Systematic review of child passenger safety laws and their associations with child restraint system use, injuries and deaths.

BACKGROUND AND OBJECTIVE: Many countries and all US states have legislation that mandates how children of certain ages and/or sizes should be restrained in vehicles. The objective of the current systematic review was to describe the associations between legislation and three outcomes: child restraint system use, correct child restraint system use and child passenger injuries/deaths. METHODS: Included studies were published between 2004 and 2020 and evaluated associations between child passenger safety laws and the outcomes described above. Three literature searches using three search terms (child passenger safety, car seat use, booster seat use) were completed in PubMed and PsycINFO, with the last search occurring in January 2021. Studies are presented based on the outcome(s) they evaluated. The original protocol for this review is registered with PROSPERO (ID: CRD42019149682). RESULTS: Eighteen studies from five different countries evaluating a variety of different types of legislation were included. Overall, positive associations between legislation and the three outcomes were reported. However, there were important nuances across studies, including negative associations between booster seat legislation and correct child restraint use. Further, there were also negative associations between various types of legislation and outcomes for populations with less formal education and lower incomes, and for racial and ethnic minorities. CONCLUSION: Overall, child passenger safety legislation appears to be positively associated with child restraint system use, correct child restraint use and child passenger injuries/deaths. However, there is a need to more comprehensively characterise how different types of legislation influence child passenger safety outcomes to promote equitable effects across populations.

Preparing to "Live a Life of Possibilities": Experiences of Healthcare Providers Readying Autistic Adolescents and Their Families for Independent Driving.

Autistic adolescents and their families may experience barriers to transportation, including independent driving, which is critical to supporting quality of life and engagement in social, educational, and employment opportunities. Healthcare providers may feel unprepared to provide guidance to autistic adolescents, although they are among the professionals families turn to for guidance. This study describes providers' experiences supporting autistic adolescents and families in the decision to pursue licensure and identifies barriers experienced in providing support. We conducted interviews with 15 healthcare providers focused on how they support autistic adolescents and their families in navigating topics related to independence, driving, and transportation. Key themes identified included: importance of understanding adolescents' perspectives and motivations, approaches to readying caregivers for children to pursue driving, and role of providers in fostering agreement between adolescents and caregivers. Results reflect healthcare providers as intermediaries between autistic adolescents and caregivers making the decision to pursue licensure and bring families to consensus. Our findings emphasize the importance of healthcare providers, in collaboration with community-based providers, in supporting autistic adolescents and their families considering licensure. Improving conversations between providers and families provides opportunity to better support quality of life among autistic adolescents and their caregivers navigating the transition to independence.

Caregivers' Perspectives on Use of and Need for Driving Resources for Their Autistic Adolescent.

Introduction: Autistic individuals who independently travel-or commute without companionship or supervision-report feeling more connected to social, education, and employment opportunities. Despite the potential for independent transportation to improve quality of life, little is known about what transportation-related resources, specifically driving focused ones, exist for autistic individuals or how they and their families find and use them. The objectives of this study were to characterize: (1) where and how families in the United States find driving-related resources for their autistic adolescents; (2) families' perceived availability and utility of identified resources; and (3) resources families believe should be developed. Methods: We conducted semi-structured interviews with 33 caregivers of autistic adolescents aged 16-24 years without an intellectual disability. We used a directed-content approach to develop and implement codes; three trained coders analyzed all transcripts (inter-rater reliability ≥0.8 for all codes). Members of the research team reviewed coded data and created code summaries, which were then developed and discussed by the larger research team to determine final consensus. Results: Caregivers described a few existing resources that were helpful in guiding driving-related decisions. In addition, caregivers voiced that there were limited resources tailored to the unique needs that arise while teaching or learning how to drive, particularly ones that support their own and their adolescent's mental health. The limited resources and services identified as helpful-specifically support groups/perspectives of other families and specialized driving instructors-are seemingly difficult to find, costly, and/or perceived as having geographic- and time-related barriers. Conclusion: There is a critical need and opportunity for stakeholders of the autism community to both expand access to existing and develop novel driving-related resources for families with autistic adolescents, with a particular focus of supporting caregiver and adolescent mental health.

Why is this an important issue?: Many autistic teens and young adults rely on caregivers, siblings, family, and friends to give them rides to the places they need to go. Research has found that resources and services created specifically for autistic people can help them decide whether driving is right for them, and if so, then learn how to drive. However, little is known about if, and if so how, families find or use these resources and services. What was the purpose of this study?: This study had three goals: (1) learn what driving resources and services autistic teens and young adults (and their families) use, (2) learn how they find these resources and services, and (3) learn what other things they think would help them make decisions about driving and learn how to drive. What did the researchers do?: The researchers asked 33 caregivers of autistic teens and young adults without an intellectual disability (ID) (teens and young adults were 16­24 years old) questions about their experiences finding and using driving resources and services. These conversations were recorded and later typed out word for word. What were the results of the study?: Caregivers said that they spend a lot of time looking for driving resources and services for their autistic teen or young adult. Many resources and services were not easy to use or helpful. Caregivers said that behind-the-wheel driving instructors with specific training teaching autistic individuals were the most helpful and/or wanted resource. However, caregivers also said that these instructors and their services were hard to find, cost a lot of money, and require families to spend a lot of time training with them to get results. In the future, caregivers said that making it easier to find and get driving resources and services (e.g., making them less expensive) was necessary. Caregivers also had strong interest in their family participating in support groups related to driving. What do these findings add to what was already known?: Previous research has shown that training, resources, and services designed specifically for autistic people help prepare autistic teens and young adults to drive. Before our study, it was unclear if, and if so how, families actually use these resources and services in the real world, or outside of academic research. Families in our study said that it is hard to find or get access to driving resources and services, especially those created specifically for autistic populations. This difficulty is one reason why families think it is stressful and hard for autistic teens and young adults to learn how to drive. What are the potential weaknesses in the study?: We only asked caregivers who lived in the Northeast part of the United States questions, so our findings may not be true for all families. Also, this study only asked questions to caregivers of autistic teens and young adults who did not have an ID. How will these findings help autistic adults now or in the future?: Our findings can help autistic teens and young adults by showing what resources and services families use and want to use while they are learning how to drive or making decisions about if driving is right for them.

US caregivers' attitudes and risk perceptions towards pediatric vehicular heatstroke: A national survey.

RESEARCH QUESTION/OBJECTIVE: In the US, child fatalities in hot cars [i.e., pediatric vehicular heatstroke (PVH)] occur on average once every 10 days. Despite national campaigns and recurring media attention, there has been little change in the rate of PVH deaths annually. The objective of this study was to characterize caregivers' beliefs, behaviors, and attitudes related to PVH risk factors and potential mitigating technologies. METHODS/DATA SOURCES: We conducted a national survey of US caregivers to: (1) determine caregivers' perceptions of PVH risk for children in their care, as well as their thoughts about adopting risk mitigating technologies, (2) characterize scenarios in which caregivers intentionally leave children unattended in vehicles, and (3) assess caregiver awareness of national PVH campaigns. We used a variety of question formats (select all that apply, multiple choice, free response). Data were analyzed data using descriptive statistics and caregiver responses related to PVH event behaviors were compared across selected demographic characteristics using chi-square tests. RESULTS: Exactly 1,500 caregivers completed the survey; 60% were female and 60% were non-Hispanic White. Most, or 88%, of our respondents reported they do not leave their child(ren) alone in vehicles for any amount of time. However, there were differences in who engages in this behavior by caregivers' gender, education, income, and number of children. Few, or 12%, believed they were at any risk for having a child overheat in a vehicle, and most caregivers described negative and/or judgmental views of those who were at-risk. Nearly all participants indicated it was important that caregivers receive education about PVH (95%), and the majority, or 90%, responded they would be willing to adopt risk mitigating technology themselves, many believing they and others would be perceived as better caregivers if they did so. SIGNIFICANCE OF RESULTS: This is the first nationally representative study to the authors' knowledge that characterizes caregivers' attitudes, behaviors, and perceived risk of PVH, along with their willingness to adopt mitigating technologies. Our dissonant finding that caregivers view those who may be at risk for PVH negatively while simultaneously viewing those who adopt risk mitigating strategies positively provides stakeholders with unique insight for future efforts. Specifically, messaging utilizing themes of positive caregiving might be more effective at increasing caregivers' adoption than threat-based campaigns focused on communicating risk. Additionally, our findings of demographic differences in behaviors related to PVH are a helpful first step to inform the development of tailored interventions (e.g., public messaging) and potential risk mitigating technologies that may be more likely to be widely adopted.

Variation in drivers' seat belt use by indicators of community-level vulnerability.

INTRODUCTION: Examining crash reports with linked community-level indicators may optimize efforts aimed at improving traffic safety behaviors, like seat belt use. To examine this, quasi-induced exposure (QIE) methods and linked data were used to (a) estimate trip-level seat belt non-use of New Jersey (NJ) drivers and (b) determine the degree to which seat belt non-use is associated with community-level indicators of vulnerability. METHOD: Driver-specific characteristics were identified from crash reports (age, sex, number of passengers, vehicle type) and licensing data (license status at the time of the crash). Geocoded residential addresses were leveraged within the NJ Safety and Health Outcomes warehouse to create quintiles of community-level vulnerability. QIE methods were applied to estimate trip-level prevalence of seat belt non-use in non-responsible, crash-involved drivers between 2010-2017 (n = 986,837). Generalized linear mixed models were then conducted to calculate adjusted prevalence ratios and 95 % confidence intervals for being unbelted for driver-specific variables and community-level indicators of vulnerability. RESULTS: Drivers were unbelted during 1.2 % of trips. Males, those with suspended licenses, and those without passengers had higher rates of being unbelted than their counterparts. An increase was observed in traveling unbelted with increasing quintiles of vulnerability, such that drivers in the most vulnerable communities were 121 % more likely to be unbelted than those in the least vulnerable communities. CONCLUSIONS: Prevalence of driver seat belt non-use may be lower than previously estimated. Additionally, communities with the highest amount of the population living with three or more indicators of vulnerability have higher rates of seat belt non-use; this may be a particularly useful metric to inform future translational efforts improving seat belt use. PRACTICAL APPLICATIONS: As evidenced by the findings that risk of being unbelted increased as drivers' community vulnerability increased, novel communication efforts tailored to drivers from vulnerable neighborhoods may optimize efforts.

Sociodemographic disparities in child restraint selection and variation in child passenger safety information sources.

PURPOSE: Marginalized and otherwise vulnerable groups remain at higher risk than their counterparts for not having all of their children appropriately restrained during vehicle trips. Little is known about potential sources of these disparities, however a commonly theorized factor has been where caregivers find or obtain information (i.e., their information sources). The objective of this study was to: (1) characterize caregivers' actual and preferred sources of information related to child passenger safety information, overall and within sociodemographic groups; and (2) determine if, and if so how, sources impact appropriate child restraint use (i.e., child/seat fit). METHODS: We conducted an online, cross-sectional survey of US caregivers. Caregivers answered questions about themselves, their child(ren), their child(ren)'s restraint use during trips, and their information sources to learn which seat their child should be using. We used Fisher's exact and Pearson chi-square tests to compare used and preferred sources of information across caregiver demographics (age, education, race/ethnicity), as well as to determine whether information sources were associated with caregivers' appropriate child restraint use. RESULTS: A total of 1,302 caregivers from 36 states with 2,092 children completed the survey. The majority (91%) of children were appropriately restrained. More caregivers from marginalized and otherwise vulnerable groups had children inappropriately restrained when compared with their counterparts. We identified multiple differences in both used and preferred information sources by caregivers' age, race/ethnicity, and education level. In addition, we found a trend that caregivers from populations with higher rates of inappropriate use seemingly used fewer information sources. Ultimately, information sources were not associated with appropriate restraint use; however, within vulnerable populations, almost all caregivers had all of their children appropriately restrained if they had used a Child Passenger Safety Technician (CPST)/Inspection Station or their Pediatrician. CONCLUSION: Our findings reiterate calls for more tailored interventions and efforts to combat widening disparities in child restraint use and crash outcomes and suggest one promising method may be providing more access to child passenger safety experts. Future studies must untangle the likely complex relationship between information sources and appropriate/accurate child restraint use.

Brief Report: Healthcare Providers' Discussions Regarding Transportation and Driving with Autistic and Non-autistic Patients.

OBJECTIVE: To characterize healthcare and behavioral service providers' transportation-related discussions with their autistic and non-autistic patients. METHOD: 78 providers completed a cross-sectional survey assessing their transportation discussions with patients. We used Mann-Whitney U tests and chi-square tests to compare differences in provider reports by patient diagnosis. RESULTS: Compared with one in two providers who reported they discuss transportation with non-autistic patients, only one in five have these conversations with their autistic patients. Few (8%) providers felt prepared to assess driving readiness in autistic patients, yet only a quarter refer patients elsewhere. CONCLUSION: There is a critical need to develop resources for use in medical settings to effectively support autistic adolescents' independence and mobility as they transition into adulthood.

Transition to Adulthood for Autistic Adolescents: Topics Discussed by Healthcare Providers With Autistic Patients and Families.

PURPOSE: We surveyed healthcare providers to determine the extent to which they discuss transition-to-adulthood topics with autistic patients without intellectual disabilities. METHODS: Seventy-four healthcare providers in the Philadelphia area reported on the patient age at which they begin transition conversations, topics covered, and provider comfort. We calculated the proportion of providers who endorsed each transition topic, overall and by clinical setting. RESULTS: Providers initiated transition-related conversations at a median age of 16 years (IQR: 14, 18), with over half reporting they were "somewhat" or "a little" comfortable with discussions. Nearly all providers discussed at least one healthcare, well-being, and mental health topic, while basic need-related discussions were limited. DISCUSSION: Results suggest providers may delay and feel poorly prepared to provide anticipatory guidance to autistic patients for transition to adulthood. Future efforts to enhance the available resources and preparation available to providers are essential to meet autistic patients' needs.

Real-World Crash Circumstances Among Newly Licensed Adolescent Drivers With and Without Attention-Deficit/Hyperactivity Disorder.

PURPOSE: Adolescents with attention-deficit/hyperactivity disorder (ADHD) have 30%-40% higher crash rates. However, we still do not understand which factors underlie heightened crash risk and if crash circumstances differ for drivers with ADHD. We compared prevalences of crash responsibility, driver actions, and crash types among adolescent and young adult drivers with and without ADHD who crashed within 48 months of licensure. METHODS: In this exploratory retrospective cohort study, we identified patients of Children's Hospital of Philadelphia's (CHOP) New Jersey (NJ) primary care locations who were born between 1987 and 2000, NJ residents, had their last CHOP visit ≥ age 12 years, and acquired a driver's license. We linked CHOP electronic health records to NJ's licensing and crash databases. ADHD diagnosis was based on International Classification of Diseases, Ninth Revision, Clinical Modification/International Classification of Diseases, Tenth Revision, Clinical Modification codes. Prevalence ratios were estimated using generalized estimating equation log-binomial regression. RESULTS: We identified 934 drivers with ADHD in 1,308 crashes and 5,158 drivers without ADHD in 6,676 crashes. Within 48 months postlicensure, drivers with ADHD were more likely to be at fault for their crash (prevalence ratio: 1.09 [1.05-1.14]) and noted as inattentive (1.15 [1.07-1.23]). With the exception that drivers with ADHD were less likely to crash while making a left/U-turn, we did not find substantial differences in crash types by diagnosis. Analyses also suggest females with ADHD may have a higher risk of colliding with a nonmotor vehicle and crashing due to unsafe speed than females without ADHD. DISCUSSION: The results suggest crash circumstances do not widely differ for drivers with and without ADHD but highlight several factors that may be particularly challenging for young drivers with ADHD.

Facilitating research on racial and ethnic disparities and inequities in transportation: Application and evaluation of the Bayesian Improved Surname Geocoding (BISG) algorithm.

OBJECTIVE: Racial and ethnic disparities and/or inequities have been documented in traffic safety research. However, race/ethnicity data are often not captured in population-level traffic safety databases, limiting the field's ability to comprehensively study racial/ethnic differences in transportation outcomes, as well as our ability to mitigate them. To overcome this limitation, we explored the utility of estimating race and ethnicity for drivers in the New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse using the Bayesian Improved Surname Geocoding (BISG) algorithm. In addition, we summarize important recommendations established to guide researchers developing and implementing racial and ethnic disparity research. METHODS: We applied BISG to estimate population-level race/ethnicity for New Jersey drivers in 2017 and evaluated the concordance between reported values available in integrated administrative sources (e.g., hospital records) and BISG probability distributions using an area under the receiver operator curve (AUC) within each race/ethnicity category. Overall AUC was calculated by weighting each AUC value by the population count in each reported category. In an exemplar analysis using 2017 crash data, we conducted an analysis of average monthly police-reported crash rates in 2017 by race/ethnicity using the NJ-SHO and BISG sets of race/ethnicity values to compare their outputs. RESULTS: We found excellent or outstanding concordance (AUC ≥0.86) between reported race/ethnicity and BISG probabilities for White, Hispanic, Black, and Asian/Pacific Islander drivers. We found poor concordance for American Indian/Alaskan Native drivers (AUC= 0.65), and concordance was no better than random assignment for Multiracial drivers (AUC = 0.52). Among White, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan native drivers, monthly crash rates calculated using both NJ-SHO reported race/ethnicity values and BISG probabilities were similar. Monthly crash rates differed by 11% for Black drivers, and by more than 200% for Multiracial drivers. CONCLUSION: Findings of excellent or outstanding concordance between and mostly similar crash rates derived from reported race/ethnicity and BISG probabilities for White, Hispanic, Black, and Asian/Pacific Islander drivers (98.9% of all drivers in this sample) demonstrate the potential utility of BISG in enabling research on transportation disparities and inequities. Concordance between race/ethnicity values were not acceptable for American Indian/Alaskan Native and Multiracial drivers, which is similar to previous applications and evaluations of BISG. Future work is needed to determine the extent to which BISG may be applied to traffic safety contexts.

Comparison of Motor Vehicle Crashes, Traffic Violations, and License Suspensions Between Autistic and Non-Autistic Adolescent and Young Adult Drivers.

OBJECTIVE: One-third of autistic individuals obtain a driver's license by age 21 years; however, prior studies suggest they may be at heightened risk for motor vehicle crashes. We compared objective rates of crashes, traffic violations, and license suspensions for newly licensed autistic and non-autistic adolescents. METHOD: This retrospective cohort study included New Jersey residents born from 1987 through 2000 who were patients of the Children's Hospital of Philadelphia health care network. Electronic health records were linked with statewide driver licensing and crash databases. Autism status was classified via International Classification of Diseases (ICD) diagnostic codes; individuals with intellectual disability were excluded. We compared rates among 486 autistic and 70,990 non-autistic licensed drivers over their first 48 months of driving. Furthermore, we examined the proportion of crashes attributed to specific driver actions and crash types. RESULTS: Compared with non-autistic drivers, autistic drivers were estimated to have lower average monthly rates of crash involvement (adjusted rate ratio (adjRR) = 0.89, 95% CI = 0.75-1.05), moving violations (adjRR = 0.56, 95% CI = 0.48-0.67), and suspensions (adjRR = 0.32, 95% CI = 0.18-0.58). Among drivers involved in a crash, autistic drivers were half as likely to crash because of unsafe speed, but substantially more likely to crash because of their failure to yield to a vehicle/pedestrian and while making left-turns or U-turns. CONCLUSION: Newly licensed autistic adolescent drivers have similar to lower estimated rates of adverse driving outcomes; the extent to which these can be attributed to different driving patterns is a critical point for future investigation. There were several notable differences in the characteristics of these crashes, which directly inform interventions to improve driving safety of autistic adolescent drivers.

Evaluating disparities in child occupant protection using a proportion-eliminated approach to mediation.

OBJECTIVE: While there are clear racial/ethnic disparities in child restraint system (CRS) use, to date no studies have identified mediators that quantitatively explain the relationship between race and CRS use. Therefore, the objective of this study was to provide an example of how a proportion-eliminated approach to mediation may be particularly useful in understanding the complex relationship between race and CRS use. METHODS: Sixty-two mothers with a child between 4-8 years old completed a survey and had their CRS use assessed by a Child Passenger Safety Technician using a structured assessment based on the 2018 American Academy of Pediatrics' Best Practice guidelines. Recruitment and data collection occurred in Birmingham, Alabama between June 2018 and January 2019. We used chi-squared tests, logistic regressions, and a proportion-eliminated approach to mediation to compare our variables of interest and to estimate the amount of the association between racial group membership and errors in restraint use that may be explained by sociodemographic, psychosocial, and parenting variables. RESULTS: Before mediation, Nonwhite mothers in this sample had a 7.38 greater odds of having an error in CRS use than White mothers. Mediation analyses indicated that being married and self-reported seatbelt use explained 47% and 35% of the effect of race on CRS use errors, respectively. CONCLUSION: A proportion-eliminated approach to mediation may be particularly useful in child passenger safety research aiming to inform the development of interventions tailored for racial minority populations.

Variations in booster seat use by child characteristics.

INTRODUCTION: Child weight and height are the basis of manufacturer and best practice guidelines for child restraint system use. However, these guides do not address behavioral differences among children of similar age, weight, and height, which may result in child-induced restraint use errors. The objective of this study was to characterize child behaviors across age in relation to appropriate restraint system use during simulated drives. METHODS: Fifty mother-child (4-8 years) dyads completed an installation into a driving simulator, followed by a simulated drive that was video-recorded and coded for child-induced errors. Time inappropriately restrained was measured as the total amount of the simulated drive spent in an improper or unsafe position for the restraint to be effective divided by the total drive time. Kruskal-Wallis tests were used to determine differences across age in the frequency of error events and overall time inappropriately restrained. RESULTS: Children in harnessed seats had no observed errors during trips. Within children sitting in booster seats there were differences in time inappropriately restrained across age (p = 0.01), with 4 year-olds spending on average 67% (Median = 76%) of the drive inappropriately restrained, compared to the rest of the age categories spending less than 28% (Medians ranged from 3% to 23%). CONCLUSION: Some children may be physically compatible with booster seats, but not behaviorally mature enough to safely use them. More research is needed that examines how child behavior influences child passenger safety. Practical Applications: Not all children physically big enough are behaviorally ready to use belt positioning booster seats. Primary sources of information should provide caregivers with individualized guidance about when it is appropriate to transition children out of harnessed seats. Additionally, best practice guidelines should be updated to reflect what behaviors are needed from children to safely use specific types of child restraint systems.

Vehicle safety characteristics in vulnerable driver populations.

OBJECTIVE: National data suggest drivers who are younger, older, and have lower socioeconomic status (SES) have heightened crash-related injury rates. Ensuring vulnerable drivers are in the safest vehicles they can afford is a promising approach to reducing crash injuries in these groups. However, we do not know the extent to which these drivers are disproportionately driving less safe vehicles. Our objective was to obtain population-based estimates of the prevalence of important vehicle safety criteria among a statewide population of drivers. METHODS: We analyzed data from the NJ Safety and Health Outcomes warehouse, which includes all licensing and crash data from 2010-2017. We borrowed the quasi-induced exposure method's fundamental assumption-that non-responsible drivers in clean (i.e., only one responsible driver) multi-vehicle crashes are reasonably representative of drivers on the road-to estimate statewide prevalence of drivers' vehicle characteristics across four driver age groups (17-20; 21-24; 25-64, and ≥65) and quintiles of census tract median household income (n = 983,372). We used NHTSA's Product Information Catalog and Vehicle Listing platform (vPIC) to decode the VIN of each crash-involved vehicle to obtain model year, presence of electronic stability control (ESC), vehicle type, engine horsepower, and presence of front, side, and curtain air bags. RESULTS: The youngest and oldest drivers were more likely than middle-aged drivers to drive vehicles that were older, did not have ESC, and were not equipped with side airbags. Additionally, across all age groups drivers of higher SES were in newer and safer vehicles compared with those of lower SES. For example, young drivers living in lowest-income census tracts drove vehicles that were on average almost twice as old as young drivers living in highest-income tracts (median [IQR]: 11 years [6-14] vs. 6 years [3-11]). CONCLUSIONS: Vehicle safety is an important component of seminal road safety philosophies that aim to reduce crash fatalities. However, driver groups that are overrepresented in fatal crashes-young drivers, older drivers, and those of lower SES-are also driving the less safe vehicles. Ensuring drivers are in the safest car they can afford should be further explored as an approach to reduce crash-related injuries among vulnerable populations.

Assessment of Caregiver-Targeted Interventions for Use of Motor Vehicle Passenger Safety Systems for Children: A Systematic Review and Meta-analysis.

Importance: Caregiver-targeted interventions to improve the use of child restraint systems (CRS) in motor vehicles are common and heterogeneous in their implementation. The effectiveness of these interventions is unknown. Objectives: To quantify the effects of caregiver-targeted interventions using meta-analytic methods, assess the quality of published studies, and assess for publication bias. Data Sources: PubMed and PsychINFO (January 1, 2004, to April 1, 2019) were searched for English-language studies using a list of search terms. The search and screening process was completed between May 25, 2018, and April 1, 2019. Study Selection: Studies met inclusion criteria if they included a caregiver-targeted intervention that focused on increasing CRS use for children (age, ≤9 years) and report the use of CRS before and after the intervention. Data Extraction and Syntheses: Cochrane and PRISMA guidelines were used for the meta-analysis and risk-of-bias review. Information was extracted on intervention type, setting, implementation, and attributes of the study independently between 2 coders. Data were pooled from independent samples, with 1 outcome measure from each intervention implementation or study. Main Outcomes and Measures: This study was an exploratory random-effects meta-analysis. Unadjusted odds ratios were calculated using the sample size and the observed number of children in incorrect or correct restraints in motor vehicles before and after the intervention to determine the odds of incorrect CRS use after completing an intervention. Setting, measurement method, randomization, use of vouchers, and types of restraint were tested as moderators. A funnel plot was used to assess for publication bias. Results: Of 1240 potential articles, 51 were deemed eligible for screening and 10 (8238 participants total) were included in the meta-analysis. Caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS (odds ratio, 0.51; 95% CI, 0.36-0.71; P < .001). Variance in the averaged effect size was driven by self-report methods (when removed from analyses, I2 = 61.8%; R2 change = 26.3; P = .02) and hospital settings (when removed from analyses, I2 = 70.7%; R2 change = 17.4; P = .002). Risk of bias was high in most studies; however, there was low evidence for publication bias. Conclusions and Relevance: In this meta-analysis, caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS in motor vehicles; however, the methodological rigor of intervention studies should be enhanced.

The impact of atypical sensory processing on social impairments in autism spectrum disorder.

Altered sensory processing has been an important feature of the clinical descriptions of autism spectrum disorder (ASD). There is evidence that sensory dysregulation arises early in the progression of ASD and impacts social functioning. This paper reviews behavioral and neurobiological evidence that describes how sensory deficits across multiple modalities (vision, hearing, touch, olfaction, gustation, and multisensory integration) could impact social functions in ASD. Theoretical models of ASD and their implications for the relationship between sensory and social functioning are discussed. Furthermore, neural differences in anatomy, function, and connectivity of different regions underlying sensory and social processing are also discussed. We conclude that there are multiple mechanisms through which early sensory dysregulation in ASD could cascade into social deficits across development. Future research is needed to clarify these mechanisms, and specific focus should be given to distinguish between deficits in primary sensory processing and altered top-down attentional and cognitive processes.

Neural networks underlying language and social cognition during self-other processing in Autism spectrum disorders.

The social communication impairments defining autism spectrum disorders (ASD) may be built upon core deficits in perspective-taking, language processing, and self-other representation. Self-referential processing entails the ability to incorporate self-awareness, self-judgment, and self-memory in information processing. Very few studies have examined the neural bases of integrating self-other representation and semantic processing in individuals with ASD. The main objective of this functional MRI study is to examine the role of language and social brain networks in self-other processing in young adults with ASD. Nineteen high-functioning male adults with ASD and 19 age-sex-and-IQ-matched typically developing (TD) control participants made "yes" or "no" judgments of whether an adjective, presented visually, described them (self) or their favorite teacher (other). Both ASD and TD participants showed significantly increased activity in the medial prefrontal cortex (MPFC) during self and other processing relative to letter search. Analyses of group differences revealed significantly reduced activity in left inferior frontal gyrus (LIFG), and left inferior parietal lobule (LIPL) in ASD participants, relative to TD controls. ASD participants also showed significantly weaker functional connectivity of the anterior cingulate cortex (ACC) with several brain areas while processing self-related words. The LIFG and IPL are important regions functionally at the intersection of language and social roles; reduced recruitment of these regions in ASD participants may suggest poor level of semantic and social processing. In addition, poor connectivity of the ACC may suggest the difficulty in meeting the linguistic and social demands of this task in ASD. Overall, this study provides new evidence of the altered recruitment of the neural networks underlying language and social cognition in ASD.