Parent Opinions About the Appropriate Ages at Which Adult Supervision Is Unnecessary for Bathing, Street Crossing, and Bicycling FREE

Parental supervision has been recognized as vital to childhood injury prevention by national organizations devoted to improving the welfare of children. The American Academy of Pediatrics, Safe Kids Worldwide, the National Highway Traffic Safety Administration, and the Consumer Product Safety Commission have created numerous guidelines regarding supervision of children, including those participating in water,^1- 7 pedestrian,^6- 8 and pedal-cyclist activities.^7,9- 10 However, these organizations do not all agree on the appropriate age for a child to be left unsupervised in any of these activities. The American Academy of Pediatrics recommends that children 6 years and younger need adult supervision for crossing streets,⁷ whereas Safe Kids Worldwide recommends this supervision for children 10 years and younger.⁸ Many recommendations do not specify an age when supervision is no longer required. The American Academy of Pediatrics recommends that “young children should ride [bicycles] only with adult supervision.”⁹ Similarly, the Consumer Product Safety Commission recommends against leaving “young children” alone in the bath,¹ whereas the American Academy of Pediatrics specifies 5 years as the youngest age for unsupervised bathing.⁵ The variability and lack of specificity are partly due to the recognition that individual differences affect the child's attainment of the cognitive and motor skills necessary to successfully complete each task and partly because the literature on when children are, on average, able to accomplish various tasks is limited.¹¹

Numerous studies have attempted to define the relationship between supervision and subsequent childhood injury.^12- 22 Morrongiello et al¹⁵ have shown that mothers who reported leaving children unsupervised at younger ages had children who experienced more injuries. Parental supervisory behavior may act as a mediator between child behavior and a hazardous environment.^{14,17- 18,23} How the parent chooses to modify this mixture of one-on-one supervision with environmental safeguards is influenced by the attributes of the parent,^{14- 16,18,21,24- 27} the child,^{15,17- 18,21,24,26} and the environment.^12,14,20,25 The overall effectiveness of parental supervisory behavior, however, depends on how it mediates the dynamic of the child's behavior and interaction with the environment.

The effect of parents' attributes on their beliefs about the appropriate age to leave children unsupervised has not been well characterized. Parents who take risks with their own behavior may similarly allow more risk taking in their children, by freeing them from adult supervision at younger ages. Differences in beliefs about parental supervision may mediate previously reported differences in injury risk by race, ethnicity, and immigration status.^28- 31

The aims of our study were to describe parent opinions about the ages at which a typical child can be allowed to bathe in a tub or ride a bicycle on a busy street without direct adult supervision or to cross a busy street without holding hands, and to examine how characteristics of the household or parent may influence this opinion.

We performed a cross-sectional analysis using the Colorado 2004 linked Behavioral Risk Factor Surveillance System (BRFSS)–Child Health Survey (CHS). The Colorado Department of Public Health and Environment (including J.G. and J.D.), in consultation with investigators from the University of Colorado School of Medicine (including L.A.C. and C.D.) and local and state agencies, constructed the 124-item CHS as an add-on to the Colorado 2004 BRFSS. The BRFSS collects annual prevalence data on adult risk behaviors and preventive health practices using random-digit dialing and computer-assisted telephone interviewing.³² The goal of the CHS was to collect similar data on children aged 1 to 14 years. Using standard BRFSS sampling methods,³² a representative sample of Colorado households with telephones was selected for the initial BRFSS. The response rate (completed interviews from among eligible households in the sample) for the Colorado 2004 BRFSS, computed in accordance with standards defined by the Council of American Survey Research Organizations,³³ was 62.7%.³⁴ Among all states, the median 2004 BRFSS response rate was 52.7% (range, 32.2%-66.6%).³⁴

Households completing the BRFSS telephone questionnaire that reported children aged 1 to 14 years living in the home were then asked to complete the additional CHS telephone survey 1 week later. When more than 1 eligible child resided in the house, 1 child was randomly selected as the survey subject. Whenever possible, the adult caregiver with the most knowledge of the child was selected as the respondent. The Council of American Survey Research Organizations response rate for the CHS was 76.8%. The overall response rate for the BRFSS-CHS was therefore 48.2%.

We excluded households in which the respondent declined to link BRFSS and CHS data. Of 997 CHS surveys completed in 2004, 980 respondents (98.3%) agreed to data linkage.

The 3 primary outcomes measured by the CHS were the ages at which the caregiver believed that a typical child is able to bathe without an adult in the room, to ride a bicycle in a busy street without an adult, and to cross a busy street without holding hands (Table 1). Questions on bathtub and pedestrian supervision were taken from the unpublished Injury Control and Risk Survey 2, phase 2 (Karin Mack, PhD, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; written communication; May 1, 2006). These questions have not been validated against observed behavior, but their face validity is supported by similarities to the validated supervision instrument devised by Morrongiello and Corbett.³⁵

Numerous factors that may be associated with parent opinion about the study outcomes have been identified,^{12,14- 16,18,20- 21,24- 27} and those characteristics included in the linked data set were considered for analysis. We chose caregiver risky and protective behaviors to model themes of conscientiousness and locus of control devised by Morrongiello and colleagues.^18,35 These included whether the child rode in a car in the past 30 days with an adult or friend who had just consumed at least 1 alcoholic beverage or used marijuana or another illicit drug; whether the child always used a motor vehicle occupant restraint; whether a firearm was kept in the house; and the frequency with which the child rode in a car with someone who drove at least 10 miles per hour above the speed limit within the past 30 days, categorized as occurring 0, 1 to 4, or 5 or more times and treated as linear for these 3 categories. We also assessed risky drinking (>2 drinks per day for men and >1 drink per day for women) in the past 30 days, and any history of suicidal ideation (ie, seriously thought about trying to hurt oneself in a way that might have resulted in death) in the past year in the BRFSS respondent (not necessarily the caregiver). Parent- and self-reported safety behaviors agree moderately well or better with observed behavior, demonstrating a modest social desirability bias.^36- 39 Self-reported alcohol use in the BRFSS is highly correlated with per capita alcohol sales.⁴⁰ The BRFSS questions on suicidal ideation and gun ownership have high test-retest reliability.⁴¹

Household and family characteristics included the child's race and ethnicity, number of children younger than 18 years at home, single vs multiple caregivers in the household, the caregiver's relation to the child, annual household income, urban vs rural residence, the child's insurance status, and the highest educational level obtained by any adult in the household.

Of 997 completed surveys, 813 (81.5%) had complete data for every variable and an additional 108 (10.8%) were missing data for only 1 study variable. Cases missing responses for questions on unsupervised bathing (1.2% of completed surveys), crossing a busy street (1.4% of completed surveys), and cycling on a busy street (1.4% of completed surveys) were excluded from the relevant analyses. For independent variables in which less than 1% of the total sample had missing values, responses were assumed to be missing at random; these cases (1.0%) were dropped.⁴² We eliminated 25 cases (2.5%) in which responses to questions on income, educational level, and race/ethnicity were all missing. All other cases without analyzable responses for race/ethnicity (1.5%) were coded as “other/unspecified race.” For all other variables, we imputed the value of missing responses as the median or the modal category.⁴³ These variables included annual household income (4.4% “don't know”; 1.4% “refused”), insurance coverage (0.4% “don't know”), the child riding with a speeding driver in the past 30 days (3.2% “don't know”; 0.2% “refused”), and keeping a firearm in the home (0.4% “don't know”; 1.0% “refused”).

Our final data set included 945 CHS surveys (94.8% of all completed CHS surveys). This data set was similar to the 2004 Colorado population⁴⁴ in terms of race/ethnicity of children aged 1 to 14 years (eg, 67.0% of respondents vs 65.7% in the Colorado population being non-Hispanic white), annual household income (29.5% vs 31.3% earning ≥$75 000; 19.4% vs 20.5% earning <$25 000), having at least a high school degree (92.9% vs 88.7%), and urban residence (81.4% vs 84.5%).

Weighted Colorado population estimates and means were calculated for all independent variables. For each outcome, the weighted percentage was calculated for the full sample of 945 respondents. Outcome means and medians were calculated after excluding parent responses of “never” (eg, child should never be allowed to bathe without an adult present). For crude and adjusted analyses, we assigned all “never” responses to 21 years of age (indicating adulthood).

Because of the inconsistency and lack of specificity in national recommendations for the ages at which children can be free from supervision, we were unable to define specific ages to differentiate adequate vs inadequate supervision. Moreover, categorizing parent responses using a cut point could imply that extreme age values are adequate even if inappropriate (eg, that a typical 15-year-old should bathe with an adult in the room). Instead, we constructed separate multiple linear regression models for each of the 3 primary outcomes, accounting for survey weights and strata, to calculate the mean ages at which surveyed parents indicated that typical children could be free of supervision. For each outcome, we first analyzed its association with each household, family, and behavioral characteristic. Independent variables related to any of the 3 outcomes at P < .15 were retained, and the rest were omitted from further analysis. We then modeled each dependent outcome with these initially retained variables, using a backward elimination approach, removing the variable with the highest P value at each step, examining coefficients to ensure any change in the coefficients was less than 20%, and retaining in the final regression model those variables with P<.15. For each variable, estimated mean differences from the age specified as the reference value, with 95% confidence intervals, are reported.

Telephone consent was obtained at the time of each call. The institutional review board of the Colorado Department of Public Health and Environment approved the BRFSS and CHS instruments, and the University of Colorado Multiple Institutional Review Board approved the data analysis plan.

Table 2 shows unweighted frequencies from the linked BRFSS-CHS and weighted Colorado population estimates for each independent variable. The majority of children were non-Hispanic white, insured, and lived with both parents; about half of households surveyed had an income of $50000 or more per year and included an adult with at least a college degree.

The mean and median ages reported by parents to be appropriate for a child to bathe without an adult in the room were 6.7 and 6.0 years, respectively (range, 2-15 years). Crude mean ages, overall P values, and adjusted mean age differences (in years) with 95% confidence intervals are presented in Table 3. Parents of children who had ridden with an impaired driver in the past 30 days, on average indicated that a child could be allowed to bathe alone at an age 9.6 months younger than parents of children who had not. Younger ages for bathing alone were also associated with other risky behaviors in crude analyses, but none were retained in the adjusted model. An older age for allowing a child to bathe alone was reported by Hispanic compared with non-Hispanic white parents and by parents in households in which the highest educational level was less than a college degree compared with those with a college degree or higher; differences for Hispanic white parents and those with some college or less than a high school degree were statistically significant. A younger age for allowing a child to bathe alone was reported by black compared with white parents, by parents with annual household incomes of less than $75 000 compared with those with higher incomes, and by those whose child lacked insurance coverage vs those whose child did not, although the differences were modest and, in most cases, may have been due to chance.

Parents reported that a typical child could safely cross a busy street without holding hands at the mean and median ages of 9.0 (range, 3-16) years. The more often the child had ridden with a speeding driver in the past 30 days, the younger the age at which parents believed a child could be allowed to cross a busy street without holding hands, with a reduction of 3.6 months in age with each categorical increase in frequency (Table 3); this difference was marginally significant. Compared with non-Hispanic white parents, parents in all other racial/ethnic groups believed a child should be older (by 0.7-1.2 years) before being allowed to cross the street without holding hands, as did parents of children living in single- vs multiple-caregiver households. Older ages were also reported by parents whose children did not always use passenger restraints in the car compared with those who did, and rural vs urban parents, although these differences may have been due to chance.

The mean and median ages reported by parents to be appropriate for a child to bicycle on a busy street without an adult were 12.2 and 12.0 (range, 6-21) years, respectively. Caregivers in households with a risky drinker reported an age that was 1.5 years younger than caregivers in other households. As with pedestrian activity, the more often the child had ridden with a speeding driver in the past 30 days, the younger the age at which parents believed a typical child should be allowed to bicycle on a busy street without an adult, with a reduction of 6 months in age with each categorical increase in frequency. Caregivers with an annual household income of less than $25 000 reported an age 1.4 years older than that reported by caregivers with incomes of $75 000 or higher (Table 3). Parent opinions about bicycling on a busy street unsupervised were not associated with race/ethnicity or educational level.

We found a wide distribution in the ages at which caregivers report that a typical child should be allowed to undertake certain activities unsupervised. Parent opinions about appropriate ages were associated with caregiver behaviors and family and household characteristics. A wide range of risky behaviors were associated with younger crude mean ages for unsupervised activity. In contrast, Hispanic ethnicity, low levels of income and household education, living in a single caregiver household, lack of insurance coverage, and rural residence were all associated with higher crude mean ages for freedom from supervision. Several of these relationships changed in adjusted analyses, reflecting correlations among the risky behaviors and the household and family characteristics.

Applying our results for family and household characteristics to previous studies may shed light on previously observed, unexplained differences in pediatric unintentional injury rates. Nationally representative samples have shown lower unintentional injury rates in Hispanic compared with non-Hispanic white children that were not explained by health insurance status or poverty^28,30- 31 and lower injury risk in children of low-income immigrant compared with US-born mothers that was not explained by health care accessibility, parenting style, or assistance with parenting.²⁹ Overpeck and colleagues³⁰ also found that lack of health insurance and poverty did not explain lower unintentional child injury rates in households having less than a high school education. Perhaps the older suggested ages for supervision reported in our study by Hispanic parents and parents in households with low educational levels indicate differences in the culture of these household environments that could partly explain the observed lower unintentional injury rates, especially given that the home environment is the most common location of unintentional injuries to children.^{28,31,45- 48} Schwebel et al²⁹ suggested that interventions targeted toward at-risk children might be informed by identification of protective factors exhibited by lower-risk families, such as Hispanic or immigrant families. Differences by ethnicity and educational level could also reflect differences in real or perceived dangers of the neighborhoods in which the families reside, eg, crime or traffic danger, such that supervision until an older age is appropriate.

Morrongiello and colleagues^17- 18 conducted observational studies and surveys to elucidate the relationship between supervision and childhood injury. Although their findings may not be generalizable to all populations, the studies have shown that attributes of both the parent and child influence the extent of supervision reported, with more conscientious caregivers likelier to keep the child in view, and mothers of 4- to 5-year-olds less likely to supervise than mothers of 2- to 3-year-olds. In our study, caregivers who reported risky behaviors also reported lower ages for freedom from supervision, consistent with the validated construct of conscientiousness (or lack of it) and locus of control (fatalism) devised by Morrongiello and Corbett.³⁵ If direct supervision is a protective factor in unintentional pediatric injury, then parents who display risky behaviors (lack of conscientiousness) would be expected to have children with higher rates of unintentional injuries.^14- 16 Unfortunately, we were not able to measure unintentional injury rates in our study sample.

The association of younger reported ages for allowing unsupervised activities among parents who report risky behavior may also be explained by a lack of awareness or understanding by the caregivers of what is safe and appropriate behavior for themselves and their children. The wide range of reported ages for unsupervised activities suggests substantial caregiver uncertainty. This uncertainty is not surprising given the lack of specificity and agreement among national organizations regarding what ages are appropriate and safe for unsupervised pedestrian, bicycling, and bathing activities.^1- 11 Under these circumstances, considerable variation in caregiver understanding of when children can safely participate in various activities alone is expected.

Our study was limited by the use of parent-reported opinions about a hypothetical situation for a typical child, as opposed to their actual behavior in real-life situations. However, similarities of our variables to the constructs of Morrongiello et al,¹⁷ who produced more accurate supervision assessments, support the validity of our results. In addition, our study used a population-based sample that collected broader sociodemographic information in the context of parent opinion on supervision for these activities. A second limitation is the possibility of selection bias given the combined response rate for the BRFSS-CHS of 48.2% and the elimination of additional cases with missing data. Despite these issues, our final study sample was similar in race/ethnicity, annual income, educational level, and urban residence to 2004 statewide census data, suggesting that it was a reasonable representation of the state population. Our results may also have been biased by residual confounding from unmeasured covariates, although we were able to examine and control for a variety of sociodemographic characteristics in our analyses. However, we lacked data on positive attributes, such as social support or environmental protective factors, that are likely to influence parent opinions about child supervision. Finally, there is the potential for bias from our use of median imputation for selected missing responses. Zhou and colleagues⁴³ have compared median imputation to multiple imputation and found no significant differences in the observed results in samples as large as ours was. However, the median imputation method may reduce standard errors, resulting in smaller P values than with multiple imputation.

Adequate child supervision is likely to be the most effective defense against many childhood unintentional injuries. However, the wide range of appropriate ages for supervision reported in our study reflects the variability in supervision recommendations among organizations that parents trust as sources of information, which may be due at least in part to difficulty in defining what constitutes supervisory neglect.²² A lack of self-efficacy among child health care providers on how to educate parents on appropriate supervision practices may also affect parent reports of appropriate ages for supervision. Further research should apply validated supervision measures³⁵ to population-based studies to gain insight into how attributes of the individual parent and household environment, as well as those of clinicians, influence supervision practices and ultimately unintentional injury risk. Research should also clarify the ages at which a child is developmentally capable of successfully participating in activities unsupervised that carry a high potential for moderate to severe unintentional injury. In the meantime, clinicians should highlight the importance of appropriate supervision by assessing the parent's understanding of the appropriate ages for freedom from supervision, the safety of the physical and social environment to which the child is exposed, and the value placed on direct supervision vs environmental buffers (such as safety gates and pool fences) and counseling parents appropriately in response to this assessment.

Correspondence: Carolyn DiGuiseppi, MD, MPH, PhD, Department of Preventive Medicine and Biometrics, University of Colorado School of Medicine, 4200 E 9th Ave, Campus Box B119, Denver, CO 80262 (Carolyn.DiGuiseppi@uchsc.edu).

Accepted for Publication: January 18, 2007.

Author Contributions: Dr Porter had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Porter and DiGuiseppi. Acquisition of data: Drisko. Analysis and interpretation of data: Porter, Crane, Dickinson, Gannon, and DiGuiseppi. Drafting of the manuscript: Porter and DiGuiseppi. Critical revision of the manuscript for important intellectual content: Porter, Crane, Dickinson, Gannon, Drisko, and DiGuiseppi. Obtained funding: Drisko and DiGuiseppi. Administrative, technical, and material support: Gannon and Drisko. Study supervision: DiGuiseppi.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant R49-CCR811509 from the Centers for Disease Control and Prevention and grant D33HP02610 for Preventive Medicine Residencies from the Health Resources and Services Administration (Dr Porter).

Disclaimer: The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Health Resources and Services Administration.