Current research in childhood automotive injury can best be considered by classifying the injuryproducing automotive event into three time phases: 1) the period before the accident, 2) the accident itself and 3) the post-accident or clean-up phase. All three phases are crucial to the reduction of death and disability; research into all three is essential.
THE PRE-ACCIDENT PHASE
Research in this area has aimed at a systematic analysis of childhood pedestrian behavior. If unsafe behavior, rather than the accident per se, can be used to furnish data, the dependent variable, the accident, may be separated from the independent variable, unsafe behavior. Thus, unsafe behavior can be studied even when it does not produce an accident or injury. Noteworthy for this methodolgy is the work of Dr. Norman Heimstra and his group.1 By means of a hidden motion-picture camera, they systematically observed children in a street-crossing situation. They studied the approach behavior and the behavior at curbs of a homogeneous group of kindergarten children. Eleven parameters were recorded, including such observations as whether the child ran or walked when approaching, whether he was interacting with others during approach and whether he looked both ways before crossing. Unsafe behavior as defined by failure to stop and/or look before crossing was validly ascertained. The limitations of the child in such a hazardous situation were defined as an age-specific defect in peripheral vision and an inability to estimate accurately the speed of approaching cars by sound. The questions that arise from this kind of study are: 1) How can we identify children who consistently display unsafe behavior? 2) How do these children differ from their peers? 3) How can unsafe behavior be modified or changed?
Another area of concern is the adolescent driver. Driver training programs have been endorsed in some areas for their effect on the incidence of moving violations2 but have been questioned by other investigators.3 Meaningful research recognizes that such training programs should go beyond the usual routine of showing the student how to operate the controls, give signals and read road signs. What is needed are more in-depth studies of driver motivation. Classic among such studies is the work of Dr. Stanley Schuman at the University of Michigan.4 He showed a series of five-minute provocative films to teenage audiences which were followed by open discussion. From this, insights into the man-vehicle relationship became available. What changes occur in the driver as he takes charge of his vehicle? To what extent does he live out his life role in the areas of competition and risk-taking? (Is a male driver the same after having been left behind at a stop-sign by a female driver, for example?) What does the automobile represent to the adolescent? Is it an extension of his ego? What is its transcendental meaning as a status symbol or sex symbol? The Schuman studies offer preliminary but fascinating methods of arriving at pre-accident knowledge of these important questions.
THE ACCIDENT ITSELF
Principles of epidemiology are being applied to understanding injuries received during the first and second automotive collisions involving juvenile passengers or pedestrians. Two large-scale epidemiologic studies by Read5 and Ryan6 have produced data which should be helpful to community preventive programs. Read has pointed out the planning necessary to separate juvenile pedestrians and motor vehicles in an urban area. Children injured during his Vancouver study were engaged in three basic action patterns: 1) coming from between parked cars, 2) playing in the street or 3) crossing an intersection. Most of the autos which struck children (87 per cent) were driven by males who had no driver training. They were usually driving cars in good mechanical condition and were not traveling at excessive speeds. Most drivers did not see the child in time to react (if they saw him at all). Environmental factors were important. The highest incidence of injuries were in June (when school had just let out) and in September (when the great back-to-school migration had begun). Forty-five per cent of accidents occurred between three and six p.m. and 20 per cent between four and five p.m. Accidents occurred most often on weekdays and, not surprisingly, in busy congested areas. Children between three and seven years of age were most often injured, boys more often than girls. Children injured in pedestrian accidents tended to come from families where there was illness, maternal preoccupation and less opportunity for protected play. Mothers tended to be younger, more often worked outside the home and tended to discontinue supervision of their young child at an earlier age.
Ryan studied 408 injury-producing accidents in Adelaide, South Australia, over two years. An injuryproducing accident was defined as one after which an ambulance was called. His on-scene investigations reveal that for passenger protection, the truck was safer than the auto, the auto was safer than the motorcycle, the motorcycle was safer than the bicycle and the pedestrian was least safe of all. Regardless of the category of transportation, injuries to the head and neck were two to four times more common than to any other body part area when injury was of a moderate or severe degree. Most pedestrian injuries were collisions with cars where the patient was run under rather than run over; that is, he was impacted by the front of the car and hurled up onto the hood or against the windshield. Bicycle accidents showed a remarkable similarity. The car was moving straight ahead when the bicycle, driven usually by a male under 15 years, unexpectedly turned into its path. Conversely, young people on motorcycles were injured most commonly by a pattern of collision resulting from the car turning into the path of the motorcycle. Car accident injuries resulted from front or side collisions resulting in the unrestrained passenger being thrown forward to strike his head on the windshield, his thorax on the steering wheel, his lower extremities on the dashboard or his upper extremities against the door.
Since it is Utopian to expect to prevent all accidents, research must give more attention to diminishing death and injury by improved "packaging" of a vehicle's occupants. Improved design can reduce injuries from initial impact as well as from the second collision between the passenger and some structure within the vehicle. Of special interest in this are the various prototype safety-car projects, especially those sponsored by the state of New York in cooperation with the Fairchild-Hiller Corporation7 and by the Liberty Mutual Insurance Company. Many innovative and ingenious features have resulted from such research. Until they are incorporated into commercial vehicles, however, the most important preventive in second collision accidents will be a proper restraining system.
The special problems associated with restraints for juvenile passengers have been extensively studied.8,9,10,11,12 The restraint should be appropriate for the size of the child. Many available car-seats are entirely unsatisfactory and can increase, rather than decrease, the risk. Current research on restraints recommends:13
a) Babies under 12 pounds should be placed in a car bed in the back seat. A strong netting should cover the bed, and the axis of the bed should be parallel to that of the automobile so that its legs can be secured by front and rear seat belts.
b) The 12-24 pound child should wear an adquately designed safety harness or be placed in a toddler seat with some upper shoulder restraint.
c) Children from 25-50 pounds should be placed in a safety seat or in a shield- type device.
d) Children weighing more than 50 pounds but measuring less than 55 inches should use an adult safety belt but no shoulder harness.
e) Children over 55 inches tall may wear both the adult seat belt and the shoulder harness.
Whatever device is used, it should conform to Federal Vehicle Safety Standards.
The development of air-bag type passive restraint systems has raised some questions regarding small children as front-seat passengers. Research has indicated that the impact of the expanded air-bag might be sufficient to hurl unrestrained children into the back seat or produce hyperextension injuries to restrained small children.
Derwyn Severy at the U.C.L.A. School of Traffic and Transportation carried out a very dramatic and informative research project into passenger injuries. In this study14 various crashes between school buses and a school bus and an automobile were simulated. Anthropomorphic dummies of sizes comparable to school children were positioned in the crashed vehicles. Transducers attached to the dummies permitted the electronic pickup and recording of data. The following recommendations were made for school bus design:
1) Seat backs should be raised to a height of 28 inches.
2) Seat backs and armrests should be adequately padded.
3) Drivers should wear seat belts.
4) Seats should be anchored and should withstand a decelerative force of 3OG.
5) Windows should stay in place, even after being struck by passenger's head or shoulders.
6) Rigid protruding structures should be eliminated inside buses.
7) No persons should be allowed to stand.
8) At least four emergency exits should be available.
The development of retroreflective material has been revolutionary in improving the visibility of pedestrians, bicycles and cars. These materials are made by placing thousands of small beads on a fabric which acts to reflect light directly back to its source. Such materials have been incorporated into the design of garments or made into various stick-on or sew-on tapes. Hazlett and Allen.15 using a method of recording driver reaction to dummies covered with various types of materials, found that reflectorized dummies were seen much sooner than the rest. Studies in various states have shown that retroreflective license plates reduce the number of nighttime collisions.16
POST ACCIDENT PHASE
The emergency care of injured children at the roadside must be improved to save children who might otherwise die preventable deaths. There are four areas of priority:
1) First aid and rescue.
This involves basic training programs in first-aid skills for the public and advanced training for policemen, firemen and ambulance drivers.
Much research is being done to improve communication between police and ambulance dispatching facilities. The installation of roadside signal boxes (such as those on the Baltimore-Washington Beltway) has been highly effective, although expensive.
There is an effort to improve training of ambulance personnel and to improve ambulance equipment, especially for resuscitation, and to make greater use of helicopters.
The American Academy of Pediatrics has recommended the development of childhood injury centers as an extension of the poison control center concept. Improved patient care, emergency equipment and personnel training are being researched.
1. Heimstra. N.; Nichols, J. and Morton. G An experimental methodology tor analysis of child pedestrian behavior. Pediatrics 44 (1969). 832.
2. High School Driver Education Proves its Worth in Illinois. Published by Secretary of State's office. Springfield, III.
3. Conger, J.; Miller, W. and Ramey, R Effects of driver education: the role of motivation, intelligence, social class, and exposure. Research Review (Sept . 1966). 67.
4. Schuman. S.; McConochie, R. and PeIz, D. Reduction of young driver crashes in a controlled pilot Study. J.A.M.A. 218 (1971). 233.
5 Read, J Trattic Accidents Involving Child Pedestrians, a Program for their Prevention Proceedings of the Second National Childhood Injury Symposium. Charlottesville. Va.. 1968.
6. Ryan, G Injuries in traffic accidents New Eng J. Med. 276 (1967). 1066
7. Wakeland, H and Stieglitz. W Safety Assurance and the Design Process in a Public Responsible Safety Car Proceedings American Association for Automotive Medicine. 1968. ? 127
8 Aldman. B Protection of Small Children in Cars The Official Swedish Council on Road Safety Research. Medical Research Laboratory Publication. Stockholm. Sweden
9. Selecting Automobile Safety Restraints for Small Children Public Service Publication No. 1783, U.S. Dept. of HEW National Center for Urban and Industrial Health.
10. Motor Vehicle Restraining Devices for Children. Technical Report No 917.01. New York University School of Engineering and Science. Research Division, New York, NY
11. King. B ; Paul. E and Spitznagel. C Children's Automobile Safety Restraints Characteristics and Body Measurements Society of Automotive Engineers. 2 Pennsylvania Plaza. New York. NY
12 Burdi. R : Huelke. D ; Snyder, B and Lowrey. G A study of concepts in child seating and restraint systems Biomechanics 2 (1969). 267.
13. Burg. F : Douglass. H : Diamond. E and Siegel, A. Automotive restraint devices for the pediatric patient Pediatrics 45 (1970). 49
14 Severy. D . Brink. H and Baird. J School Bus Passenger Protection Society of Automotive Engineers. New York. N.Y.
15 Hazlett, R and Allen M The ability to see a pedestrian at night, the effects of clothing reflectorized Amer J Optometry 45 (1967). 246
16 Campbell B and Rouse. W Reflectorized license plates and rear end collisions at night Research Review (June. 1968)