razors are the weapons most likely to be found on students in most

areas sampled by the YRBSS (40). According to

MetLife, 55 percent of students bring knives or

switchblades to school (45). Suburban Prince

George’s County, Maryland (near Washington,

D.C.), has charted a 94 percent increase in knife

The difficulty in tracking weapons possession in schools stems primarily from the fact that many

school districts report the most serious offense as the primary incident. Therefore, weapons are ignored

as a secondary offense and consequently are not often reported in school incident data. In South Carolina, for example, from June 1992 through May 1993 there were 626 incidents (21 percent) with weapons

possession as the most serious offense. However, the total number of incidents involving weapons was

1,055, 36 percent of all school incidents reported in South Carolina during the 1992–93 school year.

Other schools districts, such as Los Angeles Unified School District, further classify weapons incidents to

distinguish between assaults and possessions and also to determine at what level such incidents are

occurring (whether elementary, junior high school, or senior high school). Still, the newness of mandatory

school crime reporting legislation in South Carolina and other areas means that good baselines are in

process of being created to measure trends in these offenses and incidents.

Although the diversity in mechanisms and definitions used to collect statistics on weapons possession

has made it impossible to generalize trends outside a given school district or state, most school districts

reporting to OTA stressed that knives and other sharp objects, such as “box cutters” (instruments used to

cut boxes and commonly found on students who have after school jobs where such instruments are

used), are the most commonly employed or confiscated weapons. Perhaps this is due to the accessibility

and low cost of knives. In the 1992–1993 school year, South Carolina’s Department of Education reported

that approximately 42 percent of weapons incidents involved knives or sharp objects. Handguns and

other firearms are usually the second most popular choice of weapons among students in California,

Connecticut, and New York, where more comprehensive statistics have been kept.

SOURCE: Office of Technology Assessment, 1995.

BOX 3-14: Weapons Confiscated on School Campuses
104 | Risks to Students in School

possession during the past year. One in five New

York City high school students recently reported

carrying a weapon anywhere at least once during

a 30-day period: 16 percent carried knives or

razors, and 7 percent carried handguns (89). Significantly, the same survey also found that

weapon carrying of all types was lower inside the

building and going to and from school than at

other locales outside the school environment.

Twelve percent of students admitted carrying a

weapon inside the school building, with 10 percent of that group reporting that they carried

knives or razors and 4 percent indicating that

they carried handguns.

Increasingly, metal detectors and scanners are

being employed to prevent weapons from being

carried into schools. The NSBA survey in 1993

found that 15 percent of all districts reported

using metal detectors (58). In its examination of

different localities, the NSBA found that 39 percent of urban districts, 10 percent of suburban,

and 6 percent of rural districts reported using

metal detectors.

There are some empirical and anecdotal data

on the effectiveness of metal detectors in preventing the entrance of guns, knives, and weapons into school buildings, but to date there have

been no controlled studies evaluating the effectiveness of metal detectors in reducing weaponrelated violence and injuries in schools. In June

1992, researchers from the CDC, the New York

City Board of Education, and the New York City

Department of Health administered a questionnaire to students as part of an effort to examine

violence-related attitudes and behaviors among

public high school students (89). The study

found that students who attended schools with

metal detectors (about 18 percent of all high

school students) and students who attended

schools without metal detectors were equally as

likely to carry weapons anywhere (22 percent

versus 21 percent, respectively). There was a difference reported, however, with respect to carrying weapons into the school building: 7.8 percent

of students who attended schools without metal

detector programs reported that they had carried

a weapon inside the school building during the

30 days preceding the survey, while 13.6 percent

of those who attended schools with such programs indicated that they had carried weapons

into the building.

As the authors of this study point out, these

findings do not include data on intentional injury

rates in school, and do not have “pre” and “post”

measures of weapon-carrying rates in schools

that were participating in the metal detector program at the same time of the survey. Nor do the

study’s results indicate how underreporting by

students at schools with metal detector programs

may have influenced the findings. The forthcoming 1995 results from CDC’s first question

related to carrying weapons inside the school

building (and not “anywhere” as in previous

YRBSS local and national samples) should help

to establish important baselines for further

school-based research.

Assaults

Assaults present a major problem for investigations of intentional injury among students in the

school environment. The lack of a precise definition of “assault” in much of the literature makes

it difficult to sort out which behaviors precipitated the labeling of an offense as an assault, particularly among school data (44). This problem

primarily reflects the lack of standardization in

local and national reporting of school crime in

either medical or crime reports. As one observer

at an OTA workshop explained, two types of

documents about violent incidents often exist

within schools: an informal categorization based

on a principal’s subjective decision and an official police document with a crime report. A principal’s report of a physical fight in school, in this

context, may not meet the national crime definition for an assault but may be considered such by

school authorities.

The characterization of physical—and to a

lesser extent, verbal and psychological—

assaults has been perceived as a major problem

in understanding school violence by most

researchers. The NSBA estimates, however, that

assaults rank at the top of a list of more than

16,000 violent incidents reported on a daily basis
Chapter 3 Injury to Students in School | 105

in school buildings (58). Of the more than 2,000

school districts reporting to the NSBA survey

about violence, 78 percent noted that they have

had problems with student-on-student assaults

during the past year. This response came from 91

percent of urban districts, 81 percent of suburban

districts, and 69 percent of rural districts.

New York City and Los Angeles, for example,

are two cities that keep assault statistics in Divisions of School Security run by administrators

who maintain surveillance databases based on

official police categories. Yet such databases

often suffer from underreporting at the building

level. Trends observed for various assault

offenses in NYC and Los Angeles and other

areas are reported in table 3-12.

Physical fighting

Physical fighting is often cited as an index of

how young people in the United States deal with

conflict in the school environment (40). It has

also been highlighted in the literature as an

important correlate of weapon carrying. Data on

the prevalence and severity of physical fighting

among school-aged youth have emerged from

recent national and local surveys. The YRBSS

found that 4 percent of all students reported that

they had been in at least one physical fight that

resulted in an injury requiring medical treatment

during the 12 months that preceded the survey

(40). Among students who fought, about half

indicated that they had fought one time, another

quarter of respondents indicated that they had

fought two or three times, and about 10 stated

that they fought at least four times.

Researchers have also identified differences in

incidence rates for physical fighting with regard

to gender. The 1993 national YRBSS, for

instance, identified a higher rate of physical

fighting among males than females (91). A rate

of 173 incidents per 100 students occurred

among males during the previous 12 months,

while females were engaged in 96 incidents per

100 students, or almost twice as many incidents

among males as females.

Social attitudes about physical fighting among

younger adolescents in the school environment

are generally under-researched, but several studies document the extent to which weapon carrying is viewed as a deterrent to physical fighting

among older adolescents (46,68,100). A 1992

study of violence-related attitudes and behaviors

among a representative sample of 9th- to 12thgrade public high school students in New York

City found that students who carried a weapon at

school were more likely than others to believe

that they could protect themselves from fights if

they flashed a weapon, such as a club, knife, or

gun (89). When compared with all students,

those who brought a weapon to school during the

30 days preceding the survey were more likely to

believe that threatening others with a weapon (21

versus 44 percent for all students) and carrying a

weapon (20 versus 48 percent) were effective

ways to avoid a physical fight. A significant percentage of students who carried weapons to

school also reported that their families would

support their decision to protect themselves from

physical attack even if it meant using a weapon

(44 versus 68 percent) (89).

Physical fighting appears to be more prevalent

among out-of-school youth than in-school youth.

According to a CDC study, there is a difference

in the prevalence of certain risk behaviors among

adolescents aged 12 to 19 years, based on school

enrollment status. The CDC conducted a survey

of adolescents aged 12 to 19, between April 1992

and March 1993. The survey found a higher percentage of adolescents “out of school” who indicated that they had participated in a physical

fight in comparison to students who stayed in

school: 51 percent of out-of-school youth, compared with 44 percent of in-school students. Furthermore, 23 percent of out-of-school youth

admitted carrying weapons, 7 percent higher than

the number of in-school students admitting such

behavior. In New York City, 8 percent of high

school students sampled entered into a physical

fight inside their school buildings compared to

25 percent of students who reported engaging in

fights anywhere (89). Fourteen percent reported

being threatened inside the school, as compared

with 36 percent who reported that they were

threatened anywhere.
106 | Risks to Students in School

Violence or threatened violence in school is a

reflection of violence elsewhere in the community. Officials from the NSSC often stress this

point in their reports on school crime and violence, as they also acknowledge that schools

exist in the context of a broader community

(59,90). Although rates for physical fighting may

on some level be reflective of a high degree of

interpersonal violence within the school environment, students generally seem to enter conflict to

a lesser extent when in school.

Gangs

The preponderance of research about physical

fighting has revealed gangs as an important factor in interpersonal violence in some schools

(16,38). According to the Northern Californiabased Center for Safe Schools and Communities,

“youth gangs of all races have increased by 200

percent in the last five years and female gangs

now represent 10 percent of all gang groups in

the nation” (17). Some scholars suggest that

gangs can be important places of refuge and

TABLE 3-12: Violent Offenses in Selected Areas, July 1992–July 1994

Type of offense 1988–89 1989–90 1990–91 1991–92 1992–93 1993–94

Florida (Dade)

Homicide 0 0 1 3 2

Sexual batterya 34 50 24 23 23

Assaultb 1,889 1,999 2,125 1,947 2,060

Weapon possessionc 393 468 558 568 571

Sex offensed 128 131 133 159 126

New York City

Homicide 0 1 2 2 2

Assault 1,356 1,684 1,260 1,880 2,643

Weapon possessione 1,854 1,891 2,045 2,416 2,444

Sex offense 78 94 65 121 91

Gang Fight 1 0 5 1 0

Los Angeles

Homicide 1 1 2 0

Assault 68 74 66 107

Assault with a deadly weapon 285 292 236 361

Weapon possessionf 863 926 845 1,300

Sex offenseg 53 87 70 119

South Carolina

Homicide 002

Aggravated Assault 300 251 410

Weapon offense 540 626 917

Sexual offenseh 27 44 52

aincluding attempts

bincluding threat of or physical harm

cincluding brass knuckles/firearms, etc.

dincluding lewd behavior/indecent exposure

eincluding weapons that are not illegal, but prohibited by New York City Board of Education

f

including gun and knife replicas and other weapons

gincluding misdemeanors and felonies

hincluding forcible and non-forcible

SOURCE: Office of Technology Assessment, 1995.
Chapter 3 Injury to Students in School | 107

identity formation for students in some areas of

the country (2,16). Trend data on gangs are

sparse, but gang membership in school may

begin as early as the 4th grade for many students

(34).

Many school districts do not keep consistent

statistics on gang activity, which may lead to

underreporting. It is also unclear in many

instances whether definitions of gang-related

problems in the school environment are limited

to the building, or its immediate vicinity, or

whether they include students going to and from

school, as well. The available epidemiological

evidence suggests that many of the injuries

resulting from gang activity occur away from

school (17). Of students sampled in the National

Crime Victimization Survey, 79 percent said that

no gangs were present in their schools. Of those

students reporting the presence of gangs, 35 percent indicated that they feared an attack on

school grounds, as compared to 18 percent of

students who reported no gang activity (92). A

recent analysis of the Los Angeles Police Department, which reports 400 gangs with a total membership of 60,000 in the city, notes that less than

1 percent of injuries stemming from gang rivalry

during 1991 took place at public schools or in

public parks (38). Approximately 60 percent of

urban school districts have also reported gang

activity to the NSBA, as suburban and rural districts also find themselves grappling with gang

violence (58). Since schools are one of the most

important places for socialization of young

adults who can wind up in gangs, gang membership rates should continue to be cause for concern.

INTENTIONAL INJURY CONCLUSIONS

OTA has found that for two prominent causes of

death—homicide and suicide—students are at

less risk in schools than out of schools. An average of 44 homicides occurred annually among

students in the school environment during the

1992-1993 and 1993-1994 school years—about

1 percent of all homicides for that age group in

1992. With respect to suicide, an average of 9

occurred in schools annually over these two

years, or less than 1 percent of all suicides committed in that age group in 1992.

OTA’s investigation of the epidemiological

and educational literature as well as school-based

records reveals very few intentional injury surveillance mechanisms in local school districts to

monitor school violence. The National Research

Council’s 1993 report, Understanding and Preventing Violence, singled out “violent events in

schools” as an area in which “high priority be

placed on modifying and expanding relevant statistical information systems” (53). OTA has

found these shortcomings in most school districts, a fact made clear by the identification of

only three states that could supply comprehensive data on school crime and violence covering

the past few years. Fortunately, local and

national public health officials appear to be moving toward public policies that recognize the

value of more systematic data collection efforts

on intentional injury as an important basis for

prevention.

The poor quality of data on the risk of intentional injury in the school environment makes it

impossible to discern the impact and severity of

risks from violence, in a national context and in

many local districts. Furthermore, the lack of

adequate baseline data for particular behaviors in

school, such as weapon carrying, is a local and

national problem, which results in not being able

to determine trends for intentional injury in

schools. These problems stem from the reluctance of school authorities to report crimes to the

appropriate education officials and crime authorities. OTA identified three states that require

reporting of school crime; additional states have

voluntary reporting. Most policymakers rely on

self-report surveys (often with poor response

rates) to characterize trends in school violence.

INJURY IN SCHOOL CONCLUSIONS

With respect to the leading causes of unintentional and intentional injuries among schoolaged children, schools are a relatively safe environment. The primary reason for this is that
108 | Risks to Students in School

schools are not typically the location of the leading causes of injury deaths to school-aged children—motor vehicle crashes, homicide, and

suicide. For fatal injuries such as homicide and

suicide, about 1 percent of deaths for persons

aged 5 to 19 occur at schools. One study of

severe injuries, using data from the National

Pediatric Trauma Registry (NPTR), found 3 percent of the injuries admitted to participating

trauma units occurred at schools (29). However,

for certain types of injuries, such as athletic injuries, the percentage of injuries incurred in

schools may be higher than outside the school

environment.

Table 3-13 presents the approximate number

of fatalities due to injury that occur at schools

each year. However, fatalities represent only the

tip of the injury pyramid, as most students who

are injured do not die of their injuries. A population-based study of childhood injuries in Massachusetts showed that for each death of a child (19

years of age or under), there were 45 hospitalizations and 1,300 emergency room visits (30). The

number of injuries treated elsewhere or not

treated was not known. These ratios are probably

greater in relation to school injuries—additional

analysis of the data showed that injuries at school

resulted in fewer hospitalizations than injuries

incurred elsewhere (63). Moreover, leading

causes of mortality incidence may not reflect the

leading cause of morbidity incidence (70). Thus,

to determine the extent of school injury incidence, both quality mortality and morbidity data

must be developed and examined.

Currently, mortality data are generally more

comprehensive and reliable than morbidity data

because death records are maintained by all

states; mortality data are compiled annually from

death certificates at both the state and national

level. Yet these statistics are not detailed enough

to analyze unintentional fatalities trends at

schools because the location of the death may not

be reported. Morbidity data are even less complete, often precluding detailed analysis of the

circumstances under which injuries occur. Moreover, data on school injury outcome, rehabilitation, and long-term disability are virtually

nonexistent, making the determination of injury

severity and impact nearly impossible. The disparity in the quality of national mortality and

morbidity data is due in part to the absence of

mandatory reporting for the external cause of

injury and school as a location category on injury

coding forms.

In 1985, the National Research Council report

Injury in America concluded that “most of the

data sources currently available for the study of

injury have serious inadequacies” (54). The

information has not improved much during the

intervening time (70). Although morbidity and

mortality estimates are available for injuries

TABLE 3-13: Selected Fatalities 

Occurring in Schoola

Related activity/factor

Approximate 

number of fatalities per year

Playground 8–9b

Sports 20c

School bus-related crash (passengers) 12d

School bus-related crash (pedestrians) 37–38e

School bus-related crash (bicyclists) 3.2f

Homicide 44g

Suicide 9g

aThese fatalities represent only the most prominent reported fatalities

from the sources cited. It is likely that other fatalities occurred in

schools from other causes.

bCPSC’s 1990 Playground Equipment-Related Injuries and Deaths

reported 276 fatalities over the 16-year study period. About 50 percent of the deaths were of children under the age of six. Schoolaged fatalities, therefore, averaged eight to nine a year. Importantly,

these are equipment-related fatalities only.

cF.O. Mueller, C.S. Blyth, and R.C. Cantue, Tenth Annual Report of

the National Center for Catastrophic Sports Injury Research, fall

1982–spring 1992 (Chapel Hill, NC: University of North Carolina,

1993). This number does not include fatalities which occurred during

physical education.

dNational Research Council, Transportation Research Board, Committee to Identify Measures that May Improve the Safety of School

Bus Transportation, Improving School Bus Safety (Washington, DC:

National Academy Press, 1989).

eIbid.

f

Ibid.

gNational School Safety Center and CDC, average of the total numbers of homicides and suicides found in the 1992–93 and 1993–94

school years.

SOURCE: Office of Technology Assessment, 1995.
Chapter 3 Injury to Students in School | 109

incurred by school-aged children, data on schoolrelated injuries are wanting. Definitional inconsistencies, the lack of accurate baselines, underreporting, and the absence of a national—and, in

most cases, state-level surveillance system—

complicate the characterization of trends in injuries at school and undermine public health intervention efforts to stem the impact and severity of

risk factors related to school injuries.

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Chapter 3 Injury to Students in School | 113

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| 195

5

Using the

Data

hapters 3 and 4 of this report are compilations of information about health and

safety risks in school. This chapter discusses how these data—along with

other types of information—can help set priorities for risk reduction. In the end, surveys and

studies of illness, injury, and death can provide

only part of the picture. Decisionmakers are still

faced with questions of which risks can be remediated and at what cost.

Moreover, even with good health and safety

data (uncommon) and good information about

the effectiveness and costs of risk reduction measures (even less common), the decision about

which risks to focus on first would not be

straightforward. These decisions go well beyond

counts of illness and injury and costs of improvements, to difficult ethical, social, and emotional

choices.

Inevitably, the course of deciding which risks

matter the most leads to suggestions for the use

of comparative risk assessment (CRA). Following a discussion of the different risk-related concerns, this chapter briefly explains CRA and the

opportunities and problems it presents for making risk comparisons and deciding on priorities

for risk reduction.

RISK DIMENSIONS

What is presently called “risk comparison” usually compares the number of injuries, illnesses,

or deaths each risk may cause, without any other

factor distinguishing them. Risk estimates alone

do not necessarily relay the entire picture concerning the health effects involved, such as information on the nature of the death, illness, or

injury, and the costs involved (13). The challenge for analysts is to present quite varied risks

in rich, informative, and nonmanipulative ways.

The starting point for broadening the scope consists of a fuller enumeration of the attributes or

dimensions of risk.

It is natural for most people to order things by

their size or severity, yet simple point estimates

of risk often do not convey how risks, even of

similar numbers of deaths, illnesses, or injuries,

can differ. As an illustration of the importance of

risk attributes beyond magnitude, consider the

data presented in chapter 3 on deaths to students

from school bus crashes and from in-school

homicides. In both cases the severity is the same

and the number of annual fatalities is roughly

equivalent (40 to 50 cases in recent years). Nevertheless, there can be no doubt as to which cause

of death is presently of greater public concern:

school homicides. One indication of this public

C
196 | Risks to Students in School

concern is the number of bills appearing before

Congress on these issues. The 103d Congress

introduced 61 bills dealing specifically with

school violence and only two on school bus

safety—of which one was a resolution for a

“school bus safety week.” Clearly, setting priorities involves more factors than just the number

and severity of injury or illness.

This report discusses those risk attributes that

can be considered in efforts to compare and

rank diverse in-school risks, which inevitably

involves value judgments as well as scientific

estimates and measurements. It organizes the relevant risk attributes, or “dimensions,” into three

categories: magnitude of the risk; fear; and social

contexts of the hazard (table 5-1).

The risk magnitude refers to the quantitative estimates of the likelihood of adverse

health effects arising from the hazardous conditions. This category reflects the more conventional notions of the number of cases of injury

and illness and their severity. There are several

common measures for quantifying risk magnitude, some of which measure the individual

probability of risk or the risk to the population.

This report uses the number of incidents and

incidence rates as measures of injury or illness in

the school population and lost school days as a

measure of severity. One measure of particular

relevance in this report is in not treating all fatalities as equal; instead, the death of a child can be

weighted more heavily than that of an adult,

accounting for the additional years of life lost for

the child.

Fear can be one of the most significant

dimensions of risk, especially in schools, and

one that varies widely across individuals and

communities. Contributing to the fear of a hazard is the extent to which individuals can or cannot control the risk through personal action.

Parents may fear their child’s in-school exposure

to asbestos or students carrying weapons because

they cannot control these things, but they are

probably less afraid of the exposures to infectious pathogens—even though bacteria and

viruses are responsible for more lost school

days—because they have more control from antibiotics, vaccines, and bedrest. The irreversibility

TABLE 5-1: The Dimensions of Risk

Category I: Magnitude

■ Unweighted population-based measures of magnitude.

■ Weighted population-based measures.

■ Individual-risk measures that are independent of the number of persons at risk.

■ Hybrid measures that incorporate characteristics of both population and individual-risk criteria.

■ Measures that incorporate the concept of “background.”

Category II: Fear

■ Degree of fear.

■ Degree of irreversibility.

■ Degree of individual controllability. 

■ Degree of deferral to future generations.

Category III: Social Contexts of the Hazard

■ Salience of blame.

■ Degree of identifiability of those at risk.

■ Benefits of the risky activity or exposure.

■ Cost and feasibility of reducing risk.

■ Risks of the intervention itself.

SOURCE: A. Finkel, “Comparing Risks Thoughtfully,” unpublished contractor report prepared for the Office of Technology Assessment, U.S. Congress, Washington, DC, September 1994.
Chapter 5 Using the Data | 197

of an illness or injury also adds to the fear associated with a hazard; the more irreversible the

effect, such as spinal cord injury or HIV infection, the greater the fear.

In contrast to magnitude, much of the

social context of different risks cannot be

readily quantified. Some risks are more worth

taking—or bearing—than others. This difference

is largely governed by the perceived benefits that

accompany the risk. Football, for example, is

among the most hazardous athletic activities—in

terms of the number and severity of injuries—in

which high school students participate; yet the

perceived benefits of athletic accomplishment

and social recognition encourage continued participation in it. The risk of a student dying in a

car crash on the way to and from school may be

high, but the risks are offset by the considerable

time saved or the risks averted from having to

walk home in the dark.

Analysts and decisionmakers must also consider impacts other than health, such as the disruption of the learning process that occurs from

lost school days. One study found that absenteeism can present a social hazard, in terms of maladaptive behavior, difficulties in finding and

maintaining employment, and welfare costs (20).

Another intangible factor is the desire to focus

attention on reducing risks where in so doing

injustices can also be redressed and blame for the

hazard can be affixed. Toxic releases from

nearby hazardous waste sites or industry discharge generate more attention than comparable

or even greater risks from radon because, in part,

radon, unlike toxic releases, where a culpable

polluter can usually be identified, is a natural gas

and no one is responsible for its generation or its

presence in indoor air.

The last category of risk attributes is an

especially important consideration now confronting schools: the cost and feasibility of

reducing risks. Small risks that are cheap and

easy to eliminate may deserve priority attention,

whereas even very large risks may not emerge as

priorities from a thorough risk comparison—if

reducing them would be technically infeasible or

prohibitively expensive. Metal detectors, for

instance, may provide added protection from

firearms in schools, but they are expensive and

school boards must decide if the risks at their

schools justify the costs. Not only the cost, but

the risk of the intervention itself, the dimension

of “offsetting or substitution risks,” arises whenever reducing one risk would create new risks in

so doing. For example, closing the schools to

remove asbestos exposes the children to risks of

being out of school.

COMPARING RISKS

Risk comparisons are ubiquitous. Even though

the most well-known types of comparisons

involve environmental and human health risks, it

is important to keep in mind that everyone has

experience comparing many other risks as well.

People may fear airplane travel and instead opt

for travel by car—even though the risks of the

latter are far greater. Some may fear bacterial

contamination of fish and poultry or pesticides in

their salads, yet are unconcerned about smoking

cigarettes or drinking alcohol before driving.

To provide a context for the use of the data

presented in this report, this section describes

different types of comparative risk assessments,

ways to conduct those assessments and, finally,

factors to consider when setting priorities for risk

reduction.

❚ Types of Comparative Risk 

Assessments

Some analysts distinguish between two different

types of comparisons that differ in motivation as

well as methodology.1 These comparisons can be

called “small” and “large” CRA paradigms.

“Small” CRA involves the quantitative side-byside comparison of single risks. Ten or 15 years

1 See A.M. Finkel and D. Golding (eds.), Worst Things First? The Debate Over Risk-Based National Environmental Priorities (Washington, DC: Resources for the Future/Johns Hopkins Press, 1994).
198 | Risks to Students in School

ago, the most well-known examples of “small”

CRA were the juxtaposition of markedly dissimilar risks, often with one risk of the pair a voluntary risk and the other the result of an involuntary

exposure. Such “hang-gliding is riskier than

benzene comparisons” were performed and popularized for their supposed value in communication

and public education (2). Some, however, viewed

this type of analysis as manipulative and grounded

in numerical sleight-of-hand rather than a neutral

desire to inform and help put risks in perspective

(3,14). In any case, the acknowledged intention of

these efforts is to provide the perspective on a

given risk with a comparison with others risks

encountered in everyday life (see box 5-1).

Other types of “small” CRA are entering into

current decisionmaking. The U.S. Environmental

Protective Agency has recently begun to compare risks closely linked to intended regulatory

actions; for example, the comparison of health

risks of various automotive fuels and the ongoing

assessment of the choice between cancer risks

caused by the chlorination of drinking water and

pathogenic risks due to the failure to disinfect.

“Large” CRA is a more recent phenomenon. It

involves the comparison of categories of risks,

and is increasingly being undertaken both for

symbolic and practical purposes. The most prominent examples of “large” CRA have come from

EPA’s 1987 report “Unfinished Business” (18)

and its 1990 study “Reducing Risks: Setting Priorities and Strategies for Environmental Protection” (19). Both reports explored whether setting

agency priorities using, in part, a risk-based

approach would save more lives and provide better protection without increasing the agency’s

total budget.

Many state and local governments are experimenting with CRA in ranking environmental

problems by severity and comparing risk-reduction strategies. As discussed in box 5-1, at least

BOX 5-1: Comparing Risks in the States

At least 30 city, state, and tribal CRA projects are completed, under way, or in the planning stages.

These efforts attempt to rank risks and priorities for environmental problems by incorporating qualitative

information and value-laden judgments. Various experts in different environmental health fields provide

their qualitative estimates of risk, but these estimates are broadened and enriched by public involvement.

These studies are part of a nationwide effort by the U.S. EPA to help regulatory agencies in each state

identify their most pressing environmental risks. The idea is to help cash-strapped states cope with growing federal environmental legislation and regulations by making it easier to compare the costs and benefits of proposed regulations to existing rules.

Comparative risk analysis deals with the full range of environmental problems and in large areas. It

depends heavily on qualitative information and value-laden judgment in addition to the estimates of the

magnitude of risk. Comparative risk analysis is a process that can be divided into two phases: risk analysis and risk management. In the analytic phase, participants try to understand how environmental problems affect the things they value, such as health or environmental quality. The first phase ends when

participants rank the problems in order of their severity.

In the second phase, participants analyze and compare strategies for better addressing the problems

they find are important. Most projects use an open process designed to bring the public into both the

analytic design of the projects and the decisionmaking itself.

The ranking process is the key event in the first phase of a comparative risk project because it forces

participants to make sense of all they have learned about the causes and consequences of pollution, the

distribution of risk, and the quality of data and the uncertainties inherent in risk assessments. Although

comparing dissimilar risks is not a technical or scientific process, the framework of comparative risk

makes the process systematic, thoughtful, and illuminating.

SOURCES: Office of Technology Assessment, 1995, based on R. Stone, “California Report Sets Standard for Comparing Risks,”

Science 266:214, 1994, and R. Minard, “Comparative Risk Analysis,” testimony presented at hearings before the Subcommittee

on Technology, Environment, and Aviation. Committee on Public Works and Transportation, House of Representatives, U.S. Congress, Washington, DC, February 3, 1994.
Chapter 5 Using the Data 199

30 city, state, and tribal CRA projects are completed, under way, or in the planning stages

(11,16) (figure 5-l). These efforts attempt to

rank risks and priorities for environmental problems by incorporating qualitative information

and value-laden judgments. Various experts in

different environmental health fields provide

their qualitative estimates of risk, but these estimates are broadened and enriched by public

involvement.

❚ Conducting Risk Assessments

Whatever process society chooses for putting

comparative risk assessment into practice, it

ought to advance two distinct goals: provide a

forum for identifying, and making judgments

about, the “important” dimensions of the risks

being compared, and provide a framework for

asking, and moving towards consensus about, the

real underlying question: “What should we do to

make our schools safer, given that any intervention we undertake will use up resources from a

finite supply?”

Much of the current discussion of the process

for comparing risks revolves around the distinctions between the so-called “hard” version of

risk-based priority setting and the “soft” version

preferred by some other stakeholders (3,4). The

design of the “hard” version—also referred to as

“expert-judgment”- involves the use of a small

group of experts to develop estimates of the magnitude of various risks, as well as a ranking of

risk reduction opportunities. This strategy presumes that the experts can estimate the “actual

risk” that will be different than the “perceived

risk” of the lay public (15).

Some believe that the hard version can do

more harm than good. Certainly, confining the

ranking process to the experts, and further cirthat are complete, in progress, or in planning.
200 | Risks to Students in School

cumscribing it to deal only in the currency of

“risk numbers,” may not be productive in

advancing social judgments on risks in schools,

for two overriding reasons: 1) the conventional

ranking tool—using risk estimates—is onedimensional: many other dimensions may be of

equal or greater importance than risk magnitude

alone; and 2) even if magnitude is the most

important dimension, exclusion from the process

to determine the ranking will tend to cause

resentment and mistrust among the affected citizens, in this case parents and their children (3,7).

The soft version has its problems too. In this

paradigm, a representative group composed of

citizens and experts would work together to

generate a more impressionistic and less quantitative, magnitude-oriented ranking from a consensual weighting of the various dimensions that

distinguish the risks under consideration. In this

way the views and values held by those in the

community can be incorporated into the riskranking activity. The obvious objection to the

softening of CRA is that it allows people to make

the subjective, soft dimensions, such as fear, as

important—if not more so—than the quantitative

information on risk estimates. From its critics’

point of view, the soft version is just a polite way

to describe the emotional, haphazard, inefficient

way we currently set priorities. A perhaps less

obvious but potentially more damaging criticism

points out an ironythat while the soft version

serves as a model alternative to the technocratic

elitism of the hard approach, it may be no less

vulnerable to being dominated by special interests (10).

For all the criticism, supporters of CRA argue

that it is a logical extension of the less formal

thought process individuals and governments

already rely upon to help them make choices in

all areas of human endeavor (3). Comparison and

ranking inevitably involve value judgments as

well as scientific measurements and estimates.

One study suggests that qualitative characteristics of perceived risk are important to people in

making decisions about new technologies (8). An

open process, supporters claim, informs risk

assessors about the values of those affected and

the importance they place on these subjective

risk attributes. Moreover, they claim that even if

a CRA fails in establishing priorities, the effort

would succeed in both educating and involving

the public, engendering more public support for

resulting decisions (17). As Fischoff states, “an

objective determination of subjective values is

needed to protect individuals from being

exploited by society and society from being

coerced by individuals” (6).

❚ Lessons Learned

Regardless of the nature of the evaluative strategy, hard or soft, certain lessons can be learned

from the limited attempts at CRA currently being

conducted by local, state, and tribal governments. Few hard and fast conclusions can be

drawn until more experience has been gained.

Nevertheless, these CRA experiments reveal certain desirable features for CRAs.

The first lesson is to significantly involve the

public. Public participation has proven an invaluable aspect of CRAs. By involving the public, a

CRA can go beyond probability estimates of risk

and incorporate ethical and political concerns,

which are usually neglected in risk assessments

(6,15). An open process informs risk assessors

about the values and importance of subjective

risk attributes, such as fear, to the community.

Comparison and ranking inevitably involve

incorporating these value judgments as well as

scientific estimates and measurements.

The process also educates the public on the

scientific and technical issues associated with

risk assessment. The process should instruct

everyone involved—parents, school boards, risk

assessors, and others—about the nature of suspected risks. Risk comparisons can alienate people if the comparisons fail to inform them (5).

The next lesson is the need for a strong analysis of the available risk information and clear criteria for comparisons. The methods used by

states and EPA (1,11) for risk analysis employ

teams of experts to fashion a list of problems,

sorted by types of risk—cancer, noncancer, ecological effects, etc. Using a variety of standards
Chapter 5 Using the Data | 201

for comparison, the experts can first rank the

problems within each type of risk and then relative to hazards of other types. The initial information that flows from these analysts to the

public should be regarded as the first step. In

addition to having a central role to play in evaluating the empirical and narrative information

about the various dimensions of the risks being

compared, the stakeholders may have much to

contribute in structuring the criteria of analysis

and supplementing the information itself. Having

all participants agree to a common set of criteria

and basing the analysis on those criteria make the

results more understandable, as well as politically and socially acceptable.

The major obstacles to successful CRA

projects come from the resource- and information-intensive nature of the process. Undertaking

a CRA in a school district or state requires a

large commitment from the school board, possibly the Mayor or Governor, and others involved

in city—or statewide decisionmaking. Each

project uses the expertise of researchers from a

variety of public health fields, as well as substantial public involvement. The staff time and the

financial backing necessary to see the project to

completion may not be available in many cases.

Not only are resources difficult to obtain, but as

this report has shown, often inadequate data exist

on which to make decisions with anything nearing useful certainty. Risk ranking requires considerable information on the nature of the risk

and its potential impact on the community.

MANAGING RISKS

Setting priorities for risk reduction is more than

simply ranking risks. As many observers have

remarked, to set priorities means to guide where

resources should flow (9). The biggest problems

may bear no resemblance to the highest priorities

for risk reduction. Large risks may have no

socially, politically, technologically, or economically acceptable means of control or prevention,

while small risks may be eliminated through

actions that carry a small or even a negative economic price tag. Therefore, even if none of the

social dimensions of risk are to be included in the

analyst’s attempt at risk comparison, decisionmakers and stakeholders need information on the

feasibility and costs of specific interventions in

order to judge where resources should go. These

estimates may be as uncertain as the risk estimates and may add further complexity to the

social process, but the alternative is either to rank

the risks alone and have no guide for policy, or

(perhaps worse) for decisionmakers to assume

that the risk ranking equals the resource allocation.

Any commitment to a risk-control policy is

likely to be supported by a web of beliefs about

the magnitude of the risk and the effectiveness of

the policy (5). Some of these beliefs will be accurate, and others erroneous. Still others will be

half-truths, correct beliefs that ignore parts of the

problem—such as the other uses for the

resources being spent.

People may also be confused, caught up in the

chaotic process by which risks are nominated for

consideration. Alarming stories in the media may

psychologically commit them to certain safety

measures, such as installing school metal detectors or removing asbestos, and they may find it

difficult to abandon these strategies. They may

feel unbearable pressure to deal with minor risks

that the media and others shove into the center of

their field of vision.

Regardless of the sizes of the risks or the

strength of public perception, limited resources

constrain the possible alternatives for risk reduction. The purpose of comparing a wide range of

risks in schools is to help allocate or reallocate

resources among the many possible risk reduction options, including the option of no action on

a certain perceived risk. The result of the process

may be to reduce the controls on some risk-producing activities and channel resources elsewhere, into other risk-reducing activities or even

activities unrelated to risk reduction.

Some observers criticize these “zero-sum”

choices, where governments and school boards

declare they can address only one risk or another

(12). In fact, parents will likely view funds spent

on school safety as nonnegotiable, and they may
202 | Risks to Students in School

discount claims of fungibility: they will rarely

accept a trade of more books for less safety. The

public may accept funds being spent more efficiently, but not at a cost of visibly greater risks to

students.

To such a combustible and emotional debate,

the need for objective analyses, understandable

information, and direct communication becomes

increasingly clear. This report, then, consists of a

first step in this process.

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Chapter 5 Using the Data | 203

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