Quinlan KP, Brewer RD, Sleet DA, Dellinger AM. Characteristics of Child Passenger Deaths and Injuries Involving Drinking Drivers. JAMA. 2000;283(17):2249–2252. doi:10.1001/jama.283.17.2249
Author Affiliations: Epidemic Intelligence Service, Epidemiology Program Office (Dr Quinlan), Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control (Drs Quinlan, Sleet, and Dellinger), and Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion (Dr Brewer), Centers for Disease Control and Prevention, Atlanta, Ga.
Context Motor vehicle–related injury is the leading cause of death for
children and young adults aged 1 to 24 years in the United States. Approximately
24% of child traffic deaths involve alcohol.
Objective To examine characteristics of crashes involving child passenger deaths
and injuries associated with drinking drivers to identify opportunities for
Design, Setting, and Participants Descriptive epidemiological analysis of 1985-1996 data from the Fatality
Analysis Reporting System on deaths among US child passengers (aged 0-14 years)
and 1988-1996 data from the General Estimates System on nonfatal injuries.
Main Outcome Measures Child passenger death or injury by driver characteristics (eg, driver
age, blood alcohol concentration, and driving history).
Results In 1985-1996, there were 5555 child passenger deaths involving a drinking
driver. Of these deaths, 3556 (64.0%) occurred while the child was riding
with a drinking driver; 67.0% of these drinking drivers were old enough to
be the parent or caregiver of the child. Of all drivers transporting a child
who died, drinking drivers were more likely than nondrinking drivers to have
had a previous license suspension (17.1% vs 7.1%) or conviction for driving
while intoxicated (7.9% vs 1.2%). Child restraint use decreased as both the
child's age and the blood alcohol concentration of the child's driver increased.
In 1988-1996, an estimated 149,000 child passengers were nonfatally injured
in crashes involving a drinking driver. Of these, 58,000 (38.9%) were riding
with a drinking driver when injured in the crash.
Conclusions These data indicate that the majority of drinking driver–related
child passenger deaths in the United States involve a child riding unrestrained
in the same vehicle with a drinking driver. Typically, the drinking driver
transporting the child is old enough to be the child's parent or caregiver.
Motor vehicle–related injury is the leading cause of death for
children and young people aged 1 to 24 years in the United States.1 From 1985-1996, 24% of motor vehicle–related
deaths among children involved alcohol; 68% of these alcohol-related deaths
involved motor vehicle occupants.2 While the
relation of alcohol to the traffic deaths of teenaged drivers is well established,3 there is little information on the role of alcohol
in the traffic deaths of younger passengers. In a summary of 1997 traffic
safety statistics, the National Highway Traffic Safety Administration (NHTSA)
reported that nearly half of the alcohol-related child traffic deaths involved
child passengers riding with drivers who had been drinking alcohol.4 However, this analysis did not separately consider
the alcohol-related deaths of child passengers, pedestrians, and bicyclists.
Our recent brief report used national crash data to examine alcohol
involvement in the deaths of child passengers, pedestrians, and bicyclists.2 However, we did not specifically evaluate the characteristics
of drinking driver–related child passenger deaths. The only other work
we have found that provides any detail on alcohol-related child passenger
deaths reported that a drinking driver may be more likely involved when a
child passenger dies while riding in an older vehicle.5
In this article, we examine driver, passenger, and crash characteristics for
child passenger deaths and injuries involving drinking drivers to identify
opportunities for prevention.
For deaths, we analyzed 1985-1996 data from the Fatality Analysis Reporting
System.6 This database is maintained by the
NHTSA and is a census of all police-reported motor vehicle crashes on public
roadways that result in the death of at least 1 occupant or nonmotorist, such
as a pedestrian or bicyclist, within 30 days of the crash. For drivers without
available alcohol test results, the NHTSA estimates the distribution of blood
alcohol concentrations in 1 of 3 categories (<2.17 mmol/L, 2.17-21.6 mmol/L,
and ≥21.7 mmol/L [<10, 10-90, and ≥100 mg/dL, respectively]) using
a discriminant analysis of known information.7
For the crashes studied in this article, blood alcohol concentrations were
imputed for approximately one third of records. To assess the impact of the
imputed blood alcohol distributions on our results, we analyzed the data both
with and without the records with imputed alcohol information. We found no
meaningful difference in any of the associations when records with imputed
alcohol levels were excluded. We therefore present the results including records
with estimated blood alcohol concentrations.
For nonfatal injuries, we analyzed 1988-1996 data from the General Estimates
System.6 This database is also maintained by
the NHTSA and became operational in 1988. This system uses a stratified probability
sample of all police-reported crashes in the United States. Information from
approximately 48,000 police crash reports from 400 police jurisdictions is
abstracted each year. Alcohol involvement is coded in this system as yes or no; specific blood alcohol
concentrations are not available in the General Estimates System.
Rates were calculated using population counts from the US Census.8,9
From 1985-1996, 19,768 child passengers aged 0 through 14 years died
in motor vehicle crashes in the United States. Of these, 5555 (28.1%) involved
a drinking driver (a driver with any measurable blood alcohol concentration ≥2.17
mmol/L [10 mg/dL]). Of all child passenger deaths, the proportion that involved
a drinking driver decreased from 30.9% (470/1520) in 1985 to 23.2% (395/1701)
Of the 5555 child passenger deaths that involved a drinking driver,
3556 (64.0%) occurred while the child was riding with a drinking driver (Table 1). Of the 3556 child passengers
who died while riding with a drinking driver, 2085 (58.6%) died in single-vehicle
crashes and 1471 (41.4%) died in multiple-vehicle crashes. A total of 1999
child passengers died in multiple-vehicle crashes in which the child's driver
had not been drinking, but another driver had been drinking alcohol.
Fatality rates for child passengers killed while being transported by
a drinking driver declined from 1985 through 1990 but remained virtually unchanged
from 1991 through 1996 (Figure 1).
Among child passenger deaths involving a drinking driver, the proportion that
died while riding in the same vehicle as a drinking driver was similar from
1985 through 1996. In each of these 12 years, approximately two thirds of
the child passengers whose deaths involved a drinking driver were riding with
such a driver when they died (Figure 1).
We examined the age groups of the pairs of drinking drivers and their
child passengers who were killed. Combinations of drivers aged 21 years and
older with passengers younger than 5 years (35.5%), drivers aged 25 years
and older with passengers aged 5 through 9 years (22.4%), and drivers aged
35 years and older with passengers aged 10 through 14 years (9.1%) made up
more than two thirds of the total. The combination of drivers aged 15 through
20 years with passengers aged 10 through 14 years made up just 12.5% of the
Of the drivers involved in a crash in which a child passenger in their
vehicle died, drinking drivers were more likely than nondrinking drivers to
have been previously convicted of driving while intoxicated or to have had
their license suspended or revoked (Table
2). Overall, 7.9% of the drinking drivers and 1.2% of the nondrinking
drivers had 1 or more prior convictions for driving while intoxicated during
the 3 years prior to the date of the fatal crash (prevalence ratio, 6.6).
Similarly, 17.1% of the drinking drivers and 7.1% of the nondrinking drivers
had their driver's license suspended or revoked during the 3 years before
the fatal crash (prevalence ratio, 2.4).
For all child passenger deaths (including those not related to drinking
drivers) from 1985 through 1996, child passenger restraint use decreased as
both the child's age and the blood alcohol concentration of the child's driver
increased (Figure 2). Of the 3246
child passengers with known restraint information who died while being transported
by a drinking driver, just 584 (18.0%) were restrained in the fatal crash.
For comparison, of the 14,772 children with known restraint information who
died while being transported by a nondrinking driver, 4508 (30.5%) were restrained.
Of the 3063 cases for which restraint use was known for both the drinking
driver and the child passenger who died, both used a restraint in 345 cases
(11.3%). In 398 fatal crashes (13.0%), the drinking driver was restrained,
but the child who died was not.
An estimated 2,322,000 child passengers were nonfatally injured from
1988 through 1996. Of these injuries, 149,000 (6.4%) involved a drinking driver.
Of these 149,000 injured child passengers, 58,000 (38.9%) were being transported
by a drinking driver at the time of the crash. Of the child passengers injured
while riding with a drinking driver, 33.2% were restrained; of all children
injured while riding with a nondrinking driver (whether in alcohol-related
crashes or not), 66.0% were restrained.
In the United States, the majority of the drinking driver–related
child passenger deaths involve a child riding unrestrained in the same vehicle
as a drinking driver. Typically, the drinking driver transporting the child
is old enough to be the child's parent or caregiver. This is different than
what might be assumed from the popular media reports of children who are killed
when the vehicle in which they are riding is hit by a drinking driver.10,11
Our findings are generally consistent with an analysis of traffic injuries
and deaths among children in North Carolina that found that of the 51 child
passengers killed in alcohol-related crashes from 1979 through 1982,12 36 (70.6%) were riding with drinking drivers.
We found that among drivers involved in a crash in which their child
passenger died, drinking drivers were over 6 times more likely than nondrinking
drivers to have prior convictions for driving while impaired. This finding
underscores the serious risk that persons arrested for alcohol-impaired driving
pose to others and to themselves. Drivers who have been arrested for driving
while impaired are known to be at substantially increased risk of future death
in an alcohol-related motor vehicle crash compared with drivers who have not
been arrested for this offense.13 In addition,
studies have shown that over half of the drivers arrested for driving while
impaired are alcoholics.14 Taken together,
these findings emphasize the importance of aggressively intervening with persons
convicted of driving while impaired, including evaluating and treating them
for alcohol problems, to prevent future deaths in alcohol-related crashes.
Our ability to characterize alcohol involvement in child passenger deaths
was somewhat limited by the lack of complete alcohol testing on drivers involved
in fatal crashes. However, the discriminant analysis used in the Fatality
Analysis Reporting System to estimate the distribution of blood alcohol concentrations
when test results are unavailable consistently estimates blood alcohol distributions
within 3 percentage points of the actual distribution.7
Moreover, restricting this analysis to drivers with known test results did
not change the findings of our study.
Our study probably underestimates the actual number of child passenger
deaths involving drinking drivers and overestimates restraint use. For the
cases in which a child's driver survived, driver alcohol use was probably
underreported because alcohol testing is more complete among fatalities.15 Therefore, the proportion of drinking driver–related
child passenger deaths in which a child was in the same vehicle with a drinking
driver may be even greater than we report. In addition, the Fatality Analysis
Reporting System data we analyzed contains information only on crashes that
occur on public roadways; therefore, the system, and consequently our study,
do not include data for fatal crashes that occur on private roads or off-road
areas. Finally, our estimate of restraint use is based on police crash reports,
which have a bias toward overreporting.16
The data on nonfatal injuries from the General Estimates System were
also subject to limitations. Up to one half of motor vehicle crashes in the
United States are never reported to police; presumably, most of these involve
property damage only.6 However, some crashes
that result in injuries, such as single-vehicle crashes involving a drinking
driver, are likely to be underreported to police. Furthermore, among crashes
that are reported, alcohol involvement is underreported by police.15 Therefore, our data on nonfatal injuries probably
underestimate both the total number of child passenger injuries and the number
that are alcohol related. As for fatalities, restraint use information for
nonfatal injuries is from police crash reports, which tend to overestimate
We recommend a combination of aggressive interventions to prevent alcohol-impaired
driving. Effective general policies include administrative license suspension17 and mandatory substance abuse assessment and treatment
for driving-under-the-influence offenders,18,19
lowering the legal blood alcohol limit to 17.4 mmol/L (80 mg/dL) or lower
for adults,20,21 and zero tolerance
for alcohol use by drivers younger than 21 years.22
However, while these interventions have been shown to be effective in reducing
alcohol-impaired driving in the general driving population, it is possible
they are somewhat less effective in preventing this behavior among drinking
drivers who transport children.
Strategies to specifically deter individuals from drinking and driving
with children in the vehicle might include lower legal blood alcohol limits
for drivers transporting children and child endangerment laws. There are 2
types of child endangerment laws. Currently, 27 states have statutes that
create special sanctions for cases of driving under the influence in which
the convicted driver was transporting a child at the time of the offense.
Two additional states have applied child abuse or neglect statutes in such
situations.23 These strategies should be evaluated
for their effectiveness in reducing drinking driver–related deaths and
injuries. If effective, other states should consider adopting such laws. In
addition, we encourage families to adopt a personal policy of zero alcohol
tolerance when transporting children to decrease their risk of a fatal crash
and serve as positive role models for their children. Furthermore, we recommend
that health care providers in various settings (eg, outpatient clinics and
emergency departments) screen adult patients for alcohol problems and provide
them with brief interventions, refer them for specialized treatment, or both
depending on the severity of the drinking problem.24- 26
Health providers treating adults can also include information on the risk
to child passengers when counseling their patients about the risk of driving
while impaired. We also encourage health providers treating children to include
advice against drinking and driving in discussions of caregiver behaviors
that affect a child's injury risk (eg, proper car seat use).27
Finally, to increase restraint use among child passengers, we recommend stricter
enforcement of child safety seat laws (which currently exist in all 50 states)
and the passage of primary seat belt laws that cover all children in all seating
positions in the vehicle. Through these legal, medical, and educational interventions,
we can further reduce the unacceptable risks of child passenger injury and
death associated with alcohol-impaired drivers.