Need To Promote Occupant Restraint Use for Children, Youth, and
16- to 20-Year-Olds
The use of occupant restraints must be reinforced at an early age
to reduce the disproportionately high rates of death and injury
that young adults ages 16 to 20 experience in motor vehicle crashes.
But parents cannot bear the burden by themselves. In communities
across the country, health professionals, law enforcement officers,
educators, elected officials, and every adult, not just parents,
must develop the social and legal infrastructures necessary to make
safety belt use a lifelong habit. (See Appendix
A for statistics on the number of children and youth from birth
to age 20 who were killed in 2002 in motor vehicle crashes in each
Passenger vehicle occupant fatality and injury rates have declined
slightly during the past 10 years (see Chart 2
Chart 2 Occupant Fatality and
Injury Rates, 1993-2002
Per 100 Million VMT, In Passenger Vehicles
Rates shown in Chart 2 are calculated by dividing
the number of killed or injured occupants by the number of passenger
vehicle miles traveled in the United States.
However, thousands of children through age 20 continue to be killed
and injured in motor vehicle crashes. A total of 7,410 children
and youth from birth to age 20 were killed and approximately 730,000
were injured in passenger vehicle crashes in 2002. Despite widespread
public education campaigns promoting the use of proper occupant
restraints, nearly 50 percent of children 4 to 7 years of age and
55 percent of children 8 to 15 years of age who were killed in passenger
vehicle crashes in 2002 were unrestrained. Charts 3 and 4
illustrate the toll that motor vehicle crashes take on our children
and youth, particularly among those in the 16- to 20-year-old age
Chart 3 Occupant Fatalities in
By Age, In Passenger Vehicles
Chart 4 Occupants Injured in
By Age, In Passenger Vehicles
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Adult Safety Belt Use Makes a Difference
Research conducted by NHTSA about national occupant protection
use from 1991 to 2001 confirms that there is a strong positive correlation
between the restraint use of an adult driver and that of young children
in the vehicle.5, 6
Among fatally injured children from birth to 15 years of age, the
research revealed the following:
The probability of being unrestrained was nearly four times
greater for infants and toddlers when the child was with an unrestrained
driver, versus being with a restrained driver.
When drivers were unrestrained, 68 percent of children up
to 3 years of age were also unrestrained; conversely, when a driver
was wearing a safety belt, 28 percent of children up to 3 years
of age were unrestrained.
Among fatally injured passengers ages 4 to 7, 84 percent
were unrestrained when the driver was unrestrained; conversely,
when the driver was wearing a safety belt, 36 percent of children
ages 4 to 7 were unrestrained.
Among fatally injured child passengers 8 to 15 years old,
91 percent were unrestrained when the driver was unrestrained. Conversely,
when the driver was wearing a safety belt, 46 percent of children
8 to 15 were unrestrained.
Exhibit 1 illustrates the relationship between
driver and child restraint use in crashes in which a child was fatally
Exhibit 1 Driver and Child
Restraint Use in Fatal Crashes Involving Children From Birth to
15 Years of Age
This strong acknowledgment of the effect of parental influence
on safety belt use speaks to the necessity of maintaining ongoing
programs and outreach for children, youth, and parents to encourage
the use of occupant restraints. NHTSA’s 2003 Motor Vehicle
Occupant Safety Survey (MVOSS) further illustrates this need.
In the 2003 MVOSS, researchers asked respondents their level of
agreement with the statement, “I have a habit of wearing a
seat belt because my parents insisted I wear them when I was a child.”
Among persons 16 to 24 years of age, 69 percent either strongly
agreed or somewhat agreed with this statement.
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Occupant Restraints for All Age Groups
of the people who die in motor vehicle crashes are vehicle occupants
(less than one-fourth of fatalities caused by crashes involve pedestrians,
bicyclists, and motorcyclists). Safety belts and child safety seats
have been designed to protect drivers and passengers from death
and injury during a crash. But these restraints cannot save lives
if they are not used. See Appendix B—Passenger
Vehicle Occupants Killed in Motor Vehicle Crashes, by State and
Restraint Use, 2002.
In 2002, among passenger vehicle occupants over 4 years
old, safety belts saved an estimated 14,164 lives. Child restraints
saved the lives of 376 children.
From 1975 to 2002, safety belts prevented an estimated 164,753
According to NHTSA’s The Economic Impact of Motor
Vehicle Crashes 2000, the use of safety belts saved society
$585 billion in medical care, lost productivity, and other injury-related
economic costs (since 1975).
Child safety seats are 71 percent effective in reducing fatalities
among infants (younger than 1 year old) and 54 percent effective
for toddlers (1 to 4 years old) in passenger cars.7
For infants and toddlers in light trucks, the effectiveness
in reducing fatalities is 58 percent and 59 percent, respectively.
Booster seat use substantially reduces the risk of injury for
children 4 to 8 years old; however, most children in this age
group are currently restrained by safety belts designed for
adults. A recent study by Children's Hospital of Philadelphia
found that the use of belt-positioning booster seats lowers
the risk of injury to children in crashes by 59 percent, compared
with the use of vehicle safety belts.8
When lap/shoulder safety belts are used properly, they reduce
the risk of fatal injury to front-seat occupants riding in passenger
vehicles by 45 percent and the risk of moderate-to-critical
injury by 50 percent. For light-truck front-seat occupants,
safety belts reduce the risk of fatal injury by 60 percent and
the risk of moderate-to-critical injury by 65 percent.
Ejection from the vehicle is one of the most harmful events
that can happen to a person in a crash. In passenger vehicle crashes
in which someone died in 2002, 73 percent of occupants who were
completely ejected were killed. Safety belts are effective in preventing
total ejections. In 2002, in crashes in which someone was killed,
only 1 percent of the occupants reported to have been using restraints
were totally ejected, compared with 30 percent of unrestrained occupants
(in passenger vehicles).
Nearly 30 percent of 16- to 20-year-old occupants were killed
when they were ejected during a crash, compared with 22 percent
of the general population. This increased percentage for 16-
to 20-year-old occupants further illustrates the need to promote
safety belt use in this age group. See Chart
Chart 5 Occupant Fatalities in
By Age and Ejection Status, In Passenger Vehicles
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Closing the Gaps in Occupant Restraint Laws
Can Save Young Lives
All States (except New Hampshire) have adult safety belt laws and
all States have child restraint laws requiring the driver to restrain
children of specified ages in approved child restraint devices or
safety belts. These laws, however, do not cover all occupants in
all seating positions.
In the majority of States, laws concerning the use of child restraint
devices cover children only up to age 4, and laws concerning the
use of adult safety belts cover only front-seat occupants, leaving
large groups of children uncovered by any occupant protection law.
For example, in some States, a 10-year-old can ride legally in the
back seat without being secured because, at this age and in this
seating position, the child is not covered by either the child restraint
law or the safety belt law. Appendix
C contains information on State child restraint laws.
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Primary Enforcement Laws Help Protect Children
of All Ages
Although child restraint laws are primary laws, which allow a law
enforcement officer to stop a vehicle and issue a citation for an
unrestrained driver or passenger, the safety belt laws in the majority
of States are secondary enforcement laws. This means that a police
officer cannot stop a driver for the sole purpose of enforcing the
use of occupant restraints. Rather, a police officer can write a
ticket for not using occupant restraints only if he or she stops
the vehicle for another driving infraction. See Exhibit
2 for a map of States with primary and secondary laws.
Exhibit 2 States With Primary
and Secondary Safety Belt Laws
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Booster Seat Use Saves Lives and Reduces
the Risk of Injury
In 2002, only 33 percent of 4- to 7-year-old passenger vehicle
occupants who were killed in crashes were restrained. Persuading
parents to place their children in any kind of occupant restraint
would undoubtedly reduce the number of children killed or seriously
injured. In addition, children who have outgrown child safety seats,
but are too small to ride safely in adult belts, should be properly
restrained in booster seats until they are at least 8 years old,
unless they are 4 feet 9 inches tall. If placed in adult safety
belts prematurely, children can suffer serious internal injuries,
slip out of the safety belt, or be ejected from the vehicle during
Booster seat use substantially reduces the risk of injury for children
4 to 8 years old; however, most children in this age group are currently
restrained by safety belts designed for adults. In the 2002 study
by Children's Hospital of Philadelphia (CHOP), only 16 percent of
4-year-olds, 13 percent of 5-year-olds, and 4 percent of 6- and
7-year-olds were using booster seats.
The CHOP study found that the use of belt-positioning booster seats
lowers the risk of injury to children in crashes by 59 percent compared
with the use of vehicle safety belts. The study also found that
none of the 4- to 7-year-olds who were in belt-positioning booster
seats had any injuries to the abdomen, neck, spine, or back. Yet,
such injuries did occur in children who used safety belts alone.
Children who are 4 feet 9 inches tall before their eighth birthday
may be ready for adult belts. They can start using a safety belt
when they can place their back firmly against the vehicle seat back
cushion with their knees bent over the vehicle seat cushion.
When this booklet was published, 26 States and the District of
Columbia had enacted provisions in their child restraint laws
mandating booster seat or appropriate restraint use for older
children passengers. They are AR, CA, CO, DE, DC, GA, IA, IL,
IN, LA, ME, MD, MT, NE, NH, NJ, NV, OK, OR, PA, RI, SC, TN,
VA, VT, WA, and WY. See Exhibit 2 for a map of States that mandate
booster seat or appropriate restraint use by older passengers.
A number of other States are considering legislation that would
require similar upgrades for booster-age child passengers.
5NHTSA Research Note: The Relationship
Between Driver and Child Passenger Restraint Use Among Fatally Injured
Child Passengers Ages 0-15, NCSA, March 2003.
6NHTSA Research Note: The Relationship Between
Driver and Child Passenger Restraint Use Among Infants and Toddlers,
NCSA, March 2003.
7Passenger cars are one of two vehicle types included in the passenger vehicle category. Passenger cars and light trucks combined make up passenger vehicles.
8Winston FK, Journal of the
American Medical Association. Partners for Child Passenger
Safety (PCPS), The Children’s Hospital of Philadelphia, June 4,
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