Preventing Death and Injury in Childhood: A Synthesis of Child Safety Seat Efforts Michael C. Roberts, PhD Daniel S. Turner, PhD

Virtually all children are at risk for injury and death as passengers in moving vehicles. Between 70% to 90% of the injury and death could be reduced or prevented if children were restrained in safety seats. However, studies show that only a minority of children are properly protected. Numerous efforts have been made to increase the number of children riding in car safety seats. This article reviews and synthesizes the various attempts to motivate safety seat usage by examining the literature on (1) informational and educational programs; (2) safety seat loaner programs; (3) state laws requiring seat usage; (4) behavioral improvement emphasis programs; (5) reward-based programs; and (6) passive prevention approaches through airbags. No one approach appears to be the solution to the complex problem of motivating the preventive behavior of acquiring and consistently using safety seats. Recommendations are forwarded for: (1) developing and determining the best techniques for which settings through comparative research; (2) utilizing a developmental perspective in identifying when and what interventions are needed; and (3) implementing creative and comprehensive programs in communities. Children’s involvement in vehicle accidents remains a large health problem despite numerous attempts to reduce it. Nationwide, children aged 0 to 14 years as passengers account for over 125,000 injuries and over 1,500 deaths per year.’ Accidents are the leading cause of death in childhood with motor vehicle accidents, in particular, producing the largest number of child injuries and death. Children are particularly vulnerable in vehicle accidents for two primary reasons: ( 1 ) they have a higher proportion of body mass in the head propelling them forward through inertia, .2 and (2) cars are built with some padding protection for larger humans but with protrusions of knobs and gears at the child’s level.; There are additional indications that unrestrained children actually contribute to motor vehicle collision.’ Professionals estimate that 70% to 90% of injury and death could be reduced or prevented if the child victims were

Michael C. Roberts is Associate Editor of the Journal of Pediatric Psychology and AssociProfessor, Department of Psychology, and Daniel S. Turner is Department Chairperson, Department of Civil Engineering, the University of Alabama, University, AL. Work on this review was supported in part by a Biomedical Research Support Grant, University of Alabama. Address reprint requests to Michael C. Roberts, Department of Psychology, Box 2968, University of Alabama, University, AL 35486. ate

181-

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in safety seats.5 Consequently, in the last decade prevention professionals focused their efforts on achieving preventive benefits by encouraging use of child safety devices. In this article we will review the existing prevention literature to document the problems and contributions directed at this aspect of prevention. The problems facing prevention professionals working on vehicle safety are a little different than those facing most preventionists. In particular, there is a high effectiveness of safety seats when used consistently and correctly. Thus, the primary problem is not one of first developing and implementing an effective intervention as in many prevention programs. Although some would argue that existing restraint systems are inadequate because their features frustrate actual use, safety seats offer more effective prevention when used and may have fewer barriers to implementation than many other types of prevention. Rather than a problem of creating an intervention, the problem facing professionals in the child passenger area is that of motivating parents to acquire and use approved safety seats and to get children to allow themselves to be buckled into the seat. Indeed, it appears that seat usage remains in the minority of the affected population. Reported observations of children as car passengers find that the incidence of properly restrained children is rarely higher than 15%.7-u In addition, of the children whose parents have acquired seats, about 70% fail to use them properly.14 This particular problem of failure to use an extremely effective safety device has led to a number of attempts to motivate parents to use child safety seats. This motivation for behavior is clearly the realm of behavioral health-getting people to do something to prevent accidental death and injury.’s-&dquo; Professionals have produced an abundance of articles on this subject from a variety of disciplines including medicine, engineering, public health, and psychology. In this article we will highlight these various attempts to motivate parents to use child safety seats in a consistent and correct manner. These techniques include informational and educational campaigns, safety seat &dquo;loaner&dquo; programs, newly enacted state laws requiring restraint use for specified age groups, behavioral improvement emphasis programs, reward-based programs, and passive prevention. The coverage of the literature in this synthesis is comprehensive in cutting across disciplines and topics, but not exhaustive in the sense of reviewing everything ever written. This review highlights important features of prevention efforts both to inform and to stimulate additional work in this important area of child health.

properly restrained

INFORMATION AND EDUCATION PROGRAMS

Early efforts to increase use of safety seats were based on health education principles. The basic idea was to provide information about health hazards and let the parent determine the appropriate preventive action based on that information Several different modes of educational efforts have been used for providing the information about safety restraints including mass media, pamphlets, booklets, slide-and-tape programs, films and filmstrips, oral presentations, and group discussions. P’ess’~ reviewed the pediatric literature on physicians’ attempts to encourage use of restraints. He concluded that the efficacy of health education appeared &dquo;limited&dquo; based on several controlled studies that had physicians or health educators present information on the safety benefits of child seats through a variety of modalities (in-

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presentation, group discussion, and films). In many of the studies not significantly increased over baseline use (around 25%) shown 19-21 In contrast to these overall poor results for these preventive a control by group. other studies on educational programs report positive effects on observed programs, and self-reported seat usage after instruction.8.9.22-25 These latter studies are a &dquo;mixed bag&dquo; of informational techniques including demonstration, physician counseling, and massive television saturation campaigns. Additionally, many studies reporting positive results immediately after an intervention frequently show large decreases in use at follow-up. Some research has demonstrated that when informed prenatally about car seats, parents tend to use them more .212’ Thus, child and adult developmental considerations may play a role in educational programming.16.17 Consequently, some educational programs now emphasize &dquo;The First Ride, A Safe Ride&dquo; (American Acadcluding

one-to-one

reviewed, usage

was

emy of Pediatrics). The major differences between the positive and negative findings noted previously appear to derive from the programs’ differing levels of intensity, specificity, and comprehensiveness . ’ ~ In general, the more intensive the effort, the stronger the positive effect. 29 That is, programs involving targeted, intensive efforts, such as providing new parents with a free seat, with the physician talking with them, with a film strip on benefits, and with nurses demonstrating proper installation and use at discharge produce more seat use than do general programs relying solely on television and radio announcements. JO Additionally, large-scale health education programs systematically covering a wide array of facets appear more effective. ~’ However, cost effectiveness becomes an important consideration in judging the value of very intensive informational and educational programs. Many informational programs emphasize the negative aspects of not doing the prevention action (e.g., the tragic consequences of a child in a car accident). These fear appeals specifically try to evoke emotional arousal or threaten impending harem. 32.33 Thus, preventive action, such as using a child restraint, may be taken by the parent to avoid the feared aversive consequences. Despite the growing research base on applying fear appeals for preventive behavior in general, 33 there appear to be no studies evaluating the effectiveness of fear appeals for increasing safety seat usage. This lack of research is unfortunate since fear appeals are deliberately or unknowingly involved in most of the typical child safety messages used in television or booklet form (e.g., &dquo;Don’t Risk Your Child’s Life!&dquo;). Additionally, EtzioniJ4 objects to such fear appeals on the basis that people, already overwhelmed with such warnings, increasingly discount or ignore hazard information. Similarly, Christophersen35.36 suggests that fear appeals/informational messages lose their effects when the negative health behavior continues and no aversive consequences occur (e.g., when a child is unrestrained and not involved in an accident). Christophersen 3’ emphasizes that educational efforts should focus on the positive aspects of preventive behavior which are not necessarily descriptive of health benefits. Specific to the safety issue, Christophersen argues that parents who require children to ride in seats will be rewarded by improved behavior. &dquo;This immediate and continuing reward for the parents’ altered behavior is clearly superior to the procedure of merely providing threats about the possible negative consequences for continued failure to use car seats. 131 As noted in a following section on the behavioral improvement emphasis, evidence has been gathered to support this move away from emphasizing aversive consequences

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toward emphasizing positive aspects in educational programs. The preventive benefits of information and educational programs for increasing use of child safety seats are not clear from the research base. Nevertheless, these types of programs and components remain a major part of current prevention efforts. 7.39.40

LOANER PROGRAMS One frequently cited objection to safety seats is the cost involved with buying the restraint device (approved seats range from 20 to 75 dollars with prices depending on size and features). Some professionals point out that low-income parents may be unable to afford these seats. 41 However, it also is clear that even affluent parents do not acquire the seats, but may spend more money on items such as special wheel covers, car stereo units, etc. Thus, because of the finances or distorted priorities, many children do not have access to approved safety devices, much less have an opportunity to use them. To remedy this inaccessibility, many communities and organizations have developed programs to loan, rent, or sell car seats at low cost to parents who have not otherwise obtained them. The variety of entities starting programs is remarkable for the extensive community involvement including hospitals and clinics, civic and service groups, police units, newspapers, health departments, safety councils, PTAs, and school systems. These programs have been aided by the seat manufacturers, 42 federal agencies, 41 professional groups (e.g., American Academy of Pediatrics; National Child Passenger Safety Association ; Physicians for Automotive Safety), and various state agencies [e.g., Project KISS (Kids in Safety Seats) in Maryland]. There are a number of sources available which describe the various components necessary for developing a loaner/rental program such as organizing, assessing needs, acquiring operating funds, managing the program and publicizing.7,42,44,45 A major consideration of these loaner programs is the preventive benefit gained by providing seats in this manner. Several studies have examined different aspects of loaner program effects. Culler and Cunningham&dquo; found low-income mothers who were offered safety seats from a loaner program acquired them more often than mothers who did not have such access. Rental for a small fee in this program resulted in greater self-reported use than did outright loaning. Other studies found that loaner program clients reported high usage, and after returning the loaned seat, a substantial majority reported acquiring larger car seats than did control group members. 7.41 Other researchers have focused on increases in actual use where loaned seats were available. Reisinger and Williams21 and Christophersen and Sullivan 21 provided free restraints to parents and then noted an increase in observed use. After 104 infant restraint loaner programs were established in Iowa, an observational survey found that restraint usage had increased significantly. 41 Jewett47 also reported an observed increase from 7% to 45% use after a loaner program had been available for some time in one community. As more loaner programs are established and more safety seats are in parents’ cars, there should be some increase in usage and, consequently, preventive benefits.4x However, despite the increased availability, the primary problem remains that many parents own them but use them incorrectly or not at all. Regardless, loaner programs provide accessibility to and availability of the basic and necessary element for the preventive behavior to be exhibited.

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STATE LAWS Recent attempts to increase use of child restraints have come in the form of state laws. As of June 18, 1984, forty-seven states and the District of Columbia have some 14 type of law requiring the use of the restraints by certain age groups of children. The specific points of each law differ for each state, but the basic elements include a statement of: ( 1 ) the age of the children affected (usually referring to all children under a specified number of years, e.g., four years in Missouri and Tennessee, three years in Alabama); (2) type of restraint required (federal standards); (3) the conditions of seating (e.g., if in the front, the child must be in a safety seat; if in back, child must be in safety seat or car seat belt); (4) person responsible for taking action (adult operator); and (5) the level of infraction for violation of the law (e.g., misdemeanor, fine of $10 or $25). Some state laws allow waiving of the fine if the parent can produce a receipt for purchase of safety device. (A good summary of child passenger protection laws may be found in PAS News.41) The enactment of legislative regulation for safety seats is relatively new; Tennessee was the first in 1978. Efforts to evaluate the various laws’ effects are still continuing, yet it is obvious that problems with implementation can impede potential benefits. One problem has been that the level of awareness of a new restraint law correlates with compliance.&dquo; Intensive efforts to publicize the laws via television, for example, have resulted in increased self-reported ownership of safety seats&dquo; and, in some instances, increases in observed usage. 50 However, other comparative studies have found that law awareness and seat ownership do not lead to consistent actual use of the seat. 51-54 A second problem with evaluating the laws’ effects has been that law enforcement is typically spotty with very few citations being written. Some state public safety officers consider the law virtually unenforceab1e.55 For some police departments, the law represents, at best, a societal statement of the importance of protecting child passengers. Other state police have embraced the laws and worked actively to implement them, but without relying on the punitive aspects. For example, Tennessee state troopers carry safety seats in their patrol cars to provide to violators who later acquire their own in exchange for waived fines.55 A third potential problem has been that regulatory prevention of this type involves issues of personal rights and freedoms. Currently, regulation is generally in political disfavor. However, public opinion polls have found consistent and overwhelming public endorsement of child restraint laws either enacted or being considered .5 ’ &dquo;’ This public approval contrasts with other political trends and lessens one potential hinderance to prevention-public disapproval and active resistance to the laws’ concepts (although passive resistance and inaction do prevail). These problems, potential and actual, have influenced the laws’ effects on usage. Several observational studies have examined safety seat usage before and after law enactment or by comparing one state with a law to another without. Williams54 and Williams and Wells&dquo; found that safety seat usage increased in Tennessee after law enactment and implementation. This increase was in comparison to Kentucky without a restraint law where seat usage only minimally increased during the same time period. In a second study in Rhode Island, Williams and Wells57 also found increased use after law implementation. Unfortunately, in these studies, between 60% and 80% of the targeted children remained unrestrained. Even with relatively high rates of non-

186

restrained children, the results of one study in North Carolina demonstrated a correlation between the state law and a decrease in death and injury These prevention-oriented state laws mandating safety seats for children require continual evaluation of effects. They are an advancement for prevention, but obviously are not the panacea. Even modest increases in seat use produced by these laws represent potential prevention of deaths and injuries not to mention the prevention of their financial and psychological concomitants.

BEHAVIORAL IMPROVEMENT EMPHASIS PROGRAMS A new and innovative technique to increase parental use of safety seats was developed by Christophersen and Gyulay.38 This approach emphasizes that seat use increases the appropriate behavior of children. 37 The improved behavior becomes naturally rewarding to the parents, and failure to restrain the child punishes the parents by allowing the children to exhibit inappropriate behavior. In this program, parents are provided written brochures describing guidelines for making car riding more enjoyable for both parent and restrained child. For example, the protocol shows the best way to introduce the seat to the child, and how to issue praise for appropriate behavior while restrained. No mention is made to the parent about the negative aspects (death, injury) of nonrestrained children in accidents or even of the positive preventive benefit; only the positive behavioral improvement is emphasized. The program has been evaluated in a limited series of eight subjects demonstrating positive increases in seat usage.&dquo; This approach is receiving extensive attention in the pediatric literature and articles for the general public.35.59.60 Following this approach, the &dquo;First Ride-Safe Ride&dquo; program of the American Academy of Pediatrics also produced a bumper sticker stating &dquo;Driving’s Easier ... When Your Kids Are Buckled Up.&dquo; While this technique has not been independently and successfully replicated, Embry6l modified it with some successful results. This approach may have some theoretical and practical limitations. Presumably, the intrinsic reinforcement of a better behaved child would be present whenever a parent buckles in his or her child. Yet, this process apparently breaks down because many parents who consistently secure their infants stop doing so at some point as the children get older. Nonetheless, this behavioral improvement emphasis is conceptually appealing. Because of its adaptability, it may be capable of handling the additional considerations raised by child developmental changes, for example, increases in child resistance to being tied down. This approach to prevention follows the noted move to emphasize positive outcomes of preventive behavior-without mentioning the preventive aspects or the negative outcomes of not doing the behavior. Additional evaluation may warrant inclusion of this approach in the passenger safety armamentarium.

REWARD BASED PROGRAMS

Psychological learning theory has generated influential mechanisms for behavior change through the application of rewards. The basic premise is that behavior increases in frequency when followed by a reward. Positive reinforcement has been used in

187

motivating behavior, including preventive actions.’6 Incentives or for adult seatbelt use have increased usage rates significantly. 12- 61 techniques Roberts and Tumer* provided lottery-based tokens to parents when their Recently children were properly restrained upon arrival at two-day care centers. Winning tokens were redeemable for prizes of pizzas, movie theater passes, chicken dinners, etc. From a baseline of 11.3% usage at one center, the reward program increased usage to an average of 54%. A second center increased from 49% to 73% with reward. Some drop-off occurred at follow-up. The significant feature of this approach is that parents can and will use safety seats under incentive conditions. Considerable work remains to establish the parameters of rewards to parents for encouraging use of safety seats. Additionally, rewarding the children themselves for being restrained needs to be pursued.’ This includes the possibility of instructing or modeling reward techniques to parents to use in their own efforts to establish and maintain seat use (perhaps in conjunction with a behavioral improvement emphasis). A potentially valuable aspect of this prevention approach may come through implementing a system of rewards offered by people in the natural environment (e.g., driveup bank tellers, gas station attendants). This approach by itself may not be the complete answer to the problem of nonuse of seats, but it may be used in combination with other techniques to produce beneficial preventive effects. numerous

ways for

reward

PASSIVE PREVENTION Passive prevention is a final concept relevant to this discussion. This concept provides preventive interventions that require little or no action in order to receive preventive benefit. For example, flouride in drinking water is a recipient-passive step that requires no additional action and effectively prevents much dental caries. Many health professionals now conclude that passive prevention will prove maximally effective in a number of areas since &dquo;such protection is totally independent of the wisdom, caution, skill, and psychological make-up of the individuals who are protected. 1161 Studies show that passive prevention is effective with a variety of problems including the prevention of poisoning, bums, and infant crib strangulation. 16.66 The employment of passive occupant restraints in passenger cars through airbags or automatically closing seat belts is another example of passive prevention approaches. Airbags are crash protection bags housed in the car dashboard or steering wheel that inflate under crash conditions protecting occupants from contact with interior surfaces. Airbag protection would primarily benefit front seat adult passengers (with some advantage to child passengers) without requiring direct action. Back seat occupants would still require seat belt/child safety seat protection. Studies have shown that airbags reduce accidental injury and death for adults. At present in the United States, airbagequipped cars number in the low thousands, including vehicles remaining from 197374 General Motors airbag programs. The Federal Government has begun experiments with driver airbags in 500 state police cars and will begin production of 5000 General Services Administration cars equipped with airbags in 1985. In Europe, Mercedes sold approximately 24,000 driver airbag cars in model years 1981-82, and sales have been extended to the United States in the model year 1984. Automatically closing seat belts are usually attached to the vehicle door and fit over the occupant when the door closes. They provide protection almost equal to that of

188

require no active role for the occupant. As currently developed, they provide protection for front seat occupants only. Secretary Elizabeth Dole of the Department of Transportation recently outlined a contingency policy for mandatory airbags or automatic seat belts to begin phasing in from 1986 to 1990. This regulation would be revoked if states comprising two-thirds of the United States population pass mandatory seat belt laws by 1989.67 In any case, the continued use of safety seats for maximum protection will be necessary for some time. Airbag/passive protection might, one day, have the advantages of protecting all occupants without personal effort. But at present, some combination of active and passive protection approaches appear to be the most beneficial, at least across the broad range of occupants, seating positions and accident types. Some health professionals view the passive prevention aspects of airbags as the solution to the nonuse or misuse of safety belts and child safety seats.&dquo; Other health professionals are less optimistic since less conclusive data are available on the safety implications of airbags and children (with and without safety seats).68 We mention this approach because of the airbag’s potential for yielding preventive benefit. In actuality, the correct use of car seats will make the benefits of airbags less necessary. Moreover, today’s well designed and properly installed child seat and child harness provide better protection than frontal airbags alone, particularly in side impacts, and rollovers, although concepts for advanced airbag and airpad systems have been, and are being, developed.&dquo; Nevertheless, passive prevention is an intriguing concept with direct application and benefit in this problem area. manual belts but

DISCUSSION to do preventive behavior such as acquire and consistently use child remains a major behavioral health issue. As can be seen from this review, the efforts to increase safety seat use have not met with consistent success. Motivational and behavior change techniques should have positive application, but often do not due to naive or inconsistent implementation. For example, health educational efforts are too frequently started without clear ideas of goals, effective procedures, and evaluation. At the present time, the primary conclusion to be drawn from this review of safety seat efforts is that no one solution appears obvious for this complex problem. Multifaceted efforts are required to motivate behavior changes on the part of parents and

Getting people

safety

seats

policy-makers. There

several facets of the child passenger

safety problem each requiring a scheme to increase the number of comprehensive children protected by safety seats. The first problem is that of availability and acquisition of appropriate seats. Despite the variety of seat styles and moderate prices, not enough parents own seats. Where financial factors are a consideration, loaner or rental programs can help meet the needs. Such programs are increasing in number, but no figures are available on how widespread they are. Still, there are locales without loaner programs, and some are underutilized. Continual programming of education and information is needed to get parents to acquire seats. Prenatal interventions through physicians and childbirth classes seem optimal for a major emphasis of starting families in safety. Thus, convincing parents to acquire seats is the first problem facing health and safety professionals. are

separate approach that fits into

a

189

The second problem is getting parents to use the seats properly and consistently. Education and information programs are necessary, but apparently not sufficient, approaches. The recently enacted state laws will have some beneficial effects, but these effects may be more from the publicity and informational aspects surrounding the laws than from enforcement. Additionally, since law enactments, the knowledge of laws and the need for seats has increased more than actual seat usage. 51.52 Two special interventions appear promising for increasing usage-the behavioral improvement emphasis and the rewardbased programs. These interventions would require large-scale projects if implemented as outlined in the research protocols.&dquo;-’ However, modifications of each might make them feasible and effective in communities which form supportive networks. Furthermore, dissemination of the behavioral improvement approach could be made repeatedly through various media. Despite the promise of these approaches, research and implementation studies&dquo;’ have yet to determine definitively: ( 1 ) the best techniques for motivating seat usage; and (2) the settings in which various techniques are effective. Each of the techniques reviewed in this article has been independently evaluated. However, only rarely have the interventions been compared to each other to determine relative efficacy. Arguments have been raised against the repeated comparisons of one technique against no-treatment or control groups as so much of the research has done in this area .71 -’2 Peterson and Brownlee-Duffeck 71 state this most emphatically: It is far more profitable both theoretically and pragmatically to know what works best than to know that multiple techniques are each, one at a time, better than nothing. Those who apply techniques need to know what treatments are available and what the different treatments do.

Such

comparative research is needed in the child passenger safety area for determining optimal strategies for increasing safety seat usage. A developmental perspective also may aid in identifying when and what interventions are needed.It>.17 That is, by following a developmental framework that takes into account the changes in child psychology and physical development, comprehensive programs might be made more effective. For example, using informational interventions might be effective for seat acquisition in the prenatal period combined with hospital-based informational programs and a discharge-into-safety-seats policy for the newborn period. Hospitals also seem the logical place for loaning or renting infant safety seats. Follow-up well baby visits to the pediatrician can reemphasize knowledge base and commitment of the parents. In subsequent months, as the child might grow out of an infant sized seat, availability of larger sizes could be made readily available through community groups. When the child begins a fairly normal developmental pattern of autonomy seeking and resistance to the seat restraints at 1-1 /2 to 2 years, child care professionals (nurses, pediatricians, day care workers) can assist the parents in using the behavioral improvement protocol of verbally and visually stimulating, distracting, and rewarding the child for compliance while riding. Later, as the child achieves more self-control and cognitive abilities at ages 3 to 6 years, external, tangible rewards, given directly to the child on a random basis, can be provided by various community agents for seat and seat belt usage. At any age of the child, special interventions may be required whenever misuse or nonuse is identified. These interventions should include feedback to parents on misuse and proper use, and possibly

190

rewards to parents for appropriately buckling their children into safety seats.6‘’ The intervenors might be trained volunteers, or people in various occupations in the course of their duties (e.g., police or parking meter readers, gas station attendants, etc.). This developmental perspective can help identify special characteristics and needs at different ages. On a related issue, professionals working in this area need to be more creative in selecting settings for intervention-wherever children gather (schools, day care centers, organized sports and recreation centers) and wherever parents can be found (e.g., PTAs, ball games, churches, movies). Some of this creativity has begun through Department of Transportation special funding of service projects utilizing the National Parent Teacher Association&dquo; and the National Association for the Education of Young

Children.&dquo; Child passenger safety, unfortunately, has not been routinized or institutionalized in the sense that concern and action are systematically automatic. For example, as noted earlier, it could be made hospital policy to only allow newborn discharge to parents owning a seat2’ and at discharge, place the child directly in the seat. This policy could be implemented independent of the proclivities of nursing staff. Day care center staff could habitually instruct parents in proper usage and reward consistent use. All too often, however, it appears that successful programs depend on the personal fervor of a few people; when that person or group leaves or loses interest, the program folds. An involved community is necessary for optimal seat usage rates. Such a model would involve the various personnel in numerous settings with access to children, parents, or cars. These include pediatricians and nurses, day care and school teachers, gas station and parking lot attendants, public safety officers, Sunday school teachers and ministers, children’s organizations (Boy and Girl Scouts), parent-teacher associations, etc. Civic groups and businesses can provide organization, personnel, and material resources. Different roles may be taken by the various identities, but all would be organized around the child passenger safety theme. Public health departments seem optimally situated for coordination of an involved community effort, although other entities (civic groups, for example) might assume that role. Some states and locales have started comprehensive efforts along the lines discussed here (e.g., Maryland’s Project KISS); many more are needed. Children riding in cars are at higher risk than the risk from other physical and mental health problems. Virtually eaew child is at risk. The various efforts to increase seat usage have had some benefits, but they are inadequate. Two conclusions appear evident from the present synthesis. First, the efforts to increase use of safety seats have been varied with mixed results; considerably more research work is needed to find ways to maximize seat usage. Second, programs that are more comprehensive are needed to accomodate developmental changes related to seat usage and to involve the entire community to increase and maintain usage.

References 1. National Safety Council: Accident Facts. Chicago, National Safety Council, 1983. 2. Alcoff JM: Car seats for children. Am Fum Physician 25:167-171, 1982. 3. Children in Crashes. Washington, DC, Insurance Institute for Highway Safety, 1981. 4. Hall WL, Council FM: Warning: In cars, children may be hazardous to their parents health: The role of restraints in preventing collisions. Proceedings of American Association for Automotive Medicine 34th Annual Conference. Rochester, NY 24:132-146, 1980.

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