Objective. This study was designed to characterize the restraint use of children in fatal crashes and to determine factors that were related to child restraint use.
Methods. Crashes in which a vehicle occupant died were selected from the 1994 Fatal Analysis Reporting System data. Restraint use of children (0–9 years) in these crashes was characterized and examined in relation to vehicle and driver characteristics.
Results. Restraint use declined with increasing age of children and increasing number of occupants. Restraint use was also lower in older vehicles, in pickups and large vans, between 3am and 6 am, and in rural areas. Driver characteristics associated with lower restraint use of child passengers included unrestrained drivers, younger drivers, and alcohol use at the time of crash. Driver restraint use was the strongest predictor of child restraint use. Differences in restraint use by age of the child, number of occupants, time, urban/rural area, and driver restraint use persisted in a logistic model.
Conclusion. Restraint use in crashes is substantially lower than that in observational studies, suggesting that these studies are not reflective of high-risk conditions for crashes in which children are involved. Child occupant protection counseling must stress restraint use under all conditions of travel. Local, state, and national efforts must be aimed at increasing family occupant protection for the entire family.
Despite technological improvements in crash worthiness of vehicles, effectiveness of restraint systems, and mandatory child passenger safety laws in the United States, motor vehicle crashes remain a major source of morbidity and mortality among children. In 1996, 1811 children <15 years old were killed and 305 000 were injured as occupants in motor vehicles.1
Both observational studies and self-reports of restraint use have found high levels of restraint use for young children and decreasing use with increasing age of the children. Observed and reported restraint use for children is high, but decreases with increasing age of the child.2–5 A recent National Highway Traffic Safety Administration (NHTSA)-funded observational study conducted in four US states reported 96% child safety seat (CSS) use for children <20 pounds (infants); 89% for children 20 to 40 pounds (1–4 years); and 81% for children 40 to 60 pounds (5–9 years).2 Another observational study that used data from 19 US cities reported lower rates than the NHTSA study: 83% restraint use for infants, 84% for toddlers, and 57% for children 5 to 11 years old.3Restraint use in crashes has been found to be somewhat lower. Using the National Accident Sampling System (NASS) of vehicles that were not driveable after the crash, overall restraint use was 71% for children ages 0 to 12 years. As in observational studies, the proportion of restrained children decreased with increased age of the child.6
Restraint use by drivers is the strongest predictor of child restraint use.2,,5,6 Restraint use increases with adult educational attainment.5 Both adult and child occupant restraint use are higher in states with an adult safety belt use law compared with states without such a law.5 At a recent automotive safety conference, Miller and colleagues7 reported similar findings from a study of both fatal and nonfatal crashes and, in addition, found that more children were unrestrained if the driver was male, young, a drinking driver, and traveling at night.
There is limited data in the medical literature regarding restraint use of children who are at high risk for injury because of involvement in a crash. Such data can be used by pediatricians and others concerned with child occupant protection to identify those at risk for nonuse, and target educational messages and develop appropriate programs. This study was designed to characterize the restraint use of children in fatal crashes and to determine factors that were related to restraint use of the children.
Data were obtained from the Fatal Analysis Reporting System (FARS), which is maintained by the NHTSA. FARS collects data on all fatal traffic crashes within the United States. In each state, the data are compiled by trained analysts from police accident reports. Although most of the data items are collected by all police agencies in the United States, definitions and policies regarding specific items may vary between states and police jurisdictions. Age in years, gender, and outcome are recorded for each occupant. Restraint use is recorded by the investigating officers, based on his or her observations and witness statements. Beginning in 1994, FARS included codes for restraint misuse, but these codes were used for only 5% of children in CSSs and 3% of children in seatbelts. The only measures of crash severity are the routine estimates in the police accident report.
Children <10 years old who had known restraint use and were passengers in the interior of a car, van, or truck involved in a crash in which a vehicle occupant died were selected from the 1994 FARS data. Crashes occurring in Maryland, Massachusetts, and Virginia were excluded because these states did not list or did not report the restraint use of uninjured passengers. Seven children who were alone in the vehicle were also excluded. A total of 297 children (6% of children who met the other criteria) were excluded because of missing data for restraint use. The sample included 4405 children in 2893 vehicles involved in 2749 crashes. Codes for incorrect seatbelt or CSS usage were grouped with other restraint use codes for the analysis. The data were analyzed with contingency tables, χ2 test for independence, and logistic regression.
Among children <10 years old who were involved in fatal crashes, 56% were restrained. Restraint use varied with age and decreased with increased age (Table 1). Sixty-six percent of infants <1 year were restrained. The highest restraint use (71%) was among 1-year-olds. The lowest restraint use was 47% among 9-year-olds.
Restraint use decreased with increasing numbers of occupants in the vehicle (Table 1). Seventy-two percent of children in a vehicle with only one other occupant were restrained while only 12% of children in a vehicle with nine passengers were restrained.
Restraint use varied with model year of the vehicle and was lower in older vehicles (Table 1). The lowest proportion of restrained children (31%) was in model years before 1976. The highest proportions of restraint use was 66% in model years between 1990 and 1995. In a logistic model, the odds of restraint use decreased 7% for each successively older model year (not shown).
Differences in the proportion of restrained children were noted by type of vehicle. Restraint use was lower in large vans (46%) and pickup trucks (42%) than in automobiles (59%), sport utility vehicles (62%), and minivans (63%), as shown in Table 1.
Restraint use among children in fatal crashes varied by time of day. The highest levels of restraint use (60%–62%) were found between 9am and 6 pm (Table 1). The proportion of children restrained decreased to a low of 23% between the hours of 3am and 6 am.
Rural/urban differences were also found. Child restraint use was 54% in rural fatal crashes in contrast to 61% for urban crashes.
Restraint use was also related to driver characteristics. More children were restrained in vehicles with a drivers 18 years or older than in vehicles with 15- to 17-year-old drivers. Many more children were restrained in vehicles with restrained drivers. A higher percentage of children were restrained with drivers who had not been using alcohol.
Differences in restraint use by age of the child, number of occupants, time, urban/rural area, and driver restraint use persisted in a logistic model. The effects of driver age were removed and the effects of vehicle age and driver alcohol use were reduced by more than half in logistic models that included driver restraint use. The decreases in restraint use in large vans and in vehicles with an adult passenger were removed in logistic models that included the number of occupants.
As in observational studies, restraint use among children involved in fatal crashes decreased with increased age of the child.2,,3 Use of restraints was substantially lower in older vehicles, perhaps in part reflecting the availability of seatbelts or discomfort or poor fit of older restraint designs. Alternatively, lower restraint use in older model vehicles may be reflective of lower economic status, which has been reported to be associated with lower restraint use. For example, in the 1990 National Health Interview Survey on Injury Control and Child Health, reported child safety seat use increased with increased family income.4
Differences in restraint use were found by vehicle type. Use was lower in large vans and pickup trucks. This may reflect the availability of restraint systems, compatibility issues between CSSs and vehicle seats in these types of vehicles, or perhaps characteristics of drivers of these vehicles compared with other passenger vehicles. This is consistent with other studies that have found seat belt use among pickup truck drivers to be lower than among drivers of passenger cars.8 Similar to adult restraint use, child restraint use was lower in rural areas.
Restraint use among these children in fatal crashes decreased with an increased number of occupants in the vehicle. In contrast to Miller and colleagues,7 our analysis showed that it was not the presence of an adult per se, but rather the total number of other occupants that were in the vehicle that negatively influenced child restraint use in the FARS database. Lack of available seating positions did not fully explain this trend—restraint use also decreased with an increasing number of occupants in large vans. This trend toward failure to restrain children in the presence of other occupants is disconcerting as one might expect that the influence of others in the vehicle might be a positive influence for restraining children. Reasons for these findings, especially in the situations where there are available seating positions, need further exploration.
Not unexpectedly, observational studies report considerably higher levels of restraint use than those found in this study of children involved in fatal crashes.2,,3 This is in part attributable to the effectiveness of restraints. (Fatalities prevented by restraint use are not found in these data.) In addition, drivers at higher risk for crashes may also be less likely to use restraints for their child passengers. Furthermore, restraint use was significantly less during late night and early morning hours but observational studies are conducted during daylight hours. These may be different types of trips compared with those more likely in observational studies. Night travel may involve longer trips on different types of roadways than daylight travel and children may be allowed to ride unrestrained so they can lie down and sleep during the late hours. This raises concerns as to whether parents and drivers vary restraint use according to time, duration, or type of trip. Alternative ways to determine restraint use under varying conditions need to be explored. The practicality and feasibility of conducting observational studies during nondaylight hours when fewer children travel will limit this as a viable approach. One option would be parent surveys that can identify possible variation in restraint use under varying conditions. Additional research is needed to better understand what factors influence restraint use and parents' decision to restrain their children and under what circumstances. Counseling by pediatricians must stress the need to restrain children at all times.
As in other studies, including observational studies, driver restraint use influences restraint use of children.2,5–7 A restrained driver was three times more likely to restrain a child. Restraint use of the child was more likely with increasing age of the driver and was lowest among drivers <18 years old. This has implications for restraint use campaigns, suggesting that driver restraint use must be an integral part of campaigns for children. Stronger, consistent enforcement of both mandatory seatbelt use laws, as well as child restraint use laws, could have a positive impact. This finding also argues for primary enforcement of mandatory seatbelt use laws, assuming that the restrained driver will more likely restrain the child occupant. Other measures, such as requiring traffic violators classes for those who fail to restrain their children as well as themselves may prove effective. Such a program has been instituted in Los Angeles County; but remains unevaluated (Cheryl Kim, Safety Belt Safe USA, personal communication, 1998). Increasing insurance premiums for violation of both child restraint use and mandatory seatbelt use laws might be a way to promote increased restraint use for both children and adults.
Driver alcohol use was associated with lower restraint use. This has also been found in other studies.7 This is most likely indicative of high-risk drivers who are less likely to restrain children. Obviously, the same measures as discussed above, as well as ticketing for driving under the influence, are recommended.
This study is based on children in crashes in which a vehicle occupant died. Children in these crashes are not representative of the population of children who travel in motor vehicles because characteristics that are risk factors for a fatal crash are overrepresented in these data. Nevertheless, children in these crashes are representative of children at increased risk of crash involvement, and should be targeted for efforts to increase child restraint use.
For pediatricians, the significant message is to continue to counsel patients in all settings regarding occupant protection and use the concept of family restraint use. The family that does not restrain themselves and their children may have other risk factors for injury that need to be addressed. Because these drivers may be the most resistant to traditional anticipatory guidance, other measures such as sanctions are necessary.
This study indicates that continued efforts are needed to increase children's restraint use, especially in rural areas, in large vans and pickup trucks, and at night. There is a need to encourage restraint use for all occupants at all times and under all conditions of travel.
The results of this study indicate issues that need to be addressed related to occupant protection for children. Further improvements in automotive and car seat design may be necessary to make riding restrained easier and more comfortable for children, especially when traveling long distances and while sleeping. Caution should be taken when interpreting restraint use data because observational studies that provide the most reliable data are not able to capture the full range of conditions under which children travel. Research is needed to better understand what factors and circumstances influence parents' decision to restrain their children.
Pediatricians need to continue to counsel families regarding occupant protection for all and should be encouraged to be proactive in local programs as well as state and national initiatives aimed at occupant protection in motor vehicles.
- Received February 10, 1998.
- Accepted June 8, 1998.
Reprint requests to (P.F.A.) Health Policy and Research, University of California, Irvine, Irvine, CA 92697-5800.
- NHTSA =
- National Highway Traffic Safety Administration •
- CSS =
- child safety seat •
- NASS =
- National Accident Sampling System •
- FARS =
- Fatal Analysis Reporting System
- ↵US Department of Transportation, National Highway Traffic Safety Administration. Traffic Safety Facts 1996. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 1997
- ↵US Department of Transportation, National Highway Traffic Safety Administration. Occupant Protection Trends in 19 Cities. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 1991
- ↵Mayer M, LeClere FB. Injury Prevention Measures in Households with Children in the United States, 1990. Advance Data From Vital and Health Statistics; No. 250. Hyattsville, MD: National Center for Health Statistics; 1994
- ↵Edwards J, Sullivan K. Where are all the children seated and when are they restrained? Presented at the Society of Automotive Engineers, Government/Industry Meeting; May 5–7, 1997; Washington, DC. SAE 971550
- ↵Miller TR, Spicer RS, Lestina DC. Who's driving when unrestrained kids get hurt? Proceedings of the Association for the Advancement of Automotive Medicine 41st Annual Conference; November 10–11, 1997; Orlando, FL
- ↵US Department of Transportation, National Highway Traffic Safety Administration. Observed Safety Belt Use in 1996. Research Note. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 1997
- Copyright © 1998 American Academy of Pediatrics