In 1997, researchers at Children’s Hospital of Philadelphia partnered with State Farm Insurance, one of the largest automobile insurance companies in the U.S., to create the nation’s first large-scale, child-focused crash surveillance system. Over the next 10 years, the Partners for Child Passenger Safety Program (PCPS) studied more than 875,000 children involved in 600,000 car crashes, conducted 33,000 in-depth interviews, and analyzed over 800 on-site investigations. By its close in 2007, the world’s largest study of children in crashes had produced a robust set of recommendations based on hard data and backed by scientific expertise that would shape and advance legislation, vehicle design, and public health education for years to come. Since PCPS began, the U.S. has cut the number of children dying from crash-related incidents every year in half — from more than 2,000 deaths in the 1990s to about 1,000 deaths today. Countless more children have been spared from serious injuries.
We celebrated the program’s 20th anniversary in 2017, recognizing both its tremendous impact and the unique research-to-action method that it deployed: A true “collaboration” in every sense of the word, PCPS involved industry stakeholders and child and traffic safety organizations from the very beginning — a decision that would drive the greatest impact for children’s health.
“We found this marriage that just fit, lock and key, from day one,” said Flaura Winston, MD, PhD, founder of the Center for Injury Research and Prevention (CIRP) and the PCPS Program, as well as a professor of Pediatrics at the University of Pennsylvania. “There was a compelling need to protect children from motor vehicle crashes, the leading cause of death and acquired disability, and we had the intellectual capital to help guide an evidence-based strategy. We were the discovery people, and State Farm had the claims infrastructure to support the research and the network to help spread the findings. It was a magical thing where they could collect the data at scale, and we could use their muscle to help move the needle on policy.”
Getting on the Right Track
PCPS began in the cafeteria of CHOP’s Leonard and Madlyn Abramson Pediatric Research Center with a chance discussion between Dr. Winston, Dennis Durbin, MD, MSCE, former chief clinical officer at the CHOP Research Institute, and a State Farm Insurance researcher.
It was the mid-1990s, and the State Farm researcher had come to CHOP to discuss crash safety research. Dr. Winston’s work as a pediatrician-researcher in the CHOP Emergency Department had brought the problem of airbags to national attention, with the identification of the first fatality from an airbag in July 1995. As she and Dr. Durbin took the State Farm researcher on a tour around the main hospital, the two initiated a partnership that would grow far larger than they then imagined. They recruited Kristy Arbogast, PhD, now co-scientific director of CIRP and a professor of Pediatrics at Penn, as one of the first members of the team.
“One of the greatest benefits of the grant was the ability to attract stellar young talent, most notably Kristy Arbogast,” Dr. Winston said. “Cutting her teeth on PCPS, Dr. Arbogast is now a world leader in pediatric biomechanics, auto safety design, and concussion, and my co-director here at CIRP.”
Over the next 10 years, State Farm identified crashes involving children from auto insurance claims and forwarded the data electronically to CHOP, with appropriate consent and security safeguards in place. Eligible participants for the study included State Farm-insured children younger than age 16 who were riding in a model year 1990 or newer vehicle that had been involved in a crash. The data represented participants from the District of Columbia and 16 states.
Once they received the data from State Farm, a research team led by CHOP conducted in-depth telephone interviews, while Dr. Arbogast dispatched a team for on-site crash investigations for a select subsample of crashes. Analyses by the team produced comprehensive reports about the range of crash and injury severity, and the mechanisms and reasons why children are injured in crashes.
PCPS Research in Action
Between 1998 and 2011, PCPS published over 80-peer reviewed scientific papers in more than 20 journals and presented at hundreds of academic, advocacy, and government meetings around the world. They summarized their findings in a series of 15 reports that included prolific statistics, in-depth analysis, and suggested action points for change.
One of the first and most influential PCPS findings involves the use of child restraints: In 1998, PCPS reported that most children ages 3 to 8 years old were being placed in seat belts designed for adults rather than booster seats or other proper child restraints. PCPS data also revealed that children ages 2 to 5 years old who were placed in adult seat belts were three and a half times more likely to be injured in crashes compared to those in booster seats. Through promotion of this information by child passenger safety organizations and educational and legislative interventions, the research solidified into impact: From 1999 to 2007, studies showed that more families were using proper child restraints, including booster seats. Child restraint use for children 4 to 8 years old increased from 15 percent in 1999 to 63 percent in 2007. Child restraint use for children through age 8 increased from 51 percent in 1999 to 80 percent in 2007. The recommendation from PCPS stood validated: Until they reached 4 feet 9 inches in height, children younger than age 9 should ride in a proper child restraint.
PCPS also gathered a wealth of insights into the most common types of crashes and the ages and ways that children were most likely to get injured. As children age, their injury risk in a crash rises, partly due to the ways they are restrained and where they sit at each age. For most children in most vehicles, those sitting in the front seat were more likely to be injured compared to those sitting in the back. Head injuries formed the most common injuries for both children and drivers. Finally, frontal impact crashes proved the most common, at 40.2 percent, but crashes that involved rollovers had the highest risk of injury, at 78.3 for every 1,000 children. These findings, along with others, gave insights into the injuries attributable to vehicle and restraint designs, such as jump seats in extended cab pickup trucks and air bag designs. The research also helped to shape and inform testing and regulations, including the use and design of advanced airbags and the electronic stability control that became standard in SUVs.
Protecting Child Passengers Today
The legacy of PCPS continues through a number of current projects at CIRP, including investigations conducted through the Center for Child Injury Prevention Studies (CChIPS), a National Science Foundation Industry/University Cooperative Research Center (I/UCRC) co-directed by Drs. Winston and Arbogast. Out of over 80 I/UCRC centers in the U.S., CChIPS is the only one focused exclusively on child and teen injury prevention. In the synergistic spirit of PCPS, CChIPS involves collaborative research between industry members and investigators at CHOP, the University of Pennsylvania, and the Ohio State University.
The 2017 CCHIPS Annual Report highlights several fascinating projects in child passenger safety research, many in partnership with the automobile industry. One multi-year investigation led by Dr. Arbogast tests the different features of forward-facing car seats, and analyzes how each feature might provide protection in oblique impacts. In the real world, side impact crashes are more likely oblique (tilted) rather than directly lateral. Now in its third year, Dr. Arbogast and her team have made the important finding that child seat kinematics were improved with the use of a tether.
“Dr. Arbogast has done a phenomenal job of working with industry in so many ways,” Dr. Winston said.
Dr. Arbgoast and her team also developed a low-speed human volunteer sled to test pediatric subjects. The crash test sled mimics the safe crash experienced by children and adults when they ride an amusement park bumper car. It is the first and only effort to test pediatric subjects in this manner and has allowed the research team to collect the only known data on the kinematics and kinetics of restrained 6- to 14-year-old pediatric human volunteers in low speed impacts.
Another CCHIPS study involves investigating the safety of self-driving cars with the use of the CIRP driving simulator. Led by CIRP Scholars Helen Loeb, PhD, and Aditya Belwadi, PhD the research looks at how drivers of different ages interact with self-driving technology, including the ability to regain control in an emergency situation when alerted by a warning system. A pilot study revealed habits of drivers when the vehicle is in self-driving mode and differences in crash rates by age (more teens experienced simulated crashes than adults) and gender (females crashed less than males).
International bodies have recognized the impact of CIRP’s child occupant protection research, including the Association for the Advancement of Automotive Medicine and the Society of Automotive Engineers, as well as National Highway Traffic Safety Administration, American Society of Mechanical Engineers, the American Academy of Pediatrics, the Governor’s Highway Safety Association, the American Philosophical Society, the US Maternal and Child Health Bureau, the US Centers for Disease Control and Prevention, the American Public Health Association, and the American Institute of Medical and Bioengineering.
As the automobile industry moves into a new era of innovation, the advanced technology will bring both new challenges and greater opportunities to drive novel research to protect children’s safety, as PCPS did over 20 years ago.