Majority of parents don't install car seats correctly
This series, originally published by the Arizona Republic, was produced by the Dennis A. Hunt Fund for Health Journalism and the National Health Journalism Fellowship, initiatives of the Center for Health Journalism at the University of Southern California's Annenberg School of Journalism. Other pieces in this series include:
What you need to know about car-seat safety
5 most common mistakes with car or booster seats
Seat them safely: Car-seat check events
Seat Them Safely: Reporting spurs community project
Two vehicles rest at the intersection of 67th Avenue and Van Buren Street after colliding on July 13, 2015. (Photo: Anthony Marroquin/The Republic)
They never saw it coming.
Shortly before sunrise on July 13, Alfonso Beltran was driving with his girlfriend, Letitia Greyeyes, and her 3-year-old daughter, Aria, in his Chevy Suburban. Two teens drove through a red light at full speed, broadsiding the Suburban.
The Suburban tumbled across Van Buren and 67th Avenue. Amid a shower of glass, Aria flew out of her car seat through a side window onto the asphalt. The impact fractured her right arm and leg and skull. As the crumpled SUV pitched up against a traffic-light pole, the crushed roof and sides trapped the injured Beltran and Greyeyes inside, helpless.
Beltran said he's sure he buckled Aria in her car seat. But police said Aria must not have been fastened in properly, and that the seat itself was not installed correctly. Weeks later, Aria clings to life in critical condition at Phoenix Children's Hospital.
What happened to her is anything but rare. More children in Arizona and across the country die or are injured in vehicle accidents because they weren't secured properly than for any other reason.
Despite the best of intentions, roughly four out of five parents don't install car seats correctly, a consistent rate for decades, according to repeated surveys and medical studies.
Hispanic and Native American parents are even less likely to buy and use car seats correctly, for a variety of cultural and economic reasons. An analysis of studies by The Arizona Republic found that, depending on the child's age, the type of seat and other factors, Hispanic and Native American children were from two times to as much as 10 times likelier not to be properly restrained.
As a result, Hispanic and Native American children are killed or injured in car accidents at significantly higher rates than other children, the studies indicate.
Even after we account for parents' education level, their income level, we still see these disparities in restraint use for kids 8 and younger," said Michelle Macy, a pediatrician, emergency-room physician and the author of several studies on car-seat use.
All parents can benefit from training on putting in and using seats properly. For Hispanics, she said, "it's an issue that goes deeper into the culture of a community and expectation around safety that we need to better understand."
Cultural roadblocks
The difference in car-seat use and proper installation can be enormous: Last year, a child under 5 who wasn't secured properly in a car seat was more than 31 times likelier to die when they were in an accident, according to state data.
Last year, 3,380 Arizona children under 14 were injured in motor vehicle accidents, and 28 were killed. Of those killed, 12 were not restrained properly, according to state data. In accidents with deaths or injuries, less than 5 percent of children under 5 were either unsecured or improperly secured; but those children accounted for 44 percent of the deaths.
One glaring problem: Child car seats aren't easy to install or to use properly. Repeated studies across the country have found that from 75 to 90 percent of the time, parents make mistakes in how they install or use car seats.
Improper use has been a consistent problem for more than 30 years. Automotive companies and child-safety-seat makers have been aware of the issue for decades, but failed to fix it.
The problem is particularly acute for Hispanic and Native American children, who are more likely to die or be injured in car accidents for several reasons:
- Hispanic and Native American parents, and to a lesser extent Black parents, don't buy and use car seats as consistently as other parents. For some, it's a matter of cost; more often, the issues stem from cultural differences. Surveys show that Hispanic parents are likelier not to secure children for short rides, when children are asleep, or when they complain.
- Hispanic parents, especially immigrants, are likelier to believe, falsely, that it's safer for a mother to hold an infant in her arms than to use a safety seat.
- Hispanic parents often move children too soon from rear-facing infant seats to forward-facing seats, and too soon either to booster seats or to regular seat belts. These mistakes increase the likelihood of a child being injured or killed in a crash.
- In Mexico and Central America, child car-seat use is much less common than in the United States. Mexico just adopted laws requiring the use of child car seats last year. Recent immigrants from those countries often know very little about car-seat laws or proper usage.
- Public-education campaigns don't reach enough parents across all ethnicities. Beyond that, campaigns in English aren't very effective in reaching families for whom English is a second language.
Groups such as the Governor's Office of Highway Safety, the Phoenix Fire Department and various hospitals reach out to Hispanic and immigrant families, but those programs have limited reach and funding. Those running them say they struggle to find and train enough Spanish-speaking car-seat technicians who can show families how to install and use car seats properly.
At Phoenix Children's Hospital, Angelica Baker, a child passenger safety specialist, said that Hispanic children account for half of the emergency-room visits and hospitalizations of children injured in motor vehicle accidents — a high figure, given that Hispanics make up 31 percent of the state's population.
ER doctor Macy led a 2013 Michigan-based study that found minority parents in that state were three times more likely thanWhite parents to move children into booster seats too soon.
"As an emergency-room physician, I see what happens when parents make the wrong choice," she said.
The frightening consequences
At Maricopa Integrated Health System's main hospital just east of downtown Phoenix, emergency-room doctor Paola Pietri sees children wheeled in from car accidents almost daily.
Over the past five years, half the children treated there after car accidents had been unrestrained or improperly restrained. Only one in five had been in the correct seat, properly secured – and they're the ones with the fewest and most minor injuries.
You definitely know when one wasn't belted properly," Pietri said. "Devastating injuries occur even in minor accidents without child restraints. Those are the ones I see a lot; the head hits the window and they have a skull fracture."
Children moved too early into a booster seat or a seat belt more often suffer abdominal injuries in a crash, she said. "The torso goes forward; there's a compression effect on the abdomen. It squeezes your organs; your bowels can pop like a balloon."
Booster seats help ensure that the part of the seat belt that runs across the lap doesn't compress the abdomen, and that the shoulder belt doesn't run across the neck, which can be easily damaged.
Under Arizona law, children under 8 years old or under 4 feet, 9 inches tall must be in a car seat. State laws don't specify when children should be placed in rear-facing infant seats, when they can face forward, or when they can use booster seats.
The American Academy of Pediatrics recommends that all infants should be in rear-facing car seats until they are at least 2. Children should be in forward-facing safety seats until they are at least 5, and most children should be in belt-positioning booster seats until they are at least 8.
Those who treat accident victims or work on safety issues professionally have their own standard: Keep them in the safest seat you can for as long as possible.
"My youngest turns 6 this month. He's still in a five-point harness," said Macy, referring to the standard style of forward-facing car seat. "He complains, sometimes; but that's really the safest way for him to be traveling. His 9-year-old brother is still in a booster, even though the law says we could have moved him over to a seat belt.
"The majority of his friends are out of their boosters, but he's been good about it. It's easy to show him where the seat belt hits on his belly on the wrong spot, where it rubs against his neck," she said.
Jennifer Pelky, a vehicle-safety engineer at Toyota, said no child under 13 should ride in the front seat of a car, period.
"If you haven't been in a car accident," she said, "you don't realize how violent it can be and how quick it happens – in the blink of an eye."
Arizona law is also muddled. Though one section of the law requires children under 8 to be properly restrained, another section allows children to ride in the beds of pickups. At least two children died that way in Arizona accidents last year..
Allowing children to ride in the bed of pickup trucks stupefies child-safety experts.
"That one just makes you scratch your head, with vehicle crashes being the leading cause of death and disability for kids," said Kristy Arbogast, co-scientific director of Center for Injury Research and Prevention at Children's Hospital of Philadelphia. The center designed a model program for improving car-seat use, focusing on parent education in English and Spanish.
Providing parents clear, consistent information is the key, researchers say.
"Parents generally think they're doing a good job; but they often just don't know or don't understand the proper seat to use," said Beth Ebell, director of the Harborview Injury Prevention and Research Center in Seattle. Ebell is one of the country's leading researchers in child car-seat use among Hispanics and Native American populations.
"I work at a trauma center all day long. I could count on two hands the number of seriously injured kids I've seen who were properly buckled in a car seat. They work so well, they're fantastic — a critical element in survival," Ebell said.
But those problems have been recognized and tackled before.
In 1997, pediatrician and epidemiologist Gregory Istre launched the first of a series of projects to boost the use of car seats in two predominantly Hispanic neighborhoods on the west side of Dallas.
In three years, his team tripled the rate of child car-seat use in those areas to more than 60 percent, about the same level as other parts of Dallas at that time, Istre said. They reached out through day-care centers, medical clinics, Catholic churches, and neighborhood organizations and stores — in essence, enrolling the whole community.
"We found that if the driver of the car was wearing a seat belt, the preschool child was five times as likely to be in a car seat compared to if the driver was not wearing a seat belt," among other findings, Istre said.
In Cincinnati, the once-modest Hispanic community began growing rapidly in about 2002, with migrants arriving to work in the tobacco fields in neighboring Kentucky, and for other jobs.
"That's when we started seeing the difference in our emergency room — we didn't have a lot of Hispanic children in our area, but we were seeing a lot of Hispanic children being injured in car crashes," said Gloria Del Castillo, a community engagement specialist at Cincinnati Children's Hospital.
A program established by that hospital in partnership with Toyota in 2004, Buckle Up for Life, now operates in 14 cities.
The hospital found the same barriers that Istre had run into: language, education, sometimes money — and cultural expectations.
She said: "People would say, "que sea lo que Dios quiera, de algo vamos a morir." (It will be as God wills, we all die of something.)
Del Castillo, who is from Honduras, wasn't having it. She tells parents they can let God take care of their souls, but protecting themselves and their children is their job.
Another common misconception in Hispanic communities with large numbers of immigrants from Mexico: "The culture says you've got to hang on to the baby, that it's safest in the mother's arms. That's what I hear over and over again," said Alberto Gutier, director of the Arizona Governor's Office of Highway Safety.
Del Castillo tackles that belief with basic physics.
"Speed by weight equals force of impact. I'd say, 'Mira, señora, in a crash at 30 miles an hour with your 10-pound baby, you have to multiply 10 by 30, he becomes a 300-pound projectile you can't hold in your arms,'" Del Castillo said. "They look at you like, 'What?' But, yeah, there's absolutely no way you can hold your baby."
"We always get mothers saying, 'My baby was hungry, my baby was crying.' I say, 'Señora, babies don't die from crying. They do die from being held in your arms in a crash.'"
This belief isn't unique to Mexicans.
Arbogast, of the Children's Hospital of Philadelphia, attended a child-safety conference last fall in China where he learned that some families hire someone to ride with them to hold their children.
"They believe that that is the safest way to protect the child," she said.
- For short trips near home (36 vs. 20 percent)
- When the booster or seat is missing (32 vs. 15 percent)
- As a "reward" to the child for good behavior (33 vs. 13 percent)
- If a parent is holding the child (30 vs. 13 percent)
- If the child keeps climbing out of the seat (31 vs. 11 percent)
- If they're in a rush (28 vs. 10 percent)
Such misconceptions are one reason that organizations that provide car seats insist on training parents first on how to install and use them.
At one recent training, conducted by technicians from Phoenix Children's Hospital at Capilla Calvario, an evangelical church in south Phoenix, "all the families, the fathers, the mothers, the uncles, were very interested in learning," said Alfredo Hernandez, an assistant pastor.
"Most used seat belts or car seats, but many were not installed correctly. Parents didn't know the size or the limits on when to change to a forward-facing seat, or when to change to a booster seat. … It made them much more conscious," Hernandez said.
But such efforts are limited by resources.
Phoenix Children's Hospital is part of the Buckle Up for Life partnership with Cincinnati Children's Hospital. Maricopa Integrated Health System, the Phoenix Fire and Police departments, and most other organizations in Arizona primarily rely on seats from the Governor's Office of Highway Safety for the events most hold a couple of times a year.
But Gutier, the director of that office, who has worked for 20 years to boost child car-seat use, said his office is almost out of money to buy seats.
Despite its name, the Governor's Office of Highway Safety gets only 3 percent of its funding for seats from the state budget. The rest comes from federal grants, Gutier said, and those currently are running dry.
Gutier recently translated into Spanish his office's guide on how to install and use car seats.
His message is the same as that of nearly everyone involved in trying to save children's lives: Put them in the right seat. Don't make exceptions.
"People don't realize that more than 60 percent of crashes involving children occur less than 10 minutes from home," said Pelky, the Toyota engineer. "Most of your driving is close to home; and at intersections, stop signs, stop lights, there are more opportunities for people to make mistakes."
Alfonso, she said, raised four children in an earlier marriage. "He always made sure they were buckled in their car seats; I brought him up that way," she said. And he said he was sure he had buckled Aria in.
The 14-year-old driver of the other car, Miguel Maldonado, will be tried as an adult on four charges of aggravated assault with a deadly weapon.
Letitia Greyeyes wasn't talking to reporters; but on a post she placed on GoFundMe, a crowdsource fundraising site, seeking help to pay Aria's medical bills, she wrote that she woke up in the hospital remembering no details of the accident.
Not until she was released, three days later, and saw Aria herself, did she understand the extent of her daughter's injuries.
"She has too many tubes and wires hooked up to her," she wrote. "My precious baby girl was laying there with so much wrong and there isn't anything I can do ... I tell her I love her and can only hope and pray for the day she can say it back."
On Wednesday, Aria was released from the hospital and went home.