As a primary care pediatrician, I see my role as helping families to anticipate and manage their children’s health and address developmental and safety issues so that children can realize their full potential. Long ago, I realized that for my clinical care to be effective, I had to tailor it to the unique needs of the child in front of me. Soon, the promise of 'Precision Medicine' will become a reality, and my care will mean getting the right treatment to the right patient for the right medical condition at the right time.
Will injury prevention be ready to be part of this revolution in care? CIRP@CHOP has always aimed to infuse new evidence-based ideas and approaches into gaps in pediatric injury prevention. We do this across a wide range of topics: traffic safety, concussion, and violence, to name a few. 'Precision Prevention' is a new concept that we are introducing to re-tool the future of injury prevention, keeping prevention in alignment with advances in personalized care.
And we are starting with teen drivers. When I re-examined teen driver crash injury prevention, I realized that for the most part, we are treating every teen driver the same – giving the same advice to each family as if it is a recording. What a mismatch between clinical medicine and clinical prevention.
Just like we need 'Precision Medicine' to tailor care to the unique patient, so, too, do we need 'Precision Prevention' to tailor our preventive care and anticipatory guidance.
Here’s a hypothetical example to consider:Two teens come into my office, and their parents tell me that they are concerned because, as new drivers, they received speeding tickets. What do we counsel? Don’t speed. But let’s look a little more deeply.
One of the teens is impulsive and reckless. Speeding is just one of his many dangerous behaviors. It ends up that, after careful assessment, we determine that he has Attention Deficit Hyperactivity Disorder (ADHD). We provide proper pharmacologic and behavioral therapy, and three months later, he is no longer speeding and is also doing better in other areas of his life.
The other teen tells me that he received the speeding ticket in the morning on his way to school. Probing more deeply, we learn that he had overslept and gotten a late start. To make up for lost time, he sped to school. All he needed was an alarm clock.
Two speeding teens, but two very different causes for this risky behavior that necessitate quite different prevention strategies.
Nearly two decades ago, the Institute of Medicine (IOM) in the US recognized a range in the nature and severity of risk for unhealthy behaviors across and within individuals over time. Known as “tiered risk,” the multi-tiered framework for prevention proposed by the IOM addresses the disparate needs of individuals (and within individuals over time) and provides differential and increasingly more intense preventive intervention based on level of risk and response to prior intervention.
In an editorial recently published in Injury Prevention, my colleagues and I propose a similar approach to injury prevention, 'Precision Prevention'. This approach goes beyond universal interventions by putting in place intervention strategies to meet the typical needs of individual members of a population. As a first priority, we need to create and evaluate a wide range of evidence-based interventions that will meet the needs of individuals and conduct the science around implementation.
Again, turning to young drivers as an example, there is no 'one-size-fits-all' approach across drivers, and even within the same driver, the interventions may be different over time. While new teen drivers are typically at heightened risk of crashing when compared with adults, some teen drivers are at even higher increased risk. As our research shows, each teen approaches the driving task with assets, as well as challenges. Once we figure out what they are, then we can put into place a personalized care management plan.
A Tiered Approach to Teen Crash Prevention
Tier 1: Universal: The typically developing teen has no significant learning, behavioral, medical conditions, or other risk factors. For these teens, universal interventions with little tailoring might be sufficient (i.e., Graduated Driver Licensing systems).
Tier 2: Selective: Young drivers with risk factors need to be identified BEFORE they display unsafe driving behaviors, and interventions need to be developed and delivered to meet their needs. Risk factors include medical conditions such as ADHD, a family history of poor driving, and uninvolved or permissive parents.
Tier 3: Indicated: Young drivers who have crashed, received citations, or display dangerous driving behaviors, especially those who do not follow driving laws, pose the highest safety risk and require added attention and a multi-faceted, tailored prevention strategy.
The good news is that we have a firm foundation for a tiered risk strategy for teen crash prevention. Graduated Driver Licensing (GDL) is a good example of a “universal” or 'one-size-fits-all' intervention. There is still room to bring down crash risks for typically developing teens by ensuring that strong GDL is in every jurisdiction and that parents are aware of and support the law.
Going further, however, I propose 'Precision Prevention’s' tiered-risk framework be built on the foundation of GDL. While GDL is directed at changing the norm and for influencing the attitudes and behaviors of the population as a whole, it does not consider individual risk. We may need a tailored approach to help the more high-risk teens stay safe behind the wheel.
The Injury Prevention editorial challenges our colleagues to take a more clinical approach to injury prevention. For instance, let’s focus more research resources on developing strategies to meet the needs of those who are likely contributing to most of the crashes--those who fall through the cracks because GDL is insufficient to meet their needs. They require a more individualized, targeted approach.
We have substantial hope that the successes already achieved in injury prevention can also be extended to those at highest risk by using the ‘Precision Prevention’ approach. As a start, we can draw from proven tiered-risk strategies for mental and physical health promotion. ‘Precision Prevention’ could guide current strategies to meet the needs of individual young drivers and their families, as well future research to determine the best ways to reach those teens at highest risk of crashing.
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