Journal of Pediatric Psychology, Vol. 6, No.

3, 1981

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Parental Compliance with Car Seat Usage:
A Positive Approach with Long-Term Follow-up1
Edward R. Christophersen2 and Jo-Eileen Gyulay
University of Kansas Medical Center, Kansas City, and University of Kansas, Lawrence

The present study assessed the effectiveness of a single clinic visit and
written protocol in increasing mothers' compliance with a health care
provider's recommendation for using child safety restraints in
automobiles. The use of car seats and the behavior of children was
recorded by an observer who accompanied eight mother-child pairs on
numerous 15-minute automobile rides. After a varying number of rides
during which hone of the subjects were observed to use car seats, each
mother was scheduled for a clinic visit. During this visit each mother was
told that her child's behavior would improve if a car seat were used
consistently, and she was given a brief written protocol which described
how to interact with a child who was restrained in a car seat. Immediately
after the clinic visit, five mothers (62%) began requiring their children to
use car seats, and their children's behavior showed marked improvement.
At 3-month follow-up, six mothers (75%) were using the seats. At 6
months, five (62%) were using the seats, and at 1 year three (37%) were
still using the seats. These data represent a higher rate of car seat usage
than has previously been reported and provide the longest follow-up yet
reported.

'This research was partially supported by a grant from NICHD (HD 03144) to the Bureau of
Child Research and from General Motors Corporation to the first author. The research was
submitted by the second author in partial fulfillment of the requirements for the MA degree
in Human Development, University of Kansas.
'All correspondence should be directed to Edward R. Christophersen, Department of Pe-
diatrics, University of Kansas Medical Center, 39th Street at Rainbow Boulevard, Kansas
City, Kansas 66103.
301
0146-8693/81/0900-0301S03.00/1 © 1981 Society of Pediatric Psychology
302 Christophersen and Gyulay

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Professionals in the field of child health care agree that parents should
require their children to use a safety restraint car seat whenever they
travel by automobile (Lieberman, Emmet, & Coulson, 1976; Richelderfer,
1976). Attempts to increase car seat usage have involved verbal and/or
written instructions (Allen & Bergman, 1976; Bass & Wilson, 1964;
Kanthor, 1976; Miller & Pless, 1977), and modeling and behavioral
rehearsal (Shelness & Charles, 1975). On the whole, attempts led to car
seat use by only 25-30% of the mothers involved in the studies. Automobile
accidents overshadow all other causes of death among children, claiming
the lives of more children than the six leading pediatric diseases combined
(Lieberman et al., 1976). However as Pless (1978) has concluded that:
in the field of automobile safety at least the efficacy of health education seems
limited. . . . We must return to the drawing board and look carefully at how others
succeed in influencing behavior, (p. 434)

Each of the previously referenced studies on the use of safety restraints

emphasized as a basic premise the increased risk of death or injury to
children who do not use car seats on auto trips. Christophersen (1977)
suggested an alternative strategy to use with parents. He conceptualized
the typical parent education program as emphasizing avoidance, i.e., the
negative consequences of not using car seats. The proposed alternative
was to emphasize to parents how much better their children would behave
if they were properly restrained on auto rides, i.e., positive reinforcement.
Christophersen (1977) compared the behavior during auto rides of
two groups of children. One group was recruited specifically because the
children routinely used a restraint seat, the other group because they did
not use a restraint seat. His data demonstrated that the children who
routinely used car seats exhibited substantially less inappropriate behavior
than children who routinely rode unrestrained. Christophersen suggested
that this fact, the increase in approriate behavior during auto rides, might
well be used by the pediatric health care provider as a selling point for car
seat use, instead of the traditional "scare tactics" of quoting statistics on
injuries and deaths of unrestrained children.
The present study was designed to assess the long-term effects on car
seat use of a single office visit during which the health care provider
stressed (verbally and with the use of a written protocol) the importance
of the car seat in reducing inappropriate behavior in the auto. Following
the emphasis of Reisinger and Williams (1978) and Pless (1978) on the im-
portance of observing actual car restraint seat usage rather than relying
on parental report, the present study utilized repeated measures during
actual car rides.
Compliance with Car Seat Usage 303

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METHOD

Subjects

An advertisement was placed in a local biweekly newspaper asking

mothers with children 2 to 4 years of age to participate in 15-minute car
ride observations. An incentive payment of $5 was offered for each 15-
minute local trip with an observer present. The mothers were told that the
study was concerned with children's behavior during auto rides.
Eight toddlers (average age 27 months, range 23 to 46 months) and
their mothers served as subjects. The families that participated in the
study were all middle-income families, had from one to five children",
and resided in middle-income suburbs in the metropolitan Kansas City,
Kansas, area. Informed voluntary consent to participate in the study
(which was approved by the Medical Center Human Subjects Committee)
was obtained from the mothers.

Setting

Observation and recording sessions were conducted in the mothers'

cars. An observer (the second author) accompanied the mother-child
pair on the car ride to record observations about the children's behavior
and whether or not a car seat was used. Prior to the observations, the
mothers were instructed to interact with their child as they would
normally. Mothers were free to stop during the 15-minute ride for short
errands, during which time no observations or recording took place. Two
of the mothers stopped, once each. S, stopped for 37 minutes, and S,
stopped for 7 to 10 minutes. In both cases this was after the clinic visit,
and the child stayed in the car seat.
The observer (seated in back) watched the child (seated in front) via
a mirror fastened to the passenger seat sun visor. A time-sampling
procedure was utilized for the behavioral observations. The observer
carried a battery-operated cassette tape recording, which served as a
portable audible timer. Through an earphone connected to the tape
recorder, the observer heard 5-second tones alternating with 10 seconds of
silence. During each silent period the observer watched the child. During
the subsequent tone period, the observer scored the occurrence or
nonoccurrence of each of the defined behaviors.
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Child Behaviors

An interval was scored by the observer as inappropriate if any of the

following behaviors occurred anywhere in the car during that interval.
Kicking. A thrusting or striking of the foot or feet of the child which
causes a resounding thud.
Sitting. With one or both feet under the buttock.
Standing. Child in the upright or erect position on seat or floor of
the car.
Crawling. A creeping movement that is pawing in nature on both
hands and feet.
Fighting. Striking, hitting another individual. It makes no difference
who initiated the interaction.
Kneeling. The placement of the knees holding the weight of the child
on the seat or floor of the car. Direction makes no difference.
Walking. Moving about on both feet in the upright position by the
child, whether on the seat or the floor.
Climbing. To arise or ascend, to mount step by step by means of the
hands and feet.
Grabbing. Grasping, touching, or feeling of objects on the
dashboard, keys in the ignition, or steering wheel that is distracting to the
driver while the car is in motion.

Reliability

Reliability was not actually assessed on the child's use of the car
seat. The reliability observers were not told that the study was con-
cerned with car seat usage. It was felt that asking the observers to record
whether or not a car seat was used would give away the study's purpose.
Reliability of the observational measures of the child's behavior was
assessed by having a second observer accompany the regular observer on
a car ride on 32 occasions. At least one reliability check was performed
for each subject during baseline and after the clinic visit. Three checks
were done at 3-month rides and three at the 6-month rides. The reliability
of the observational measures of the child behaviors was checked an
average of three times per child. The second observer independently
recorded her observations, and reliability coefficients were later obtained
by comparing the two sets of written records. Each of the individuals who
served as reliability checkers was given a written Observer Packet that
contained instructions on the operational definitions in use, how the
observing timing was accomplished, and how the individual data sheets
were to be scored (a copy of the Observer Packet is available from the
authors). Occurrence reliability for the child behaviors ranged from
98.3% to 100% and averaged 99.8°7o.
Compliance with Car Seat Usage 305

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Experimental Design

A multiple baseline design across subjects was employed to assess

the effects of the single clinic visit on the use of car seats, and the effects
of the car seats on children's behavior. This design was employed to allow
systematic comparison of subjects who had already talked to the project
director to those who were still in the baseline condition. Two mothers
were scheduled for a clinic visit with the project director after five rides,
while the remaining six subjects remained in the baseline condition. Then
after two more rides (a total of seven baseline rides), two additional
mothers were scheduled for a clinic visit. Another two mothers were
scheduled for a clinic visit after nine baseline rides. The last two mothers
were scheduled after 11 baseline rides.

Clinic Visit

The mothers were told that the observer would not participate in this
interview, nor did the observer know what would take place during the
interview. The interview was conducted by the project director (the first
author) in the clinic at the convenience of both parties. At that time the
mother was given the following written protocol (© 1978 by Jo-Eileen
Gyulay and Edward R. Christophersen) and a verbal description of same.

Using Automobile Car Seat

Guidelines for Parents
Car riding can and should be a pleasant time for you and your child. This is an ex-
cellent time for pleasant conversation and for teaching your child acceptable and
appropriate behavior in the car. It is also the safest mode of travel, even on short
trips, for your child.
1. Introduce the car seat to your child in a calm, matter-of-fact manner as a learning
experience. Allow him to touch it and check it out.
2. Remind the child about the rules of behavior nicely before the first ride and in
between rides.
3. Your first rides with the seat should be short practice ones to teach him the ex-
pected and acceptable behavior, perhaps once around the block. Point out interesting
things that he can see. Make it a positive experience for both of you.
4. Praise him often for appropriate behaviors. (Example: "Mike, you are sitting
so quietly in your seat. Mommy is proud of you. You are a good boy".) This ex-
planation teaches him the expected and appropriate behavior. Young children need
specific directions. They cannot make the opposite connection of what is meant by
"Quit that!" Catch him being.good! You cannot praise him too often!
5. Include the child in pleasant conversation. (Example: "That was sure a good
lunch . . . you really like hot dogs . . . you were a big help to me in the store . . .
it'll be fun visiting grandma".)
6. This is also a good time to teach your child about his world. (Example: "Jon,
see that big, red fire truck? Look at how fast it is going. What do firemen do?
The light on the top is red... what else is red?") This needs to be geared to the age
of your child.
306 Christophersen and Gyulay

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7. By your frequent praise, teaching, and pleasant conversation, your child will
remain interested and busy and will not spend his time trying to get out of the seat.
He will have your frequent attention.
8. Ignore yelling, screaming, and begging. The instant he is quiet, praise him for
being quiet. You also should not yell, scream, and beg. Remember, remain calm
and matter-of-fact. Keep your child busy in conversation and observations of his
world. Do not give in and let him out. This only teaches him that yelling, screaming,
and begging will finally break mom or dad into letting him do what he wants.
Who's the boss?
9. Older siblings should also be expected to behave appropriately. If the young child
sees an older sibling climbing or hanging out the window, he will want to become a
participant. The older sibling(s) should also be included in the conversation, praise,
and teaching.
10. Provide one or two toys that your child associates with quiet play such as books,
stuffed animals, dolls, etc. It may help to have special quiet riding toys that are
played with only in the car. This decreases boredom. Remember, the young child's
attention span is very short. Do not expect him to keep occupied for more than a
couple of minutes or less, particularly at the begining and depending upon his age.
Anticipating this will prevent throwing of toys, temper tantrums, crying, or fussing.
11. Reward him with five to ten minutes of your time doing an activity that he likes
immediately after the ride such as reading a story, playing a game, helping prepare
lunch, helping put away the groceries, etc. Do not get into the habit of buying your
child favors or presents for his good behavior. He enjoys time with you and it's less
expensive and more rewarding for both of you! Remember, CATCH HIM BEING
GOOD—AND PRAISE HIM OFTEN.
12. If your child begins to try to release his seat belt or to climb out of the car
seat, immediately tell him "No!" in a firm voice. On your first few trips, which
should be just around the block, stop the car if you think that is necessary. Also,
consider stating the rule once, clearly, "Do not take off your seat belt!" and
administer one firm slap on his hands.
13. Remember, without the praise and attention for good behavior in the car, your
child will learn nothing from the training trips. The combination of praise and at-
tention, with an occasional hand slap can and will teach the behavior you want in
the car.
The mother was also given a GM Love Seat™, if she did not already
have a car seat, and its use was demonstrated. At no time during the
clinic visit was any mention made of the safety implications of the use of
the car seat. The entire emphasis was placed upon the child's appropriate
car behavior. The mothers received no monetary reimbursement for this
interview, nor were they charged for it.
Mothers were requested by the project director not to discuss, the
iwritten protocol or the use of the car seat with the observer(s). Any
questions regarding the car seat, the child's behavior, or any part of the
written protocol were to be addressed to the project director. None of
the mothers had contact with the director after the one clinic visit.

RESULTS
Figures 1 and 2 show the rides during which car seats were used, and
Figures 3 and 4 show the percent of intervals scored as inappropriate for
Compliance with Car Seat Usage 307

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CLINIC VISIT
YES-

NO-

VES-

(A NO-

YES-

J
te.
<
NO-

YES-

NO •

I I I 1 I I I I I I I I I I
1 2 3 4 5 6 7 S 9 10 1112 1314 15 3 6 12
mos.
FO
CAR RIDES "°WUP
CHILD ALLOWED TO CET OUT OF SEAT

Fig. 1. Use of car seats by Subjects 1 through 4.

each child. As shown by Figures 1 and 2, none of the mothers required

their child to use a car seat prior to the clinic visit, and as shown by
Figures 3 and 4, all children showed a substantial rate of inappropriate
behavior during the baseline rides.
After the clinic visit, five mothers (62%) began regularly to require
their children to use car seats, and their children showed concomitant
decreases in inappropriate behavior. These five subjects were still using
car seats at the 3-month follow-up, and Si was doing so as well, and all
six of these children showed zero or near-zero rates of inappropriate
behavior. At the 6-month follow-up, Subjects 2, 3, 4, 7, and 8 were using
car seats, with zero or near-zero rates of inappropriate behavior. One year
after the clinic visit, Subjects 3, 7, and 8 were still using the car seats with
308 Christophersen and Gyulay

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BASELINE CLINIC VISIT
YES-

NO-

YES-

Ul

<
Ul
(f)
YES-

<
NO-

YES-

NO-
I I I I 1 I I I I I I' I I I |/>4VA»/H—
1 2 3 4 5 6 7 8 9 10 11 12 1314 15 3 6 12
tnos.
Follow-up
CAR RIDES
X IOOSTC> SCAT USED

Fig. 2. Use of car seats by Subjects 5 through 8.

near-zero rates of inappropriate behavior. (The average duration of the

clinic interview was 38 minutes). The longer visits also included discus-
sion on such topics as bedtime or mealtime problems.

DISCUSSION
The results of this study suggest that the child health care provider
can increase the likelihood of car seat use by mothers by supplying the
mothers with a positively oriented written handout. The rate of restraint
seat usage is much higher than that reported elsewhere, suggesting that
the positive rationale might very well be the most effective means of
 Compliance with Car Seat Usage 309

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BASELINE '-^-CLINIC VISIT

i 'i i n ; ; i /AVM
12 3 4 5 6 7 8 9 10UU13M1S 3 6 12
Allow-up
CAR RIDES
)( lUIJtIILITI C»£C« COHOUCIli

Fig. 3. Percent intervals with inappropriate behaviors by Children 1 through 4.

The x's indicate sessions with interobserver reliability checks.

encouraging parents to restrain their children in car seats during

automobile trips.
The length of time devoted to acquainting parents with the benefits
of using a car seat could no doubt be substantially decreased if the use of
the car seat were introduced by the regular pediatrician during the course
of a routine well-child visit. This time could probably be further
decreased by discussing car seat use as early as possible, perhaps
prenatally or neonatally.
310 Chrislophersen and Gyulay

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BASELINE •4-CLINIC VISIT
100 T

23-

I I I I I I I I
1 2 3 4 S 6 7 8 9 1011 1213 U IS 3 6
mot.
Follow-up
CAR RIDES
X H U M I L I T Y CHECK COKBUCTI*

Fig. 4. Percent intervals with inappropriate behaviors by Children 5 through

8. The x's indicate sessions with interobserver reliability checks.

All eight of the subjects in the present study reported that they had
used car seats at one time. Two of the subjects still had car seats, and six
had sold or given them away (one as recently as 1 week prior to the
study). The authors elected to offer free seats to those subjects who no
longer owned car seats. This offer was made to eliminate the effects of
suggesting that the parents purchase a second car seat after they had
already had a negative experience with their first car seat. One subject
who received a free car seat (Ss) never used it. Another (S«) discontinued
Compliance with Car Seat Usage 311

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using the car seat after the 3-month follow-up. The remaining four
subjects who received free car seats (Subjects 3, 4, 7, and 8) used them
consistently after the clinic visit. Interestingly, three of them (Subjects 3,
7, and 8) subsequently purchased car seats for siblings to use. These were
the same three subjects who were using the car seats at 1-year follow-up.
Of the two mothers who had retained their original car seats, one
(Si) did not have seat belts in her car and never used the car seat. The
other mother (S2) used the car seat only sporadically after the clinic visit,
but used it during both the 3-month and 6-month follow-up rides.
In the earlier study by Reisinger and Williams (1978), the highest rate
of car seat usage (27%) was observed in that group of mothers which
received free car seats in addition to literature describing the safety
aspects of car seat use. This fact, in conjunction with the results of the
present study, indicates that car seat usage was indeed affected by the
offer of free car seats. However, the substantially higher rate of usage
(62%) observed in the present study must be attributed to the emphasis on
the positive effects of using car seats rather than the negative effects of
not using them.
The small number of subjects in the present study was necessitated
by the experimental design, which required that one and sometimes two
observers actually ride with mothers to record whether or not car seats
were used and how the children behaved during the rides. Since the results
are so similar to those obtained in the earlier study by Christophersen
(1977), they constitute a systematic replication adding to the study's
scientific merit. However, to conduct a study with a large clinic
population, while retaining the observer data collection, would be highly
impractical. Anecdotally, it may be reported that many clinicians who
have utilized the procedures evaluated in this report have found the same
results in their experience. None have reported any unfavorable reactions
by the mothers in their practices.
Pless (1978) has suggested that psychologists can add a great deal to
the area of medical education. The present study supports his suggestion.
The approach described herein encompasses the educational modalities of
verbal and written instruction, modeling, and behavioral rehearsal, all of
which have been well established in the field of psychology. From a
conceptual standpoint, the parents' behavior of requiring their child to
use the car seat is consistently reinforced when the expectation planted by
the health care provider (i.e., improved child behavior during car rides) is
realized on most, if not all, subsequent rides. This immediate and
continuing reward for the parents' altered behavior is clearly superior to
the procedure of merely providing threats about the possible negative
consequences for continued failure to use car seats.
312 Chrislophersen and Gyulay

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