Driving
Safety
and Adolescent
Behavior
Richard
C. Brown,
MD, Joe M. Sanders,
Jr, MD, and
S. Kenneth
Schonberg,
MD
From the Department of Pediatrics, San Francisco General Hospital, San Francisco; Adolescent Medicine Service, Fitzsimons Army Medical Center, Aurora, CO; and Division of Adolescent Medicine, Montefiore Medical Center, Bronx, NY
ABSTRACT. Accidents, and mainly automotive
acci-dents, are currently the leading cause of mortality and morbidity among young people. Understanding and ad-dressing the issue of automotive accident prevention re-quires an awareness of the multiple psychodynamic, fa-milial, and societal influences that affect the development and behavior of adolescents. Risk-taking behavior is the product of complex personal and environmental factors. As pediatricians, we have the obligation and the oppor-tunity to improve the safety of our youth who drive and ride. This opportunity is available to us not only in our roles as counselors to youth and families, but also as we serve as role models, educators, and agents for change within our communities. Pediatrics 1986;77:603-607; ac-cident, automobile, safety, adolescent.
“By a wide margin, the major public health prob-lem for teenagers in the United States is injuries associated with motor vehicle use.” Accidents are the leading cause of death among adolescents in the United States, and the majority of these fatalities are related to motor vehicles. In addition to mor-tality, motor vehicle collisions account for signifi-cant morbidity, not only in the United States but also in all of the developed countries of the world. Our national statistics are striking and give clues for possible clinical, community, and public health interventions in defining and possibly ameliorating this serious health issue. Prevention represents a cornerstone of the pediatric discipline, and pedia-tricians should assume a leadership role in provid-ing health care by ending this carnage of our youth.
Received for publication Dec 17, 1984; accepted Nov 13, 1985.
Reprint requests to (R.C.B.) Department of Pediatrics, Room
6831, San Francisco General Hospital, 1001 Potrero Aye, San
Francisco, CA 94110.
PEDIATRICS (ISSN 0031 4005). Copyright © 1986 by the
American Academy of Pediatrics.
EPIDEMIOLOGY
OF ACCIDENTS
Motor vehicle collisions account for nearly half of the deaths of adolescents between the ages of 16 and 19 years. If the age grouping is expanded to include young adults, such accidents are responsible for two thirds of the fatalities in the age group 15 to 24 years.’ Motor vehicle collisions are also a major cause of death in the 1- to 14-year age group, accounting for 20% of all fatalities in this age group. In the United States, 145 persons die each day as a result of vehicular accidents, and the majority of
these deaths are children, adolescents, or young adults.
Teenage drivers contribute substantially to ye-hicular fatalities, both their own and those of oth-ers. More deaths per licensed driver are associated with the automobile crashes of 18-year-old drivers than for any other year of age, with 16-, 17-, and 19-year-old drivers having the next highest rate of death per driver, in that order. Male teenagers have a much higher rate of driver involvement in fatal crashes than do female teenagers. More than half of the 16- or 19-year-old drivers and/or passengers who sustain fatal injuries do so in accidents occur-ring between the hours of 9 PM and 6 AM.2
When teenagers drive, they also contribute sub-stantially to the deaths of others. Starting at age 13 years, motor vehicle passenger death rates per capita increase sharply in the teen years compared with rates in passengers of other ages, and the majority of teenage passengers sustain these inju-ries in vehicles driven by other teenagers. In 1978, 72% of the passengers fatally injured in vehicles driven by teenage drivers were also teenagers.3
young drivers to be more aware of risks than older
drivers, yet young drivers continue to be involved in accidents more frequently than experienced
driv-ers.4
FACTORS CONTRIBUTING TO AUTOMOTIVE ACCIDENTS AMONG ADOLESCENTS
Any attempt by the pediatrician to influence the high rate of injury and mortality experienced by young people secondary to automotive collisions must be based on an understanding of those factors that place teenagers at special risk. Among these
factors are not only characteristics inherent to the process of adolescence and, hence, applicable to all teenagers, but also issues that are encountered with
some frequency among that subgroup of adolescents who are experiencing difficulty and disruption in their progress toward adult status. It should be noted that it is the rare teenager who does not from time to time experience some difficulty and disrup-tion, and it is during these episodes that the teen-ager’s risk of injury in an automobile, as well as other untoward outcomes, is increased.
The vast majority of Americans first learn to drive during their teen years. Although sound bod-ies, intact senses, and rapid reaction times may make adolescence the prime time for athletic ac-complishments, a lack of driving experience, judg-ment, and skills places the teenager at special risk. Driving an automobile is not unlike other voca-tional or leisure activities, such as operating dan-gerous machinery or skiing, in which safety is a by-product of experience. In addition to a lack of experience, there are struggles with fears regarding human fallibility and mortality. In the normal struggle with resolution of childhood feelings of omnipotence and perceptions of fallibility, adoles-cents often react against these feelings with coun-terphobic actions that are defiant and dangerous, as if to challenge death itself. Reckless and dare-devil driving may result.
The establishment of an acceptable self-identity and sexual identity is inherent to adolescence and inevitably involves a degree of social experimenta-tion. This experimentation is likely to involve dan-gerous activities, particularly for young men who feel pressured to be brave and exhibit a “macho” image. Some of the unfortunate facets of this at-tempt to appear macho are driving without regard for speed limits and other traffic safety laws and an intentional failure to use passenger restraints. Recent observational studies reveal that only 12% of drivers are belted and that teenagers used seat belts about half as often as adults.5 Beyond these motivations for unsafe driving practices which arise from within the teenager, there are also pressures
exerted by the peer group. Encouragement for speeding, overcrowding vehicles, and drinking while driving and the disdain of using seat belts often arise from the cohort offriends struggling with their own developing images, fallibility, and mortality.
The onset of intoxicant use, both alcohol and now marijuana, takes place during the teen years. A clear and indisputable relationship between in-toxication and both automotive injuries and fatali-ties is long established. Adolescents are not only learning to drive, but they are also simultaneously learning to use intoxicants. The knowledge of limits of one’s abilities to drink alcohol or smoke man-juana and the compromise of one’s capabilities
sec-ondany to such use are gained through experience. Unfortunately, such learning often takes place with risk to life and health. The concomitant inexpeni-ence with both intoxicants and driving represents a most important factor in adolescent automotive mishaps.
Beyond the developmental issues that would be common to all adolescents, there are concerns that are relevant to those teenagers who are expenienc-ing persistent behavioral difficulties which place them at special risk. Although all teenagers will at times experience some behavioral difficulty and place themselves at special risk during those epi-sodes, some young people exhibit disruptive behav-ion on a continuing basis and, therefore, require particular attention. Among those factors that are concomitants of persistent difficulties are issues of substance abuse, delinquency, family turmoil, and depression.
Although occasional recreational intoxication is common for most older adolescents, some young people exhibit a life-style in which substance abuse is routine and constant. Such teenagers are not only subject to those risks inherent to intoxication, but also they most often evidence a lack of concern for societal regulations, their own safety, and the safety of others. This combination of factors makes them dangerous when they are driving an automo-bile.
Those adolescents who are engaged in delinquent behavior are, by definition, violating the rules of society. Laws intended to promote safe driving are frequently ignored by young people engaged in an-tisocial behavior. Beyond law breaking, there are considerations of depression, a lack of concern for self-preservation, and an exaggeration of the nor-mally encountered but dangerous issues of the im-portance of a macho self-image. All of these factors place the delinquent youth in danger of injury and death from a host of behaviors including driving.
developing adolescent. If the family is in turmoil or under great stress, the youth loses that stabilizing resource. Adolescent growth tasks and normal psy-chosocial development become challenged and corn-promised, and disruptive behavior is likely to ensue. Of particular concern to the pediatrician are fami-lies facing separation, divorce, the death ofa parent, socioeconomic hardship, alcoholism, or disongani-zation of any cause. Any of these issues may give rise to adolescent behaviors that involve special
risk. Addressing the difficulties of the family, there-fore, will play an indirect but important role in the prevention of motor vehicle injuries.
Depression among adolescents, with its concom-itants of suicide attempts and other self-destructive behaviors, has become a major cause for concern among those who care for youth. Drug abuse, delin-quency, and family turmoil are all factors frequently associated with an underlying depression in teen-agers. Regardless of cause or concomitants, depres-sion during adolescence is associated with a de-creased concern for self-preservation. Automotive injury may result from either a conscious or sub-conscious wish to die, an attempt to ameliorate feelings of emptiness by engaging in exciting and daredevil activities, or a simple lack of concern for life and limb. By being aware of depression in adolescents and initiating a response to their diffi-culties, the pediatrician is simultaneously address-ing automotive safety.
ROLE OF THE PEDIATRICIAN
The risk factors associated with both normal and abnormal adolescent development define issues that would benefit from intervention by the pedia-tnician.
Clinical Assessment
The pediatrician uses the psychosocial history as a means of assessing an adolescent’s emotional and social development. This history includes school performance, home life, peer relations, attitudes and feelings concerning drug use and sexual activ-ity, and assessment of general emotional status. The information gleaned from this interview can reveal stresses and feelings that might lead to risk-taking behavior.
Emotional swings, including episodes of short-term depression, may contribute to erratic and un-predictable behavior. A teenager with prolonged depression should be assessed for the potential of self-destructive behavior including accident-prone activity and suicidal ideation. Peer group expecta-tions can interfere with good judgment. Family and personal turmoil contribute to problems with
im-pulse control, decreased concentration, and diffi-culty with expressions of aggressive behavior. Thus, a history of family strife, alcoholism, violence, and accident-prone behavior should alert the pediatni-cian to investigate further. Screening of the young person should include inquiry into physical and/or mental impairment and seizure disorders. Acting out and delinquent behavior, school failure, and incessant struggle between the youth and his family as noted previously are indicators of risk.
The detection of the teenager who is at special risk is the first step the pediatnicia assumes in the preventive aspect of interaction with adolescents. The second role is to provide anticipatory guidance. In this role, the pediatrician can help the young person become aware of such dangers as nighttime driving, long distance driving, and driving with an unsafe number ofpassengers. Alternatives to drink-ing and driving or being a passenger in a car in which the driver is intoxicated can be discussed with both the adolescent and the family. Dialogue between the pediatrician and the teenage patient allows potential problem areas to surface before they reach tragic proportions and, thus, provides the opportunity to diminish the stresses that would place an otherwise healthy adolescent in a circum-stance of increased risk.
Intervention
With the High-Risk
Adolescent
When a youth is determined to be at high risk, assessment of parental interest and involvement are indicated. Appropriate ongoing counseling can be initiated, depending on family resources and energy to deal with the troubled youth. Therapeutic modalities would include counseling by the pedia-tnician, family therapy, and/or mental health refer-ral depending on the extent of the problem, the extent ofthe pediatrician’s role, and the availability of other resources.
Community Involvement
by the “heroes.” (In a study of 223 prime-time television programs, only four of 869 drivers were clearly shown buckling their seat belt when they prepared to drive.6) Adolescent-initiated driving safety programs have been established in many high schools throughout the country. Students Against Drunk Driving (SADD) uses peer pressure to en-courage safe driving behavior. Pediatricians and local American Academy of Pediatrics chapters are recognizing the effectiveness of these programs and are beginning to give them active professional rec-ognition and support.
LEGISLATIVE ACTION
Pediatricians should also exert their influence in the area of legislation. There are a variety of stat-utes that require reevaluation relevant to their im-pact on adolescent driving safety.
Legal Drinking Age
Associated with the constitutional amendment lowering the federal legal voting age to 18 years in
1971, the legal drinking age was lowered in 25
states. Lowering the minimum drinking age
re-sulted in increased involvement of teenage drivers in alcohol-related fatal crashes.7 This trend was curtailed in 1973 and by 1976 began to reverse as
evidence accumulated connecting the lowered
drinking age with an increased number of motor vehicle accidents involving young people. Between
1976 and 1980, at least 1 1 states increased the legal drinking age from 18 years to 19, 20, or even 21 years. Subsequent studies have strongly suggested that the number of nighttime fatal motor vehicle accidents has been reduced in states that raised the legal drinking age.8’9 In Michigan, the drinking age was increased from 18 to 21 years; the result was 31% fewer crashes than had been predicted for the
year.’#{176}
Seat Belts
Restraint system use does not increase through driver education. New and more stringent measures of ensuring seat belt use are needed. Mandatory seat belt use for all drivers, and in particular for persons with provisional licenses, would decrease injury.” Violation of seat belt use should result in more stringent punitive measures than are cur-rently imposed.
Drinking and Driving
As in the overall adult population of drivers, some youths are at higher risk for accidents and irre-sponsible driving behavior, including driving while
intoxicated. Determining such high-risk drivers and eliminating them from driving eligibility would im-prove public safety as well as their own. Accumu-lation of violations and/or convictions should result in harsher penalties to prevent recurrence. For ex-ample, license suspension should be made manda-tory for significant violations by provisional licen-sees.
Age of Licensure
Because of the strong social and peer pressure for early licensure and the particularly high colli-sion rate for younger drivers, extension of the time periods for learner’s permits and restrictive licen-sure should be considered. A “phase in” of driving has already been instituted in some states, with parental participation in driver education and an incentive to sustain the permit as long as possible. Increasing the age of licensure to 18 years and/or prohibiting driving from 8 PM to 4 AM until the age of 18 years would decrease the number of automo-tive fatalities in youth. More than half of motor-cyclists less than 18 years have no valid license; therefore, increased enforcement of motorcyclist licensee laws would reduce the number of deaths even if present licensing ages are retained.
Driver Education
Current public policies regarding driver educa-tion are being challenged. Driver education results in earlier licensure. As a result, more young people are driving and more accidents occur.’2 Although driver education is valuable for teaching basic knowledge and skills, it has not resulted in de-creased numbers of deaths on the highway.’2 Laws facilitating early licensure or early unrestricted ii-censure after completion of a driver’s education course should be reevaluated.
REFERENCES
1. Karpf RS, Williams AF: Teenage drivers and motor vehicle deaths. Accid Anal Prey 1982;15:55-63
2. Williams AF, Karpf RS: Deaths of teenagers as passengers in motor vehicles. Accid Anal Prey 1983;15:49-54
3. Status Report: Teens and Autos: A Deadly Combination.
Washington, DC, Insurance Institute for Highway Safety, vol 16, No. 14, 1981
4. Hodgdon JD, Bragg BWE, Finn P: Youth Driver Risk-Taking Research: The State of the Art. National Highway Traffic Safety Administration, March 1981
5. Williams AF, Wells JK, Lund AK: Seat belt use among American high school students. Accid Anal Prey 1983;
15: 161-165
6. Greenberg BS, Atkin CK: The portrayal of driving on tele-vision, 1975-1980. J Commun 1983;33:44-55
1975;4:219-239 motor vehicle accidents in Michigan. HSRI Res Rev 1981; 8. Wagenaar AC: Effects of an increase in the legal minimum 11:2-8
drinking age. J Public Health Policy 1982;2:206-225 1 1. Council FM: A mandatory seat belt usage law for provisional 9. Williams AF, Zador P, Harris MS, et al: The effect of raising licensees? Presented at the Third Annual North Carolina
the legal drinking age on fatal crash involvement, in The Conference on Highway Safety, November 1976
Highway Loss Reduction Status Report. Washington, DC, 12. Robertson L, Zador PL: Driver education and fatal crash Insurance Institute for Highway Safety, 1981, vol 10, pp 1-5 involvement of teenage drivers. Am J Public Health 1978;
10. Wagenaar AC: Effects of the raised legal drinking age on 68:959-965
MAY
CHILDREN
GO BAREFOOT
WITHOUT
INJURY?-AS
VIEWED
IN
1885
The question of whether to allow children to go barefoot or not remains a contemporary question. This is how this question was answered a hundred years ago in an editorial in the Lancet.’
This question is every now and again proposed for discussion; and when it is so, we
are compelled to give the same answer. On physiological grounds it is manifestly a sound
practice to accustom children to develop the circulation and muscular systems of the lower extremities, precisely as those of the hand are developed, by free use and exposure. It is not supposed to be either necessary or desirable that children should wear gloves for hygienic purposes. When the hands of little folk are thus decorated, the parental idea
is confessedly to give them what is conventionally regarded as a genteel appearance. No one thinks the child ought to be protected from the weather so far as its hands are concerned. Precisely the same view holds good with regard to the lower extremities. Contact with bodies that abstract heat, even more than the earth abstracts it, is an
almost constant condition of child-life. In short, it is entirely in deference to fashion and
the usages of society that children wear foot coverings. There is much to be said in favour of a more natural practice. The foot is an organ of wonderous complexity, regarded
as a bony and muscular apparatus. It is, moreover, provided with nerves and bloodvessels of special intricacy. The softest and most flexible shoe to a very great extent, and a boot almost entirely, reduces this organ to the character of a jointed block with little self-movement. Obviously this reduction must detract not only from the efficiency of the
foot, but of the organism as a whole. In one aspect too commonly overlooked we think this reduction of the foot to ajointed block is especially injurious-namely, the limitation of the ordinary capacity, and exceptional dilatability, of the vascular system which results. A study of the effects of drawing blood to the extremities by special appliances
for medical purposes should place this matter in a clear light. If the blood-vessels of the
foot and leg are fully developed, as they can only be when the foot is habitually exposed,
the quantity of blood which the lower extremity can be made to receive, and if need be
to attract for a time, is very considerable. Returning to the immediate subject before us,
we can only say that children who are allowed to go barefooted enjoy almost perfect
immunity from the danger of “cold” by accidental chilling of the feet, and they are
altogether healthier and happier than those who, in obedience to the usages of social life, have their lower extremities permanently invalided, and, so to say, carefully swathed and put away in rigid cases. As regards the poorer classes of children there can be no
sort of doubt in the mind of anyone that it is incomparably better they should go
barefooted than boots that let in the wet and stockings that are nearly always damp and
foul.
Noted by T.E.C., Jr, MD
REFERENCE
