Parenting Style, Lack of Knowledge and Low-Risk Perception are Surmountable Barriers to Booster Seat Use


PHILADELPHIA, Oct. 7 /PRNewswire/ -- Parents who restrain their children in belt-positioning booster seats say safety is not negotiable in their households. Bedtime and eating vegetables are negotiable, but when it comes to life-and-death issues like riding in a car, these parents insist their young children use booster seats on every ride.

In contrast, parents who prematurely move their children into adult seat belts alone hold opposite views regarding negotiability. In addition, they perceive less risk of being in a car crash and less risk of crash-related injuries to their children. This perception of low risk persists even though motor vehicle crashes are the leading cause of death among children 4 to 14 years old.

Researchers at The Children's Hospital of Philadelphia conducted in-depth focus groups and telephone interviews with parents and with booster-age children to gain an understanding of their child restraint use behaviors and their perceived barriers to using proper restraint. The study, published in this month's issue of Pediatrics, found that lack of knowledge was only one of several barriers that hinder parents from following best practices for child passenger safety. Parents suggested that media campaigns, as well as the development and enforcement of booster seat provisions within state child restraint laws, would be effective strategies to convince parents to use booster seats.

While booster seats have proven to be an effective injury prevention strategy, 86 percent of children who should be restrained in car seats or belt-positioning booster seats are still inappropriately restrained in adult seat belts. Belt-positioning booster seats are recommended by the National Highway Traffic Safety Administration (NHTSA) and the American Academy of Pediatrics for children who have completely outgrown their forward-facing car seat but do not yet fit into an adult seat belt. Most children will not fit into an adult seat belt until they reach a height of 4 foot 9 inches.

The belt-positioning booster seat is a platform that raises a child so that the lap portion of the seat belt fits snug across the hips and the shoulder portion of the belt fits across the middle of the shoulder and chest. These booster seats come in a variety of styles - highback, backless and combination. The combination seat is a forward-facing car seat with removable harness that converts to a belt-positioning booster seat.

The Children's Hospital study describes parent characteristics such as perception of risk, booster seat awareness and knowledge, and parenting style that determine a parent's choice to restrain their child in a booster seat or an adult seat belt.

"One key difference between parents who use booster seats and parents who use seat belts for their children is negotiability," states Flaura K. Winston, M.D., Ph.D., a study author and Director of TraumaLink: The Interdisciplinary Pediatric Trauma Research Center at The Children's Hospital of Philadelphia. "Parents who used booster seats drew a distinction between safety, which was non-negotiable, and child actions like eating habits and naps, which were negotiable. For these children, booster seats were accepted as the only option."

On the other hand, parents of seat belt users felt that the dread of a child's resistance to booster seats played a major role in the decision to transition a child to a seat belt. For these parents, booster seat use was as negotiable as non-safety-oriented child actions.

A lack of knowledge about the purpose of booster seats and the potential injuries to young children in seat belts was a common barrier to booster seat use. Also, many parents who used seat belts to restrain their children justified their actions based on their state's child passenger safety law. Most state child restraint laws require only that children up to age 4 years be restrained in a child safety seat, allowing parents to infer that it is appropriate to move children into adult seat belts after their fourth birthday.

Some parents, particularly parents of seat belt users, felt booster seats to be inconvenient and costly. One parent thought that a booster seat cost $100. However, many retailers carry booster seats that cost as little as $20.

"Clearly, standardized child passenger safety awareness programs and upgraded state child restraint laws would do much to eliminate parents' confusion and misperceptions regarding booster seats," said Dr. Winston.

Children's Hospital researchers recommend the following strategies to increase booster seat use:

-- Close the gaps in state child passenger safety and seat belt laws to provide provisions for booster seat requirements. Laws would educate parents and arm them with the weight of the law when dealing with a resistant child.

-- Increase awareness of the benefits of booster seat use versus the risks of non-use and premature graduation to adult seat belts alone.

-- Emphasize extending booster seat use to parents who use booster seats for their young children but prematurely move them into seat belts. It is easier for parents to keep children in booster seats as they grow older rather than convince a seat belt user to move back into a booster seat.

-- Develop parenting skills so that consistency and non-negotiability are stressed in issues regarding child safety.

-- Promote the booster seat message through established outlets like the media, school programs, and community agencies.

-- Educate parents about proper seat belt fit so that they can correctly judge when their child is ready to move into a seat belt.

The Children's Hospital of Philadelphia recently launched a multimedia Web site to address many questions people have about appropriate restraint and correct installation of child restraint systems. Parents can view brief videos, listen to helpful instructions and browse quick tips at

Flaura K. Winston, M.D., Ph.D. is senior author of the Barriers to Booster Seat study. Edith M. Simpson, R.N., PhD. is lead author. Co-authors include Elisa K. Moll, B.A., Nancy Kassam-Adams, PhD., and Gwenyth J. Miller, M.A. This research study was supported by the National Highway Safety Traffic Administration, U.S. Department of Transportation.

Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is recognized today as one of the leading treatment and research facilities for children in the world. Through its longstanding commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered medical discoveries, innovations and breakthroughs that have benefited children worldwide.

Contact: Suzanne Hill of The Children's Hospital of Philadelphia, +1-215-590-1417 or